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-C3 ORIF

back to skeleton

Glossary

1 General considerations top

Preliminary remark

C3 fractures, with extensive comminution of coronoid and radial head are characteristic of posterior transolecranon fracture dislocation. Lateral collateral ligaments are typically disrupted. Restoration of elbow stability requires repair of the proximal ulna, radial head ORIF or replacement, and lateral collateral ligament repair.

Radial fracture repair or replacement usually follows reduction and fixation of the coronoid process. Exposure of both fractures is a good initial step.

Stability of the elbow must be confirmed at the conclusion of reduction and fixation. If instability remains, supplementary external fixation may be necessary.


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Multifragmentary radial head fractures

In three-part fractures where the fragment configuration allows reconstruction, the radial head is reconstructed with lag screws and attached to the shaft with a T-plate. Proximal radius fractures with more than three fragments can usually not be repaired satisfactorily.

The lag screws may be inserted through the proximal holes of the plate.

2 Positioning of plate and screws top

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The radial head is completely covered with articular cartilage. The implant is applied to the radial head in a location that causes the least compromise of full pronation and supination.

Safe zone for plate and screw insertion

To determine the location of the "safe zone“, reference marks are made along the radial head and neck, to mark the midpoint of the visible bone surface. Three such marks are made with the forearm in neutral rotation, full pronation, and full supination as shown in the illustration.

The posterior limit of the safe zone lies halfway between the reference marks made with the forearm in neutral rotation and full pronation. The anterior limit lies nearly two thirds of the distance between the neutral mark and the mark made in full supination.

Note
The nonarticulating portion of the safe zone for the application of implants to the radial head (or safe zone forprominent fixation) consistently encompasses a 90 degrees angle localized by palpation of the radial styloid andLister's tubercle.

3 Reduction and preliminary fixation top

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Exposure

Release the annular ligament as necessary to see the radius.

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

Remove hematoma and irrigate.


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Reduction

Directly reduce the joint fragments with the help of small pointed reduction forceps and provisionally fix them with two K-wires.

If joint depression is encountered, the depressed joint fragment is elevated and the underlying defect may be bone grafted with bone from the lateral humeral condyle.

4 Plate preparation top

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As the radial head is a small fragment, a mini fragment 1.5 or 2.0 T-plate, or a locking proximal radius plate is used to allow purchase of two or three screws in the proximal fragment.

Prebend the plate according to the surface anatomy of the proximal radius.

5 Proximal fixation with lag screws and plate top

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Apply the properly contoured plate to the radial head and insert two horizontal lag screws (1.5 or 2.0 mm) into the proximal fragment.

 


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These screws are inserted through the plate to achieve absolute stability of the anatomically reduced joint fragment.

Note
The plate position on the radial head is dictated by the fracture configuration to allow optimal stability and function. If the latter is not possible with the lag screws through the plate, the lag screws may be inserted outside the plate and the plate is fixed in its optimal position.

6 Distal plate fixation top

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Finally attach the plate to the radial shaft with two or three screws, thereby fixing the joint fragment to the diaphysis.

7 Ligament repair and test of stability top

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Repair the annular ligament using non-absorbable sutures.

Test the elbow medial stability by applying valgus stress. If there is an instability, the medial collateral ligament should be repaired.

8 Final assessment top

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Following repair of fractures and ligaments, elbow stability should be assessed through a full range of flexion-extension. Radiocapitellar and ulnohumeral joints should remain located.

Also check supination and pronation. Fixation should be stable. Crepitus or restricted motion should be absent. Check fractures and fixation with image intensifier or x-ray.

If elbow instability or dislocation are identified, it is essential to maintain elbow alignment. This can be done with temporary hinged external fixation. If a hinged external fixator is not available, the significantly unstable elbow should be bridged with a non-hinged external fixator.

v1.0 2016-10-24