A Intermediate Evaluation and Management 1 Perform focused history and physical exam recognizes implications of soft tissue injury open fracture median nerve dysfunction DRUJ instability check radial/ulnar artery patency of operative extremity with Allen’s test 2 Orders/ interprets advanced imaging: 3 Makes informed decision to proceed with operative treatment describes accepted indications and contraindications for surgical intervention surgical indications displacement of both bones instability 4 Perform a closed reduction and splint appropriately place in sugartong splint after reduction 5 Recognition/ eval fragility fx orders appropriate work-up and/or consult 6 Modify and adjust post-op plan when indicated postop: 2-3 week postoperative visit wound check and remove sutures diagnose and management of early complications remove surgical splint and place in removable splint begin range of motion exercises to wrist and hand continue non-weightbearing from 2-6 weeks 5 lb weight restriction restricted work duty including no repetitive forearm twisting until union occurs postop: 6 weeks check radiographs for union if union present, remove restrictions if union has not occurred, place a 20 lb weight restriction postop: 1 year postoperative visit B Advanced Evaluation and Management 1 Interpretation of diagnostic studies for fragility fractures with appropriate management and/or referral C Preoperative H & P 1 Perform history and physical exam check radial/ulnar artery patency of operative extremity with Allen’s test 2 Orders and interprets basic imaging studies need biplanar films of wrist, forearm and the elbow compare to contralateral wrist xray for on the lateral the radial styloid is aligned with the center of the lunate the head of the ulna should be obscured by the radius place in sugartong splint 3 Perform operative consent describe complications of surgery including nonunion malunion infection wound breakdown compartment syndrome radioulnar synostosis
E Preoperative Plan 1 Identify fracture characteristics fracture pattern DRUJ disruption amount of comminution 2 Execute surgical walkthrough describe key steps of the procedure to the attending verbally prior to the start of the case describe potential complications and steps to avoid them F Room Preparation 1 Surgical instrumentation ensure desired plate system of choice is present in the room 2 Room setup and equipment setup OR with standard operating table and radiolucent hand table turn table 90° so that operative extremity points away from anesthesia machines c-arm perpendicular to hand table with monitor in surgeon's direct line of site 3 Patient positioning supine with shoulder at edge of bed centered at level of patient’s shoulder arm tourniquet placed on arm with webril underneath (optional) G Posterior Approach to the Radius 1 Mark out the anatomy palpate Lister`s tubercle at the dorsal aspect of the distal radius palpate the lateral epicondyle 2 Mark both structures 3 Extend the diathermy cord between these bony prominences 4 Center the skin incision over the fracture site 5 Identify the fracture site place a straight metal instrument transversely to the forearm and expected fracture site use fluoroscopy to find the level of the fracture site mark the fracture site with a transverse line 6 Make the skin incision 7 Perform blunt superficial dissection in the interval between the ECRB and the EDC distally where the abductor pollicis longus transversely spans the forearm by extending the incision proximally, the PIN will be exposed where it leaves the supinator 8 Mobilize the PIN from the deep head of the supinator 9 Identify the radius split the deep head to reach the radius proximally be aware that fibers from the pronator teres encroach into the field over the middle radius 10 Expose enough radius for placement of the plate distally lift the APL from the radius to provide room for the plate H Posterior Approach to the Ulna 1 Identify the fracture site use a straight metal object to identify the fracture site using fluoroscopy 2 Center the incision over the fracture 3 Identify anatomic landmarks palpate the olecranon and the ulnar head 4 Make a skin incision make the incision over the fracture so that it is in line with the olecranon and the ulnar head 5 Deepen the incision down to the fascia open the epimysium over the ECU expose the interval between the ECU and the FCU distally expose the interval between the FCU and the anconeus proximally I Reduction of the Radius 1 Prepare the fracture ends use bone holding clamps to deliver the radius fracture ends into the wound with oblique fractures use a lobster claw reduction clamp placed on either side of the fracture site angle the clamp about 30 degrees to the longitudinal axis of the bone this should allow control of both fracture fragments prepare the fracture fragments by completely cleaning off any soft tissue debris 2 Reduce the fracture reduce the fracture fragments by applying longitudinal traction and rotation 3 Place provisional fixation place a bone clamp to obtain provisional stability across the fracture site J Reduction of the Ulna 1 Prepare the fracture ends use bone holding clamps to deliver ulna the fracture ends into the wound with oblique fractures use a lobster claw reduction clamp placed on either side of the fracture site angle the clamp about 30 degrees to the longitudinal axis of the bone this should allow control of both fracture fragments prepare the fracture fragments by completely cleaning off any soft tissue debris 2 Reduce the fracture fragments reduce the fracture fragments by applying longitudinal traction and rotation 3 Place provisional fixation place a bone clamp to obtain provisional stability across the fracture site K Fixation of the Ulna 1 Place the plate lift the clamp and place the plate 2 Replace the clamp 3 Place initial screws fill the two holes closest to the fracture fragment first 4 Place an interfragmentary screw 5 Check the reduction of the radius after reduction of the radius fill the remaining screw holes with nonlocking or locking screws 6 Confirm placement and reduction using fluoroscopy L Fixation of the Radius 1 Place the plate lift the clamp and place the plate 2 Replace the clamp 3 Place initial screws fill the two holes closest to the fracture fragment first place an interfragmentary screw fill the remaining screw holes with nonlocking or locking screws N Wound Closure 1 Irrigate the wound 2 Deep closure use 3-0 vicryl for the subcutaneous tissue 3 Superficial closure use 4-0 monocryl
O Perioperative Inpatient Management 1 Discharges patient appropriately pain meds wound care do not remove splint until follow up appointment in 2 weeks prescribe outpatient physical therapy non-weightbearing