Radius & Ulnar Shaft Open Reduction Internal Fix - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes open reduction internal fixation of forearm fractures.
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The majority of both bone forearm fractures (radius and the ulna), require open reduction and internal fixation. We usually use a plate which will give a stable fixation and also primary bone healing. Bone healing with a transverse fracture of the radial shaft that is reduced and stabilized with a compression plate will have primary bone healing with Haversian remodeling. You should delay removal of the plate because this remodeling may take up to 2 years. Even with 5 degrees of angulation, you will do open reduction internal fixation for the radius and the ulna (must restore the radial bow). Early weight bearing after surgery is not safe. For noncomminuted fractures, you will use a compression plate technique (you want to achieve absolute stability). For comminuted fractures, you will use open reduction internal fixation with a bridge plate. We will use indirect reduction technique to achieve relative stability. We are going to use a biological technique to preserve the soft tissue attachment and avoid devascularization of the fragments. In comminuted fractures, do not disturb the fracture pieces, line up the fracture well, make sure that the rotation and angulation is good and do not do early bone grafting. The union rate does not differ between the grafted and nongrafted comminuted fractures. If you wait a little bit more, the fracture will heal, even if it is comminuted. Do not use a single incision. Use two incisions, one for the radius and one for the ulna. If you use a single incision, there will be a higher incidence of synostosis. Heterotopic ossification may occur between the radius and the ulna and that can limit the rotation of the forearm. In open fractures, you will do irrigation and debridement and immediate open reduction and internal fixation unless the wound is dirty. If the fracture is an open fracture and comminuted, and the defect is more than 1/3 of the circumference and less than 5 cm, then you will do bone graft or bone graft substitute depending on the case (grafting is usually not done acutely). If the defect is more than 5 cm, then you will probably need a free vascularize fibular graft. You will do open reduction internal fixation of the ulna if the fracture is in the proximal third of the ulna or if there is more than 50% displacement or more than 10 degrees of angulation. Fracture in the proximal ulna, you will use a posterior plate which will act as a tension band plate (it will resist the distractive forces across the fracture). Geleazzi fracture is fracture of the distal 1/3 of the radius shaft plus disruption of the distal radioulnar joint (DRUJ). If the fracture is less than 7/5cm from the joint, then there is a high incidence of DRUJ injury. We usually do open reduction internal fixation of the radius first, then we check the stability of the DRUJ. We may need to immobilize the forearm in supination or we may need to pin the DRUJ if it is unstable. If the DRUJ is irreducible, make sure that the extensor carpi ulnaris tendon is not entrapped into the joint. For metaphyseal radial fracture, use locking plate if the patient has severe osteoporosis. The IM rod in adults will give you rotational instability and axial instability if the fracture is comminuted (might be a high rate of nonunion and it is difficult to achieve the radial bow). In nonunion of the radius or the ulna, the treatment is done with a compression plate and some sort of bone graft. If you have an ulnar nail and it causes nonunion, removal of the nail is needed and then do plate and bone grafting. In general, you will do revision of the fixation if needed, utilizing the proper compression technique and the proper number of screws. Usually bone graft or bone graft substitute is used.

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