Ulna Fracture: Case Discussion

Today, we are shedding light on a case study of Ulna Bone Fracture. Forearm fractures are common fractures. Here we are talking about when to go for conservative treatment & when to opt for surgical procedure.

Clinical Presentation

• 37 year old male
• History of RTA
• Presented on the day of injury
• Pain and swelling over right forearm
• Co-morbidities – None
• No neuro-vascular deficit

Investigations

• X-ray of the suspected region- pelvis/chest/spine screening/limbs.
• X-ray of affected region- Anteroposterior & Lateral
• Blood workup for surgical fitness

Most common causes of forearm fractures

• Direct impact (Assault)
• Fall on an outstretched arm or fall from a height
• Road traffic accident

Treatment forearm fractures- Surgical

• When to go for conservative treatment?
  • Isolated undisplaced fracture
  • No associated injury of ipsilateral limb
  • No neurovascular compromise

• Treatment modalities
  • Muenster cast or olecranon bearing cast
  • Functional bracing

Olecranon bearing cast or Functional bracing

• Cast/brace should extend just above elbow to control forearm rotation
• With extension the proximal limit of cast should rest on olecranon process
• High chances of displacement in early stages(check x-ray after 1 week)
• 6-8 weeks of immobilization
• Chances of malunion/nonunion

Surgical Approach

Subcutaneous Approach to Ulnar Shaft

Internervous plane between Extensor carpi ulnaris (ECU) and Flexor carpi ulnaris (FCU) supplied by PIN & ulnar nerve respectively.

Neurovascular structure encountered:

Ulnar vessel and nerve: subperiosteal dissection of FCU as these structure travel under FCU.

Surgical Plan

• Implant GPC Medical Ltd.– Dynamic self compression plate for small fragment
• In Anteroposterior view, the fracture is appearing as undisplaced, however in lateral view transverse fracture is seen with butterfly fragment splinting of distal fragment.
• Plan: Position the plate over the butterfly fragment and convert a three fragment fracture to two fragment fracture and achieve compression

Orthopaedics Beyond Implant Surgery

Today, we’re going to talk about Orthopaedics beyond the implant surgery. Here is one of the cases of comminuted fracture of patella, with partial bone loss. Patellectomy was performed. All that was needed was cerclage wire, of course with excellent surgical skillset.

Clinical History

• 27 year old male
• History of RTA
• Presented on the day of Injury
• Wound over right knee

Pre-operative Plan

• Encirclage wiring + figure of eight wiring + removal of small bony fragments
• Back up plan: total patellectomy

• Patellectomy is still considered as the last reserve in treatment of certain conditions including comminuted fractures, advanced chondromalacia or osteoarthritis, infections, and tumoral conditions.
• Problems associated with this procedure are:
  • Decrease in the moment arm of the extensor mechanism
  • Alteration of the forces acting on the tibiofemoral joint and instant center of motion
  • Limitation of range of motion
  • Anterior instability
  • Loss of protection of the trochlea from injury
  • Poor cosmesis

• Extensor mechanism may be repaired in a transverse or longitudinal fashion.
• Transverse repair only 15% of additional force was required to extend the knee after a transverse repair compared with 30% after a longitudinal repair.
• The main objection to a transverse repair is that complete flexion of the knee is limited because of the decrease in the length of the quadriceps-patellar tendon unit.
• An additional criticism is the longer period of immobilization that is needed to protect the tension on the suture line.(Transverse repair)

To Overcome Certain Challenges of Patellectomy

• Some parts of the quadriceps muscle are advanced over the site of the excised patella.
• These techniques provide relatively better cosmesis and better protection of the trochlea from injury.
• Anterior instability and lateral subluxation of the tendon also are avoided when these techniques are used.

Miyakawa technique of patellectomy

• In this technique, a strip of quadriceps tendon is pulled distally to fill the void that was left by the removal of the patella; the vastus medialis and lateralis then are advanced over the site of the excised patella.

Gunal technique- Patellectomy + vastus medialis obliquus advancement technique.

• In this technique, the defect is closed longitudinally and the vastus medialis obliquus is advanced distally and laterally and distal 1 cm and is plicated to increase the angle of insertion in the sagittal plane
• Patella is an important part of the exterior mechanism and should be preserved if possible; when patellectomy is indicated, it seems logical to combine patellectomy with reinforcement techniques.
• For reference

Elbow Reconstruction – Understanding Failure (PART 2)

Continuing on last post on elbow reconstruction, today we’re going to talk about the contingency plan i.e. when the surgeon attempted to reconstruct column, but failed to achieve intra-articular fragment reduction.

Clinical Presentation

• 29 year old female
• Thinly built
• Road traffic accident with injury to the left elbow
• Trauma to the skin (abrasion) overlying the fracture
• Closed fracture without any neurovascular deficit
• Co-morbidities – None

Investigations

• X-ray of the suspected region- pelvis/chest/spine screening/limbs
• X-ray of affected region- anteroposterior/ lateral/ traction views (author preference)
• CT scan of elbow (cost constraint)- gold standard
• Blood workup for surgical fitness

What should have been done?

• Author’s preferred method- discussed in one of earlier discussion on distal humerus fractures.
• Simple plan
  • Olecranon osteotomy
  • Intercondylar partially threaded cancellous screw (lag effect)
  • Temporary column fixation
  • Medial column single screw fixation
  • Lateral column fixation by 3.5 mm LCP/Lateral Distal humerus plate

Fixation Issues

• No compression in between two condylar articular fragments
• Medial column not restored
• Anterior angulation of distal humerus not maintained
• Lateral distal fragment- capitullum is fixed in rotation
• Short screw length
• Slab application (length) is not appropriate for such injuries

Why does one land in such issues?

• Pre-op formulate a plan to fix such complex trauma case
• Follow the plan, ensure each step is correctly addressed
• Back-up plan should be there in case difficulty/ problem in original plan (author would have to drop idea of single medial screw and go for medial plate due to comminution)
• Critical analysis of the postop case to ensure adequate results in next case

Last Case Discussion

• Pre-op & contingency plan
• Importance of exposure and different methods
• C-arm visualization
• Patient expectancy from injury
• Strongest bone lies along medial and lateral columns and therefore the implant should be placed here
• Intra-articular anatomical reduction and fixation by lag screw placed from medial to lateral direction
• With normal 40° anterior angulation of the condyles and humeral shaft restored, lateral plate is positioned posteriorly & medial plate in saggital plane along the medial border.
• Screws in the distal fragment need to be as long as possible,engaging as many fracture fragments as possible, ensuring screw tip is not impinging into the joint
• Medial and lateral column screws should “interdigitate“ such that they have hold on opposite column fracture fragment 
• Check ROM and fracture fixation stability on the OT table before closure

Elbow Reconstruction in Trauma Cases – PART 1

Today, we’re going to talk about Elbow Reconstruction in trauma cases. The main principle which we have to keep in mind when reconstructing the elbow is- stable internal fixation of articular surface & also stable internal fixation of the articular segment to the metaphysis & diaphyseal fragments.

Clinical Presentation

• 34 year old male
• History of RTA
• Presented on the day of Injury
• Pain and swelling over left elbow with abrasion and bleeding from the wound
• Difficulty in elbow movement
• Co-morbidities – None

Investigations

• X-ray of the suspected region- pelvis/chest/spine screening/limbs.
• X-ray of affected region- anteroposterior/lateral/traction views (author preference)
• CT scan of elbow (cost constraint)- gold standard
• Blood workup for surgical fitness
• Additional test as required for co-morbidities if any

Clinical Evaluation

• Soft tissue envelope
• Neurological status distal to injury
• Vascular status distal to injury

Goal and Principle of Surgical Fixation

Goal of treatment

To achieve stable fixation, union of fracture fragments with restoration of function of elbow.

Principles of fixation

• Anatomical reduction of intra-articular fragments
• Preservation of blood supply
• Stable fixation
• Early and safe mobilization

Importance of Surgical Plan

• Surgeon needs to pre-formulate a surgical fixation plan and the necessary approach for adequate exposure.
• In addition to the above planning, a backup/contingency plan also needs to be formulated in such complex trauma cases.

Surgical Issues

• Principle of stable fixation constitute
  • Stable internal fixation of articular surface
  • Stable internal fixation of the articular segment to the metaphysis and diaphyseal fragment

• The surgeon although was able to achieve reduction of the intra-articular fragment, the distal construct was fixed in translation to the proximal construct.
• Different exposures gives good to complete visualization of articular surface
• Choose the exposure depending upon
  • Surgical experience
  • Type of implant
  • Patient factors- skin condition/age/fracture pattern
  • Future need of elbow arthroplasty

• Author’s preference
• Olecranon osteotomy (fixation with TBW/ Long screw+ SS wire)
• Byran-Morrey Approach (Triceps-sparing postero-medial approach)
  • Midline incision
  • Ulnar nerve identified, mobilized and latex loop placed
  • Medial edge of triceps and distal forearm fascia elevated as single unit off olecranon and reflected laterally
  • Resection of extra-articular tip of olecranon(better visualization, later helps during ROM exercises)

Adequate Visualization on C-arm During Surgery

At 90° flexion: The olecranon overlaps only a small part of the medial joint surface

• If elbow flexion is increased to 110°- free and complete joint surface is seen on lateral radiograph
• It is therefore important to have proper patient positioning allowing elbow movement and facilitate radiography.

Pre-op Counselling

What patients may expect?

• Loss of 15-25° of flexion and extension
• Maintain most of supination and pronation
• Decrease in muscle strength (triceps)
• Implant impingement (especially olecranon fixation implant)
• Complications associated with the procedure

Fracture Olecranon Management with TBW (Tension Band Wiring)

Check out our latest blog post where we are putting a spotlight on tension band wiring for Olecranon Fractures with relative case studies and imagery. We also discuss concerns relating to Olecranon Fracture and K-wires and discuss possible alternatives for the same.

Clinical History

• 17 year old male with history of RTA
• Pain, swelling with restricted movement of left elbow
• No distal neurovascular deficit

Treatment Planning

• Xray- Comminuted fracture olecranon
• Ideal surgical treatment option- Olecranon plating
• Cost concerns- TBW
• The principles of tension band wiring is conversion of tensile forces into compression forces.
• In the olecranon, the figure-of-eight wire loop lies on the posterior surface acts as a tension band during elbow flexion.
• For success of tension band wiring in olecranon fracture, the anterior cortex cannot be comminuted and must provide a buttress to allow compression.
• Multifragmentary olecranon fractures cannot be fixed with tension band wiring.

Issues with fixation

• Fracture reduction is unsatisfactory- inadequate hold of K wire on one fragment leading to displacement.
• No transcortical fixation of K wires
• Triceps tendon shadow visible under the Wire loop. Wire loop should pass under the triceps to provide compression of fracture during loop tightening.
• K wires not sitting on the proximal fragment.
• Wire loop placement on distal fragment should pass through centre of ulnar distal fragment.
• Comminuted olecranon fracture [Types IIB, Mayo Classification] a posterior splint with the elbow in a semi-flexed position applied for a period of 2–3 weeks to prevent fracture collapse and displacement. In this case its slab in 90 degree flexion.

Olecranon fracture surgical management concerns

• High chance of needing a secondary procedure for hardware removal due to irritation.
• Frequently a loss of terminal elbow extension of 10-15 degrees without any functional deficit
• Fractures of the olecranon are intra-articular injuries and require anatomic reduction.  Be careful to reduce the bare area of the articular surface.
• Do not malreduce the fracture and narrow the distance between the coronoid process and tip of the olecranon.

Sullivan CW, Herron T, Hayat Z. Olecranon Fracture. [Updated 2020 Nov 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK537295/