Upper Limb Orthotics/Ulna Shaft Fracture/Nightstick Fracture

Describe your case study
The patient is a 21 year old male who suffered a transverse fracture of the ulna shaft. He suffered this injury by raising his hand to protect his face from an assailant and there are also some abrasions in the area from the attack. The ulna has a transverse break with no rotation and <5mm of angulation. There is pain and swelling of the area with localised abrasions that will need to be monitored. The patient currently has bandages for the abrasions and is in need of an orthotic device for the injury. The patient would like to retain as much range of motion as possible while wearing the orthosis.

Orthotic Treatment of Ulna shaft fracture/Nightstick fracture
A fracture of the ulna shaft is often called a nightstick fracture as this certain type of fracture is usually obtained by raising your arm to protect the head from a blunt force as you would if you were attacked with a nightstick. Other causes of the nightstick fracture are motor vehicle accidents and falls. Symptoms of a nightstick fracture include pain, swelling, tenderness and inflammation (Orthopaedicsone, 2009) A nightstick fracture can be transverse or oblique and have a variety of angulations. A fracture with a higher degree of angulation is usually defined as more severe compared to those with a lower degree of angulation. The position of the fracture along the ulna will also change the severity, if the fracture is in the proximal 3rd of the ulna or has >10 degrees of angulation (Zych, Latta, & Zagorski, 1987, Gebuhr et al., 1992,, Mackay, Wood, & Rangan, 2000) it is usually considered too severe for a non-surgical treatment. The fracture will result in a loss of pronation, supination, permanent angulation and possibly some shortening of the forearm (Handoll & Pearce, 2012, Zych, Latta, & Zagorski, 1987, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998, Mackay, Wood, & Rangan, 2000). The amount of shortening and loss of pronation varies and can be reduced by high quality management of the fracture during healing. The goal when treating a nightstick fracture is to keep 90% or more of the original range of motion (Zych, Latta, & Zagorski, 1987) but as Stern & Drury (1983) mention “The ulna remains the most difficult bone in which to achieve primary healing. This may be due to torsional stresses incurred during pronation and supination.” It has been shown that there are a variety of options to treat a nightstick fracture both surgical and non-surgical. All of these options are viable but some are better suited to achieve certain goals (Handoll & Pearce, 2012, Mackay, Wood, & Rangan, 2000). The role of an orthosis in treating a nightstick fracture is to be rigid and provide appropriate support, pressure and protection for the site of injury while it can heal. The recommended orthosis for a nightstick fracture encompasses the wrist joint to restrict pronation, supination, and flexion/extension of the joint as to avoid misalignment of the fracture but allow some movement to increase the strength of the ulna once the fracture has healed (Sarmiento, Latta, Zych, McKeever, & Joseph, 1998).

Orthotic treatment options
Orthotic treatment of a nightstick fracture can include a short arm below elbow brace or a long arm plaster cast. Each has been shown to be effective, but have minor differences in there outcome. A short arm brace can be pre-manufactured or custom made for the client. Both pre-manufactured and custom braces have the same function, to restrict the movement of the fracture while healing by providing different forces to different areas of the forearm. The long arm plaster cast serves the same purpose as the short arm brace but provides a larger surface area by encompassing the elbow joint for extra stability. The downside of the long arm plaster cast is it greatly restricts movement of the elbow joint which has been deemed un-necessary restriction of movement (Mackay, Wood, & Rangan, 2000) and therefore the short arm brace has been found to be a more viable treatment option for those who wish to keep active while healing. Gebuhr et al. (1992) compared using the short arm brace and long arm cast and found that the short arm brace allowed patients to get back to work while healing. The short arm brace was also found to be more popular than the long arm cast, the same result was found in a study by (Handoll & Pearce, 2012). The long arm cast was found to heal the fracture an average of 6 days earlier than the short arm brace. The results of the study also showed there was no significant change in pronation, supination and elbow range of motion between the two interventions.

Orthotic treatment vs Surgical intervention
“Widely displaced or unstable fractures should be treated by open reduction and internal fixation using a compression plate.”(Mackay, Wood, & Rangan, 2000) The surgical intervention options for a nightstick fracture are external fixation and compression plating. External fixation is commonly used in modern day medicine to treat most fractures as it can provide great control over the pressure of the fracture site and allow limited mobility. External fixation is the use of pins and wires attached to the bone on either side of the fracture site and an external scaffolding to remove pressure from the fracture site and support the limb (Fragomen & Rozbruch, 2007). External fixation is rarely used on nightstick fractures as the ulna is rarely under enough pressure to justify the excessive procedure. External fixation comes with some complications such as infection at pin sites, malunion and adverse fractures of the ulna(Fragomen & Rozbruch, 2007). If the pin sites aren’t monitored and kept sterile then infection can easily set in. There is a possibility that the fracture unify using this form of treatment, though modern fracture management approaches have minimalized this problem (Fragomen & Rozbruch, 2007). The ulna may fracture after it has healed due to stress fractures of the pin sites or re-fracturing the original fracture site due to a lack of movement during the healing process (Fragomen & Rozbruch, 2007, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998). Compression plating is a less used form of surgical intervention used for fractures as it requires a large surgical area to operate. Compression plating is a surgical treatment option where a thick heavy plate is placed alongside the broken long bone and attached via screws (Harvey, 1971). This provides a stable backing to remove pressure from the fracture and allow healing. This method has been shown to have been a great method of achieving bone union in the fracture but has many complications. The complications of using compression plating are that it leaves the ulna weakened and brittle (Harvey, 1971). This is caused by the bone not moving during the healing phase and then suffering from atrophy (Harvey, 1971). The ulna may re-fracture after healing due to the holes left in the bone by the screws used to hold the metal plate to the bone. There is also a possibility of infection during the initial treatment or when removing the plate. (Harvey, 1971, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998) Depending on the severity of the fracture orthotic treatment may be preferable over any form of surgical intervention. Nightstick fractures with an angulation of less than 10 degrees and if the fracture is in the distal 2/3 of the ulna are seen to be not as severe (Gebuhr et al., 1992, Zych, Latta, & Zagorski, 1987, Mackay, Wood, & Rangan, 2000) and it is more efficient to treat them non-surgically via orthosis.

Search strategy
My search strategy used the latrobe database, Medline and cinahl. Search terms include: 'orth*' 'ulna*' 'fracture' 'nightstick' 'cast' 'functional' 'compression plate' 'external fixation'

Functional Aims and Goals
The functional aims and goals of my device are to immobilise and protect the fracture site by restricting ulna-deviation but also maintaining full ROM of the elbow joint, fingers and thumb. An additional aim for my device is to allow easy donning and doffing to change bandages and monitor the wound that will be underneath the device.

Design
The WHO I have designed for this particular patient provides adequate protection and support for the fracture site while limiting movements such as ulna deviation and wrist flexion/extension which could cause damage to the fracture site. The device is made out of LTT, but it would be better suited to the current situation with a thicker plastic, I have compensated for this by putting a second layer of plastic over the medial side of the device to strengthen it and prevent buckling of the device if the patient would try to ulna deviate. The device has been attached by three Velcro straps attached at the proximal and distal ends of the device and over the wrist joint. This allows easy donning and doffing of the device so that the wounds under the device can be easily accessed for maintenance. The proximal trim line for the device is three fingers width away from the anticubital crease and the distal trim line is at the distal palmar crease.



Materials

 * 1.	A sheet of LTT
 * 2.	Scissors
 * 3.	A marker
 * 4.	Hook/loop Velcro
 * 5.	Foam
 * 6.	Paper to make template
 * 7.	Contact adhesive

Manufacturing process

 * 1.	Take an outline of the patients arm from the fingers to elbow, marking the distal palmar crease and wrist joint.


 * Armoutline.jpeg


 * 2.	Draw the template onto the outline matching the distal palmar crease with the distal boarder and mirroring the image but slightly larger to form the full shape.
 * 3.	Cut your template out of the LTT (heating slightly will make the plastic easier to cut through).




 * 4.	Heat and fold back the distal trim line of the device to prevent any unwanted sharp edges.
 * 5.	Apply to the patient making sure it isn’t hot enough to burn them. Match the distal trim line with just below the distal palmar crease and align the proximal trim line so that it is at least 3 fingers width from the anticubital crease. Apply a small amount of pressure around the forearm to get a good contour but not so much pressure as to make indents in the device. At this stage you can remove the device and re-heat to make any adjustments that you may need to make.




 * 6.	Slightly flare out the proximal end of the device.
 * 7.	Cut out a strip of LTT and stick it onto the device on the ulna side making sure to cross the wrist joint equally on both sides as to provide extra support (this step could be skipped if using a thicker plastic than LTT).




 * 8.	Cut two squares of hook Velcro and dry heat (using a heat gun) the back of them as well as the ulna side of the device and stick them together.




 * 9.	On the anterior distal tab of the device dry heat a small strip of loop Velcro (on the loop side) and attach it.
 * 10.	On the posterior distal tab attach a small piece of hook Velcro on an angle to match up with the strip on the anterior side attached in step 8.




 * 11.	Cut two longer loop strips of Velcro for the wrist strap and proximal strap.




 * 12.	Cut a piece of foam that will fit between the gaps on each of the straps that is slightly wider than the Velcro straps and hook Velcro to match the length of the foam but slightly smaller. Attach the hook Velcro in the centre of the foam using contact adhesive and attach to the inner side of the straps when the adhesive is set.




 * 13.	Fit the device to the patient by placing in on the arm and doing up the straps firmly (for the wrist strap and proximal strap put one end of the loop Velcro at the midline of the attached hook Velcro and wrap around to meet the other half).




 * 14.	Trim off any overlapping Velcro.

Critique of fit
My orthotic device was prescribed to a patient with a nightstick fracture and abrasions on the affected forearm which need to be accessed for cleaning and monitoring. The device was made to prevent ulna deviation and limit flexion and extension of the wrist joint, while providing protection of the fracture site while it is healing. An additional preference for the device was easy donning and doffing for the wound management. The device covers the ulna side of the forearm to protect the fracture site and allow the easy donning and doffing.

The forces of the device are adequate as the straps are in the right positions and the device conforms to the forearm well, though there may be a slight pressure area over the ulna styloid.



The trimlines are in the right allow movement where necessary except there is a little restriction of the thumb.



The device has nice smooth trimlines that don’t cause any pressure areas. There are pen marks on the edges of the device.



Outcome measures
I have chosen the QuickDASH outcome measure survey as it assesses relevant actions for my client. Measuring the daily activities that my client may encounter is a good form of assessment, but the orthosis is not made to allow/improve the clients capability of these activities it is to protect the fracture as it heals.The tests we’re very easy to implement and are extremely easy to repeat. Being a survey it is subject to bias from the client.



Referral Letter
29 May 2014

Dr Patton

La Trobe Medical Centre

Plenty Road

Bundoora VIC 3038

Dear Dr Patton

I am writing to refer Braiden for assessment of an Ulna/nightstick fracture of the right forearm.

Braiden is a 21 year old male who suffered a transverse fracture of the ulna shaft. He suffered this injury by raising his hand to protect his face from an assailant and there are also some abrasions in the area from the attack. The ulna has a transverse break with no rotation and <5mm of angulation. There is pain and swelling of the area with localised abrasions that will need to be monitored.

I have been treating Braiden and have provided him with a wrist-hand orthosis to protect the fracture site and restrict some movement that could damage the area. The wound under the dressing will still need to be monitored and cleaned.

I am referring Braiden to get some better management of the wound on the effected limb.

Yours sincerely, Joshua Wright

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