Updated: 10/4/2016

Both Bone Forearm Fracture ORIF

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Cases
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Techniques
1

Preoperative Patient Care

A

Intermediate Evaluation and Management

1

Perform focused history and physical exam

  • recognizes implications of soft tissue injury
  • open fracture
  • median nerve dysfunction
  • DRUJ instability
  • check radial/ulnar artery patency of operative extremity with Allen’s test

2

Orders/ interprets advanced imaging:

3

Makes informed decision to proceed with operative treatment

  • describes accepted indications and contraindications for surgical intervention
  • surgical indications
  • displacement of both bones
  • instability

4

Perform a closed reduction and splint appropriately

  • place in sugartong splint after reduction

5

Recognition/ eval fragility fx

  • orders appropriate work-up and/or consult

6

Modify and adjust post-op plan when indicated

  • postop: 2-3 week postoperative visit
  • wound check and remove sutures
  • diagnose and management of early complications
  • remove surgical splint and place in removable splint
  • begin range of motion exercises to wrist and hand
  • continue non-weightbearing
  • from 2-6 weeks
  • 5 lb weight restriction
  • restricted work duty including no repetitive forearm twisting until union occurs
  • postop: 6 weeks
  • check radiographs for union
  • if union present, remove restrictions
  • if union has not occurred, place a 20 lb weight restriction
  • postop: 1 year postoperative visit
B

Advanced Evaluation and Management

1

Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral

C

Preoperative H & P

1

Perform history and physical exam

  • check radial/ulnar artery patency of operative extremity with Allen’s test

2

Orders and interprets basic imaging studies

  • need biplanar films of wrist, forearm and the elbow
  • compare to contralateral wrist xray for
  • on the lateral
  • the radial styloid is aligned with the center of the lunate
  • the head of the ulna should be obscured by the radius
  • place in sugartong splint

3

Perform operative consent

  • describe complications of surgery including
  • nonunion
  • malunion
  • infection
  • wound breakdown
  • compartment syndrome
  • radioulnar synostosis

Operative Techniques

E

Preoperative Plan

1

Identify fracture characteristics

  • fracture pattern
  • DRUJ disruption
  • amount of comminution

2

Execute surgical walkthrough

  • describe key steps of the procedure to the attending verbally prior to the start of the case
  • describe potential complications and steps to avoid them
F

Room Preparation

1

Surgical instrumentation

  • ensure desired plate system of choice is present in the room

2

Room setup and equipment

  • setup OR with standard operating table and radiolucent hand table
  • turn table 90° so that operative extremity points away from anesthesia machines
  • c-arm perpendicular to hand table with monitor in surgeon's direct line of site

3

Patient positioning

  • supine with shoulder at edge of bed centered at level of patient’s shoulder
  • arm tourniquet placed on arm with webril underneath (optional)
G

Posterior Approach to the Radius

1

Mark out the anatomy

  • palpate Lister`s tubercle at the dorsal aspect of the distal radius
  • palpate the lateral epicondyle

2

Mark both structures

3

Extend the diathermy cord between these bony prominences

4

Center the skin incision over the fracture site

5

Identify the fracture site

  • place a straight metal instrument transversely to the forearm and expected fracture site
  • use fluoroscopy to find the level of the fracture site
  • mark the fracture site with a transverse line

6

Make the skin incision

7

Perform blunt superficial dissection in the interval between the ECRB and the EDC distally where the abductor pollicis longus transversely spans the forearm

  • by extending the incision proximally, the PIN will be exposed where it leaves the supinator

8

Mobilize the PIN from the deep head of the supinator

9

Identify the radius

  • split the deep head to reach the radius proximally
  • be aware that fibers from the pronator teres encroach into the field over the middle radius

10

Expose enough radius for placement of the plate

  • distally lift the APL from the radius to provide room for the plate
H

Posterior Approach to the Ulna

1

Identify the fracture site

  • use a straight metal object to identify the fracture site using fluoroscopy

2

Center the incision over the fracture

3

Identify anatomic landmarks

  • palpate the olecranon and the ulnar head

4

Make a skin incision

  • make the incision over the fracture so that it is in line with the olecranon and the ulnar head

5

Deepen the incision down to the fascia

  • open the epimysium over the ECU
  • expose the interval between the ECU and the FCU distally
  • expose the interval between the FCU and the anconeus proximally
I

Reduction of the Radius

1

Prepare the fracture ends

  • use bone holding clamps to deliver the radius fracture ends into the wound
  • with oblique fractures use a lobster claw reduction clamp placed on either side of the fracture site
  • angle the clamp about 30 degrees to the longitudinal axis of the bone
  • this should allow control of both fracture fragments
  • prepare the fracture fragments by completely cleaning off any soft tissue debris

2

Reduce the fracture

  • reduce the fracture fragments by applying longitudinal traction and rotation

3

Place provisional fixation

  • place a bone clamp to obtain provisional stability across the fracture site
J

Reduction of the Ulna

1

Prepare the fracture ends

  • use bone holding clamps to deliver ulna the fracture ends into the wound
  • with oblique fractures use a lobster claw reduction clamp placed on either side of the fracture site
  • angle the clamp about 30 degrees to the longitudinal axis of the bone
  • this should allow control of both fracture fragments
  • prepare the fracture fragments by completely cleaning off any soft tissue debris

2

Reduce the fracture fragments

  • reduce the fracture fragments by applying longitudinal traction and rotation

3

Place provisional fixation

  • place a bone clamp to obtain provisional stability across the fracture site
K

Fixation of the Ulna

1

Place the plate

  • lift the clamp and place the plate

2

Replace the clamp

3

Place initial screws

  • fill the two holes closest to the fracture fragment first

4

Place an interfragmentary screw

5

Check the reduction of the radius

  • after reduction of the radius fill the remaining screw holes with nonlocking or locking screws

6

Confirm placement and reduction using fluoroscopy

L

Fixation of the Radius

1

Place the plate

  • lift the clamp and place the plate

2

Replace the clamp

3

Place initial screws

  • fill the two holes closest to the fracture fragment first
  • place an interfragmentary screw
  • fill the remaining screw holes with nonlocking or locking screws
N

Wound Closure

1

Irrigate the wound

2

Deep closure

  • use 3-0 vicryl for the subcutaneous tissue

3

Superficial closure

  • use 4-0 monocryl

Postoperative Patient Care

O

Perioperative Inpatient Management

1

Discharges patient appropriately

  • pain meds
  • wound care
  • do not remove splint until follow up appointment in 2 weeks
  • prescribe outpatient physical therapy
  • non-weightbearing
 

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