Pearls & Pitfalls Orthobullets Technique Guides cover information that is "not testable" on ABOS Part I Preparation compare operative forearm to contralateral side xray in terms of radial bow and ulnar variance radiolucent hand table with bed turned 90° c-arm perpendicular to bed Positioning supine with shoulder at edge of bed centered on hand table Approach volar approach to radius (Henry) and subcutaneous approach to ulna for radius: plane proximally between brachioradialis (BR) and pronator teres distally between BR and FCR for ulna: plane between ECU and FCU Reduction expose both radius and ulna fractures, reduce using lobster claws and traction Fixation 3.5mm DCP plates (min 3 screws on each side of fracture, 8-hole plates) over radius and ulna Closure coagulate bleeders for hemostasis, carefully examine forearm compartments Postoperative soft dressing, 2 wks sugartong splint for immobilization, and sling for comfort. rehabilitation 2 wks non-weight bearing in splint, 2 wks non-weight bearing in Munster or short-arm cast, 4 wks in removable wrist splint with range of motion exercises Planning & Preparation Template Fracture identify fracture pattern, location, displacement, comminution, angulation, and rotation based on pre-reduction and post-reduction xrays evaluate DRUJ and elbow for associated injuries (Galezzi, Monteggia fractures) check compartment pressure (pain with passive finger stretch) if concern for compartment syndrome document radial and ulnar pulses along with median, radial, and ulnar nerve function compare operative forearm to contralateral forearm xray in terms of radial bow and ulnar variance Plan Approach plan out volar approach to radius (Henry), proximally between BR and pronator teres, distally between BR and FCR subcutaneous approach to ulna between ECU and FCU Table and Imaging setup OR with standard operating table and radiolucent hand table centered at level of patient’s shoulder turn table 90° so that operative extremity points away from Anesthesia machines c-arm perpendicular to OR, monitor in surgeon direct line of site check surgical seat heights and placement to ensure proper surgeon positioning Equipment & Positioning Potential Hardware Systems Synthes Small Fragment 3.5mm DCP Plates and Screws (2.5mm drill, 3.5mm screws and plates) Synthes Mini-Fragment 2.0mm Plates and Screws (1.5mm drill, 2.0mm screws and plates) Patient Position supine with shoulder at edge of bed centered at level of patient’s shoulder, hand centered on hand table, supinate arm arm tourniquet placed high on upper arm with webril underneath can use small stack of towels or bone foam under operative extremity during sterile prep Radius Shaft ORIF Approach plan out volar approach to radius (Henry), proximally between BR and pronator teres, distally between BR and FCR mark out radial styloid distally and biceps tendon and elbow flexion crease proximally draw straight line between landmarks using bovie cord and marking pen, mark out fracture site palpate and mark out subcutaneous border of ulna, mark out fracture site dry lap over marked incisions, then exsanguinate limb and inflate tourniquet Soft Tissue Dissection 15 blade through skin along, tenotomy for subcutaneous dissection incise deep fascia in line with skin incision develop plane proximally between BR and pronator teres, and distally between BR and FCR identify superficial radial nerve underneath BR carefully cauterize branches radial artery for hemostasis retract BR radially, retract FCR ulnarly, watch out for radial artery (retract in whichever direction it moves easiest) depending on level of fracture and dissection, retract supinator/pronator/quadratus ulnarly with deep Gelpi sharply take off of bone, supinate hand to get PIN out of the way Fracture Preparation and Reduction identify fracture site and clean out hematoma and interposed tissue sharply clean edges, use curettes, small rongeurs, irrigation to clean fracture site use wood handled elevator to free up surrounding periosteum and callus critical to adequately clear off proximal and distal periosteum in order to get reduction and plate on correctly place lobster clamps on both ends of bone fragments to twist and manipulate to free up edges once radius fracture adequately freed, move to ulna fracture to expose and mobilize fracture site, often difficult to reduce radius if ulna is malreduced Plate and Screw Fixation after fracture reduced for both radius and ulna, check on AP/Lat fluoro can place minifrag lag screw perpendicular to fracture site to hold if no comminution can get provisional stability by placing 5-hole 2.0mm plate from minifrag set drill 1.5mm unicortical, use 6-8mm screws place 1st screw to get plate to bone, 2nd screw in compression mode to bring fracture site together place 2 screws proximal and distal to fracture site once satisfied with initial reduction and minifrag plate, place 8-hole 3.5mm DCP plate over fracture site to check fit want 2 holes over fracture site, 3 bicortical screws proximal and distal to fracture contour radius plate for anatomic coronal and sagital bow of radius using plate bender on back table, recheck fit on fluoro using neutralization mode, place 2 bicortcal screws proximal and distal in 8-hole plate 2.5mm drill bicortical perpendicular to plate using soft tissue guide (typically 16mm long) don't insert all screws into plate, move back to ulna to check reduction and alignment Ulna Shaft ORIF Approach plan out subcutaneous approach to ulna, plane between ECU and FCU assistant holds elbow flexed to bring ulna into semivertical position for incision Soft Tissue Dissection 15 blade through skin along subcutaneous border of ulna, tenotomy for subcutaneous dissection incise deep fascia in line with skin incision knife down to bone between ECU and FCU, at middle 1/3 of ulnar must divide fibers of ECU subperiosteal dissection at fracture edges, extraperiosteal proximal and distal Fracture Preparation and Reduction identify ulna fracture site and clean out hematoma and interposed tissue as above sharply clean edges, use curettes, small rongeurs, irrigation to clean fracture site place lobster clamps on both ends of bone fragments to manipulate into position and reduce pull traction on hand and rotate as needed to bring fracture fragments together place lobster clamp or pointed reduction clamp over fracture site once reduced once both radius and ulna fragments are freely mobile, move back to radius and attempt reduction and fixation Plate and Screw Fixation after radius fracture provisionally fixed with 3.5mm plate, repeat reduction steps as above for ulna place 8-hole 3.5mm plate, place dorsal or volar on ulna but not along subcutaneous border due to potential hardware irritation fill 2 holes with bicortical screws proximal and distal for ulna plate (typically don't need to bend) check on fluoro AP/Lat for radial bow, alignment, and ulnar variance complete and fill remaining radius and ulna bicortical screw holes insert auto/allograft bone graft into fracture sites as needed insert remaining screws into radius plate and remove minifrag 2.0mm plate from radius if used Confirm Hardware Position final tighten radius and ulna plate screws check forearm pronation/supination clinically check forearm compartments (volar, dorsal, mobile wad) for impending compartment syndrome take final fluoro AP/Lat of forearm, compare to pre-op xrays of contralateral forearm Closure Irrigation & Hemostasis irrigate wounds thoroughly and deflate tourniquet cauterize any bleeders carefully, watching out for damage to radial artery or vein Closure deep closure over plates with 0-vicryl to reduce hardware irritation subcutaneous closure with 2-0 vicryl 3-0 nylon vertical/horizontal mattress for skin Dressing & Splint incision dressing (gauze, webril) followed by sugartong splint for immobilization Sling for comfort Postoperative Care 2 Weeks wound check and remove sutures remove splint and place in Munster or short-arm cast non-weight bearing 4 Weeks remove cast and place in removable wrist brace non-weight bearing begin range of motion exercises to wrist and hand 6 Weeks advance weight-bearing status in removable wrist brace advance rehabilitation Complications Document Complications forearm compartment syndrome nerve damage to PIN or superficial radial nerve neurovascular injury (radial/ulnar artery) nonanatomic restoration radial bow radioulnar synostosis malunion and nonunion superficial and deep infection