 |
On-line CEUs
ULNA RADIUS FRACTURES - October/November 2004
Katherine Bagnato, OTC, ATC
Available credit for this article: 1 CEU
An eight year-old male who was playing on the monkey bars, fell and landed on left upper extremity. The child was in severe pain with a gross deformity and open wound to the left forearm. He was taken to the emergency room for evaluation and treatment. Upon review of x-rays, the patient was diagnosed with a Type 1 Open left both bone (ulna/radius) fracture. The ulna and radius were in severe volar position where the radius had punctured the skin causing the open fracture. The patient was given a tetnus injection and antibiotic IV for possible infection. The risks of infection, non-union, mal-union, anesthesia, neurovascular injury and benefits of proper healing and alignment of the forearm as well as the procedure involved were discussed with the patient’s parents and consent for the surgery was given. He was taken to the operating room for Irrigation and Debridment (I&D) and Open Reduction Internal Fixation (ORIF) with intramedullary nailing of the ulna and radius.
 |
|
Left Ulna Radius Fracture
|
The patient’s left arm was draped and prepped. A longitudinal incision was made over the open wound on the volar aspect of the forearm. The wound andfracture site were irrigated and debrided for infection. Utilizing C-arm x-ray, a small incision was made at the proximal tip of the olecranon of the ulna and a steinmann’s pin was drilled into the intramedullary canal of the ulna to stabilize the ulna fracture. The pin was bent and left outside the skin at the elbow. Then, a small incision was made at the distal tip of the radius. The sensory branch of the radial nerve was dissected. This was to avoid any neurovascular compromise to the innervation of the dorsum of the hand. A steinmann’s pin was drilled into the intramedullary canal of the ulna to stabilize the radius fracture. The pin was bent and left outside the skin at the wrist. Upon fi nal evaluation under x-ray, there was adequate alignment and stability of the both-bone (ulna-radius) fracture. Xeroform dressing and sterile gauze were applied to the pin sites. The pin sites were well padded and a sugar-tong splint was applied to the left upper extremity. The procedure was well tolerated. The patient and parents were educated in proper splint/cast care, elevation of the extremity, and post-operative swelling. He was released from the hospital 1 day post-operatively.
At one-week post-operative, the patient returned to the office for evaluation and treatment of his left both-bone fracture. The sugar-tong splint was removed. The incisions and pin sites were examined and found to be clean, dry and intact. There were no signs of infection, drainage or erythema (redness) at the forearm. This was important to rule out any underlying infection processes. The left upper extremity was neurovascularly intact. There was swelling present in the forearm and tenderness over the fracture site. X-rays were taken and showed good alignment and position of the hardware and fractures. The risks and complications of casting were explained to the patient and parents. Instructions on proper cast care were given and the patient was placed in a long arm cast (LAC) with the elbow at 90 degrees and wrist in neutral for three weeks. He was instructed to return to the office for evaluation by x-ray and discuss further casting versus pin removal.
|
|
|
Left Ulna Radius Fracture - ORIF
|
At 4 weeks post-operatively, the patient returned to the office for evaluation and treatment. The
long arm cast was removed. The incisions and pin sites were examined and found to be clean, dry and intact. There were no signs of infection, drainage or erythema. The left upper extremity was neurovascularly intact. There was swelling to the forearm and tenderness over the fracture sites. Xrays were taken and showed good alignment and position of hardware and fracture. There were good callus formations on the ulna and radius fracture sites. Pin removal procedures were discussed with the patient and parents and consent was given. The ulnar and radial steinmann pins were removed in the office. The wounds were redressed and a long arm cast reapplied for two weeks. At 6 weeks post-operatively the patient returned to the office for evaluation and treatment. The long arm cast was removed. The incisions and pin sites were examined and found to be clean, dry and intact. The left upper extremity was neurovascularly intact. There was no swelling of the forearm and minimal tenderness over the fracture sites. The left elbow exhibited 30-120 degrees of flexion, 80 degrees of supination and 50 degrees of pronation. X-rays were taken and showed large callus over the ulna and radius fractures. At this time the treatment plan consisted of wearing a wrist-hand orthosis with removal for bathing and range of motion exercises.
The patient was shown a home exercise program (HEP) consisting of stretches and exercises in the office. He was instructed to remove the brace 3-5 times daily for this and to perform activities of daily living (ADL’s) as tolerated. The patient and parents were given patient education with written instructions for review. He was instructed to return to the office in two weeks for a range of motion check of the elbow and wrist.
At 8 weeks post-operatively, the patient returned to the office for a final evaluation. The incisions were healed. The left upper extremity was neurovascularly intact. The left elbow exhibited 5 degrees hyperextension, 140 degrees flexion, 90 degrees supination, and 70 pronation. The left wrist exhibited full range of motion (FROM). There was no swelling of the forearm and no tenderness over the fracture sites. This was clinical evidence that the fractures were healed. Xrays were taken and showed a healed both bone (ulna-radius) fracture. The patient was instructed to continue with his activities of daily living. The wristhand orthosis was discontinued. Once full pronation had been achieved in approximately 2 weeks, return to sports was allowed. At this time the patient and parents were instructed to return on an as needed basis (PRN) .
EMAIL THE NAOT OFFICE TO REQUEST THE QUESTIONS FOR ON-LINE CEUS
(period to obtain CEUs on-line for this article expired December 22, 2004). |
|
