1 General considerations topenlarge
Plating is the standard technique for treating forearm fractures in adults and is also appropriate for children approaching skeletal maturity.
Children with open physes have thick active periosteum favoring stability and rapid healing with ESIN techniques. In more proximal ulnar fractures plating may be used in younger children.
Combination with other treatment options
Plating the ulna may be combined with ESIN of the proximal radial fracture.
This allows for stable anatomical restoration of the forearm axis and early motion.
K-wire fixation of the radial fracture may be performed but is not recommended. This provides less stability and requires additional immobilization.
2 Order of reduction and fixation topenlarge
The ulnar fracture (1) is treated first.
The radial neck fracture (2) may spontaneously reduce after anatomical reduction and fixation of the ulna.
The radial neck fracture should be fixed with an intramedullary nail to prevent redisplacement and to allow early joint mobilization.
3 Patient preparation topenlarge
This procedure is normally performed with the patient in a supine position.
4 Choice of approach topenlarge
The ulna is exposed through a posterior approach.
An alternative is the posterolateral approach, which provides access to both the proximal ulna and the radial head. A disadvantage of this approach is the potential for cross-union.
If there is residual displacement of the radial neck fracture after optimization of the ulnar correction, a closed reduction using ESIN or an open reduction should be performed.
Open reduction may also be necessary if an image intensifier is not available or if soft-tissue structures are trapped between the fragments.
A lateral approach centered on the epicondyle may be used to visualize the radial neck fracture.
5 Reduction and fixation of the ulna topenlarge
The proximal ulnar fracture should be reduced and stabilized anatomically. The type of plate fixation depends on the fracture pattern.
Ensure that the ulna is out to length and rotationally aligned. With Monteggia equivalents an overreduction of the ulna is not required.
6 Reduction and fixation of radial head/neck topenlarge
Entry points to the radius
The distal lateral entry point is in common use and shown in this example.
The dorsal entry point (Lister’s tubercle) is also well established and offers more versatile nail manipulation.
Find more details in ESIN entry points (radius).
The steps required for proximal radial fracture fixation are described in the ESIN procedure, illustrated with a 21r-E/1.1 fracture.
This technique is also appropriate for reduction and fixation of other proximal radial fracture types.
7 Final assessment topenlarge
Check the completed osteosynthesis with image intensification. These images should be retained for documentation.
If an image intensifier is not available an x-ray should be obtained before discharge.
Make sure that the plate is at the correct location, the screws and the nail are of appropriate length and the desired reduction has been achieved.
Check the forearm rotation.