Throughout this treatment option illustrations of generic fracture patterns are shown, as four different types:
A) Unreduced fracture
B) Reduced fracture
C) Fracture reduced and fixed provisionally
D) Fracture fixed definitively
The modular external fixator is optimal for temporary use. It is rapidly applied without need for intraoperative x-rays and can be adjusted later.
Details of external fixation are described in the basic technique for application of modular external fixator.
Specific considerations for the forearm shaft are given below.
In Galeazzi fracture-dislocations, anatomical reduction and stable fixation of the radius are mandatory if accurate and stable reduction of the ulnar head and a satisfactory outcome are to be achieved.
For details on the stabilization of a dislocated distal radioulnar joint see:
DRUJ stabilization (Galeazzi fracture-dislocation)
If stabilization is not possible a joint bridging fixator may be used.
Beware of injuries to the neural structures:
Blunt dissection is performed using an instrument such as a small artery clip. This should displace important anatomic structures, which may then be retracted with small Langenbeck retractors. It is important to be aware of the anatomic structures at each level so that care can be taken to avoid damaging them (see Safe zones for pin placement in the forearm).
The pin should be inserted in the first cortex and through the center of the bone into the far cortex. Care should be taken to avoid the tip of the pin protruding significantly through the far cortex to avoid damage to neurovascular structures.
In the distal third of the forearm, the track for the pin passes between the extensor pollicis longus (EPL) and the radial wrist extensors.
The pins need to be inserted under direct vision using retractors down to the bone to avoid the superficial branch of the radial nerve.
Great care is required during the manual insertion of the proximal radial pins.
The supinator muscle cloaks the dorsal aspect of the upper 3rd of the radius, with the posterior interosseous nerve running through its substance.
The track for the pin must be distal to the neck of the radius and passes between the extensor carpi ulnaris muscle and the mobile wad. It will penetrate the supinator muscle.
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.
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.
This is repeated with the wrist in full supination and full pronation.
In order to test the stability of the distal radioulnar joint, the ulna is compressed against the radius...
...while the forearm is passively put through full supination...
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.
Proper pin insertion
To prevent postoperative complications, pin-insertion technique is more important than any pin-care protocol:
Various aftercare protocols to prevent pin-track infection have been established by experts worldwide. Therefore, no standard protocol for pin-site care can be stated here. Nevertheless, the following points are recommended:
Pin loosening or pin-track infection
In case of pin loosening or pin-track infection, the following steps need to be taken:
Before changing to a definitive internal fixation an infected pin track needs to heal. Otherwise infection will result.
Functional aftercare should be performed.
See patient 7-10 days after surgery for a wound check. X-rays are taken to check the reduction.