fig2 shows an instrument 10 according to certain aspects of the invention operable with an image - guided surgical navigation system . as described above , an image - guided surgical navigation system can be any of a variety of systems that capture anatomical characteristics and / or other references connected to the body and / or other surgical devices and / or other structures associated with a reference . such a system then tracks parts of the body and the surgical devices relative to one another . generally , reference to a system as “ image - guided ” means that the system produces images by which surgical navigation information is conveyed to the user . for example , a computer display showing virtual representations of an instrument and its relationship with a bone is considered one example of an image - guided system . as shown in fig2 , the position and orientation of instrument 10 are being recorded by placing finger 14 on a portion of a bone reference 15 . as shown , the bone reference 15 is connected to an upper proportion 16 of a femur . the instrument 10 may be used to align fractured segments of a bone such as the upper portion 16 of a femur and a lower portion 20 of the femur shown in fig3 . as illustrated in fig2 , instrument 10 includes an elongated body 11 and a reference 12 that is coupled to the elongated body 11 . fig4 shows elongated body 11 in one embodiment of the invention . as shown , the elongated body 11 is tubular or in similar terminology , cannulated . in other embodiments , the elongated body 11 may be solid . fig2 and 12 illustrate an elongated body 11 greater than half the greatest length of the fractured bone 25 . in other embodiments such as shown in fig1 , the elongated body 11 may be less than or equal to half the greatest length of the fractured femoral bone 26 . the condition of being less than or equal to half the greatest length is not limited to association with the femur , but can be with regard to any bone . the elongated body 11 may be curved as shown in fig1 or substantially straight as shown in fig1 and 16 . the elongated body 11 shown in fig2 and 4 has substantially the same curvature as an implant 21 ( for example , the implant shown in fig3 ). implant 21 may be used to fix bone segments such as upper portion 16 and lower portion 20 in place . the intramedullary reduction device may be bent to follow the shape of whatever implant is used for fixation : im nails , im rods , im hip screws , etc . this has the benefit of positioning the segments in the same position as the subsequent fixation device . however , less exact bends in the elongated body 11 may also be beneficial . the reference 12 enables the instrument 10 to be located by an image - guided surgical navigation system . as illustrated in fig2 , reference 12 is coupled to the elongated body 11 in a predefined physical relationship . fig4 – 11 show one embodiment of a structure for coupling the reference 12 to the elongated body 11 . as illustrated , a bracket 30 is rigidly affixed near a proximal end 17 of the elongated body 11 . as best seen in fig6 – 8 , a dovetail mount 31 is located at one end of the bracket 30 . the dovetail mount 31 is designed to be received by a reference 12 that has a mating dovetail opening ( not shown ). bracket 30 is shown as adapted to slide over proximal end 17 of elongated body 11 . although not shown , it is understood that the bracket may alternatively be a clamp that opens and closes to secure elongated body 11 or any other attachment device or structure suitable for attaching components to each other . those skilled in the art will understand that any member that can rigidly attach reference 12 to instrument 10 is considered a “ bracket ” within the scope of this invention . another embodiment of this invention provides a reference 12 having an integral attachment structure ( not shown ). attachment structure may be a bracket integrally formed with reference 12 or any other connection element that will achieve securement of reference 12 to instrument 10 . fig1 and 15 show articulating brackets 32 releasably movably coupled with elongated body 11 . with such a feature , the instrument 10 can be effectively used on either side of the patient by moving the articulating bracket 32 among two or more predetermined positions . in some embodiments , the instrument 10 is releasably movable between positions located at ninety degree intervals around the elongated body . in other words , viewing elongated body from one end , instrument 10 may be positioned at a first ninety degree position , a second ninety degree position , a third ninety degree position , or a fourth ninety degree position . it is advantageous in some embodiments of the invention to limit the number of positions to which the articulating bracket 32 , and thereby the reference 12 , may be positioned . this is because a predefined physical relationship must be maintained between the elongated body 11 and the reference 12 . by limiting the number of positions , the number of predefined relationships may be more easily defined and tracked . fig5 illustrates an embodiment of the bracket 30 a that is asymmetrically coupled to the elongated body 11 . consequently , if a reference 12 were coupled to the bracket 30 a , the reference 12 would also be asymmetrically fixed relative to the elongated body 11 . such an arrangement may be beneficial to more effective use on a particular side of a patient and is sometimes preferred . in other instances , a reference may be symmetrically coupled to the elongated body 11 . preferences are typically dictated by the ability of the image - guided surgical navigation system to effectively detect a reference in a particular application . in some embodiments , the system &# 39 ; s detector is a line - of - site device . the reference 12 may also include energy - reflecting surfaces 13 that are detectable by a sensor . fig2 shows four such energy - reflecting surfaces 13 mounted on the reference 12 . as illustrated , the energy - reflecting surfaces 13 reflect energy in at least the visible and infrared ranges . however , as discussed in the background section above , various types of energy detectors may be employed . energy - reflecting surface 13 is considered a passive device because it does not internally generate or convert energy to emit . fig1 illustrates an active energy emitting component 23 that is incorporated into an active reference 22 . note that the active reference 22 includes a wire 24 through which electricity is supplied to the active energy emitting components 23 . as shown , there are four active energy emitting components 23 . as with the passive device , the active energy emitting components 23 may be operable with various types of energy detectors . in some embodiments of the invention , the instrument 10 may include a handle 40 ( shown in fig1 , 13 , 21 ) connected at proximal end 17 . such a handle 40 would be useful in manipulating the instrument 10 during a surgical procedure . the handle 30 may or may not be removable from instrument 10 . if handle 40 is not removable , bracket 30 may be a clamp or other device or structure suitable for attaching components to each other . some embodiments of the invention also include a finger 14 , shown for example in fig4 . fig1 shows a variety of finger shapes that may also be advantageous in various embodiments of the invention , although different finger shapes may be preferred for various procedures . note that each of these shapes may be placed on the end of a solid or cannulated elongated body and may themselves be solid or cannulated . the invention may also be embodied in a system for enabling reduction of a fractured bone . the system is operable to virtually represent at least one fractured segment of the bone and virtually represent an instrument for aligning the at least one fractured segment . the system includes a first reference coupled to the at least one fractured segment , and a second reference coupled to the instrument . the first reference may be coupled to a bone segment through which the instrument is inserted . in this case , position and orientation of another segment of the bone would have to be determined as well , which could be accomplished in any technically effective way . alternatively , the first segment could be coupled to a segment of bone toward which the instrument was being directed . in any case , the system also includes a detector operable to collect position and orientation information regarding the at least one fractured segment and the instrument . as discussed in the background section above , the detector could be an infrared camera , visual camera , or any of a variety of sensors capable of detecting any kind of reference or characteristic . the system also includes a data processing device operable to store position and orientation information about one or more fractured segments and the instrument . the data processing device calculates virtual positions of the at least one fractured segment and the instrument based upon inputs from the detector . such calculations could involve matrix transformations , table look - up functionality , or any other operation effective in calculating the respective virtual positions . an indicator device for notifying a user of the relative positions of the at least on fractured segment and the instrument is also provided . such an indicator could be a visual cue on a computer screen such as color changes or alignment of articulating lines , sounds , flashes of light , or any device for showing a changeable condition , or some combination of any of these . another embodiment of the invention is a method of aligning segments of a fractured bone . as shown in fig3 , one method includes attaching a first reference , such as a distal reference 18 , to a first segment of a fractured bone , such as a lower portion 20 . the position and orientation of distal reference 18 may then be recorded relative to a first datum . as used herein , the term “ recording ” includes without limitation capturing or storing in computer memory or on a tangible medium such as film . any such acquisition of information associated with position or orientation , regardless of how transiently maintained in a system , medium , or component is within the definition of recording as used herein . in some embodiments of the invention , recording may include the use of an infrared camera that registers the positions of energy - reflecting surfaces 13 . alternatively , a reference may not be coupled with a segment of bone , but may be attached to a probe . such a probe may be recorded at a predetermined anatomical position and orientation . therefore , by knowing the position of the reference attached to the probe , and the probe &# 39 ; s position and orientation on the anatomy , the position of the anatomy can be calculated . in either case , a position and orientation of the first segment of the bone relative to a second datum is recorded . such a recording may be accomplished by capturing fluoroscopic images of the first segment . as discussed in the background section , the imaging may be through processes other than fluoroscopic imaging , such as ct , mri , or other effective technologies . the first datum may be the same as the second datum , or information relating the first datum and the second datum may be stored such that transforms relating their relative positions may be calculated . as a result , the first segment will be located relative to the first reference . the term “ datum ” as used herein is generally a coordinate system to which three - dimensional association can be made . as such , a number of datums can be defined and then associated to one another by use of three - dimensional transforms , matrix calculations , or the like . such calculations are well - suited to implementation on computing devices . similarly , objects being tracked can be positioned and oriented relative to a single datum . in any case , to effectively track objects &# 39 ; positions and orientations , association among the objects must be established and maintained . a strength of the current system is that sensor or camera positions and orientations and patient and instrument positions and orientations may change relative to one another , but through the tracking that embodiments of the invention provide , accurate location and bone segment alignment can be accomplished . as shown in fig2 , a second reference , such as bone reference 15 , may be attached to a second segment , such as upper portion 16 . as with the first segment and reference , the positions and orientations of the second reference and the second segment are recorded relative to respective third and fourth datums , and the second segment is located relative to the second reference . a third reference is attached to an instrument 10 , such as a reducer . as described above , the reducer is operable to align segments of a fractured bone through the medullary canal of the segments . the term “ reducer ” as used herein may refer more generally to any instrument used to assist with the alignment of bones . as with the first and second references , a position and orientation of the third reference relative to a fifth datum is recorded . in the case of a reducer or other instrument , locating the reducer relative to the third reference is simplified because there is a predetermined relationship between the reducer and the third reference . as discussed in association with the bracket 30 , a single or at least finite number of predetermined relationships between portions of the instrument and the associated reference may be defined . given a predetermined setting of the instrument relative to the reference , tracking of the reference is effective to track the instrument . recording of the third reference position and orientation may be accomplished inter - operatively or prior to the beginning of an operation . once all of the references , segments , and instrument ( or instruments ) have been located , they may all be continuously or intermittently tracked without the use of fluoroscopy for as long as desired . as used herein , “ continuously ” shall mean at a rate that appears substantially continuous to a user , but could include tracking accomplished at a standard electronic sampling rate such as a rate greater than one sample per second . typically , this tracking is accomplished by use of a computer system that is interfaced with an infrared camera or other device , the computer also calculating transforms regarding each datum and its relationship to each other datum . insertion of the instrument 10 may be accomplished prior to , during , or after the process of recording and locating described above . with each of the first segment , the second segment , and the reducer being tracked , the reducer can be aligned with a representation of the second segment . for instance , a surgeon could hold and manipulate a first segment of fractured bone with an inserted reducer while observing a representation of the second segment on a computer screen . the image on the computer screen may also include representations of other bone segments or instruments , such as the reducer . when an indication is received that alignment has been achieved , the surgeon inserts the reducer into the medullary canal of the second segment . the upper portion 16 of a femur shown in fig2 and the lower portion 20 of a femur shown in fig3 are merely examples of the first and second segments . as previously discussed , the fractured bone need not be a femur . additionally , the first and second segments may be either the lower or upper portions of bone , depending upon surgeon preference . in many orthopedic procedures , entry can be made from two or more possible approaches . in some embodiments of the invention , a representation of alignment may include only a representation that the first segment and the second segment , each of which is being tracked , are aligned . in other embodiments , the key to a representation of alignment may be the reducer that is being tracked . in some embodiments of the invention , only two of a first segment , a second segment , and an instrument may need to be recorded , located , and tracked . for example , if two segments are being tracked , alignment of those segments could be indicated to the user . given the fact that the user knows that the reducer is located in the medullary canal of one of the segments , the user would know that the reducer could be pushed into the medullary canal of the other segment . similarly , if only the reducer and the segment into which the reducer is to be inserted second are being tracked , the locations of only that second segment and the reducer could be represented to the user . in this embodiment , the reducer is located in the medullary canal of the other segment . therefore , by aligning the reducer with the segment into which the reducer is to be inserted second , the user has adequate information to accurately complete the procedure . in other embodiments and for some procedures , an at least partially flexible reducer 50 , as shown in fig2 , may be beneficial . for instance , a surgeon may desire to use a flexible reducer if the bone fracture to be aligned or reduced is so misaligned that a rigid reducer is not workable or would be particularly difficult to use . for example , two bone segments of a fracture may be so offset from one another that a rigid reducer would not appropriately engage the second segment . in these instances , the at least partially flexible reducer 50 of the present invention could be used . ( for the purposes of this document , “ at least partially flexible ” and “ flexible ” mean capable of being even slightly flexed or bent , turned , bowed , or twisted , without breaking ; or pliable ; or yielding to pressure , whether strong pressure or slight pressure .) the flexible reducer 50 is at least partially flexible to allow the surgeon to more easily manipulate the flexible reducer 50 in order to properly guide it into the second segment . it should be understood that there may be other instances in which a flexible reduced 50 may be preferred . flexible reducer 50 according to the particular embodiment shown in fig2 features an at least partially flexible elongated portion or shaft 52 . the at least partial flexibility may be provided by a shaft that is hollow , cannulated , or solid . the shaft may have a spiral or helical configuration , a laser cut shaft , a shaft of a material that becomes flexible when subjected to heat ( for example , nitinol ), a shaft of a thin material that permits flexibility , a shaft with a plurality of flexible elements joined by a connection , a shaft having a series of inter - engaged links , a shaft with a plurality of slots ( provided in any configuration ) cut at an angle relative to the shaft , a plastic tube ( or any other material that provides at least partial elasticity ), or any other design that provides a reducer of a flexible nature . examples of flexible shafts are provided in u . s . pat . no . 6 , 053 , 922 , which is incorporated herein by this reference . once flexible reducer 50 has been positioned with respect to both bone segments , the surgeon may wish to impart at least partial rigidity to the flexible reducer 50 in order to more properly align the bone segments . in this instance , flexible reducer 50 can be provided with a separate rigid member ( not shown ), a feature or features on the flexible reducer 50 itself that imparts rigidity to the flexible reducer ( also not shown ), or any structure or mechanism that imparts at least partial rigidity to reducer 50 . for example , the flexible reducer 50 may be provided with a rigid member with an outer diameter smaller than the inner diameter of the flexible reducer 50 , such that inserting the rigid member through the flexible reducer adds rigidity at the desired point in the procedure . alternatively , the flexible reducer 50 itself can be provided with a cable or wire disposed through the flexible reducer 50 such that when the cable or wire is pulled taut , the flexible shaft 52 is forced to undertake at least partial rigidity . flexible reducer 50 may alternatively be provided with a trigger , such that once the trigger is activated , the flexible portions become rigid . the flexible portions may be made rigid by a magnetic force , by a mechanical force , or any other mechanism that imparts at least partial rigidity to the flexible reducer 50 at a specified time during the surgery . it should be understood that any feature that provides an at least partially flexible reducer 50 with at least partial rigidity is considered a feature that imparts at least partial rigidity to the reducer within the scope of this invention . one challenge presented with the use of a flexible reducer 50 is the fact that , by its very nature , it is flexible , and thus , does not retain a rigid position from tip 54 to end 56 in relation to reference 12 . this presents a challenge to the use of the image - guided systems and methods described herein , because the flexible elongated portion 52 will not necessarily remain in a fixed position with respect to the reference 12 ( or any other reference point being used , such as a bone segment , another instrument , a surgical table , etc .) in order to provide the surgeon with accurate cues about its physical position . thus , there is also a need to provide a way to determine the position of the flexible elongated portion 52 when it is flexed in a particular direction . flexible reducer 50 is consequently provided with one or more location elements 75 . one or more location elements 75 assist the determination of at least portions of the physical relationship of the flexible elongated portion 52 with respect to reference 12 . a location element 75 may be provided at or near the tip 54 of flexible elongated portion 52 , at or near the middle of flexible elongated portion 52 , at multiple positions along the flexible elongated portion 52 , or any combination of these positions . the location elements may be spaced as close together or as far apart as necessary . the more location elements 75 provided , the more trackability is provided to flexible elongated portion 52 . location element 75 may be any component or device that permits the physical position of flexible elongated portion 52 to be sensed , detected , imaged , or mapped with respect to reference 12 . for example , location elements 75 may be sensed actively or passively by one or more of the following methods : infrared , visual , reflective , sound , ultrasound , radio waves , mechanical waves , magnetic , electromagnetic , electrical , x - ray , gps systems or chips , transponder , transducer , or any other desired technique . this list is not intended to be inclusive , and any way in which the location of flexible elongated portion 52 can be relayed to a component that can track , sense , image , or map flexible elongated portion 52 for the surgeon to view is considered within the scope of this invention . it should be understood , however , that the flexible elongated portion 52 will be positioned within patient tissue in use , so the location method chosen should be able to sense location element 75 through various tissues , such as bone , muscle , blood , and skin . location elements 75 are preferably configured to sense , track , image , and map the physical position of reducer 50 in any plane , location , and / or orientation . in other words , in addition to sensing and tracking the medial - to - lateral movement of flexible reducer 50 , location elements 75 are also preferably adapted to sense and track anterior - to - posterior movement . location elements may be provided in any configuration or any shape . it is possible for location elements 75 to sense 2 - dimensional movement for a rough view of the reducer &# 39 ; s location and orientation . in other aspects of the invention , the location elements 75 sense 3 - dimensional movement and provide a finer ability to sense and track the location and orientation of reducer 50 . location elements 75 may be provided in any shape or configuration , such as the square - like elements 75 shown in fig2 , oval or round - like elements , cross - shaped elements , band - shaped elements , indented elements , bead - shaped elements , and so forth . location elements may be located along only one side of flexible elongated portion 52 , wrapped around elongated portion 52 , positioned in specific increments from one another , or scattered in various , unequal positions about elongated portion 52 . as previously mentioned , embodiments according to various aspects of this invention may include only a single location element 75 . a single location element 75 may be used to track and sense the location and orientation of elongated portion 52 with respect to reference 12 . to the extent that any other reference point is being used , such as another instrument , a bone segment , or another reference point , it is preferred that two or more location elements 75 be provided . location elements 75 may operate in conjunction with systems which are preferably connected to other systems according to various aspects of the invention which sense and track references 12 , body portions , instruments , components of other devices , and so forth . embodiments of the invention are directed toward enabling reduction of a fractured bone by virtually representing at least one fractured segment of the bone and virtually representing an instrument for aligning two or more segments of bone . as described above , positions and orientations of a segment of bone and an instrument may be recorded and tracked in three - dimensional space with the use of cameras or sensors , imaging devices , and a digital computer . then , through the use of a sound , visualization , or other stimulation , an indication that alignment has been achieved is provided to a user . alternatively or in addition , indications regarding the progress of alignment may be provided to the user . “ tracking ” as defined for use in this embodiment can include both detecting distinguishing characteristics , such as references or instrument configurations , and processing information regarding changes in position and orientation . therefore , embodiments of the invention provide for the location and tracking of bone segments and instruments such that the instruments may be aligned to assist with fixation or therapy . this is accomplished with reduced numbers of x - ray , fluoroscopic , and other such energy - intense imaging devices . there is no requirement for pre - operative imaging or any surgical procedures prior to the primary procedure . with various embodiments of the invention , continuous or nearly continuous monitoring of bone segment and instrument positions is accomplished . therefore , rapid alignment of bone segments and instruments is facilitated using images of at least one of the bone segments in combination with images of one or more implements , instruments , trials , guide wires , nails , reducers , other surgically related items , or other bone segments which are properly positioned and oriented in the images .
embodiments of the present invention include products and methods for reducing fractures with the aid of image guidance . in one embodiment , products and methods are directed to reduction for the placement of an intramedullary nail .