Plate osteosynthesis forearmshaft fracture

>Trauma Surgery >Plate osteosynthesis forearmshaft fractureAuthor: J. Sprakel, MD - Latest update: 08-12-2016

Plate osteosynthesis forearmshaft fracture

Naar boven

Pre-operative planning


Reduction and fixation plan forearmshaft fracture AO C22-C1.3 fracture AP-view

Reduction and fixation plan forearmshaft fracture AO C22-C1.3 fracture Lateral-view
Naar boven

Operative Report

Patient Name: John Doe
Date of birth: 04-07-1956

Date of operation: December 8, 2016

Preoperative Diagnosis: Forearm shaft fracture right, AO 22-C1.3 Irregular

Postoperative Diagnosis: Forearm shaft fracture right, AO 22-C1.3 Irregular

Procedure:
1. 8-hole LCP 3.5 neutralization plate with lag screw, anterior placement on radius, Synthes
2. 11-hole LCP 3.5 bridge locking plate, posterior placement on ulna, Synthes

1th Surgeon: J. Sprakel, M.D.
2nd Surgeon: W. van Wissen, M.D.

Anesthesia: Ultrasound guided supraclavicular brachial plexus block right with 25ml of 1.5% Mepivacaine with 1:300,000 epinephrine

Anesthesiologist: John Smith, M.D.
Dictated by: J. Sprakel, M.D.

Fracture characteristics, classification and goals:
Radius fracture Ulna fracture
- Simple
- Absolute stability
- Direct bone healing
- Compression plating
- Multifragmentary (irregular)
- Relative stability
- Indirect bone healing
- Bridge plating (locked plate)


Classification: AO 22-C1.3 Irregular

Report/Plan:

1. The procedure, alternatives, risks and limitations in this individual case have been very carefully discussed with the patient. All questions have been thoroughly answered, and the patient understands the surgery indicated.
2. He has requested this repair be undertaken, and a written consent was signed.
3. The patient was brought into the operating room and placed in the supine position on the operating table. The abducted right arm was placed on the operating radiolucent side table with the forearm in supination.
4. Image intensifier from lateral, image screen at the head of the patient.
5. Small fracture fragment set and 1x 8-hole LCP 3.5 and 1x 11-hole LCP 3.5 are present in the OR-theater
6. Time out procedure was performed
7. An intravenous line was started, and intravenous antibiotics (Cefazolin 1000mg) was administered IV. The patient was monitored for cardiac rate, blood pressure, and oxygen saturation continuously.
8. An ultrasound guided supraclavicular brachial plexus block right with 25ml of 1.5% Mepivacaine with 1:300,000 epinephrine was performed by the anesthesiologist.
9. A Tourniquet was placed on the right arm but not insufflated.
10. Testing the DRU joint of the uninjured side as a reference for the injured side.

Radius

11. Identification and marking of landmarks of skin incisions for a middle third Henry approach, proximally the biceps tendon and distally the radial styloid process, brachioradialis muscle with a marking pen.
12. Control with image intensification to assess position and length of skin incision.
13. Incision of the skin with a surgical scalpel (blade 15) on the middle third of the forearm.
14. Development/superficial dissection of the interval between the brachioradialis (mobile wad) and flexor carpi radialis muscles.
15. Identification of radial artery and two venae comitantes.
16. Identification and ligation of arterial branches from the lateral side of the radial artery by slipping a finger underneath them.
17. Retraction of radial artery medially.
18. Retraction of superficial radial nerve laterally.
19. The posterior interosseous nerve is not identified.
20. Pronation of the forearm to expose the lateral border of the pronator teres muscle.
21. Partially detachment of the insertion of the pronator teres from the radius.
22. Supination of the forearm gives good exposure of a simple oblique radial fracture.
23. Anatomically open reduction of the fracture using 2 Spanier blunt reduction forceps.
24. Placement of pointed Weber reduction forceps over the fracture.
25. Prebending of the 8-hole LCP 3.5 plate where the centre stands off 1-2 mm from the anatomically reduced fracture surface.
26. Unicortical drilling of first cortex with 3.5mm drill for the first lag screw perpendicular to the fracture.
27. Unicortical drilling of the second cortex with 2.5mm drill for the first lag screw perpindicular to the fracture.
28. Measurement for screw lengths (..mm).
29. 3.5mm tapping of drillhole and placement of first non-self tapping 3.5mm fully threaded cortex lag screw (hexagonal) (1-2)
30. Placement of LCP neutralization plate and temporary fixation with a small Verbrugge clamp on the bone without any soft-tissue interposition.
31. Two times bicortical drilling with 2.5mm drill for the second and third screw in the distal and proxmal part of the radius most nearest hole to the fracture in neutral mode.
32. Measurement for screw lengths (..mm & .. mm).
33. 3.5mm tapping of drillhole and placement of second and third non-self tapping 3.5mm fully threaded cortex screw (hexagonal) (1-2)
34. Insert additional fully threaded cortex screws in neutral mode (hexagonal) (4-6)
35. Control of reduction, plate and screw placement by image intensification

Ulna

36. Forearm held vertically and the elbow resting on the side table.
37. Identification and marking of landmarks of skin incisions for a standard ulnar approach using the minimally invasive plate osteosynthesis (MIPO) technique, subcutaneous border of the ulna, a line between the tip of the olecranon process and the ulnar styloid process with a marking pen.
38. Control with image intensification to assess position and length of the two skin incision.
39. Incision of the skin with a surgical scalpel (blade 15) on the distal and proximal third of the forearm.
40. Superficial dissection and deep dissection interval between the flexor carpi ulnaris and the extensor carpi ulnaris muscles.
41. Identification of the dorsal branch of the ulnar nerve at the distal incision.
42. Placement of 11-hole LCP 3.5 plate under extensor carpi ulnaris using the MIPO technique.
43. 3 possible reduction techniques, if necessary:
             a. Manual traction and applying clamps
             b. Temporary external fixator
             c. Plate and distraction with a laminar spreader against an independent screw (push-pull technique)
44. Temporary fixation with 2 small Verbrugge clamps on the bone without any soft-tissue interposition.
45. Control with image intensification to assess reduction.
46. Bicortical drilling with 2.8mm drill for the first screw in the proximal part of the ulna most farthest to the fracture in locking hole.
47. Measurement for screw length (..mm)
48. Placement of first self tapping 3.5mm locking screw (Star Drive T15) (7)
49. Bicortical drilling with 2.8mm drill for the second screw in the distal part of the ulna most farthest to the fracture in locking hole.
50. Measurement for screw length (..mm)
51. Placement of first self tapping 3.5mm locking screw (Star Drive T15) (8)
52. Gently examine the range of forearm rotation
53. Use image intensification to check plate length and position
54. Insert additional self tapping 3.5mm locking screws (Star Drive T15) (9-12)
55. Control of reduction, plate and screw placement by image intensification
56. Stabilization of epicondyles and control of forearm rotation between the radial and ulnar styloids.
57. Control of stability of the Distal Radioulnar Joint (DRUJ).
58. Careful hemostasis was obtained with a monopolar cautery.
59. Closure of the wounds with subcutaneous with Vicryl 3.0 and intracutanous Monocryl 3.0 sutures.
60. A well-padded, bulky splint bandage was applied.
61. Blood loss was estimated to be around 200cc.
62. Sponge and instrument counts were correct x2 at the end of the operation.
63. Sign out procedure.
64. Family was contacted after the operation.

Post-operative instructions:
- Well-padded, bulky splint for 14 days (to allow adequate soft-tissue healing)
- Start with elevation, gentle finger motion, active and passive, together with elbow flexion/extension and shoulder motion (non-weightbaring exercises)
- After splint removal: Active assisted range of motion exercises, including gentle forearm rotation (non-weightbaring exercises)
- Restriction of lifting and resisted exercises, start with more intensive exercises until radiographic signs of healing appear

Outdoor department appointments:
- 2 weeks (wound inspection, removal of splint, X-ray control)
- 6 weeks (Function control, X-ray control)
- 3 months (Function control, X-ray control)
- 6 months (Function control, X-ray control)
- Optional: 12 months (Function control, X-ray control)

Removal of osteosynthesis:
- Removal only in symptomatic patients, possibly only on the ulna where the implants are subcutaneous
- Removal no earlier than 2 years after osteosynthesis
- If both bones have been plated, sequential removal of implants with a least 6 months in between is recommended (risk of refracture).