AP and lateral views of the both bones fracture of the forearm, demonstrating significant shortening and relatively simple

oblique fracture patterns.

RADIAL ARTERY

BICEPS TENDON

FLEXOR CARPI RADIALIS (FCR)

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

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

FCR RADIAL ARTERY

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

RADIAL ARTERY AND VENOUS COMMTANTES A closeup of the distal aspect of the wound demonstrating The radial artery and its venous commtantes.

FCR

RADIAL ARTERY The fascia on the radial side of the flexor carpi radialis is released, exposing the deep tissue. The radial artery can be followed now throughout the entire incision.

FCR

RADIAL ARTERY
The radial artery may be taken in either direction, however, typically it is easier to take the artery to the radial side.

The deep dissection is now performed between the flexorpronator mass on the ulnar side and the artery and the mobile wad on the radial side.

PRONATOR For the proximal dissection, the forearm is brought into supination and the pronator, FDS and FDP are released from the volar aspect of the radius

FDS

The pronator is being released from the radial aspect of the radius in a subperiosteal manner. This subperiosteal dissection continues distally to release the origin of the common flexor.

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

FCR

RADIAL ARTERY Each side of the fracture is be delivered in order to expose and clean the cortical edges.

These figures demonstrate delivery of the distal fragment and a curved curette being used to clean the cortical edge. No cleaning should be performed within the intramedullary canal,as this is healthy tissue and can be useful for the healing process.

Once the fractures are completely cleaned along their cortical edges such that the fracture reduction can be visualized, the two clamps are used to reduce the fracture. If a butterfly fragment exists, it is necessary to fix this with a lag screw back to one of the fracture ends in order to realign the fracture.

In the current case, the fracture is a simple pattern and is reduced by delivering the bones jointly, accentuating the deformity and then rotating and fitting the bones together with progressive compression while pushing the bones back into the wound, obtaining alignment by steric interference of one side against the other.

Once the bones are held reduced, as seen in the following sequence, an appropriate dynamic compression plate is placed and held in place with a clamp. It is important that this plate must have the appropriate bend for the volar aspect of the forearm so as not to gap open the dorsal side as the plate is fixed to the bone. Thus, it should be slightly underbent with respect to the standard volar concavity.

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

The following sequence demonstrates using the offset drill guide to place an eccentrically drilled hole away from the fracture. The screw is placed to the point where it abuts but is not inserted completely within the plate until it is affixed on the other side.

HOLE ECCENTRICALLY ILLUSTRATED

In a similar fashion to the first screw, the second screw is placed on the opposite side of the fracture, also eccentrically away from the fracture. By compressing these two screws against the plate the fracture is translated and compressed together as shown in the following sequence.

This image demonstrates the reduced fracture, viewed from the volarly.

This image shows that the fracture is also compressed on the opposite side due to proper contouring of the plate. Once the radius is fixed, the ulna is approached using a standard subcutaneous longitudinal incision with the arm flexed, as seen in the next image.

These images demonstrate the superficial dissection down to the fascia directly over the ulna, which is the common fascia between the flexor carpi ulnaris and the extensor carpi ulnaris. This is divided in line with the muscles directly over the subcutaneous border of the ulna.

FCU
FLEXOR CARPI ULNARIS

ECU
EXTENSOR CARPI ULNARIS

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

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

Intraoperative fluoroscopic views demonstrate accurate reduction and appropriate length of screws.

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