diaf an brat

8/2/2019 Diaf an Brat

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AP and lateral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simpleoblique fracture patterns.


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The patient is positioned supine with the arm prepped anddraped to just above the elbow and a tourniquet in place.This figure demonstrates the arm held in supination. Note theposition of the biceps insertion as well as the palpable tendon

of the FCR and radial artery.

BICEPS

TENDON

RADIAL

ARTERY

FLEXOR CARPI

RADIALIS

(FCR)


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A useful technique to make the skin incision is to take a bovicord and pull it taught from the radial side of the biceps tendonto the FCR at the level of the wrist. This can then be used asa template for the incision line.


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The incision is taken down through the skin, identifying the fasciallayer with care taken not to damage any superficial veins that maybe intact. The FCR tendon is clearly visible throughout the wound,as is the radial artery in the distal extent of the wound.

FCR

RADIAL

ARTERY


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A closeup of the distal aspect of the wound demonstratingThe radial artery and its venous commtantes.

RADIAL ARTERY AND

VENOUS COMMTANTES


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The radial artery may be taken in either direction, however,

typically it is easier to take the artery to the radial side.

FCR

RADIAL

ARTERY


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The deep dissection is now performed between the flexor-pronator mass on the ulnar side and the artery and themobile wad on the radial side.


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PRONATOR

For the proximal dissection, the forearm is brought intosupination and the pronator, FDS and FDP are released

from the volar aspect of the radius


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FDS

The pronator is being released from the radial aspect of theradius in a subperiosteal manner. This subperiostealdissection continues distally to release the origin of the

common flexor.


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After exposure of the volar aspect of the radius proximallyand distally, two clamps can be placed on the ends of thebone in order to deliver them for cleaning.


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FCR

RADIAL ARTERY

Each side of the fracture is be delivered in order toexpose and clean the cortical edges.


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These figures demonstrate delivery of the distal fragment and acurved curette being used to clean the cortical edge. Nocleaning should be performed within the intramedullarycanal,as this is healthy tissue and can be useful for the healing

process.


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Once the fractures are completely cleaned along their corticaledges such that the fracture reduction can be visualized, the twoclamps are used to reduce the fracture. If a butterfly fragmentexists, it is necessary to fix this with a lag screw back to one of

the fracture ends in order to realign the fracture.


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In the current case, the fracture is a simple pattern and is reducedby delivering the bones jointly, accentuating the deformity and thenrotating and fitting the bones together with progressive compressionwhile pushing the bones back into the wound, obtaining alignmentby steric interference of one side against the other.


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Once the bones are held reduced, as seen in the followingsequence, an appropriate dynamic compression plate isplaced and held in place with a clamp. It is important thatthis plate must have the appropriate bend for the volaraspect of the forearm so as not to gap open the dorsal sideas the plate is fixed to the bone. Thus, it should be slightlyunderbent with respect to the standard volar concavity.


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These figures demonstrate reduction of the fracture with a plateheld in place on the flat, volar aspect of the bone.Once the reduction is confirmed fixation of the plate is performedusing a compressive technique through the plate.


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The following sequence demonstrates using the offset drillguide to place an eccentrically drilled hole away from thefracture. The screw is placed to the point where it abuts

but is not inserted completely within the plate until it isaffixed on the other side.


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HOLE

ECCENTRICALLY

ILLUSTRATED


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In a similar fashion to the first screw, the second screw is placedon the opposite side of the fracture, also eccentrically away from

the fracture. By compressing these two screws against the platethe fracture is translated and compressed together as shown inthe following sequence.


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This image demonstrates the reduced fracture, viewedfrom the volarly.


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This image shows that the fracture is also compressed on the oppositeside due to proper contouring of the plate. Once the radius is fixed, theulna is approached using a standard subcutaneous longitudinal incision

with the arm flexed, as seen in the next image.


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These images demonstrate the superficial dissection downto the fascia directly over the ulna, which is the commonfascia between the flexor carpi ulnaris and the extensor

carpi ulnaris. This is divided in line with the muscles directlyover the subcutaneous border of the ulna.


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ECUEXTENSOR

CARPI ULNARIS

FCUFLEXOR

CARPI ULNARIS


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A periosteal elevator is used to cleanthe external surface of the ulna.


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This is cleaned, reduced and fixed in exactly the same fashion asthe radius was, using a 6-hole DCP plate and in compressive mode.These images show the plate in place with screw holes, allowing forcompression in the final compressed fracture.


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Intraoperative fluoroscopic views demonstrate accuratereduction and appropriate length of screws.


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Postoperative AP and lateral views demonstratinganatomic reduction and alignment of the radius and ulna.

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