Approach to distal ulnar

1. APPROACH TO
DISTAL ULNA &
TBW DISTAL ULNA
PRESENTER: HANIS
SUPERVISOR: MISS NADIAH

3. OPTIONS OF SURGICAL MANAGEMENT
FOR DISTAL ULNA FRACTURE
• TENSION BAND WIRE
• LAG SCREW
STYLOID PROCESS
• LAG SCREW+ PROTECTION PLATE
• COMPRESSION PLATE
SIMPLE FRACTURE
• BRIDGE PLATE
• HOOK PLATE
COMMINUTED FRACTURE,
EXTRAARTICULAR

4. POSITIONING

5. ◦ 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

6. 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

7. REDUCTION

8. 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

9. 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

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

12. ‘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

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

15. 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

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

17. 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

18. 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.

19. Assessment of Distal Radioulnar Joint
(DRUJ)

20. Assessment of Distal Radioulnar Joint
(DRUJ)

21. SKIN INCISION

22. REDUCTION

23. 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.

24. 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.

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

26. AFTERCARE

27. References
1. ANATOMIC CONSIDERATIONS FOR
PLATING OF THE DISTAL ULNA
◦ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC
4530182/#:~:text=Typically%2C%20the%20distal
%20ulna%20is,sheath%20to%20avoid%20tendo
n%20irritation
2. ULNAR APPROACH TO DISTAL ULNA
◦ https://surgeryreference.aofoundation.org/ortho
pedic-trauma/adult-trauma/distal-
forearm/approach/ulnar-approach-to-the-distal-
ulna