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Open Reduction Closed Fixation of the Left Ulna and Radius
Melissa S. Black
San Joaquin Valley College
Surgical Technologist Program

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INTRODUCTION OF TOPIC: Your forearm is made up of two bones, the radius and ulna. In most cases of adult forearm fractures, both bones are broken. Fractures of the forearm can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone. This article focuses on fractures that occur in the middle segments of the radius and ulna. Fractures that involve the wrist or the elbow are discussed in separate articles. Forearm bones can break in several ways. The bone can crack just slightly, or can break into many pieces. The broken pieces of bone may line up straight or may be far out of place.

Fractures of both the radius and ulna: In some cases, the bone will break in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone. This is called an open fracture and requires immediate medical attention because of the risk for infection. Because of the strong force required to break the radius or ulna in the middle of the bone, it is more common for adults to break both bones during a forearm injury. When only one bone in the forearm is broken, it is typically the ulna — usually as a result of a direct blow to the outside of your arm when you have it raised in self defense.
PATIENT HISTORY: Patient is an 11-year-old female, weighing in at approximately 81.5 lb (36.9 kg), and is 56.7″ (144 cm). Patient has no prior illnesses nor injuries and is current on all vaccinations and in generally good health. At birth patient was diagnosed with an underdeveloped cochlea and has one hearing aid in the left ear. Patient was at school and fell from a swing set, approximately 7ft off the ground and fell with her full body weight directly upon her left forearm at an unnatural angle causing an unknown obvious break/defect. Patient was transported directly from school via ambulance to the hospital and was immediately added onto the surgical schedule after in-processing in the emergency room. Several x-rays were taken with the portable imaging machine, displaying a fracture to the left radius and the left ulna bones. Due to the obvious deformity, patient pain and stress level, the patient was not moved from the ambulance gurney and was brought to the Operating Room suite upon the ambulance gurney after acquiring consent for treatment from the parents of the patient.
PATIENT CONDITION: The patient’s left arm has an obvious and easily visible deformity and has broken skin from where the radius perforated the skin and was exposed to the outside of the arm. The Ulna bone is not visible and there is no perforation of the skin, only moderate discoloration from bruising. Patient is very guarded with the left arm to the point that the RN circulator and assisting team members are unable to move the patient onto the operating room table, so on the recommendation of the doctor of anesthesiology, the transfer of the patient to the operating room table will wait until after the second stage of anesthesia has occurred. The anesthesiologist
PATIENT SYMPTOMS: Acute, incredibly sharp pain in the forearm at time of patient injury, the patient’s pain level increases and intensifies anytime there is movement and the patients clothing touches the injury site. There was a large amount of swelling around the two fractured bones, and a obvious deformation of the arm, the arm was floppy and the patient was unable to extend the arm straight, there was bleeding, feeling of bone fragments were palpable when examining the forearm, our patient’s inability to extend and straighten the arm and inability to rotate it, was because of the fracture.

PATIENT COMPLICATIONS: Some of the common types of complications after the closed reduction of a diaphyseal forearm break in pediatric patients can be re-displacement which is when the bone goes back to the same way as it was when it broke. Sometimes a loss of reduction can occur where the bones slide into a different location from where the original break occurred. Other times a re-fracture can happen where it has healed some, (such as the patient had left the fracture unfixed for days, weeks, months, or even a number of hours and the healing process has begun) and then it is rebroken, either on the initial site break or sometimes can break further bone. All of these types of complications can lead to increased stiffness of the forearms and sometimes even result in loss of motion and loss of range. These breaks and rebreaks can end up causing severe deformity and intense pain in the pediatric patient. Some of these factors that relate to the loss of reduction can be increased initial displacement of the fracture, or even the inability to get a proper anatomic reduction of the fracture during the time of initial treatment. Other times a poor casting job which is measured by the cast index occurs. A cast placed too tightly can be the beginning of compartmental syndrome. Compartmental syndrome is where the cast has been applied to the broken bone site too tightly and the initial swelling after reduction causes increased pressure in that tight space, it can compromise the tissues, nerves, and can cause them to die or suffer permanent damage. Sometimes loss of motion after the fracture of the forearm has healed is related directly to residual angulation, and also due to damage to the soft tissues. Complications after the treatment process can be as simple as an infection, and ranging to irritation from hardwares, neuropraxia, rupture of the tendons, compartmental syndrome, a delayed union, or even radioulnar stynosis.

PATIENT CONSIDERATIONS: Hearing aid and glasses, scared because can’t see so can’t lay back to be anesthetized.
DIAGNOSTIC TESTS: The diagnosis process begins with a study of the clinical history and the mechanism of injury leading up to the forearms fracture. The initial examination focuses on skin lacerations, open fractures appearance and coloring, and evaluation of the bruises on the skin. The exam continues to the shoulder and the upper arm, then moving to the wrist and the hand to diagnose if there are noncomitant injuries. The area is palpated to get a basis for the pain and tenderness of the area while also feeling for injury to the blood vessels and testing to see if the radial nerve has been damaged. It is important to establish what the patients range of motion currently is so treatment can be planned. X-rays are then taken both antero-posterior and laterally of the radius and ulna together to get an evaluation of the fracture. No CT scan or MRI was completed as a diagnostic test for this patient. Sometimes for these patients are given doppler ultrasonography to ensure that the vasculature of the forearm is intact, or get an evaluation where damage may have occurred.
WHAT TECHNIQUES WILL BE USED: Open Reduction, Internal Fixation (O.R.I.F.) will be utilized for our patients forearm fractures. For this patient the Nancy Nail system will be used for temporary fixation to align the bone shafts properly prior to plate placement. These nails will be placed percutaneously through the elbow under live xray visualization. It will begin with a large skin incision, place a plate along the fracture and then it will be fixed into place with screws. This method is the most common and sometimes can require a bone graft when the fracture has been open and sections or pieces of the bone have gone missing now. Since this is a pediatric patient the hardware will be removed after 6-8 weeks because the patient is still growing, the plates and nail system will hinder the proper growth of the bones.
SETUP OPENING SUPPLIES, instruments, sets, trays: SYNTHES Mini Fragment Instrument and Implant Set with Self Tapping screws, In House Ortho tray, stryker drill set, stryker LG batteries x2, Lambotte bone chisel tray assorted, spint curette tray set, K-wires 2-0, 2.5, 3.0, Freer, osteotome set, Strylker core Driver set, Nancy Nail Set For Elastic Stable Intramedullary Nailing (ESIN,
SETUP BACK TABLE:
SETUP MAYO STAND:
PATIENT POSITIONING: supine, left arm extended on arm board
PATIENT PREP:
PATIENT DRAPING/CONSIDERATIONS:
DRAPING OF THE C-ARM:
TIMEOUT CONDUCTED:
SKIN MARKING:
INCISION:
DERMIS LAYER OF SKIN AND WHAT IS HAPPENING:
DEEPENING THE INCISION:
WHAT IS HAPPENING IN THE WOUND/PASS SOME RETRACTORS:
PREPARATION OF HARDWARE:
ORDER OF PASSING MY INSTRUMENTS AND COMPLICATIONS AS IT GOES WITH THE RESIDENT
TAKING IMAGES WHILE WE WORK, WHAT DOES IT LOOK LIKE:
BLEEDING CONTROL AND EXAMINATION OF HARDWARE OPTIONS:
ONCE HARDWARE IS SELECTED, HOW IS IT IMPLANTED:
THE PLATE IS IN, NOW THEY DRILL GUIDE HOLES
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(RADIUS SCREW 1) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLES
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(RADIUS SCREW 2) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLES
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(RADIUS SCREW 3) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
IMPLANT IS SEATED, WHAT DOES IT LOOK LIKE ON IMAGES, HOW MANY PICTURES ARE TAKEN:
MOVING TO THE ULNA, INCISION, RETRACTION, BLOOD LOSS:
PICK SIZE OF PLATE:
NOW THEY DRILL GUIDE HOLES
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 1) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
PLATE IS HOLDING ON NOW WITH 1 SCREW, WHAT DOES IT LOOK LIKE ON IMAGES, HOW MANY PICTURES ARE TAKEN:
NOW THEY DRILL GUIDE HOLE FOR NEXT SCREW:
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 2) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLE FOR NEXT SCREW:
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 3) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLE FOR NEXT SCREW:
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 4) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLE FOR NEXT SCREW:
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 5) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
NOW THEY DRILL GUIDE HOLE FOR NEXT SCREW:
USING THE DEPTH GUAGE WHAT TYPE OF SCREWS ARE THEY USING AND WHY?:
PASSING A DRILL WITH THE REQUIRED BIT:
(ULNA SCREW 6) NOW THAT THERES A SCREW HOLE AND IT’S BEEN MEASURED PASS THE SCREWS ON DRILL BIT AND THEN PASS A HAND TAMP:
THERE WILL BE A LOT OF IRRIGATION DONE NOW START AT RADIUS MOVE TO ULNA:
RADIUS CLOSURE OF THE MUSCULAR LAYER:
RADIUS CLOSURE OF THE FATTY LAYER:
RADIUS CLOSURE OF THE SKIN LAYER:
ULNA CLOSURE OF THE MUSCULAR LAYER:
ULNA CLOSURE OF THE FATTY LAYER:
ULNA CLOSURE OF THE SKIN LAYER:
WHAT KIND OF DRESSING IS BEING DONE:
CLEANUP OF FIELD:
BREAK SCRUB AND HELP TRANSFER PATIENT TO GURNEY:
PATIENT LEAVES, WHAT IS THEIR FINAL DIAGNOSIS AND HOW DID THEY TOLERATE THE PROCEDURE:
CLEANUP OF FINAL ITEMS, PUTTING SPRAY ON THE INSTRUMENTS:
WASTE AND WITNESS:
ROOM TURNOVER/CASE COMPLETE:

References:

https://orthoinfo.aaos.org/en/diseases–conditions/adult-forearm-fractures/
References:
https://www.netdoctor.co.uk/procedures/surgical/a4619/radius-and-ulna-fracture-8211-internal-fixation/
https://www.ncbi.nlm.nih.gov/pubmed/8865053
http://pathologies.lexmedicus.com.au/pathologies/forearm-fractures-2
https://www.hss.edu/conditions_distal-radius-fractures-of-the-wrist.asp
https://emedicine.medscape.com/article/1239870-treatment
http://www.pei.ie/PEI/media/PEI-media/PDFs/PDFs_Ortho/PDFs_Ortho_Products/PDFs_Ortho_Products_DePuy/nancy_nails_surgical_technique.pdf

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