Approach to distal ulna.pptx

Approach to distal ulnar

1. Approach to distal ulna & tbw distal ulna PRESENTER: HANIS SUPERVISOR: MISS NADIAH

2. OPTIONS OF SURGICAL MANAGEMENT FOR DISTAL ULNA FRACTURE

3. POSITIONING

4. A straight, longitudinal incision is made over the distal ulna, between the tendons of the extensor and flexor carpi ulnaris . ULNAR APPROACH TO DISTAL ULNA

5. SURGICAL DISSECTION Dorsal branch of ulnar nerve may be seen Care should be taken to avoid injury to this nerve Expose the fracture If necessary, might need to release the ulnar attachment of the extensor retinaculum

6. REDUCTION

7. PLATING To fix the fracture without causing impingement during wrist rotation or irritation to the extensor carpi ulnaris tendon There are plates specifically made for periarticular distal ulna fractures and fractures of the ulnar head

8. ANATOMIC CONSIDERATIONS IN PLATING DISTAL ULNA A plate placed too far dorsally may cause irritation to the ECU tendon If the plate is placed too distally or too radially, the plate will impinge and impede motion of the DRUJ

9. ‘SAFE ZONE’ FOR PLATING OF DISTAL ULNA The distal ulna was divided up as a clock face, with the ulnar styloid being assigned the 12 o'clock position Safe zone for plate placement on the distal ulna is approximately be Between the 12 and 2 o'clock positions on the left wrist Between the 10 and 12 o'clock positions on the right wrist or

10. ‘SAFE ZONE’ FOR PLATING OF DISTAL ULNA The distal ulna was divided up as a clock face, with the ulnar styloid being assigned the 12 o'clock position Safe zone for plate placement on the distal ulna is approximately be Between the 12 and 2 o'clock positions on the left wrist Between the 10 and 12 o'clock positions on the right wrist or

11. PLATING – Lag screw and protection plate Main indications Unstable fracture I ndications : Oblique or spiral fracture Locking plate preferable for short distal fragments Displaced fracture Irreducible fracture

12. PLATING – Compression plate Main indications Transverse, or short oblique fracture Indications Transverse or short oblique fracture Locking plate preferable for short distal fragments Displaced fracture Irreducible fracture Unstable fracture

13. PLATING – Bridge Plate Main indications All ulnar multifragmentary extraarticular fractures, where possible Advantages Early mobilization Healing in anatomical position

14. PLATING – Hook Plate Main indications All ulnar extraarticular fractures, where possible Advantages Better control of smaller distal fragments than with conventional plate Early mobilization Healing in anatomical position Disadvantages The plate is very narrow. Because of this the narrow profile, the plate has limited use for fracture patterns where more comminution is present

15. Tension band wire distal ulna Ulnar styloid fractures can extend from the very distal tip to fractures at the base of the styloid, and may or may not be associated with instability of the distal radioulnar joint. They may also be associated with injury to the triangular fibrocartilaginous complex (TFCC). In the rare cases with significant instability, fixation of an ulnar styloid fragment should be considered. This may be with a tension band wire, or if the ulnar styloid fragment is sufficiently large, screw fixation may be an option.

16. Assessment of Distal Radioulnar Joint (DRUJ)

17. Assessment of Distal Radioulnar Joint (DRUJ)

18. SKIN INCISION

19. REDUCTION

20. INSERTION OF TENSION BAND WIRE If there is enough room, insert two smooth K-wires from the tip of the styloid Check under II for proper reduction Drill a hole through the ulna from dorsal to palmar approximately 2 cm proximal from the tip of the styloid Care needs to be taken to avoid injury to the dorsal cutaneous branch of the ulnar nerve.

21. INSERTION OF TENSION BAND WIRE Pass a wire through the drill hole. The wire is passed around the K-wires distally, to create a figure-of-eight loop Twist the wire. The wire is tensioned by pulling on the twist until the desired tension is achieved. Cut the twist and bend it towards the bone Using the bending iron for K-wires, the wires are bent at the level of the tip of the styloid through 180º, and cut short.

22. WOUND CLOSURE The extensor retinaculum is repaired, as necessary The wound is closed in layers.

23. AFTERCARE

24. References ANATOMIC CONSIDERATIONS FOR PLATING OF THE DISTAL ULNA https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4530182/#:~:text=Typically%2C%20the%20distal%20ulna%20is,sheath%20to%20avoid%20tendon%20irritation ULNAR APPROACH TO DISTAL ULNA https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/distal-forearm/approach/ulnar-approach-to-the-distal-ulna