OPEN REDUCTION AND INTERNAL FIXATION: PLATING

Indications

• Displaced fractures of the middle third of the ulna in adults.

• Monteggia fractures: fracture of the ulna shaft with fracture and/or dislocation of the proximal radius/radial head.

• Fractures of both forearm bones.

Pre-operative planning

Clinical assessment

• Mechanism of injury: Nightstick injury: direct blow; Monteggia fractures: axial compression; forearm fracture: any combination. Ensure adequate examination of the elbow and wrist joint for associated pathology.

• Low- vs. high-energy injury, ensure no open fractures are missed with ulna wound volarly and covered by splint when first examined.

• Arm at risk for compartment syndrome: document neurovascular status early and monitor changes.

• In multiple-injured patients treatment sequence follows the ‘life-before-limb’ protocol.

• Look for occult injuries in the rest of the arm, especially in the carpus/hand.

Radiological assessment

• Rule of 2: 2 views, 2 joints (and 2 visits). Radiographs may be incomplete initially as pain/splints may interfere with the result.

• Traction views in theatre may be necessary for valid pre-operative planning.

Operative treatment

Anaesthesia

• Timing of surgery essential: in low-energy injuries this is notanissue whilst in high-energyoneswith displacement, shortening and/or dislocation, early intervention is preferable to avoid complications.

• General anesthesia preferable. Avoid regional anesthetic/ blocks in acute injuries as they may mask symptoms indicating compartment syndrome in the immediate post-operative period.

• Pre-operative administration of antibiotics and prescrub the limb.

• Apply tourniquet if not contraindicated and inflate following elevation for 3 minutes once limb prepped and draped.