Introduction
Both-bone diaphyseal forearm fractures are one of the most common forms of forearm fractures seen in adult orthopedic clinical practice. Current forearm surgical fixation techniques with double incisions are safe and efficient, but they require two surgical incisions and more soft tissue handling during surgery. We undertook an alternative approach with a single dorsal incision that allows for adequate anatomical exposure for the fixation of both bone fractures by a dynamic compression plate. An open wound over the dorsum of the forearm is a forced indication of this approach.
Materials and Methods
An 80-year-old female presented with a history of trauma and was diagnosed with a left radius ulna midshaft fracture (Figure 1) with an open injury 5x7 cm in size over the dorsal aspect of the forearm (Figure 2). Primary standard care for open fracture was given. We planned for debridement and fixation of both bone forearm fractures in a single setting. Informed consent was obtained. On the operation table, the patient was positioned supine with the arm on the side table. Under general anesthesia, the operative arm was thoroughly scrubbed, painted, and draped. Wound wash was given with 10% povidone-iodine and hydrogen peroxide with 4 liters of water. This was followed by wound debridement and removal of devitalized tissue. Thereafter, a posterior incision starting from the wound edge and extending proximally in a curvilinear manner was taken (Figure 3). Afterward, blunt dissection was done between the extensor carpi radialis brevis and the extensor digitorum muscle to expose the radius fracture site. The abductor pollicis longus and extensor pollicis brevis muscles were gently retracted from the radius in the distal third. Fracture margins were cleaned and washed in view of the open nature of the fracture. Later, the reduction was achieved and held with a clamp and fixed by a contoured 7 holes dynamic compression plate with 3 proximal and 3 distal cortical screws. Then ulna was exposed by blunt dissection between extensor carpi ulnaris muscle and flexor carpi ulnaris muscle. The fracture site was cleaned, held with a clamp, and fixed with a contoured 7-hole plate with 3 proximal and 3 distal screws. The plates were applied to the posterior surface of the bones. The plate was positioned underneath the extensor carpi ulnaris muscle on the ulna, avoiding the subcutaneous border. The procedure was done under C-arm guidance. The closure was done only proximally extending up to the point where no tension was observed. No sutures were taken in the distal part and it was left open with precaution to cover the plate adequately with muscle and soft tissue (Figure 4). Finally, non adhesive dressing material was used for dressing and an above elbow slab was applied. Postoperative x-ray was satisfactory (Figure 5). The patient was discharged after 2-days of surgery and was followed up a week later for dressing. Sutures were removed after 2-weeks. The slab was discontinued after suture removal, and movements were initiated gradually (Figure 6).
Results
The x-ray after 6-weeks showed a good position of fracture and implants. The patient was regularly followed up at 6 months, 12 months and 18 months with strict physical therapy and rehabilitation plan. At the latest follow-up, there was complete radiological union of both bones and the patient achieved full range of motion. There was no sign of synostosis.
Discussion
There are only 3 publications that describe a single incision approach. 1. Speed and Boyd’s approach1, 2 give good exposure to proximal radius and ulna but there are high chances of radioulnar synostosis. Bauer et al. 3 reported 5 cases with synostosis after operating on 12 cases with fractures of both the radius and ulna using the Speed and Boyd approach. 2. Colton and hall approach4 also has high chances of radioulnar synostosis. 3. We used Shenoy’s curvilinear biplanar approach5 for our case.
Commonly most surgeons prefer 2 separate incisions for fixation of radius and ulna. For radius Henry approach6 and for ulna posterior approach rather than single incision due to perceived risk of nerve injuries and radioulnar synostosis. During anterior approach detachment of muscle such as supinator, pronator teres, flexor digitorum superficialis which increases risk of radioulnar synostosis7 and also vital structures such as branches of radial artery, posterior interosseous nerve are at risk. In the posterior approach also called as Thompson’s approach8 along with subcutaneous ulnar approach has difficulty due to 2 near surgical scars adjacent to each other and exposure is also limited. In literature the incidence of radioulnar synostosis ranges from 1.2% to 9% in 2 separate incisions. R.M. Shenoy performed this operation and published this approach without single case of synostosis, similarly Abdel-Azim Hassan Wahsh2 studied 115 cases with single incision approach without complication of synososis or nerve injuries. In our case also there is no evidence of radioulnar synostosis. In our case, curvilinear incisions provided us exposure of radius as well as ulna and after skin incision we dissected up to bone through 2 separate planes, this decreases chances of radioulnar synostosis but this approach has limitations in proximal or distal shaft fracture.
In conclusion though for fixation of both bone forearm fractures combined anterior approach for radius and subcutaneous posterior approach for ulna is preferred but in special circumstances such as large wound over dorsal aspect where 3 wounds over single limb may lead complications we can choose single dorsal incision for fixation, with excellent outcomes.
