forearm fractures

Dr. Waleed Faris Al-Rawi

Fracture of radius and ulna

•The fracture occur at tree levels, proximal, middle, and distal thirds•Mechanism of injury and pathology; Fractures of the shafts of both forearm bones occur

quite commonly in road accidents. A twisting force ( usually a fall on the hand ) produces a spiral fracture with the bones broken at different levels.

•A direct blow or an angulating force causes a transverse fracture of both bones at the same level.

Clinical features;

•There is pain and deformity. Pulse must be felt and the hand examined for circulatory or neural deficit.

•X-Ray ;•If fracture transverse or oblique this mean low

energy fracture.•If fracture comminuted or segmental mean high

energy fracture

Treatment;•The treatment is increasingly difficult as forearm shaft fractures

progress from distal to proximal. In children closed treatment is usually successful, the position held by POP from axilla to metacarpal shafts and elbow in 90 degree, the position checked one week later, if successful POP retained until fracture united ( usually 6-8 weeks ).

•In adult.•If fragment undisplaced and are in closed apposition so conservative

treatment by P.O.P cast.•If fracture fragments displaced so it is difficult to do reduction or

maintaining reduction so treatment by open reduction internal fixation.•Open fracture;

•Initial care of the wound by irrigation and debridement for 2-3 weeks then if wound heal do internal fixation if fracture infected do external fixation.

Complications

•Early.•(1 )Neural injury; either by fracture or by surgeon during

operation.•(2 )Vascular injury; either radial or ulnar artery or

compartment syndrome. So repeated examination is important to detect compartment syndrome.

•(3 )Compartment syndrome .•Late.

•(1 )Malunion.•(2 )Nonunion

Fracture of a single forearm bone•Fracture of the radius alone is very rare and

fracture of the ulna alone is uncommon. These injuries are usually caused by direct trauma ( the nightstick fracture ). They are important for two reasons;

•(1)An associated dislocation may be undiagnosed either proximal or distal radioulnar joints, so entire forearm should be x-rayed.

•(2 )Non-union is liable to occur unless is realized that one bone takes just as long to consolidate as two.

X-ray

•The fracture may be any where in the radius or ulna. The fracture line is transverse and displacement is slight. In children the intact bone some times bends without actually breaking (plastic deformation ).

Treatment

•Isolated fracture of the ulna•The fracture is rarely displaced, a forearm brace leaving elbow free is usually sufficient

for 8 weeks.•Isolated facture of the radius

•Radial fractures are usually prone to rotary displacement, to achieve reduction the forearm needs to be supinated for upper third fractures, neutral for middle third fractures, and pronated for lower third fractures.The position is some times difficult hold, so internal fixation with a compression plates and screws is better.

Monteggia fracture

•Any fracture of ulna associated with dislocation of radio capitellar joint.•Mechanism of injury

•(1 )Hyper pronation; full on the out stretched hand with forceful pronation of forearm.•(2 )Hyper extention.

•3 )Direct trauma to the ulnar aspect of elbow and forearm.

Clinical features;

•Deformity and swelling of the lateral aspect of elbow and forearm. There is also pain and tenderness and limitation of elbow movements and forearm pronation and supination.

•We should examine for signs of radial nerve injury.

Treatment

•Restore length of fractured bone (ulna) by open reduction internal fixation by compression plate or inramedullary device and dislocated head radius reduced spontaneously; if not reduced we do closed reduction.

•After treatment back slab in elbow flexion and forearm supinated for 6 weeks.

Complications

•1-Nerve injury e.g radial nerve.•2-Myositis ossificans.

•3-Radio ulnar synostosis.•4-Malunion.•5-Non union.

Galeazzi fracture;

•Diaphyseal fracture in the distal third or mid distal third shaft of radius with disruption of distal radio- ulnar joint. So distal radio-ulnar joint either dislocate or

sublaxate .

Clinical features

•The Galeazzi fracture is much more common than the monteggia fracture. Prominance or tenderness over the lower end of the ulna is the striking feacture. It may be possible to demonstrate the instability of the radio-ulnar joint by balloting the distal end of the ulna ( the piano key sign ) or by rotating the wrist. It is important also to test for an

ulnar nerve which is common .

X-Ray

•A transverse or oblique fracture is seen in the lower third of the radius with angulation or overlap. The radio-ulnar joint is sublaxated or dislocated

Treatment

•As with Monteggia fracture the important step is to restore the length of the fractured bone. In children closed reduction is often successful ; in adult reduction is best achieved by open reduction and compression plating of the radius. An X-Ray is taken to ensure that the distal radio-ulnar joint is reduced. If still irreducible we

reduce it operatively .

Complications

•Ulnar nerve palsy.•Malunion of the fracture radius.

•Persistant instability of distal radio-ulnar joint .

Colles fracture

•The injury that Abraham Colles described in 1814 is a transverse fracture of the radius just above the wrist, with dorsal displacement of distal fragment. It is the most common of all fractures in older people, the high incidence being relating to the onset of postmenopausal osteoporosis

Mechanism of injury and pathological anatomy

•Force is applied in the length of the forearm with the wrist in extention. The bone fractures at the corticocancellous junction and the distal fragment collapses into extention dorsal displacement, radial tilt and shortening.

Clinical features

•We can recognize this fracture ( as Colles did long before radiography was invented) by the dinner-fork deformity, with prominence on the back of the wrist and a depression in front. In patient with less deformity there may only be local tenderness and pain on wrist movement.

X-RAY

•There is a transverse fracture of the radius at the corticocancellous junction, and often the ulnar styloid process is broken off. The radial fragment is impacted into radial and backward tilt. Some times it is severely comminuted or crushed.

Treatment

•Undisplaced fractures•If the fracture undisplaced or slightly

displaced, a dorsal splint is applied for day or two until the swelling has resolved, then the cast is completed. Cast can be removed after 4 weeks.

Displaced fractures

•Displaced fractures must be reduced under general anesthesia or Biers block. The position then checked by x-Ray. If it is satisfacary, a dorsal slab is applied extending

• from just below elbow to the metacarpal necks in flexion and ulnar deviation 20 degrees in each directions

Comminuted Colles fractures

•Plaster immobilization alone may be insufficient, this can be supplement by percutaneous K-wire fixation. In very comminuted fractures for which percutaneous wires are inadequate, external fixation is needed, bone grafts may be added if the radius has markedly collapsed

Complications

•Early•The circulation in the fingers must be checked, the

bandage holding the slab may need to be split or loosened.

•Nerve injury is rare but compression of median nerve in the carpal tunnel is fairly common, if this occur soon after injury and symptoms are mild may resole with release of dressing

Reflex sympathetic dystrophy

•There may be swelling and tenderness of the finger joints. X-Ray show osteoporosis and there is increase activity on the bone scan.

Late

•Malunion is common, either because of reduction was not complete or bcause displacement within the plaster was overlooked.

•Delayed union and non-union•It is rare that radius not unite but the ulnar styloid

process often joins by fibrous tissue only and remains painful and tender for several months.

Stiffness

•Stiffness of the shoulder, elbow and fingers from neglect is a common complications. Stiffness of the wrist may follow prolonged splintage.

•Tendon rupture ( of extensor pollicis longus ) occasionally occurs a few weeks after an apparently trivial undisplaced fracture of the lower radius

•Thank you