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Section III - Fractures of the distal ulna
- from Chapter 3
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- By Gregoris Kambouroglou, John Radcliffe Hospital
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
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- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 56-59
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- Chapter
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Summary
OPEN REDUCTION AND INTERNAL FIXATION (ORIF) FOR DISTAL ULNAR FRACTURES
Indications
Displaced isolated fractures of the distal ulna.
Fractures of the distal ulna associated with distal radius fractures.
Pre-operative assessment
Clinical assessment
High-energy fractures, often with an open wound over the ulnar fracture.
Ensure the injury is in isolation and the arm remains neurovascularly intact.
Specifically test for ulnar nerve impairment.
Radiological assessment
Ensure adequate views are available.
In complex fractures of the distal radius (Fig. 3.20) a CT scan may be helpful to delineate the injury and assist in reconstruction.
Displaced fractures must be reduced with simple means to avoid complications but also to facilitate further imaging.
Problems are often encountered related to the amount of fragmentationandthe quality of thebonein thehead of the ulna.
Operative treatment
Anaesthesia
General anaesthetic is preferred. In acute injuries the use of regional blocks is discouraged as it may mask underlying pressure phenomena or compartment syndrome.
Operative equipment
Use the mini-fragment set with 2.7mmscrews for fractures proximal to the distal radio-ulnar joint.Use a tension band for the most distal fractures.
In associated fractures of the distal radius with shortening, the small external fixator is also used as a reduction aid.
Set up and positioning
Hand table at 45°.
Imager intensifier.
Rolled up towel.
Surgeon on the head side of the table (Fig. 3.21).
Prescrub the limb.
Antibiotic prophylaxis and tourniquet if there are no contraindications.
Prepare the armto the elbow as occasionally it may be necessary to obtain a graft from the olecranon.
Section I - Fractures of the proximal ulna
- from Chapter 3
-
- By Gregoris Kambouroglou, John Radcliffe Hospital
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 45-50
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- Chapter
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Summary
TENSION BAND WIRING OF OLECRANON FRACTURES
Indications
Displaced transverse fractureof the olecranonwithdisruption of the extensor mechanism.
The technique can be used with caution in oblique or fragmented fractures once issues related to these fracture patterns are addressed.
Pre-operative planning
Clinical assessment
Mechanism of injury: forced extension usually following a fall. Beware of the high-energy fracture patterns that may suggest that the fracture is only a portion of the injury.
Findings: pain, swelling and occasionally impressive ecchymosis over the elbow region. Beware of injury to the soft tissue envelope that may interfere or preclude surgical intervention.
Findings: loss of active extension associated with displaced fractures. Beware of examination pitfall where passive gravity-assisted extension leads to the assumption of an intact extensor mechanism.
Findings: check for ulnar nerve impairmentandensure the injury is in isolation.
Radiological assessment
Anteroposterior and lateral radiographs of the elbow are the absolute minimum imaging requirement. Beware of more complex injuries that may need further imaging, most commonly in the formof a CT scan (Fig. 3.1).
Operative treatment
Anaesthesia
Regional/general.
Pre-operative administration of antibiotics (cephalosporin).
Prescrub and drying of the limb.
Tourniquet application, if there are no contraindications. Ensure the tourniquet does not interfere with the operative field and that no preparation solution leaks underneath. Inflate the tourniquet once the limb has been elevated for approximately 3 minutes.
Section II - Fractures of the ulnar shaft
- from Chapter 3
-
- By Gregoris Kambouroglou, John Radcliffe Hospital
- Peter V. Giannoudis, St James's University Hospital, Leeds, Hans-Christian Pape, University of Pittsburgh
-
- Book:
- Practical Procedures in Orthopaedic Trauma Surgery
- Published online:
- 05 February 2015
- Print publication:
- 14 December 2006, pp 51-55
-
- Chapter
- Export citation
-
Summary
OPEN REDUCTION AND INTERNAL FIXATION: PLATING
Indications
Displaced fractures of the middle third of the ulna in adults.
Monteggia fractures: fracture of the ulna shaft with fracture and/or dislocation of the proximal radius/radial head.
Fractures of both forearm bones.
Pre-operative planning
Clinical assessment
Mechanism of injury: Nightstick injury: direct blow; Monteggia fractures: axial compression; forearm fracture: any combination. Ensure adequate examination of the elbow and wrist joint for associated pathology.
Low- vs. high-energy injury, ensure no open fractures are missed with ulna wound volarly and covered by splint when first examined.
Arm at risk for compartment syndrome: document neurovascular status early and monitor changes.
In multiple-injured patients treatment sequence follows the ‘life-before-limb’ protocol.
Look for occult injuries in the rest of the arm, especially in the carpus/hand.
Radiological assessment
Rule of 2: 2 views, 2 joints (and 2 visits). Radiographs may be incomplete initially as pain/splints may interfere with the result.
Traction views in theatre may be necessary for valid pre-operative planning.
Operative treatment
Anaesthesia
Timing of surgery essential: in low-energy injuries this is notanissue whilst in high-energyoneswith displacement, shortening and/or dislocation, early intervention is preferable to avoid complications.
General anesthesia preferable. Avoid regional anesthetic/ blocks in acute injuries as they may mask symptoms indicating compartment syndrome in the immediate post-operative period.
Pre-operative administration of antibiotics and prescrub the limb.
Apply tourniquet if not contraindicated and inflate following elevation for 3 minutes once limb prepped and draped.