Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Job Classification

In most duration tables, five job classifications are displayed. These job classifications are based on the amount of physical effort required to perform the work. The classifications correspond to the Strength Factor classifications described in the United States Department of Labor's Dictionary of Occupational Titles. The following definitions are quoted directly from that publication.

Sedentary Work Exerting up to 10 pounds (4.5 kg) of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and other sedentary criteria are met.

Light Work Exerting up to 20 pounds (9.1 kg) of force occasionally and/or up to 10 pounds (4.5 kg) of force frequently, and/or negligible amount of force constantly to move objects. Physical demand requirements are in excess of those for Sedentary Work. Light Work usually requires walking or standing to a significant degree. However, if the use of the arm and/or leg controls requires exertion of forces greater than that for Sedentary Work and the worker sits most the time, the job is rated Light Work.

Medium Work Exerting up to 50 (22.7 kg) pounds of force occasionally, and/or up to 25 pounds (11.3 kg) of force frequently, and/or up to 10 pounds (4.5 kg) of forces constantly to move objects.

Heavy Work Exerting up to 100 pounds (45.4 kg) of force occasionally, and/or up to 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Very Heavy Work Exerting in excess of 100 pounds (45.4 kg) of force occasionally, and/or in excess of 50 pounds (22.7 kg) of force frequently, and/or in excess of 20 pounds (9.1 kg) of force constantly to move objects.

Reduction of Fracture or Dislocation


Related Terms

  • Closed Reduction
  • Closed Reduction and Internal Fixation
  • CRIF
  • Manipulative Reduction
  • Open Reduction and Internal Fixation
  • ORIF

Specialists

  • Hand Surgeon
  • Occupational Therapist
  • Orthopedic (Orthopaedic) Surgeon
  • Physiatrist (Physical Medicine and Rehabilitation Specialist)
  • Physical Therapist

Comorbid Conditions

  • Diabetes
  • Inflammatory conditions
  • Injury to muscles, nerves, and/or arteries
  • Neurologic conditions
  • Obesity
  • Osteoarthritis
  • Osteoporosis
  • Renal disease

Factors Influencing Duration

Type of injury, type of reduction, need for surgery, work requirements, extremity involved, and injury to a dominant hand or arm will affect duration of disability. Fractures heal less quickly and are more likely to change position (slip) as individuals age, requiring more extensive care. Some fractures heal more slowly and have a higher rate of non-union in smokers. Some dislocations, especially of shoulders and kneecaps (patellae), are more prone to repeat injury in younger individuals. Response to procedure, individual healing time based on health status (e.g., nutritional status, presence of chronic conditions such as diabetes or arthritis), and degree of compliance with after-care requirements can influence duration.

Medical Codes

ICD-9-CM:
03.53 - Repair of Vertebral Fracture; Elevation of Spinal Bone Fragments; Reduction of Fracture of Vertebrae; Removal of Bony Spicules from Spinal Canal
79.00 - Closed Reduction of Fracture without Internal Fixation, Unspecified Site
79.02 - Closed Reduction of Fracture without Internal Fixation, Radius and Ulna, Arm NOS
79.03 - Closed Reduction of Fracture without Internal Fixation, Carpals and Metacarpals, Hand NOS
79.04 - Closed Reduction of Fracture without Internal Fixation, Phalanges of Hand
79.05 - Closed Reduction of Fracture without Internal Fixation, Femur
79.06 - Closed Reduction of Fracture without Internal Fixation, Tibia and Fibula, Leg NOS
79.07 - Closed Reduction of Fracture without Internal Fixation, Tarsals and Metatarsals, Foot NOS
79.08 - Closed Reduction of Fracture without Internal Fixation, Phalanges of Foot
79.09 - Closed Reduction of Fracture without Internal Fixation, Other Specified Bone
79.10 - Closed Reduction of Fracture with Internal Fixation, Unspecified Site
79.11 - Closed Reduction of Fracture with Internal Fixation, Humerus
79.12 - Closed Reduction of Fracture with Internal Fixation, Radius and Ulna, Arm NOS
79.13 - Closed Reduction of Fracture with Internal Fixation, Carpals and Metacarpals, Hand NOS
79.14 - Closed Reduction of Fracture with Internal Fixation, Phalanges of Hand
79.15 - Closed Reduction of Fracture with Internal Fixation, Femur
79.16 - Closed Reduction of Fracture with Internal Fixation, Tibia and Fibula, Leg NOS
79.17 - Closed Reduction of Fracture with Internal Fixation, Tarsals and Metatarsals, Foot NOS
79.18 - Closed Reduction of Fracture with Internal Fixation, Phalanges of Foot
79.19 - Closed Reduction of Fracture with Internal Fixation, Other Specified Bone
79.20 - Open Reduction of Fracture without Internal Fixation, Unspecified Site
79.21 - Open Reduction of Fracture without Internal Fixation, Humerus
79.22 - Open Reduction of Fracture without Internal Fixation, Radius and Ulna, Arm NOS
79.23 - Open Reduction of Fracture without Internal Fixation, Carpals and Metacarpals, Hand NOS
79.24 - Open Reduction of Fracture without Internal Fixation, Phalanges of Hand
79.25 - Open Reduction of Fracture without Internal Fixation, Femur
79.26 - Open Reduction of Fracture without Internal Fixation, Tibia and Fibula, Leg NOS
79.27 - Open Reduction of Fracture without Internal Fixation, Tarsals and Metatarsals, Foot NOS
79.28 - Open Reduction of Fracture without Internal Fixation, Phalanges of Foot
79.29 - Open Reduction of Fracture without Internal Fixation, Other Specified Bone
79.30 - Open Reduction of Fracture with Internal Fixation, Unspecified Site
79.31 - Open Reduction of Fracture with Internal Fixation, Humerus
79.32 - Open Reduction of Fracture with Internal Fixation, Radius and Ulna, Arm NOS
79.33 - Open Reduction of Fracture with Internal Fixation, Carpals and Metacarpals, Hand NOS
79.34 - Open Reduction of Fracture with Internal Fixation, Phalanges of Hand
79.35 - Open Reduction of Fracture with Internal Fixation, Femur
79.36 - Open Reduction of Fracture with Internal Fixation, Tibia and Fibula, Leg NOS
79.37 - Open Reduction of Fracture with Internal Fixation, Tarsals and Metatarsals, Foot NOS
79.38 - Open Reduction of Fracture with Internal Fixation, Phalanges of Foot
79.39 - Open Reduction of Fracture with Internal Fixation, Other Specified Bone
79.40 - Closed Reduction of Separated Epiphysis, Unspecified Site
79.41 - Closed Reduction of Separated Epiphysis, Humerus
79.42 - Closed Reduction of Separated Epiphysis, Radius and Ulna, Arm NOS
79.45 - Closed Reduction of Separated Epiphysis, Femur
79.46 - Closed Reduction of Separated Epiphysis, Tibia and Fibula, Leg NOS
79.49 - Closed Reduction of Separated Epiphysis, Other Specified Bone
79.50 - Open Reduction of Separated Epiphysis, Unspecified Site
79.51 - Open Reduction of Separated Epiphysis, Humerus
79.52 - Open Reduction of Separated Epiphysis, Radius and Ulna, Arm NOS
79.55 - Open Reduction of Separated Epiphysis, Femur
79.56 - Open Reduction of Separated Epiphysis, Tibia and Fibula, Leg NOS
79.59 - Open Reduction of Separated Epiphysis, Other Specified Bone
79.70 - Closed Reduction of Dislocation of Unspecified Site
79.71 - Closed Reduction of Dislocation of Shoulder
79.72 - Closed Reduction of Dislocation of Elbow
79.73 - Closed Reduction of Dislocation of Wrist
79.74 - Closed Reduction of Dislocation of Hand and Finger
79.75 - Closed Reduction of Dislocation of Hip
79.76 - Closed Reduction of Dislocation of Knee
79.77 - Closed Reduction of Dislocation of Ankle
79.78 - Closed Reduction of Dislocation of Foot and Toe
79.79 - Closed Reduction of Dislocation of Other Specified Sites
79.80 - Open Reduction of Dislocation of Unspecified Site
79.81 - Open Reduction of Dislocation of Shoulder
79.82 - Open Reduction of Dislocation of Elbow
79.83 - Open Reduction of Dislocation of Wrist
79.84 - Open Reduction of Dislocation of Hand and Finger
79.85 - Open Reduction of Dislocation of Hip
79.86 - Open Reduction of Dislocation of Knee
79.87 - Open Reduction of Dislocation of Ankle
79.88 - Open Reduction of Dislocation of Foot and Toe
79.89 - Open Reduction of Dislocation of Other Specified Sites

Overview

Reduction is the repositioning a bone or bones to their normal or near normal position after a fracture or dislocation. The goals of a reduction are to restore position, which includes alignment, rotation, and length, of the bone or joint after injury. The purpose is to prevent or reduce later deformity, to encourage healing and normal use of the bone and/or joint and limb, and reduce pain. In the case of a fracture, it is also important for the bone ends to meet correctly (apposition). If a fracture is described as "nondisplaced" or in "anatomic position," no reduction maneuver is required to improve position, since the fracture is already in an appropriate position.

When a bone breaks, a blood clot (hematoma) forms at the ends of the bone fragments. The tough outer sheath of the bone (periosteum) can be intact on one side of the fracture, forming a hinge between the fragments, unless the bone is displaced completely (displaced fracture) or has broken through the skin (open fracture or compound fracture). The muscles that are attached to the bone contract or shorten during the early period after a fracture causing the bones to overlap and rotate. Muscle contraction usually continues to hold the fragments out of position.

A closed reduction is accomplished by applying traction at or across the fracture to relax and lengthen the muscles then manipulating the bone fragments back into position and holding this newly achieved position with a cast or splint. No skin incision is made or required in the closed reduction procedure. Although many fractures are reduced using conscious sedation and local or regional anesthesia in an emergency department or physician office, some individuals must be given general anesthesia in the operating room in order to provide pain control and muscle relaxation.

A closed reduction with internal fixation (CRIF) is accomplished by applying traction at or across the fracture to relax and lengthen the muscles then manipulating the bone fragments back into position and holding this newly achieved position with a percutaneous wire (K-wire), percutaneous screw, or external fixator. The hardware (metal) is used to stabilize an unstable fracture that cannot be held with a cast or splint.

An open reduction involves the same concepts but is done as a surgical procedure for fractures that cannot be reduced or held in reduced position by closed reduction. Usually internal fixation of the fracture is performed during the same operation as the open reduction (open reduction and internal fixation [ORIF]). Open reductions are also necessary to treat an open fracture or compound fracture, as open wounds must be cleaned, dead tissue and foreign material removed (débridement), and then repaired. Sometimes fractures that are initially reduced in a closed procedure need to be reduced again in an open procedure and then stabilized with hardware (ORIF) because a cast or splint cannot maintain the desired position.

If the bones in a joint are intact but out of position (dislocated), a closed reduction is usually attempted first. When traction is applied to overcome muscle spasm and regain muscle length, the bone will often slip back into place (closed reduction). Sometimes pressure must also be applied to guide the bones into correct position (manipulative reduction). Muscle spasm is often difficult to overcome without muscle relaxants, pain control (analgesia), and/or sedation, including sedation in an emergency room or the use of general anesthesia in the operating room. Some dislocated joints commonly require open reduction (e.g., finger metacarpophalangeal [MCP] joints, hip joints with fracture fragments in the joint). The longer a joint is dislocated, the more difficult it is to reduce due to muscle spasm. Fractures and dislocations often occur at the same time (fracture-dislocation), and both problems must be addressed.

Spontaneous reductions can occur with a subluxation (sometimes inappropriately described as a partial dislocation) of a joint in which contact between joint surfaces remains, but are not aligned correctly. An example of a spontaneous reduction is when the individual is able to relax the area and allow the bones to slip back into position. This usually occurs in an individual who has experienced multiple dislocations of a joint and the joint ligaments remain abnormally stretched or torn.

After returning the joint to anatomical alignment, joint reductions can be stable or unstable. With stable reductions, the joint does not re-dislocate when performing joint range of motion. This type of injury is often maintained with brief immobilization and gradual return to activities. Both rest and immobilization can be obtained with devices ranging from slings, casts, and traction, to external or internal fixation. With unstable reductions, the joint continues to pop out or re-dislocate after the reduction. This type of injury may require surgery or special splints to maintain reduction and allow for healing.

Fractures almost always require some type of support, splinting, or surgery to maintain alignment and allow for healing.

The need for a fracture reduction or reduction of a dislocation is not gender or age specific, but rather is dependent on the severity and location of the injury. Care must be taken not to overlook the need for correct restoration of bone and joint position (reduction) to ensure complete return of function. Seemingly minor injuries to toes and fingers for example can be disabling if not managed correctly.

Source: Medical Disability Advisor



Reason for Procedure

Reductions are performed to restore anatomical position of bones and soft tissues after a fracture or dislocation. This promotes normal function after the fractured bone or dislocated joint and/or the supporting tissue heals. Attention is given to the nerves and blood vessels in the injured area as these can be damaged during the injury or during reduction. Treatment of the fracture or dislocation may involve treatment of damaged nerves and blood vessels as well.

Source: Medical Disability Advisor



How Procedure is Performed

In a closed fracture reduction, after examination of the skin, nerve function, and circulation, an x-ray is taken to determine the current position of the fracture fragments. Often an x-ray of the opposite or uninjured side is also taken and used as a guide during the reduction.

Conscious sedation and local or regional anesthesia may be used to control pain and to promote muscle relaxation. The physician applies pressure above and below the fracture, often with assistance by a person or device to maintain traction on the muscles around the fracture. First, the fragments are bent in the direction of the fracture (slightly exaggerating the deformity) and then lifted into correct position. Position is first maintained manually while nerve and tendon function and circulation are checked. A cast or splint is then used to hold the bone fragments in the correct position. A final x-ray confirms the position of the fragments. If alignment is not correct, the procedure may be repeated or the individual scheduled for an open reduction with possible fixation of the fragments. Repeat x-rays and changes of the cast are done over the next several weeks because the reduction may move out of position (slip) or the bone may begin to heal incorrectly. Initially a splint or half cast may be used to avoid problems with swelling. A full cast is applied after the swelling has decreased, often after 7 to 10 days. Closed reductions are most often done in the emergency room, physician's office, or outpatient surgical setting.

An open reduction or ORIF is done when a closed reduction is not possible or when the fracture is complicated by a wound. This is an inpatient or outpatient surgical procedure performed in the operating room. An incision is made over the fracture, wounds are cleaned, and the fracture position is corrected with pressure. Sometimes the reduced position is maintained with orthopedic hardware such as screws, plates, and rods, placed through or around the fracture fragments (internal fixation). An external fixator device may be used to maintain position. The fixator is composed of pins or rods through the skin and bone, and the free ends of the rods are then attached to a long bar on the outside of the skin. This device can allow for early motion of the joints above and/or below the fracture. It is always eventually removed, often in the physician's office, while internal hardware may be left in place. If internal hardware is to be removed, another surgical procedure is required.

In reducing dislocations, x-rays are done first to confirm the position of the bones and to rule out a fracture combined with the dislocation. If there is only a dislocation, medication is given to control pain and relax the muscles around the dislocation. Gentle stretch or traction is then applied to the muscles, and the bones either slip into position or are eased into place with pressure from the physician's hands. These techniques can be done in the emergency room or doctor's office. Sometimes, it is necessary to take the individual to the operating room for general anesthesia to obtain enough muscle relaxation to manipulate the bones into the correct position. Slings or braces are used to rest the joint after reduction. If the reduction is not maintained, surgery (open reduction) may be required to tighten or strengthen surrounding tissue. External fixation rarely is used to maintain the corrected position and instead an ORIF procedure, which is more commonly used for fracture fixation, may be employed.

Source: Medical Disability Advisor



Prognosis

The outcome of a closed or open reduction depends on the type of injury and the treatment needed to maintain the reduction and achieve the healing of bone and supporting tissues (joint capsule, tendons, ligaments, muscles, nerves, and blood vessels). Generally, fractures and dislocations can be re-positioned (reduced) but this may not always be a simple, straightforward procedure. Once the reduction is complete, the healing phase may involve treatment over several months. Any complication regarding nerves or blood vessels will delay healing and may contribute to a poor outcome.

For fractures that involve joints (intra-articular fractures), the more multiple fracture fragments (comminuted fracture) affecting the joint surface and the greater joint surface deformity present after the fracture has healed, the worse the prognosis for the development of late post-traumatic arthritis of the joint. Fractures that do not involve joints but that heal with significant deformity change biomechanics of the limb and may lead to post-traumatic arthritis of adjacent joints.

Some bones such as those in the wrist (scaphoid and lunate) and hip (femoral head) have a poor blood supply to begin with and historically do not heal well. Individuals with loose tissue (laxity) have a higher incidence of recurrent dislocation, as do those with anatomical variations such as tilted kneecaps (patellar misalignment). Joints that remain dislocated for a long time have a less successful outcome.

Source: Medical Disability Advisor



Rehabilitation

Rehabilitation after reduction of a fracture or dislocation begins after some healing has occurred. The primary focus of therapy is to restore function, regain strength, and relieve pain. The time and techniques involved are dependent upon the location and type of injury, treatment used, and stability of the fracture/dislocation.

Once the dislocation or fracture has been reduced, the therapist may utilize modalities, such as heat or cold, to decrease pain and edema (Canale).

Exercises are initiated according to the recommendations of the treating physician and based on tissue healing. Therapy should begin with gentle range of motion and progress to strengthening exercises as tolerated. Intensity and duration of exercises should be advanced as indicated. A home exercise program should be taught to the individual to complement supervised rehabilitation.

All rehabilitation should be directed toward returning the individual to pre-injury status.

Additional information may provide insight into the rehabilitation needs of these individuals (Chapman).

FREQUENCY OF REHABILITATION VISITS
Nonsurgical
SpecialistReduction of Fracture or Dislocation
Physical or Occupational TherapistUp to 8 visits within 12 weeks
Surgical
SpecialistReduction of Fracture or Dislocation
Physical or Occupational TherapistUp to 12 visits within 16 weeks
Note: The number of physician and rehabilitation visits, as well as the time to initiate rehabilitation for both nonsurgical and surgical cases, is highly variable based on stability and the degree of bone and soft tissue involvement.
The table above represents a range of the usual acceptable number of visits for uncomplicated cases. It provides a framework based on the duration of tissue healing time and standard clinical practice.

Source: Medical Disability Advisor



Complications

Complications associated with reductions of fractures and dislocations include failure to obtain reduction, nerve or blood vessel damage, puncture of the skin, infection of the fracture wound or surgical wound, infection in the bone or bone marrow (osteomyelitis), and reflex sympathetic dystrophy (complex regional pain syndrome). Blood clots formed at the site of injury can dislodge and migrate to the lung (embolism). An open fracture is at greater risk of development of complications than a fracture that does not break the skin or a dislocation. Any complication involving nerves or blood vessels will delay healing and may contribute to a poor outcome. Knee dislocations with vascular complications may result in leg amputation. Advanced age and pre-existing chronic conditions (e.g., diabetes, osteoarthritis, or osteoporosis) can complicate and/or delay healing. Reactions to anesthesia may occur in some individuals. Repeat surgery sometimes is needed if healing does not occur properly. Fractures that have not healed in the expected time period for the fracture in question are called "delayed union." Fractures that have not healed, and that are no longer biologically active in the healing process are called "non union." Fractures that have healed with union in a faulty position or incomplete union are called "malunion."

Source: Medical Disability Advisor



Ability to Work (Return to Work Considerations)

Work restrictions are variable. Restrictions may not be necessary or a reduction could require that work involving the injured part be temporarily eliminated from the individual's responsibilities. In some situations, surgery to stabilize a joint that could sustain repeated dislocation may be avoided or delayed by permanently stopping the at-risk activities.

Individuals with sedentary work requirements could possibly return to work more quickly if they can prevent swelling in the injured area. Those with lower extremity injuries may have difficulty both with sitting too long and moving or standing too much. Assistive devices for ambulation may restrict some workers from being able to perform their usual activities.

For metacarpal and hand/finger fractures, duration depends on whether dominant or non-dominant extremity is involved. In knee dislocation, residual instability and/or complications frequently preclude heavy or very heavy work.

For more information refer to "Work Ability and Return to Work," pages 241–245.

Risk: Risk is dependent on the cause of the fracture or dislocation.

Capacity: Capacity is determined by the location and fracture or dislocation and the degree of involvement or damage and associated structures.

Tolerance: Tolerance is affected by pain which is impacted by the capacity, which is determined by the location and fracture or dislocation and the degree of involvement.

Accommodations: Employers able to accommodate physical demands are more likely to have employees return to work sooner.

Source: Medical Disability Advisor



Maximum Medical Improvement

This is a broad category making MMI difficult to provide. Please see specific fracture or dislocation for details.

Source: Medical Disability Advisor



References

Cited

Chapman, Michael W. Chapman's Orthopaedic Surgery. 3rd ed. Philadelphia: Lippincott, Williams & Wilkins, 2001.

Talmage, J. B. , J. M. Melhorn, and M. H. Hyman, eds. Work Ability and Return to Work, AMA Guides to the Evaluation of. Second ed. Chicago: AMA Press, 2011.

General

Canale, S. Terry, and James H. Beaty, eds. "Fractures and Dislocation, Part XV." Campbell's Operative Orthopaedics. 11th ed. Philadelphia: Mosby Elsevier, 2008.

Source: Medical Disability Advisor






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