前臂双骨折的手术入路学习课件.ppt

1、尺桡骨双骨折1 AP and lateral views of the both bones fracture of the forearm,demonstrating significant shortening and relatively simpleoblique fracture patterns.2The patient is positioned supine with the arm prepped anddraped to just above the elbow and a tourniquet in place.This figure demonstrates the a

2、rm held in supination.Note theposition of the biceps insertion as well as the palpable tendonof the FCR and radial artery.BICEPSTENDONRADIALARTERYFLEXOR CARPIRADIALIS(FCR)3A useful technique to make the skin incision is to take a bovicord and pull it taught from the radial side of the biceps tendont

3、o the FCR at the level of the wrist.This can then be used as a template for the incision line.45The incision is taken down through the skin,identifying the fascial layer with care taken not to damage any superficial veins that may be intact.The FCR tendon is clearly visible throughout the wound,as i

4、s the radial artery in the distal extent of the wound.FCRRADIALARTERY6A closeup of the distal aspect of the wound demonstratingThe radial artery and its venous commtantes.RADIAL ARTERY ANDVENOUS COMMTANTES7FCRRADIALARTERYThe fascia on the radial side of the flexor carpi radialis is released,exposing

5、 the deep tissue.The radial artery can be followed now throughout the entire incision.8The radial artery may be taken in either direction,however,typically it is easier to take the artery to the radial side.FCRRADIALARTERY9The deep dissection is now performed between the flexor-pronator mass on the

6、ulnar side and the artery and the mobile wad on the radial side.10PRONATORFor the proximal dissection,the forearm is brought intosupination and the pronator,FDS and FDP are releasedfrom the volar aspect of the radius11FDSThe pronator is being released from the radial aspect of the radius in a subper

7、iosteal manner.This subperiostealdissection continues distally to release the origin of thecommon flexor.12After exposure of the volar aspect of the radius proximallyand distally,two clamps can be placed on the ends of thebone in order to deliver them for cleaning.13FCRRADIAL ARTERYEach side of the

8、fracture is be delivered in order to expose and clean the cortical edges.14These figures demonstrate delivery of the distal fragment and acurved curette being used to clean the cortical edge.Nocleaning should be performed within the intramedullary canal,as this is healthy tissue and can be useful fo

9、r the healing process.15Once the fractures are completely cleaned along their cortical edges such that the fracture reduction can be visualized,the two clamps are used to reduce the fracture.If a butterfly fragment exists,it is necessary to fix this with a lag screw back to one of the fracture ends

10、in order to realign the fracture.16In the current case,the fracture is a simple pattern and is reduced by delivering the bones jointly,accentuating the deformity and then rotating and fitting the bones together with progressive compression while pushing the bones back into the wound,obtaining alignm

11、ent by steric interference of one side against the other.17Once the bones are held reduced,as seen in the following sequence,an appropriate dynamic compression plate is placed and held in place with a clamp.It is important that this plate must have the appropriate bend for the volar aspect of the fo

12、rearm so as not to gap open the dorsal side as the plate is fixed to the bone.Thus,it should be slightly underbent with respect to the standard volar concavity.18192021These figures demonstrate reduction of the fracture with a plateheld in place on the flat,volar aspect of the bone.Once the reductio

13、n is confirmed fixation of the plate is performedusing a compressive technique through the plate.22The following sequence demonstrates using the offset drillguide to place an eccentrically drilled hole away from thefracture.The screw is placed to the point where it abutsbut is not inserted completel

14、y within the plate until it isaffixed on the other side.2324HOLEECCENTRICALLYILLUSTRATED2526In a similar fashion to the first screw,the second screw is placed on the opposite side of the fracture,also eccentrically away from the fracture.By compressing these two screws against the plate the fracture

15、 is translated and compressed together as shown inthe following sequence.272829This image demonstrates the reduced fracture,viewedfrom the volarly.30This image shows that the fracture is also compressed on the oppositeside due to proper contouring of the plate.Once the radius is fixed,the ulna is ap

16、proached using a standard subcutaneous longitudinal incision with the arm flexed,as seen in the next image.3132These images demonstrate the superficial dissection downto the fascia directly over the ulna,which is the commonfascia between the flexor carpi ulnaris and the extensor carpi ulnaris.This i

17、s divided in line with the muscles directly over the subcutaneous border of the ulna.3334ECUEXTENSORCARPI ULNARISFCUFLEXOR CARPI ULNARIS35A periosteal elevator is used to cleanthe external surface of the ulna.36This is cleaned,reduced and fixed in exactly the same fashion as the radius was,using a 6

18、-hole DCP plate and in compressive mode.These images show the plate in place with screw holes,allowing for compression in the final compressed fracture.373839Intraoperative fluoroscopic views demonstrate accuratereduction and appropriate length of screws.40Postoperative AP and lateral views demonstratinganatomic reduction and alignment of the radius and ulna.41424344454647484950