Mechanism of Injury
Signs and Symptoms
Imaging and Other Diagnostic Studies
Pathoanatomy and Applied Anatomy
Triangular Fibrocartilage Complex (TFCC)
Proximal Radioulnar Joint
Principles of Treatment
Management of Expected Adverse Outcomes and Unexpected Complications
Implant Removal and Re-Fracture
Acute Compartment Syndrome
Author’s Preferred Treatment
Summary, Controversies, and Future Directions
DCP, dynamic compression plate; PC-Fix, point contact fixator; LC-DCP, limited contact dynamic compression plate; LCP, locking compression plate; IM, intramedullary; E, excellent; S, satisfactory; G, good; A, acceptable; UA, unacceptable; DASH, Disabilities of the arm, shoulder, and hand questionnaire.
With the patient supine and a nonsterile tourniquet on the arm, radial fractures are exposed through a volar approach for distal half to distal two-third fractures, whereas proximal third fractures are exposed via a dorsal Thompson approach. The ulna is exposed through a standard ulnar approach. The tourniquet is not routinely inflated to reduce postoperative pain and the theoretical risk of reperfusion edema, especially in longer cases. In both-bone forearm fractures, the less comminuted fracture is exposed and fixed first, followed by exposure of the other bone. This allows realignment not only of the fracture but also of the soft tissues, thereby improving orientation during exposure. Forearm shaft fractures are treated almost without exception with nonlocking plate and screw fixation using 3.5 mm implants. Dynamic plate compression, lag screw fixation with neutralization plating, and bridge plating are used according to the fracture geometry. A total of three bicortical screws are used as the norm, proximal and distal to the fracture site (Fig. 33-30). For fractures of the distal or proximal ends of the ulna or radius precontoured plates or smaller implants may be required (Figs. 33-24 and 33-31). Examination of the DRUJ and PRUJ for instability is performed once definitive stabilization has been achieved. Full pronation supination and elbow and wrist flexion–extension should be present as well.
Monteggia fractures are approached with the patient supine, a nonsterile tourniquet on the arm, and the upper extremity placed over the patient’s chest during exposure. This is the routine position for all elbow-related injuries, thereby standardizing anatomic orientation. This is of special importance when associated injuries to the proximal ulna or radius have to be addressed. In simple Monteggia fractures involving only the ulnar shaft fracture, a posterior approach is selected. An incision directly over the olecranon tip is avoided with the incision being directed radially at the level of the olecranon and redirected centrally more proximally. If the fracture affects the proximal ulnar metaphysis a proximal ulna plate is selected. Otherwise, a standard 3.5-mm plate is used and contoured as required. Care is taken not to penetrate the articular surface when proximal screws are placed. Once provisional fixation after anatomic ulnar reduction has been achieved, adequate reduction of the PRUJ is fluoroscopically confirmed. Final screw placement is then performed and the elbow checked for full elbow flexion–extension and forearm rotation. Careful examination of the DRUJ is also performed at this point.
Galeazzi fracture dislocations are addressed in a similar manner to radial shaft fractures in both-bone forearm fractures. Once anatomic reduction of the radius has been achieved, the DRUJ is examined. If reduction is not obtained or a “spongy” reduction is palpated, soft tissue interposition is suspected and the DRUJ exposed. At this point repair of the TFCC may be performed. If the DRUJ continues to be unstable after reduction of the radial shaft fracture, DRUJ translation is examined at different positions of forearm rotation. The position that allows the least amount of translation is selected and two 2 mm Kirschner wires are placed from the ulna into the radius. The most distal pin is placed just proximal to the distal ulnar facet of the radius. The second pin is placed 1 cm proximal to the first pin. Pins are then bent and cut and the forearm immobilized in a long arm splint without changing forearm rotation.