Updated: 10/4/2016

Forearm Fractures IMN

Topic
Review Topic
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Questions
7
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Evidence
7
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Cases
2
Techniques
1

Preoperative Patient Care

A

Postoperative Evaluation and Management

1

Provides post-operative management and rehabilitation

  • postop visit: 1 week visit
  • R/O Postoperative infection
  • Cast Check
  • Neurovascular check
  • AP and Lateral Forearm Xray Evaluation
  • Asses reduction and hardware location
  • postop: 4-6 week postoperative visit
  • wound check
  • change splint/cast and continue non-weight bearing
  • check radiographs
  • diagnose and management of early complications
  • postop: 6 month postoperative visit
  • remove nails in the OR

2

Capable of diagnosis and early management of complications

  • compartment syndrome
  • able to recognize the signs and symptoms of compartment syndrome
  • postoperative Neuropraxia
  • able to recognize the signs of radial, ulnar and median nerve neropraxia and take early steps at management
  • remove cast, evaluate for hematoma, compartment syndrome
B

Advanced Evaluation and Management

1

Able to recognize the signs, symptoms, and causes of delayed union and nonunion of radius and ulna fracture

2

Recognizes signs of delayed healing on radiographs

  • Orders Laboratory workup
  • Orders MRI

3

Recognizes excessive loss and manages excessive loss of range of motion

  • Orders physical therapy to treat decreased range of motion postoperatively

4

Recognizes the signs of complex regional pain syndrome

5

Recognizes and manages Compartment syndrome in timely manner

  • Able to perform compartment pressure measurements
  • Able to perform forearm compartment fasciotomies
C

Preoperative H & P

1

Obtains history and performs physical exam

  • mechanism of injury
  • check for any open wounds
  • Recognize vascular, nerve or other associated injuries
  • assess AIN, median, radial and ulnar nerve function
  • AIN neuropraxia (test A-OK sign)
  • radial nerve (thumb/wrist extension) palsy
  • ulnar nerve (hand intrinsics)
  • radial and ulnar pulse assessment
  • assesses the soft tissue

2

Order basic imaging studies

  • AP and lateral forearm radiographs
  • the entire radius and ulna are essential

3

Prescribe nonoperative treatments

  • most both bone forearm fractures are treated with closed reduction and long arm casting
  • relative indications for operative treatment with internal fixation: open fracture, loss of reduction with closed treatment, unstable fracture, pathologic fracture, refracture, floating elbow, inability to obtain adequate reduction

4

Perform operative consent

  • describe complications of surgery including
  • hardware prominence
  • sensory neuropraxia
  • infection
  • extensor tendon irritation or rupture
  • neurovascular injury
  • delayed union
  • nonunion
  • malunion
  • refracture
  • compartment syndrome

Operative Techniques

E

Preoperative Plan

1

Template fracture and determine nail size

  • characterize fracture: determine location in shaft of fracture(s); comminution; open vs closed
  • determine size of appropriate nail: measure at narrowest part of diaphysis; should have 2/3 canal fill

2

Execute surgical walkthrough

  • describe key steps of the operation verbally to attending prior to beginning of case.
  • describe potential complications and the steps to avoid them
F

Room Preparation and Positioning

P

1

Surgical instrumentation

  • flexible intramedullary nails and inserter
  • "F" reduction tool
  • basic ortho tray in case fracture needs to be opened for reduction
  • sterile tourniquet available
  • c-arm flouroscoupy
Pitfalls
  • Have sterile tourniquet available but only use during soft tissue dissection or when having to open fracture
  • Avoid using during nail placement as can increase risk of compartment syndrome

2

Room setup and equipment

  • setup OR with standard operating table
  • radiolucent hand table
  • turn table 90° so that operative extremity points away from Anesthesia machines
  • C-arm in from foot of bed

3

Patient positioning

  • supine
  • patient with shoulder at edge of bed
  • arm board centered at level of patient’s shoulder
G

Proximan Ulna Nail Entry

1

Identify the starting point

  • the starting point is on the lateral edge of the subcutaneous border of the proximal ulna
  • alternate starting point is posterior border of olecranon
  • use fluoroscopy to confirm appropriate starting point

2

Enter the intramedullary canal

  • use the awl or drill to percutaneously enter the intramedullary canal of the proximal ulna
H

Ulna Nail Placement

P

1

Nail contour- as ulna has a straight border, no real contouring is needed

  • as an alternative a smooth steinman pin of the same size caliber as a nail can be used
Pearls
  • An advantage of a large steinman pin is it can be left sticking out of the skin and removed without another operation
  • We recommend this for smaller children but not fractures that may have slower healing (open fracture, older child)

2

Advance nail

  • advance the nail through the proximal ulna
  • use fluoroscopic guidance to confirm placement in two planes
  • advance nail to the fracture site
I

Reduction of the Ulna and Nail Passage

1

Reduce the ulna

  • reduce the ulna with longitudinal traction and AP compression
  • if unable to reduce the fracture adequately closed then open fracture and reduce

2

Pass the nail across the fracture site

  • If three unsuccessful pass attempts, open fracture site and reduce before further attempts at nail passage(to avoid causing iatrogenic compartment syndrome)

3

Cut the ulna nail at the appropriate length

  • cut the nail so that it is subcutaneous
  • aim for this to be slightly palpable but not prominent
J

Distal Radius Approach

P

1

Identify the entry point for the radius nail

2

Mark level of the physis, entry point is proximal to this

Pearls
  • Can consider doing exposure/marking starting point of both nails to decrease manipulation needed after reducing fracture

3

Radial/lateral entry:

  • start the entry of the distal radius between 1st and 2nd dorsal compartments

4

Dorsal entry:

  • an alternative entry point is the interval between the second and third dorsal compartment near the proximal base of the tubercle of Lister

5

Make skin incision

  • protect the superficial branches of the radial nerve

6

Expose the distal radius

K

Distal Radius Entry and Nail Insertion

P

1

Create entry point on radius

  • use awl or drill
  • if entry point is made with a drill a small tipped rongeur can be used to turn the entry point from a circle into a oval

2

use fluoroscopic guidance to confirm the starting point (avoid physis)

3

Insert nail into radius

  • contour the nail with a smooth bend to restore appropriate radial bow
  • use partial right and left rotations to gain satisfactory entrance into the distal radius
  • insert nail under fluoroscopic and/or direct visualization
  • feel the intramedullary canal with the tip of the nail and confirm intraosseous position with AP and lateral fluoro images
Pitfalls
  • avoid acute bends in nail and aim for a smooth contour
L

Reduction and Nail Passage within the Radius

P

1

Advance nail to the fracture site

  • advance the nail to the level of the fracture

2

Reduce the fracture

  • reduction is achieved with longitudinal traction and AP compression

3

can also use "F" tool

  • if unable to reduce the fracture adequately closed then open fracture and reduce

4

Advance the nail past the fracture site

  • rotate the nail to pass the nail past the fracture site and advance to the appropriate depth
  • If unable to successfully pass after three attempts, open fracture and reduce prior to further nail passage attempts
Pitfalls
  • Avoid multiple unsuccessful passes as this may increase risk of compartment syndrome (open to reduce after 3 passes)
N

Final Rotation and Cutting of the Radial Nail and Wound Closure

P

1

Rotate the nail to restore the radial bow and check rotation

  • check the relationship between the radial styloid and the bicipital tuberosity as well as the ulnar styloid and the coronoid process

2

Cut the nail so that is slightly palpable but not prominent

Pitfalls
  • Avoid nail prominence which can cause irritation of superficial branch of radial nerve or extensor tendons

3

Irrigate the incisions

  • copiously irrigate the wound

4

Superficial wound closure

  • close the entry sites with absorbable subcutaneous (2-0 vicryl) and subcuticular suture (3-0 monocryl) and apply dermabond or steristrips

5

Dressings

  • apply light nonstick dressing, sterile gauze and sterile padding wrap.

6

Postoperative immobilization

  • depending on stability, can cast or splint for extra control and comfort
  • if swelling is of concern use sterile foam padding prior to wrapped dressings with a cast or use a splint

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharge patient appropriately

  • observe at least overnight for compartment monitoring
  • pain meds/antibiotics
  • cast/splint care
  • non weightbearing
  • manage swelling
  • monitor neurological and vascular status
  • schedule follow up in 1 week
 

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