Authors of section

Authors

Dominik Heim, Shai Luria, Rami Mosheiff, Yoram Weil

Executive Editor

Chris Colton

Open all credits

ORIF - Plating of one or both bones

1. Indications

The preferred treatment of simple fractures of the ulna is compression plating (with or without lag screw) leading to absolute stability and direct bone healing.

The preferred treatment of bifocal fractures of the radius is compression plating (with or without lag screw) leading to anatomical restoration of length and radial curvature, rotational alignment, and absolute stability. The blood supply of the intermediate fragment must be meticulously preserved throughout.

In certain circumstances, compression plating of the radius may not be achievable and other management options should be considered.

Some segmental fractures cannot be treated by compression plating for technical reasons and occasionally, bridge plating of the radius is indicated; in such circumstances, the blood supply of the intermediate fragment must be meticulously preserved.

Anatomical reduction cannot be achieved in fragmentary segmental fractures, but maintaining relative stability using bridge plating is widely accepted. Either conventional, or locked (if available), plates can be used as long as the principles of minimizing stripping, and restoring both length and alignment are respected.

2. Principles

Order of fixation

Normally, in both bone fractures, the simpler fracture will be approached first, and preliminary fixation undertaken.

Fixation of the fractures involving both bones proceeds as follows:

  1. Reduction and preliminary fixation usually starts with the ulna
  2. Reduction and definitive fixation of the radius
  3. Definitive fixation of the ulna

Never commit yourself to the definitive fixation of one bone until you have assured yourself that you can reduce the other bone.

Throughout this module, the fixation of each bone will be described to completion but the surgeon is reminded not to complete the first fixation until the second bone has been definitively fixed.

Principles

Note on approaches

When both bones need to be reduced and fixed, a separate approach to each bone should be performed in order to reduce the risk of heterotopic bone formation.

For proximal radial shaft fractures, the anterior approach (Henry) is most often used to minimize the risk of damage to the posterior interosseous nerve, which crosses the proximal radius within the supinator muscle.

In mid and distal radial shaft fractures, either the anterior approach (Henry) or posterolateral approach (Thompson) can be used, depending on surgeon’s preference.

The ulna shaft is exposed by the standard subcutaneous approach between the flexor and extensor muscle compartments.

The approach for nailing of the radius is either through the ulnar side of the radial styloid, or on the radial side of the Lister’s tubercle.

3. Patient preparation

This procedure is normally performed with the patient in a supine position.

Supine position

4. Detailed procedures

When the ulna is intact and the there is a segmental fracture of the radius, the possibility of a Galeazzi injury of the DRUJ must always be considered: this will be likely to reduce with anatomical reduction and fixation of the radius but must be checked at the end of the procedure.

Detailed procedures

In the absence of a ulnar head dislocation, the only option to be considered is compression fixation of the segmental radial fracture by plating.

If the ulnar head is dislocated, see the section on instability of the DRUJ.

Detailed procedures

In fractures where the ulna has a simple or a wedge fracture and there is a segmental fracture of the radius, the sequence of fixation is likely to be:

  1. Preliminary fixation of the ulnar fracture
  2. Definitive fixation of the segmental fracture of the radius
  3. Definitive fixation of the ulnar fracture

The required techniques are:

Detailed procedures

When the ulna has a simple or a wedge fracture and there is a fragmentary segmental fracture of the radius, the sequence of fixation is likely to be:

  1. Preliminary fixation of the ulnar fracture
  2. Definitive fixation of the fragmentary fracture of the radius
  3. Definitive fixation of the ulnar fracture

The required techniques are:

Detailed procedures

5. Completed osteosynthesis

This illustration shows an example of a completed osteosynthesis.

Completed osteosynthesis

6. Check of osteosynthesis

Check the completed osteosynthesis by image intensification. Make sure that the plate is at a proper location, the screws are of appropriate length and a desired reduction was achieved.

Check of osteosynthesis

The elbow should be stabilized at the epicondyles and the forearm rotation should be checked between the radial and ulnar styloids.

Check of osteosynthesis

7. Assessment of Distal Radioulnar Joint (DRUJ)

Before starting the operation the uninjured side should be tested as a reference for the injured side.

After fixation, the distal radioulnar joint should be assessed for forearm rotation, as well as for stability. The forearm should be rotated completely to make certain there is no anatomical block.

Method 1

The elbow is flexed 90° on the arm table and displacement in dorsal palmar direction is tested in a neutral rotation of the forearm with the wrist in neutral position.

This is repeated with the wrist in radial deviation, which stabilizes the DRUJ, if the ulnar collateral complex (TFCC) is not disrupted.

external fixation

This is repeated with the wrist in full supination and full pronation.

external fixation

Method 2

In order to test the stability of the distal radioulnar joint, the ulna is compressed against the radius...

external fixation

...while the forearm is passively put through full supination...

external fixation

...and pronation.

If there is a palpable “clunk”, then instability of the distal radioulnar joint should be considered. This would be an indication for internal fixation of an ulnar styloid fracture at its base. If the fracture is at the tip of the ulnar styloid consider TFCC stabilization.

Pronation

8. Postoperative treatment

Functional aftercare

Following stable fixation, postoperative treatment is usually functional.

Immobilization in a circular cast may compromise the range of motion later. However, since soft-tissue swelling, and edema are associated with these high-energy fractures, a temporary immobilization with a well-padded, bulky splint for 10-14 days is advised to allow adequate soft-tissue healing. During this period, elevation, gentle finger motion, active and passive, together with elbow flexion/extension and shoulder motion, can be started. The splint is then removed and active assisted range of motion exercises, including gentle forearm rotation, begin.

Lifting and resisted exercises are restricted until radiographic signs of healing appear. More intensive exercises, such as progressive resisted exercises can start at that time. Timing of return to sport will depend on the individual patient and the nature of the sport.

functional aftercare

Follow-up

Close postoperative follow-up is required in these fractures. In those that have been treated by means of relative stability, secondary bone healing with callus formation is anticipated and early signs of delayed union should alert the surgeon to consider secondary interventions, such as bone grafting.

Follow-up x-rays should be obtained according to local protocol. X-rays to assess fracture position are usually taken at 1, 2, and 4 weeks after operation. Subsequent x-rays are usually taken to assess bony healing at appropriate intervals from 6-8 weeks, depending on the fracture configuration and potential for healing.

follow-up

Implant removal

In forearm shaft fractures, the issue of implant removal is controversial. As the radius and ulna are not weightbearing bones, and as removal of plates can be a demanding procedure, implant removal is not indicated as a routine. There is a high risk of nerve damage associated with procedures to remove forearm plates.

Furthermore, as there is significant risk of refracture, most surgeons prefer not to remove plates from the forearm.

The general guidelines today are:

  • removal only in symptomatic patients, possibly only on the ulna where the implants are subcutaneous
  • removal no earlier than 2 years after osteosynthesis
  • If both bones have been plated, sequential removal of implants with a least 6 months in between is recommended (risk of refracture).