Stable anatomic reduction & internal fixation allowing early mobilisation
Indications
Any fracture of radius and/or ulna shaft in an adult & especially if displaced (due to multiple muscle attachments with angulation & rotational forces which can lead to malunion & non-union)
Contraindications
? Highly contaminated open fracture requiring washout before formal fixation
Relatively contraindicated in children in that not usually required
Techniques
Compression plate & screws
IM nailing (not discussed below as not usual technique)
Principles
Careful stripping of periosteum (just enough to allow application of plate)
Accurate reduction including reduction & lagging of comminuted fragments
Expose both fractures & temporarily fix before applying plates
Definitively fix most stable & least comminuted fracture first
Centre plates over fracture with at least 4 or preferably 6 cortices each side of fracture ensuring plates are well contoured to bone
Autogenous bone graft for comminuted fractures (>1/3 circumference) though avoid IO membrane to prevent synostosis
Secure fixation that allows early postoperative mobilisation without a cast
Removal of plates only if symptomatic & not before 2 years due to high refracture rates
Approaches
Radius
Volar Henry approach (especially distal third fractures)
Dorsal Thompson approach (especially proximal third fractures)
Ulna: Posterior approach to subcutaneous border
Position
Supine with arm on hand table & torniquet applied
Incision
Depends on approach
Procedure
Via appropriate approach expose fracture & carefully strip periosteum from bone ends
Remove haematoma from fracture ends with curette
Accurately reduce fracture by matching fracture interdigitations
Choose & contour a plate to the bone (using templates)
Apply plate & hold with plate reduction forceps
Insert 1st screw closest to fracture in neutral position
Insert 2nd screw closest to fracture on other side in compression position
Insert remaining screws in neutral position
Close subcutaneous fat & skin only
Postop / Rehab
If patient cooperative & good fixation then bandage or backslab only for approximately 1/52 until comfortable & then mobilise entire arm as tolerated
If patient or fixation dodgy then may require full cast
No heavy lifting or strenuous activity until fracture(s) healed
Complications / Dangers
Neurovascular injury (depending on approach – see below)
