前臂双骨折的手术入路

(FCR)AusefultechniquetomaketheskinincisionistotakeabovicordandpullittaughtfromtheradialsideofthebicepstendontotheFCRatthelevelofthewrist.Thiscanthenbeusedasatemplatefortheincisionline.Theincisionistakendownthroughtheskin,identifyingthefasciallayerwithcaretakennottodamageanysuperficialveinsthatmaybeintact.TheFCRtendonisclearlyvisiblethroughoutthewound,asistheradialarteryinthedistalextentofthewound.FCRRADIALARTERYAcloseupofthedistalaspectofthewounddemonstratingTheradialarteryanditsvenouscommtantes.RADIALARTERYANDVENOUSCOMMTANTESFCRRADIALARTERYThefasciaontheradialsideoftheflexorcarpiradialisisreleased,exposingthedeeptissue.Theradialarterycanbefollowednowthroughouttheentireincision.Theradialarterymaybetakenineitherdirection,however,typicallyitiseasiertotakethearterytotheradialside.FCRRADIALARTERYThedeepdissectionisnowperformedbetweentheflexor-pronatormassontheulnarsideandthearteryandthemobilewadontheradialside.PRONATORFortheproximaldissection,theforearmisbroughtintosupinationandthepronator,FDSandFDParereleasedfromthevolaraspectoftheradiusFDSThepronatorisbeingreleasedfromtheradialaspectoftheradiusinasubperiostealmanner.Thissubperiostealdissectioncontinuesdistallytoreleasetheoriginofthecommonflexor.Afterexposureofthevolaraspectoftheradiusproximallyanddistally,twoclampscanbeplacedontheendsoftheboneinordertodeliverthemforcleaning.FCRRADIALARTERYEachsideofthefractureisbedeliveredinordertoexposeandcleanthecorticaledges.Thesefiguresdemonstratedeliveryofthedistalfragmentandacurvedcurettebeingusedtocleanthecorticaledge.Nocleaningshouldbeperformedwithintheintramedullarycanal,asthisishealthytissueandcanbeusefulforthehealingprocess.Oncethefracturesarecompletelycleanedalongtheircorticaledgessuchthatthefracturereductioncanbevisualized,thetwoclampsareusedtoreducethefracture.Ifabutterflyfragmentexists,itisnecessarytofixthiswithalagscrewbacktooneofthefractureendsinordertorealignthefracture.Inthecurrentcase,thefractureisasimplepatternandisreducedbydeliveringthebonesjointly,accentuatingthedeformityandthenrotatingandfittingthebonestogetherwithprogressivecompressionwhilepushingthebonesbackintothewound,obtainingalignmentbystericinterferenceofonesideagainsttheother.Oncethebonesareheldreduced,asseeninthefollowingsequence,anappropriatedynamiccompressionplateisplacedandheldinplacewithaclamp.Itisimportantthatthisplatemusthavetheappropriatebendforthevolaraspectoftheforearmsoasnottogapopenthedorsalsideastheplateisfixedtothebone.Thus,itshouldbeslightlyunderbentwithrespecttothestandardvolarconcavity.Thesefiguresdemonstratereductionofthefracturewithaplateheldinplaceontheflat,volaraspectofthebone.Oncethereductionisconfirmedfixationoftheplateisperformedusingacompressivetechniquethroughtheplate.Thefollowingsequencedemonstratesusingtheoffsetdrillguidetoplaceaneccentricallydrilledholeawayfromthefracture.Thescrewisplacedtothepointwhereitabutsbutisnotinsertedcompletelywithintheplateuntilitisaffixedontheotherside.HOLEECCENTRICALLYILLUSTRATEDInasimilarfashiontothefirstscrew,thesecondscrewisplacedontheoppositesideofthefracture,alsoeccentricallyawayfromthefracture.Bycompressingthesetwoscrewsagainsttheplatethefractureistranslatedandcompressedtogetherasshowninthefollowingsequence.Thisimagedemonstratesthereducedfracture,viewedfromthevolarly.Thisimageshowsthatthefractureisalsocompressedontheoppositesideduetopropercontouringoftheplate.Oncetheradiusisfixed,theulnaisapproachedusingastandardsubcutaneouslongitudinalincisionwiththearmflexed,asseeninthenextimage.Theseimagesdemonstratethesuperficialdissectiondowntothefasciadirectlyovertheulna,whichisthecommonfasciabetweentheflexorcarpiulnarisandtheextensorcarpiulnaris.Thisisdividedinlinewiththemusclesdirectlyoverthesubcutaneousborderoftheulna.ECUEXTENSORCARPIULNARISFCUFLEXORCARPIULNARISAperiostealelevatorisusedtocleantheexternalsurfaceoftheulna.Thisiscleaned,reducedandfixedinexactlythesamefashionastheradiuswas,usinga6-holeDCPplateandincompressivemode.Theseimagesshowtheplateinplacewithscrewholes,allowingforcompressioninthefinalcompressedfracture.Intraoperativefluoroscopicviewsdemonstrateaccuratereductionandappropriatelengthofscrews.PostoperativeAPandlateralviewsdemonstratinganatomicreductionandalignmentoftheradiusandulna.