1 Principles topenlarge
Order of fixation
Normally, the simpler of the two fractures will be approached first and preliminary fixation undertaken. If both bones have similar fractures, then the ulna will normally be addressed first.
Most often, fixation of fractures involving both bones proceeds as follows:
- Reduction and preliminary fixation usually starts with the ulna
- Reduction and definitive fixation of the other bone, usually the radius
- Definitive fixation of the first bone
Never commit yourself to the definitive fixation of one bone until you have assured yourself that you can reduce the other bone.
If a reduction of the second bone is impossible, the preliminary fixation of the first bone has to be loosened and the other bone reduced and fixed. The first bone is then restabilized.
Throughout this module, the fixation of each bone will be described to completion, but the surgeon is reminded not to complete the first fixation until the second bone has been definitively fixed.
When both bones need to be reduced and fixed, a separate approach to each bone should be performed in order to reduce the risk of heterotopic bone formation.
For proximal radial shaft fractures, the anterior approach (Henry) is most often used to minimize the risk of damage to the posterior interosseous nerve, which crosses the proximal radius within the supinator muscle.
The ulna is exposed by the standard subcutaneous approach between the flexor and extensor muscle compartments.
2 Detailed procedures topenlarge
When both the radius and the ulna have a simple fracture pattern, either oblique or transverse (short oblique), possible techniques are:
3 Completed osteosynthesis topenlarge
These illustrations show examples of completed osteosyntheses.
4 Check of osteosynthesis topenlarge
Check the completed osteosynthesis by image intensification. Make sure that the plate is at a proper location, the screws are of appropriate length and a desired reduction was achieved.
The elbow should be stabilized at the epicondyles and the forearm rotation should be checked between the radial and ulnar styloids.
5 Assessment of Distal Radioulnar Joint (DRUJ) top
Before starting the operation the uninjured side should be tested as a reference for the injured side.
After fixation, the distal radioulnar joint should be assessed for forearm rotation, as well as for stability. The forearm should be rotated completely to make certain there is no anatomical block.
The elbow is flexed 90° on the arm table and displacement in dorsal palmar direction is tested in a neutral rotation of the forearm with the wrist in neutral position.
This is repeated with the wrist in radial deviation, which stabilizes the DRUJ, if the ulnar collateral complex (TFCC) is not disrupted.
This is repeated with the wrist in full supination and full pronation.
In order to test the stability of the distal radioulnar joint, the ulna is compressed against the radius...
...while the forearm is passively put through full supination...
If there is a palpable “clunk”, then instability of the distal radioulnar joint should be considered. This would be an indication for internal fixation of an ulnar styloid fracture at its base. If the fracture is at the tip of the ulnar styloid consider TFCC stabilization.