What is the step-by-step procedure for closed reduction and internal fixation (CRIF) with nailing for a fracture of the midshaft ulna?

Step-by-Step Procedure for CRIF with Nailing for Midshaft Ulna Fracture

Intramedullary nailing is an effective surgical technique for treating isolated midshaft ulna fractures, providing stable fixation with minimal soft tissue disruption and excellent functional outcomes. 1

Pre-operative Assessment and Planning

1. Radiographic Evaluation

   • Obtain standard AP and lateral radiographs of the entire forearm including wrist and elbow joints
   • Assess fracture pattern, displacement, angulation, and comminution
   • Consider CT scan for complex fracture patterns

2. Patient Positioning

   • Position patient supine on operating table
   • Place the affected arm on a radiolucent arm table
   • Prepare and drape the entire upper extremity from fingertips to above the elbow

Surgical Procedure

Step 1: Anesthesia and Preparation

• Administer appropriate anesthesia (general or regional block)
• Apply tourniquet at upper arm (optional)
• Prepare and drape the extremity in sterile fashion

Step 2: Closed Reduction

• Perform manual traction and manipulation to achieve anatomical alignment
• Confirm reduction with fluoroscopic imaging in multiple planes
• Ensure rotational alignment is correct by comparing to contralateral arm

Step 3: Entry Point Selection and Approach

• For retrograde approach (preferred to minimize symptomatic hardware 2):

  • Make a 2-3 cm longitudinal incision over the distal ulnar styloid
  • Protect the dorsal sensory branch of the ulnar nerve
  • Create entry point at the tip of the ulnar styloid

• For antegrade approach:

  • Make a 2-3 cm longitudinal incision over the olecranon
  • Split the triceps tendon in line with its fibers
  • Create entry point at the proximal tip of the olecranon

Step 4: Nail Insertion

1. Use an awl to create the entry portal
2. Insert a guide wire under fluoroscopic guidance across the fracture site
3. Measure appropriate nail length (should span the entire medullary canal)
4. Select appropriate diameter nail (typically 2.5-3.5 mm for adults)
5. Ream the medullary canal if necessary (optional)
6. Insert the nail over the guide wire using gentle rotation and controlled pressure
7. Advance the nail across the fracture site under fluoroscopic guidance
8. Ensure the nail is properly seated and the fracture is reduced

Step 5: Verification of Reduction and Fixation

• Obtain fluoroscopic images in multiple planes (AP, lateral, oblique)
• Confirm:
  • Proper fracture reduction
  • Appropriate nail position
  • Rotational alignment
  • No iatrogenic fractures

Step 6: Wound Closure

• Irrigate the wound thoroughly
• Close the entry portal in layers:
  • Repair the triceps tendon (for antegrade approach)
  • Close subcutaneous tissue with absorbable sutures
  • Close skin with non-absorbable sutures or staples

Step 7: Post-operative Imaging

• Obtain final AP and lateral radiographs to document reduction and hardware position

Post-operative Management

1. Immediate Post-operative Care

   • Apply a well-padded posterior splint or sugar-tong splint for 1-2 weeks
   • Elevate the extremity to minimize swelling
   • Provide appropriate pain management

2. Follow-up Care

   • First follow-up at 1-2 weeks for wound check and transition to short arm cast or functional brace
   • Subsequent follow-ups at 6 weeks, 3 months, and 6 months with radiographs to assess healing
   • Begin gentle range of motion exercises after adequate callus formation (typically 4-6 weeks)

3. Rehabilitation Protocol

   • Progressive range of motion exercises for elbow, wrist, and forearm
   • Strengthening exercises after radiographic evidence of healing
   • Return to full activities when clinically and radiographically healed (typically 3-6 months)

Potential Complications and Management

• Hardware-related issues: More common with antegrade nailing (3.97 times higher rate of symptomatic implants compared to retrograde) 2
• Delayed union or nonunion: Consider nail exchange or conversion to plate fixation
• Infection: Treat with appropriate antibiotics and possible hardware removal if persistent
• Nerve injury: Monitor for ulnar or median nerve symptoms
• Compartment syndrome: Emergent fasciotomy if suspected

Clinical Pearls

• Retrograde nailing technique is preferred over antegrade to minimize symptomatic hardware complications 2
• Ensure proper rotational alignment by comparing to the uninjured side
• Intramedullary nailing provides advantages of shorter operative time, minimal soft tissue dissection, and excellent cosmesis compared to plate fixation 3
• Consider plate fixation for comminuted fractures or those with intra-articular extension

Remember that proper nail selection and meticulous surgical technique are crucial for successful outcomes in midshaft ulna fractures treated with intramedullary nailing.