Proximal forearm

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Basic treatment techniques
Basic technique: Modular external fixation

Surgical procedures sorted by fracture type Use this menu to jump directly into a specific classification (optional):
A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2/3 B1 B2 B3.1 B3.2 B3.3 C1 C2.1 C2.2/3 C3

A1.1 Extraarticular fracture of the ulna, avulsion of the triceps insertion Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Minimal displacement (< 2 mm). Active elbow extension. Immobilization desired.
Functional treatment	Minimal displacement (< 2 mm). Active elbow extension. Immobilization unnecessary.
Triceps reinsertion	Small and/or multiple fragment(s). Osteoporotic bone.

A1.2 Extraarticular fracture of the ulna, simple metaphyseal Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced, stable fracture.
Temporary external fixation	Instability that can not be controlled with splint or cast. Significant soft-tissue injury or contamination.
Compression plate	Transverse fracture.
Compression plate and lag screw	Oblique fracture suitable for compression with both lag screw and plate.
Lag screw and protection plate	Oblique fracture. Interfragmentary compression by lag screw, but not plate.

A1.3 Extraarticular fracture of the ulna, multifragmentary metaphyseal Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced, stable fracture.
Temporary external fixation	Instability that can not be controlled with splint or cast. Significant soft-tissue injury or contamination.
Bridging plate	Unstable, displaced fracture. Instability of radiocapitellar or proximal radioulnar joint.

A2.1 Extraarticular fracture of the radius, avulsion of bicipital tuberosity Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Functional treatment	Excessive surgical risk. Low demand, elderly patient.
Biceps reinsertion	Loss of flexion and supination strength.

A2.2 Extraarticular fracture of the radius, simple radial neck Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced stable fracture. Immobilization desired.
Functional treatment	Undisplaced fracture. >70% supination and pronation.
Lag screw fixation	Oblique fracture.
Compression with T-plate	Displaced transverse fracture.

A2.3 Extraarticular fracture of the radius, multifragmentary radial neck fracture Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced fracture.
Temporary external fixation	Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss.
Bridging plate (multifragmentary fracture)	Displaced or unstable fracture. Stable fixation possible.
Replacement arthroplasty	Unstable elbow joint. Associated interosseous membrane injury (Essex-Lopresti injury).

A3.1 Extraarticular fracture of both bones, simple Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Instability that can not be controlled with cast or splint. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss.
Compression plate for ulna	Transverse fracture.
Compression plate and lag screw for ulna	Fracture suitable for compression with both plate and lag screw.
Lag screw and protection plate for ulna	Fracture suitable for compression with lag screw but not plate.
Lag screw fixation for radius	Oblique fracture.
Compression with T-Plate for radius	Transverse fracture.

A3.2/3 Extraarticular fracture of both bones, one or both multifragmentary Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss.
Compression plate for ulna	Transverse fracture.
Compression plate and lag screw for ulna	Fracture suitable for compression with both plate and lag screw.
Lag screw and protection plate for ulna	Fracture suitable for compression with lag screw but not plate.
Bridging plate for ulna	Multifragmentary fracture.
Lag screw fixation for radius	Oblique fracture.
Compression with T-plate for radius	Transverse fracture.
Bridging plate for radius	Multifragmentary fracture.
Replacement arthroplasty for radius	Unstable elbow joint. Inability to fix the radial neck satisfactorily.

B1 Articular fracture of the ulna Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced B1.1 fracture. Immobilization desired.
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Tension band wiring	Transverse simple fracture of the olecranon.
Lag screw and protection plate	Oblique fracture of the olecranon.
Tension band plate	Unifocal, transverse olecranon fracture, or minimally comminuted but with similar stability.
Bridging plate	Multifragmentary fractures.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.

B2 Articular fracture of the radius Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Circular cast or splint	Undisplaced or minimally displaced fractures with acceptable supination and pronation range. Immobilization desired.
Functional treatment	Undisplaced or minimally displaced fractures with acceptable supination and pronation range.
Temporary external fixation	Joint instability. Extensive soft-tissue damage.
Lag screw fixation	Simple displaced fractures.
Lag screws through plate	Reconstructible multifragmentary fracture. Fracture where lag screws alone provide inadequate stability.
Excision of the radial head	Isolated unreconstructable radial head fracture with stable elbow. Intact interosseous membrane and distal radioulnar joint (DRUJ).
Replacement arthroplasty	Inability to reconstruct radial head fracture so that it provides sufficient stability for elbow joint. Interosseous membrane injury (Essex-Lopresti injury).

B3.1 Simple articular ulna, extraarticular radius Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Tension band wiring for olecranon	Transverse simple fracture. No instability of radial fracture.
Lag screw and protection plate for olecranon	Oblique fracture.
Tension band plate for olecranon	Unifocal, transverse olecranon fracture, or minimally comminuted but with similar stability.
Lag screw fixation for radius	Oblique fracture.
Compression with T-plate for radius	Transverse fracture.
Bridging plate (simple, impacted fracture) for radius	Shortened radial neck fracture with loss of bone volume (impaction).
Bridging plate (multifragmentary fracture) for radius	Multifragmentary fracture with shortening.
Replacement arthroplasty for radius	Inability to reconstruct radial head or neck fracture so that it provides sufficient stability for elbow joint. Interosseous membrane injury (Essex-Lopresti injury).

B3.2 Simple articular radius, extraarticular ulna Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Lag screw fixation for radius	Simple fracture of the radial head.
Compression plate for ulna	Transverse fracture.
Compression plate and lag screw for ulna	Simple oblique fracture, suitable for compression with both lag screw and plate.
Lag screw and protection plate for ulna	Fracture suitable for compression with lag screw but not plate.
Bridging plate for ulna	Multifragmentary fracture.

B3.3 Multifragmentary articular of one bone, extraarticular of the other Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Bridging plate for olecranon	Multifragmentary fracture.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.
Lag screws and plate for radius	Reconstructible multifragmentary fracture of the radial head/neck. Fracture where lag screws alone provide inadequate stability.
Replacement arthroplasty for radius	Unreconstructable fracture of the radial head or neck.
Compression plate for ulna	Transverse fracture.
Compression plate and lag screw for ulna	Oblique fracture, suitable for compression with both plate and lag screw.
Lag screw and protection plate for ulna	Fracture suitable for compression with lag screw but not plate.
Bridging plate for ulna	Multifragmentary extraarticular fracture.
Lag screw fixation for radius	Oblique fracture.
Compression with T-plate for radius	Transverse fracture.
Bridging plate (simple, impacted fracture) for radius	Shortened radial neck fracture with loss of bone volume (impaction).
Bridging plate (multifragmentary fracture) for radius	Multifragmentary fracture with shortening.

C1 Simple articular fractures of both bones Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Lag screw and protection plate for olecranon	Oblique fracture.
Tension band plate for olecranon	Unifocal, transverse olecranon fracture, with restored stability or radial head fracture.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.
Lag screw fixation of radial head	Single-fragment radial head fracture.

C2.1 Articular fracture of both bones, Olecranon multifragmentary, radial head simple Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Bridging plate for olecranon	Multifragmentary fracture.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.
Lag screw fixation of radial head	Simple fracture.

C2.2/3 Articular fracture of both bones, olecranon or coronoid simple, radial head multifragmentary Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Lag screw and protection plate for olecranon	Oblique fracture.
Tension band plate for olecranon	Unifocal, transverse olecranon fracture, with restored stability or radial head fracture.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.
Lag screws and plate for radius	Reconstructible multifragmentary fracture of the radial head.
Replacement arthroplasty for radius	Unreconstructable fracture of the radial head.

C3 Multifragmentary articular fractures of both bones Please select a treatment option:
Treatment	Indication summary	Skill	Equipment
Temporary external fixation	Joint instability. Extensive soft-tissue damage. Severe contamination. Infection.
Hinged external fixation following ORIF	Persistent elbow instability. Protection for weak fixation. Motion desired.
Bridging plate for olecranon	Multifragmentary fractures.
Repair of coronoidal fracture	Coronoidal fracture with elbow instability.
Lag screws and plate for radius	Reconstructible multifragmentary fracture of the radial head.
Replacement arthroplasty for radius	Unreconstructable fracture of the radial head.

Special considerations
Principles of management of open fractures
Complications Infection Compartment syndrome

*Skill
	Basic surgical experience, no specialized skills
	Some specialized surgical experience
	Highly experienced and skilled surgeon

*Equipment
	Basic equipment only
	Simple surgical and imaging resources
	Full specialized surgical and imaging resources

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v1.0 2016-10-24