Guest Professor David Nelson Case 2

Ulnar styloid fractures only need fixation if there is DRUJ instability, which is not very common. However, this ulna fracture is a distal shaft fracture, and implies a much greater degree of instability than the typical ulnar styloid fracture. It has been shown by Jesse Jupiter, MD, that there is an increased incidence of nonunion of both the radius and the ulna if these are not properly stabilized. Therefore, we planned an ORIF of the ulna. Given the poor quality of bone and the poor potential for healing of the distal ulna in these osteoporotic patients, a locking plate was used. It was carefully contoured to the distal ulnar head and placed on the volar side of the ulna, to try to avoid the need for subsequent removal. Due to the short distal ulnar fragment, only 1 1/2 screws could be placed into the distal ulna.

A suture was used to supplement the marginal fixation into the distal ulna:

The suture goes under the plate and is placed into the rather substantial fibrous tissue around the ulnar head. While this does not add a lot of stability, it may add some stability to the otherwise limited fixation into the distal ulnar fragment. (Note: this technique was first described by Gustavo Mantovani, MD, of Brazil, at the 10th triennial Congress of International Federation of Societies for Surgery of the Hand (IFSSH) Sydney March 2007; also at the 6th International San Francisco Distal Radius Fracture Course, which is the biannual meeting of eRadius.)

The patient is doing well at three months, with no sign of infection. The radius fracture has healed and the ulnar fracture seems to be going on to a nonunion. There is no evidence of any infection at the ulnar nonunion site. She has no pain and is refusing revision of the ulnar nonunion. At age 73, she feels she can do her activities of daily living without a problem. Her range of motion is flexion and extension each 50 degrees, supination 40 degrees and pronation 70 degrees.

Three month followup mini-C-arm xrays (PA, oblique, lateral). The lateral is a bit underpenetrated but the ulnar nonunion is clear on the PA and the Oblique views. Note the lucency around the distal screw.

End.

Comment by Bruce Ziran, MD,
Director of Orthopaedic Trauma, St Elizabeth Health Center, Youngstown, Ohio; member, Orthopedic Trauma Association; Associate Professor of Orthopaedic Surgery, Northeast Ohio Universities College of Medicine:

As a traumatologist, we may have a few differing approaches but the principles are common. First comment is on order and method of lavage and debridement. In our circles, it is now an absolute no-no to lavage before a formal open debridement. The reason is that we have no idea what lurks below the apparent wound and zone of injury. If there was any dirt or ontamination,
lavage first method will just push the badness deeper into the wound. Ever use a pressure washer to clean your floor? Same idea.

First we would open the wounds, as wide as needed, to make sure we were able to see the entire extent of the zone of injury. Incisions are not harmful, its what we do to the bone that is bad. So, then debride, and then more debridement, followed by gentle lavage. Pulsed lavage has been shown to be detrimental to osteoblasts, fibroblasts, and overall tissue. We use pulse lavage only if heavily contaminated. For this, I believe a medium aggressive debridement, cleaning bone ends with a sterile brush and curette, soft tissue exploration, and debridement to a "surgical" wound, would be enough. Think of this and infections as a tumor (benign). Same idea.

Also, since there are two wounds and double the risk of infection, I would consider only fixing the radius and resecting the distal ulna. This may be heresy but she has bad bone, some bone loss from the post fix xray, and is probalby not lifting weights or playing piano anymore. I think it may be a bit bothersome for her if her ulna juts out a bit, bt then again so could an infection, painful hardware, etc.

The exfix is the back up and in case we need to stabilize forearm rotation.

My comments are not meant to be critical since this case looks great. Just an opinion from another world. There are many roads to Rome.

Return to page 1 2 Guest Professor Homepage