Updated: 5/2/2017

[Blocked from Release] Radius and Ulnar Shaft Fracture ORIF

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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

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