AOTrauma Webinar:  Why Do Patients Get Infection?

May 30, 2017 14:00 CET

Main Presenter: Olivier Borens, MD (Switzerland)
Chat Moderator: Stephen Kates, MD (USA)

Surgical site infections after trauma are debilitating and costly. They are feared by the surgeon and the patient alike. The incidence of this complication can be decreased by proper preoperative, intraoperative, and postoperative management.
The goal of this webinar is to present easy-to-use tools and strategies that will lead to a decrease in the incidence of infection.

More information and registration...

Infection

Executive Editor: Peter Trafton

Authors: Kodi Kojima, Steve Velkes

Proximal forearm 21-A1.2 ORIF

back to skeleton

Glossary

1 Principles top

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Compression with lag screw and protection plate

In an oblique fracture, interfragmentary compression is achieved with a lag screw.

The screw thread pulls the opposite bone fragment towards the head of the screw, compressing the fracture. On the near cortex, the thread of the screw turns freely, without purchase. Lag screws must be inserted as perpendicularly as possible to the fracture plane, to produce compression without displacement of the fracture.

Lag screw osteosynthesis alone is not able to resist functional loading. Therefore, a protection plate must be added to allow early mobilization.

Note
Whenever possible (considering soft-tissue condition, fracture configuration, associated radial head fracture etc.), position the plate so an appropriate lag screw can be insertedthrough it. This offers improved stability.


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Plate position

The plate can be applied either on the lateral, the medial, or the posterior aspect of the ulna. The optimal position depends on the fracture configuration and associated injuries.

When placing the plate in the posterior aspect, make sure that the proximal screws do not protrude into the joint.

In a medial or lateral plate position all screws can be inserted bicortically, thus having better purchase.

Note
To improve proximal stability (short fragment and/or osteoporosis) a posterior plate can be curved around the olecranon and anchored with an axial screw.

2 Reduction and preliminary fixation top

Cleaning of the fracture site

Expose the fracture ends with minimal soft tissue dissection off the bone.

Remove hematoma and irrigate.

Check elbow stability.


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Direct reduction

Reduce the fracture with the help of small pointed reduction forceps and provisionally fix with forceps or K-wires.

3 Plate preparation top

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Choosing the right plate

Use a six or seven hole plate, depending on the fracture configuration. Usually, three screws in each fragment provide sufficient stability.

The plate may be a small fragment dynamic compression plate (3.5 DCP), or limited contact dynamic compression plate (LC-DCP), or a specific proximal ulna prebent plate.

In osteoporotic bone, a locking plate (LCP) plate may be used.


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Prebending and contouring

Prebend the plate according to the surface anatomy of the ulna.

Contouring of the plate is achieved with bending irons or a bending press.

4 Lag screw insertion top

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Drilling

Drill a 3.5 mm gliding hole for the lag screw into the posterior cortical bone of the distal fragment.

Insert the 2.5 mm drill sleeve into the gliding hole until it reaches the far cortical bone.

Now drill the far cortex with the 2.5 mm drill bit.

Countersink the cortex of the distal fragment in order to have more surface area to distribute the force caused by the head of the lag screw.


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Measuring

Measure the depth of the hole with the hook of the depth gauge pointing proximally.

Tap the far cortex with the 3.5 mm cortical tap and protection sleeve.

Note
Always measure before tapping so as not to disturb the tapped thread.


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Lag screw insertion

Closely observe the compression effect on the fracture line while tightening the lag screw.

The reduction forceps should be removed just before the final tightening of the screw.

5 Protection plate top

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Plate fixation

Apply the contoured plate and fix it to the bone with three screws proximal and three screws distal to the fracture in neutral position to protect the lag screw.


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Final assessment

Finally, assess the range of motion in pronation, supination, flexion and extension.

Check results with image intensifier or x-ray.

v1.0 2016-10-24