A "reduction" is the term that doctors use to describe the process of making your arm straight again. The goal of a reduction is to restore the arm or leg back to the optimal alignment for healing and future function. This usually requires pushing on the arm or leg with some force.

How will my doctor keep this from hurting?

The process of realigning the bone begins with sedation. There are a number of different methods to make this process comfortable for the child. These include local anesthetics, intravenous sedation, and general anesthesia.

Local anesthetics

This is called a hematoma block. The doctor injects local anesthetic directly into the site of the fracture, which helps numb the ends of the bone during the manipulation. Regional anesthesia. This is a process where the doctor will make the entire arm or leg numb during the correction process. This is done by placing an intravenous (IV) catheter in to the injured extremity and applying a tourniquet above the site of the fracture. Then, the tourniquet is inflated and local anesthetic is injected into the vein. The local anesthetic will spread throughout the arm and make it go completely numb, allowing the doctor to manipulate the fracture without pain. Don't be alarmed when the arm turns a bunch of different colors while the tourniquet is up; this is normal. Once the fracture is properly aligned, the doctor will slowly deflate the tourniquet and feeling will return.

Intravenous Sedation

Intravenous sedation simply means that your doctor gives medication that provides enough sedation and pain relief that you will let them push on the fracture (and probably not remember it….) Doctors will use a variety of different medications to accomplish this. These include narcotics for pain control, medications that make you relax and not remember the procedure (Midazolam is a common one), or medications that serve as a light, short-acting general anesthetic.

"Brutane", or "OK" anesthesia.

This is where the doctor simply yanks on the arm, and says something like, "OK, this might hurt a bit…." This is not recommended for children.

When is surgery needed?

Fractures in children will need surgery in two situations: One is when the fractured bone sticks out through the skin, which gives your child a risk of developing infection in the bone. These are often more severe injuries. The surgical treatment of these open fractures usually needs to be done right away. The second situation is when your doctor feels that reasonable alignment of the bone cannot be maintained in the cast. There are a variety of different techniques for fixing fractures in children, ranging from the use of plates and screws to placement of metal pins down the center of the bone to hold proper alignment.

How does my doctor decide that the alignment "good enough"?

Many parents will notice that after their child has their broken arm manipulated and put in a splint or cast that the bones do not look perfectly lined up. A common comment from parents is, " I'm not a doctor, but those bones don't look quite right to me". So, how can you tell when it will be OK? There are several good 'rules of thumb' for parents to note. First, the younger the child, the greater the potential for remodeling of the fracture with growth. Second, although angulation of the fractures bones can remodel, it is best if the overall longitudinal alignment is fairly straight, or the arm will look crooked for some time. Third, when the ends of the bone are overriding one another, they can still heal and remodel, ultimately making a single bone again.

What is a compartment syndrome?

A compartment syndrome occurs when the swelling in the arm or leg becomes so severe that the soft tissues of the limb begin to lose their blood supply. A thick, unyielding tissue termed "fascia" surrounds the bone and muscle of the forearm. When swelling occurs within the fascial sheath of the arm, it can become severe enough to disrupt the blood supply to the muscles and nerves of the arm. If this lasts more than 6 hours, the damage can be irreversible.

There are five common signs of a compartment syndrome following a fracture:

• Pain: This is always the first sign. A splinted fracture in a child should be reasonable comfortable. You should be able to get the pain under control with simple measures such as loosening the wrapping of the splint, elevation, ice, and some pain medicine that your doctor prescribed. If the pain cannot be controlled in this manner, you should seek immediate attention in the emergency room.
• Pallor: This simply means that the fingers appear pale. Typically, if you push on your fingers, they will blanch and then turn pink again. If the fingers won't blanch and appear dusky, try loosening the splint.
• Paresthesias: This refers to tingling in the fingers, like they are going to sleep.
• Pulselessness: If the splint will allow you to feel up where you would normally feel your pulse, check for it. If all of the other symptoms are there and you can't feel the pulse, seek evaluation immediately
• Paralysis: This is a late sign of compartment syndrome. If the swelling has lasted long enough to damage the nerves to the arm, then paralysis of the affected limb is the result.

How would I know if my child has a compartment syndrome?

The most common sign of a compartment syndrome is pain that cannot be controlled with elevation of the limb, pain medicine, or loosening of the bandages. Most splinted fractures in children are reasonably comfortable with simple measures. If not sure, return to the emergency room and have a doctor check the arm for you. Compartment syndrome is a surgical emergency. The diagnosis is suspected based on the examination of the child's arm, and confirmed by actually measuring the pressure in the arm compartments. Most emergency rooms have the capability to do these measurements quickly. If a compartment syndrome is found, then immediate surgical release of the tight compartments must be done immediately to prevent further permanent damage to the arm.