open and closed reduction

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    I'm having a hard time understand the difference between internal and external fixation. I know that closed reduction is reducing a fracture without making an incision in the skin and open reduction is reducing a fracture by making an incision in the skin. I understand what internal fixation is, but my books says that external fixation is a method that is used when internal fixation is not feasible and it is called external fixation with closed reduction. How can external fixation be a closed reduction, when small incisions are made into the skin and pins are self-drilled and implanted into the bone? Please somebody help.
  2. 11 Comments so far...

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    I think the problem you're having is that you are talking about two different things. The reduction, either open or closed, is the process of putting the bone back together. Fixation is the process of anchoring the bone in place. This is done either with internal screws, rods. etc., or with an external fixator.

    In other words, you can have a reduction with or without fixation. A good example of a closed reduction is manipulating a hip or shoulder back in place when it is out of the socket.

    As for a closed reduction/external fixation, you will often see it with a tib-fib fracture. The bones are manipulated back together manually without an incision, and the external fixator is placed to ensure that the bones are held together properly until they have set.

    Hope this helps.
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    I'm still somewhat confused. I'm working on a question for class discussion today. The question is to define the operative procedure for an open reduction of a fracture and explain it's rationale. I typed up the info about the internal fixation, but I also included the procedure for external fixation, so would this be considered open reduction since an incision is made? I'm so confused. I don't know why, maybe I just have too much info. crammed into my head right now. Thanks for your help.
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    OK, let's try again...don't worry, you'll get it! Again, try not to think of the two things together, they're two completely separate things.

    A reduction is either open or closed. It is open if there is an incision made in order to repair the fracture. Think of a comminuted fracture possibly from a crushing type injury in which the bone is severely damaged and has to be pieced back together. A closed reduction would be done on a simple fracture in which the bones can be put back in place by simply manipulating them back together without making any kind of incision. Placement is confirmed by x-ray and the area of the fracture is immobilized until healed.

    Fixation is, as the name implies, the act of fixing or holding the bones together, and can be either internal or external. Both types of fixation involve the use of screws, rods, pins, ect. to repair the bone and hold it in place. Internal fixation is just that...the pins or screws are inside and not visible and are usually left in place permanently. External fixation involves pins or rods that extend out through the skin and are removed once the bone has healed.

    As for the question that you are researching, you are to define an open reduction. I don't see anything in the question about fixation, either internal or external, so I think you are focusing on the wrong thing altogether. You can have an open reduction with either internal fixation or external fixation, but it's still an open reduction.

    Again, hope this helps and doesn't confuse you more!
    Last edit by MT RN on Apr 26, '07 : Reason: clarification
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    Yes, this makes more sense. Thank you so much.
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    in addition to being an rn i am a medical coder. we need to know the definitions of medical procedures and medical diagnoses. maybe you will find these explanations helpful.

    fracture reduction
    reduction is a medical procedure that is also known by the name of "manipulation". it is the most common procedure performed in the treatment of a fracture. it involves moving the bone fragments that might have been displaced into as nearly normal an anatomic position as possible. an important concept to grasp is that not all bones become displaced when they are fractured. examples would be linear or simple types of fractures. whether or not any internal or external fixation will be done as a treatment for a fracture depends on the general condition of the patient, the presence of any associated injuries and the type and location of the fracture. reduction, or manipulation, is sometimes accomplished by merely pulling on the opposite ends of an extremity to separate the two broken pieces of bone (being held tightly in displacement by muscle spasm) and accomplishing anatomical re-alignment. this is often done with fractures of the fingers and wrists.

    internal fixation
    with internal fixation the physician makes a incision to expose the bone that needs treatment. "internal fixation includes the use of pins, screws, staples, rods, and plates that are inserted into the bone to maintain alignment. when the fractured bone is in good alignment so that no manipulation is necessary, internal fixation may be used to stabilize the bone without any fracture reduction being performed. internal fixation is also used without reduction when it is necessary to reinsert an internal fixation device because the original is either displaced or broken." (page 319-320, faye brown's icd-9-cm coding handbook, 2005 revised edition, american hospital association)

    external fixation
    many more different procedures are done by external fixation. external fixation involves the external application of something that will stabilize an injury such as a muscle sprain or a simple fracture. if the injury is a fracture "one or more pins or wires may be used. small stab incisions are made in the skin and a drill is used to make a hole into the bone. each pin or wire is inserted into the bone through the drill holes and secured to an external fixation device. this holds the fracture or joint in a stable position (page 260 of the ingenix coder's desk reference)."

    external fixation is also accomplished by noninvasive means such as traction or the use of casts or splints. the types of traction that are considered external fixation include:
    • skin traction with tape, foam or felt
    • skeletal traction with wires or pins drilled transversely through the bone and exiting through the skin
    • cervical spinal traction, such as baron's tongs, crutchfield tongs and halo skull traction
    • upper extremity traction such as dunlap's skin traction
    • lower extremity traction such as buck's extension skin traction, charnley's traction, hamilton-russell's traction, balanced suspension traction and fixed skeletal traction.
    a specific type of external fixation device used to stabilize a fractured bone is called a minifixator. it is applied under general anesthesia but considered external fixation because the bone is never openly exposed during the procedure. holes are drilled into both proximal and distal portions of the involved bone. pins are inserted through the bone and attached to the metal frame of the fixator. the pins are located internally except for the portion to which the external frame is connected. you've probably seen these on people's legs. they look like steel rods encircling the entire person's lower leg like an open cylinder.
    http://www.orthofix.com/products/sheffield.asp?cid=16 - the sheffield fixator, a type of external fixation device used for fractures. pictures of the fixator are on the right side of the page.
    Last edit by Daytonite on Apr 26, '07
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    Thank you that was a very detailed explanation. I think this would make even more sense if I actually saw it with my own eyes. It's kind of hard to grasp external fixation being done with closed reduction because when the drills are placed in the bone, there is still an incision through the skin. But, I see that your explanation says that it can also be done with foam, tape, or felt. Thanks so much for your explanation. I didn't know medical coders had to know so much about procedures. That's great!!
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    yeah, isn't that amazing! the hospital coders have to get an aa degree in this subject. i'm learning so much as a coder that i didn't know as an rn!

    you might try http://www.or-live.com/ - or live--live broadcasts of surgeries if you have dsl connection. they might have an achieved surgery of some orthopedic procedures that you can watch so you can see some of this stuff being done. if you can do it in clinical, ask to shadow an orthopedic surgeon and let him know you specifically want to get an understanding of the difference between these procedures. i'll bet you'll be able to find a willing doc.
    CrystalClear75 likes this.
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    Thank you. You are so helpful. Do you like being a coder or RN better?
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    I like both. I miss clinical nursing terribly. I like working with the numbers and the coding. It's fun to kind of be on the doctor's backs about their documentation. Ha! Ha! Payback!!! And, they do listen because the hospitals get ticked off if the doctor's documentation is the cause of them losing money on their billing. Of course, they would lose money in their private practices as well if they weren't documenting properly either. Still, I miss the patient contact. An experienced coder makes almost as much, sometimes more than an RN, did you know that?


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