What is the recommended approach for hybrid fixation in both bone forearm fractures?

Hybrid Fixation in Both Bone Forearm Fractures

For both bone forearm fractures, hybrid fixation using a combination of plate fixation for one bone and intramedullary fixation for the other bone is recommended when anatomical reduction cannot be achieved with a single fixation method alone. This approach balances the benefits of different fixation techniques while minimizing their individual complications.

Surgical Approach and Technique

Initial Assessment

• Obtain standard radiographic views (posteroanterior, lateral, and oblique) for proper fracture evaluation 1
• Consider CT scans for complex fracture patterns to identify displaced fragments and fracture orientation 1
• Assess fracture stability, displacement, and comminution to determine optimal fixation strategy

Hybrid Fixation Technique

1. Plate Fixation (typically for radius):

   • Use a volar approach between flexor carpi radialis and radial artery 2
   • Perform anatomical reduction under direct visualization
   • Apply small-fragment compression plate with at least 3 bicortical screws proximal and distal to fracture 2
   • Ensure plate length is sufficient to provide secure fixation (minimum 5 screws total) to reduce nonunion risk 3

2. Intramedullary Fixation (typically for ulna):

   • Approach along subcutaneous border between flexor carpi ulnaris and extensor carpi ulnaris 2
   • Insert intramedullary rod/nail with limited open approach as needed 4
   • Verify reduction fluoroscopically

3. Verification:

   • Ensure anatomic reduction, especially restoration of radial bow 2
   • Confirm motion/stability of elbow and wrist joints 2
   • Obtain intraoperative radiographs to verify alignment

Evidence-Based Considerations

Advantages of Hybrid Fixation

• Combines stability of plate fixation with less invasive intramedullary technique
• May reduce overall surgical exposure compared to plating both bones
• Allows for anatomical reduction of complex fractures
• Preserves periosteal blood supply in the bone treated with intramedullary fixation

Potential Complications

• Hardware migration (particularly with intramedullary fixation) 4
• Infection risk (higher with open approaches) 4
• Loss of reduction 4
• Nerve injury 4
• Decreased range of motion 4
• Radioulnar synostosis (particularly in patients with head injuries) 3

Important Technical Considerations

• Plate Selection: Use plates long enough to provide secure fixation with at least 5 screws total to reduce nonunion risk (nonunion rate is four times higher with only 4 screws) 3
• Anatomic Reduction: Critical for restoration of motion and function, especially restoring the radial bow 2
• Early Mobilization: Initiate early finger motion to prevent edema and stiffness 1
• Avoid Dorsal Approach: Prefer volar approach for radial fractures to minimize risk to posterior interosseous nerve 2

Special Situations

• Open Fractures: Can typically be treated with irrigation, debridement, and immediate fixation 2
• Comminuted Fractures: Bone grafting is rarely indicated even in comminuted fractures 2
• Unstable Patterns: May require more robust fixation; consider plate fixation for both bones in highly unstable patterns

Postoperative Management

• Initiate early finger motion exercises to prevent stiffness 1
• Regular assessment of wound healing and radiographic union 1
• Monitor for hardware-related pain or complications 1
• Consider directed home exercise program for rehabilitation 1

By following these principles for hybrid fixation in both bone forearm fractures, surgeons can achieve optimal outcomes with union rates of ≥95%, restoration of forearm strength and stability, and low complication rates 2.