Radius and Ulna Forearm Fractures

Samantha Spencer, MD

IM Rodding

Indications (Figure 12-1)

Unacceptable closed reduction as per age (will not remodel)
Unstable fractures after closed reduction
Open fractures with instability
Neurovascular compromise
Floating elbow

Position

Supine on a regular table with an attached radiolucent hand table
Table turned 90° with the child moved to the edge of the bed
Nonsterile tourniquet
Fluoroscopy parallel to the patient and perpendicular to the affected arm
Surgeon and assistant on either side of the arm

Principles

Reduce and fix easiest bone first (Figure 12-3)
- Usually ulna
Limit the number of attempts at percutaneous reduction and nail passage attempts
- Lessen the risk of compartment syndrome
- Open reduction if percutaneous reduction and fixation is not achieved in <3 attempts at passage of rod or <30 minutes
Restore radial bow
Obtain three-point intramedullary fixation in radial metaphysis proximal and distal to the fracture site

Figure 12-1 ▪ A and B, Displaced diaphyseal radius and ulna forearm fractures with overlap and malrotation.

Technique

Ulna

Either apophyseal (requires early rod removal) (Figure 12-4) or metaphyseal (buried rod can be left longer) (Figure 12-5) entry can be used
Predrill only opening cortex to prevent false passage (Figure 12-6)
Ulna shaft is straight, so prebending the nail is not necessary

Figure 12-2 ▪ Instrument set for intramedullary fixation of diaphyseal forearm fractures.

Figure 12-3 ▪ Closed reduction maneuver under sterile conditions on a fluoroscopy table.

Figure 12-4 ▪ Apophyseal entry site proximal ulna.

Figure 12-5 ▪ Metaphyseal entry site proximal ulna with awl, radius fracture with IM fixation in place.
Ulna intramedullary canal relatively narrow
- Choose intramedullary (IM) nail based on imaging in operating room (OR)
Enter cortex and pass IM nail to the level of fracture using T-handle chuck and rotatory movements or light mallet tapping
Reduce fracture and pass the IM rod across the ulna fracture site
- Use rotatory movements and change the direction of wire tip to secure intramedullary passage and not impact or comminute cortex

If reduction is not feasible after several (<3) reasonable controlled attempts, then interposed soft tissue or comminution of fracture ends may block the way

Use fluoroscopy to isolate the fracture site (Figure 12-7)

Figure 12-6 ▪ Power drilling apophyseal entry site. Be careful not to create false passage.

Figure 12-7 ▪ The pin is in the proximal ulna, the fracture site is outlined with transverse skin marking in the midst of the fracture ecchymosis, and if needed the skin incision is outlined below.

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