A Postoperative Evaluation and Management 1 Provides post-operative management and rehabilitation postop visit: 1 week visit R/O Postoperative infection Cast Check Neurovascular check AP and Lateral Forearm Xray Evaluation Asses reduction and hardware location postop: 4-6 week postoperative visit wound check change splint/cast and continue non-weight bearing check radiographs diagnose and management of early complications<br /> postop: 6 month postoperative visit remove nails in the OR 2 Capable of diagnosis and early management of complications compartment syndrome able to recognize the signs and symptoms of compartment syndrome postoperative Neuropraxia able to recognize the signs of radial, ulnar and median nerve neropraxia and take early steps at management remove cast, evaluate for hematoma, compartment syndrome B Advanced Evaluation and Management 1 Able to recognize the signs, symptoms, and causes of delayed union and nonunion of radius and ulna fracture 2 Recognizes signs of delayed healing on radiographs Orders Laboratory workup Orders MRI 3 Recognizes excessive loss and manages excessive loss of range of motion Orders physical therapy to treat decreased range of motion postoperatively 4 Recognizes the signs of complex regional pain syndrome 5 Recognizes and manages Compartment syndrome in timely manner Able to perform compartment pressure measurements Able to perform forearm compartment fasciotomies C Preoperative H & P 1 Obtains history and performs physical exam mechanism of injury check for any open wounds Recognize vascular, nerve or other associated injuries assess AIN, median, radial and ulnar nerve function AIN neuropraxia (test A-OK sign) radial nerve (thumb/wrist extension) palsy ulnar nerve (hand intrinsics) radial and ulnar pulse assessment assesses the soft tissue 2 Order basic imaging studies AP and lateral forearm radiographs the entire radius and ulna are essential 3 Prescribe nonoperative treatments most both bone forearm fractures are treated with closed reduction and long arm casting relative indications for operative treatment with internal fixation: open fracture, loss of reduction with closed treatment, unstable fracture, pathologic fracture, refracture, floating elbow, inability to obtain adequate reduction 4 Perform operative consent describe complications of surgery including hardware prominence sensory neuropraxia infection extensor tendon irritation or rupture neurovascular injury delayed union nonunion malunion refracture compartment syndrome
E Preoperative Plan 1 Template fracture and determine nail size characterize fracture: determine location in shaft of fracture(s); comminution; open vs closed determine size of appropriate nail: measure at narrowest part of diaphysis; should have 2/3 canal fill 2 Execute surgical walkthrough describe key steps of the operation verbally to attending prior to beginning of case. describe potential complications and the steps to avoid them F Room Preparation and Positioning P 1 Surgical instrumentation flexible intramedullary nails and inserter "F" reduction tool basic ortho tray in case fracture needs to be opened for reduction sterile tourniquet available c-arm flouroscoupy Pitfalls Have sterile tourniquet available but only use during soft tissue dissection or when having to open fracture Avoid using during nail placement as can increase risk of compartment syndrome 2 Room setup and equipment setup OR with standard operating table radiolucent hand table turn table 90° so that operative extremity points away from Anesthesia machines C-arm in from foot of bed 3 Patient positioning supine patient with shoulder at edge of bed arm board centered at level of patient’s shoulder G Proximan Ulna Nail Entry 1 Identify the starting point the starting point is on the lateral edge of the subcutaneous border of the proximal ulna alternate starting point is posterior border of olecranon use fluoroscopy to confirm appropriate starting point 2 Enter the intramedullary canal use the awl or drill to percutaneously enter the intramedullary canal of the proximal ulna H Ulna Nail Placement P 1 Nail contour- as ulna has a straight border, no real contouring is needed as an alternative a smooth steinman pin of the same size caliber as a nail can be used Pearls An advantage of a large steinman pin is it can be left sticking out of the skin and removed without another operation We recommend this for smaller children but not fractures that may have slower healing (open fracture, older child) 2 Advance nail advance the nail through the proximal ulna use fluoroscopic guidance to confirm placement in two planes advance nail to the fracture site I Reduction of the Ulna and Nail Passage 1 Reduce the ulna reduce the ulna with longitudinal traction and AP compression if unable to reduce the fracture adequately closed then open fracture and reduce 2 Pass the nail across the fracture site If three unsuccessful pass attempts, open fracture site and reduce before further attempts at nail passage(to avoid causing iatrogenic compartment syndrome) 3 Cut the ulna nail at the appropriate length cut the nail so that it is subcutaneous aim for this to be slightly palpable but not prominent J Distal Radius Approach P 1 Identify the entry point for the radius nail 2 Mark level of the physis, entry point is proximal to this Pearls Can consider doing exposure/marking starting point of both nails to decrease manipulation needed after reducing fracture 3 Radial/lateral entry: start the entry of the distal radius between 1st and 2nd dorsal compartments 4 Dorsal entry: an alternative entry point is the interval between the second and third dorsal compartment near the proximal base of the tubercle of Lister 5 Make skin incision protect the superficial branches of the radial nerve 6 Expose the distal radius K Distal Radius Entry and Nail Insertion P 1 Create entry point on radius use awl or drill if entry point is made with a drill a small tipped rongeur can be used to turn the entry point from a circle into a oval 2 use fluoroscopic guidance to confirm the starting point (avoid physis) 3 Insert nail into radius contour the nail with a smooth bend to restore appropriate radial bow use partial right and left rotations to gain satisfactory entrance into the distal radius insert nail under fluoroscopic and/or direct visualization feel the intramedullary canal with the tip of the nail and confirm intraosseous position with AP and lateral fluoro images Pitfalls avoid acute bends in nail and aim for a smooth contour L Reduction and Nail Passage within the Radius P 1 Advance nail to the fracture site advance the nail to the level of the fracture 2 Reduce the fracture reduction is achieved with longitudinal traction and AP compression 3 can also use "F" tool if unable to reduce the fracture adequately closed then open fracture and reduce 4 Advance the nail past the fracture site rotate the nail to pass the nail past the fracture site and advance to the appropriate depth If unable to successfully pass after three attempts, open fracture and reduce prior to further nail passage attempts Pitfalls Avoid multiple unsuccessful passes as this may increase risk of compartment syndrome (open to reduce after 3 passes) N Final Rotation and Cutting of the Radial Nail and Wound Closure P 1 Rotate the nail to restore the radial bow and check rotation check the relationship between the radial styloid and the bicipital tuberosity as well as the ulnar styloid and the coronoid process 2 Cut the nail so that is slightly palpable but not prominent Pitfalls Avoid nail prominence which can cause irritation of superficial branch of radial nerve or extensor tendons 3 Irrigate the incisions copiously irrigate the wound 4 Superficial wound closure close the entry sites with absorbable subcutaneous (2-0 vicryl) and subcuticular suture (3-0 monocryl) and apply dermabond or steristrips 5 Dressings apply light nonstick dressing, sterile gauze and sterile padding wrap. 6 Postoperative immobilization depending on stability, can cast or splint for extra control and comfort if swelling is of concern use sterile foam padding prior to wrapped dressings with a cast or use a splint
O Perioperative Inpatient Management 1 Discharge patient appropriately observe at least overnight for compartment monitoring pain meds/antibiotics cast/splint care non weightbearing manage swelling monitor neurological and vascular status schedule follow up in 1 week