forearm fractures medscape

8/19/2019 Forearm Fractures Medscape

1/16

Forearm Fractures

Author

Gopikrishna Kakarala, MBBS, MS MRCSEd, Fellow, Department of Orthopedics, New

Cross Hospital, UK

Updated: Oct !, "!#$

%ac&'ro(nd

)he forearm is a comple* anatomic str(ct(re ser+in' an inte'ral role in (ppere*tremit-f(nction. )he de*terit- of the (pper lim/ depends on a com/ination of hand and wristf(nction and forearm rotation. )he forearm /ones can /e considered str(ts lin&in' thetwo hal+es of a cond-lar 0oint formed /- the pro*imal and distal radio(lnar 0oints. )h(s,an- chan'e in the 'eometr- of the radi(s or (lna alters the con'r(enc- and ran'e ofmotion of this cond-lar 0oint.

Mal(nion, especiall- shortenin' and an'(lation of the radi(s or (lna, ma- ca(sef(nctional pro/lems at the wrist or el/ow. 1f f(nctional disa/ilit- is to /e a+oided afterfract(re, precise anatomic red(ction is necessar-.

2s a res(lt of the comple* arran'ement of ne(ro+asc(lar str(ct(res s(rro(ndin' theradi(s and (lna, s(r'ical approaches to the forearm for fract(re fi*ation re3(irepartic(lar care in plannin' and e*ec(tion. )o restore the f(nctional d-namics of the(pper lim/, +er- caref(l attention m(st /e paid to acc(rate reconstr(ction of in0(redstr(ct(res.

1n children, rapid /onehealin' times and the possi/ilit- of remodelin' with 'rowth allow

conser+ati+e treatment m(ch of the time. 4#5 1n ad(lts, nonoperati+e treatment in the formof plaster castin' is often inade3(ate to ens(re anatomic red(ction and healin'.

2chie+in' anatomic red(ction /- closed methods is diffic(lt, and maintainin' a red(ctionis often impossi/le.

For an optimal res(lt, the /asic r(le is that a sta/le anatomic red(ction with preser+ationof mo/ilit- m(st /e achie+ed. Operati+e treatment is therefore the r(le, rather than thee*ception, in ad(lts, the treatment principles of the 2O 'ro(p 6 Arbeitsgemeinschaft fürOsteosynthese, or 2ssociation for the St(d- of Osteos-nthesis7 ha+e re+ol(tioni8edtreatment of radi(s and (lna fract(res.

)his article addresses in0(r- to the diaph-seal radi(s and (lna, as well as associatedin0(r- to the distal and pro*imal radio(lnar 0oints.

2natom-

)he radi(s and (lna f(nction as a (nit, /(t the- come into contact with each other onl-at the ends. )he- are /o(nd pro*imall- /- the caps(le of the el/ow 0oint and theann(lar li'ament and distall- /- the caps(le of the wrist 0oint, the dorsal and +olarradio(lnar li'aments, and the fi/rocartila'ino(s artic(lar dis&.

http://emedicine.medscape.com/article/1245884-overviewhttp://emedicine.medscape.com/article/1244885-overviewhttp://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1244885-overviewhttp://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1245884-overview


2/16

)he (lna is relati+el- strai'ht, has sta/le artic(lation with the distal h(mer(s at theel/ow, and r(ns +irt(all- s(/c(taneo(sl- distall- to the (lnar st-loid at the wrist. )heradi(s is /owed alon' its len'th and th(s an'les at least #9 opposite to the /ow toartic(late with the capitell(m. )he radi(s and (lna form a 0oint at the distal end, wherethe str(tli&e radi(s sweeps and rotates aro(nd the relati+el- fi*ed (lna with pronation

and s(pination.

%etween the shafts of the radi(s and (lna is the interosseo(s space. )he fi/ers of theinterosseo(s mem/rane r(n o/li3(el- across the interosseo(s space from their distalinsertion on the (lna to their pro*imal ori'in on the radi(s. )he central portion of theinterosseo(s mem/rane is thic&ened and is appro*imatel- .$ cm wide. Hotch&iss et alshowed that ma&in' an incision on the central /and red(ces sta/ilit- /- #;, whereasma&in' an incision of the trian'(lar fi/rocartila'e comple* and the interosseo(smem/rane pro*imal to the central /and decreases sta/ilit- /- onl- ##;. 4"5

1n the treatment of fract(res of the forearm, the radial /ow and proper interosseo(sspace m(st /e maintained for normal motion to /e achie+ed. Schemitsch et al reported

that restoration of the radial /ow is related in a linear fashion to the 3(alit- of theo(tcome.45 )he normal ma*imal radial /ow, meas(red from the area /etween the radi(sand the (lna across the interosseo(s mem/rane, is #$ mm. )o achie+e

Fract(res of /oth /ones of the forearm are (s(all- classified accordin' to the le+el offract(re, the pattern of the fract(re, the de'ree of displacement, the presence or

a/sence of commin(tion or se'ment /one loss, and whether the- are open or closed.Each of these factors ma- ha+e some /earin' on the t-pe of treatment to /e selectedand the (ltimate pro'nosis.

Disr(ption of the pro*imal or distal radio(lnar 0oints is of 'reat si'nificance to treatmentand pro'nosis. Determinin' whether the fract(re is associated with 0oint in0(r- isimperati+e /eca(se effecti+e treatment demands that /oth the fract(re and the 0ointin0(r- /e treated in an inte'rated fashion.

Etiolo'-

)he mechanism of in0(r- is +aria/le. )he most common ca(se is a direct /low to the

forearm, prod(cin' a sin'le 6ni'htstic&7 fract(re of the (lna, the radi(s, or /oth. )he ne*tmost li&el- mechanism is a fall on an o(tstretched hand with the forearm pronated.Other mechanisms of in0(r- incl(de road traffic accidents and athletic in0(ries. )he force'enerated is (s(all- m(ch 'reater than that re3(ired to ca(se a Colles fract(re. Mostforearm shaft fract(res res(ltin' from falls occ(r in athletes or in persons who fall fromhei'hts.


3/16

>(nshot wo(nds can res(lt in fract(re of /oth /ones of the forearm. )hese in0(ries arecommonl- associated with ner+e or softtiss(e deficits and fre3(entl- ha+e si'nificant/one loss. Se+erel- de/ilitatin' and m(tilatin' in0(ries are ca(sed /- accidents in+ol+in'farm-ard machines and ind(strial machiner-. )hese se+erel- man'led e*tremities posea challen'e from the time the decision is made to sal+a'e the lim/ (ntil the final res(lt.

Epidemiolo'-

1n "!#!, accordin' to data from the "!#! National Electronic 1n0(r- S(r+eillance S-stem6NE1SS7 data/ase and the "!#! US Cens(s, forearm fract(res were the most commont-pe of fract(re in the pediatric pop(lation 6a'e ran'e, !#? -ears7 and acco(nted for#.


4/16

)he important feat(re common to these st(dies, in which a (nion rate of more than ?!;was reported, was the ri'idit- of the fi*ation. 1f intramed(llar- nails are (sed, the- m(stcontrol rotation of the fra'ments and /e st(rd- eno('h to resist an'(lator- forces. 1fplates and screws are (sed, the- m(st /e lon' eno('h and stron' eno('h to resistloosenin' and /rea&a'e.

)he pro'nosis is more '(arded for open fract(res of the shaft of the radi(s and (lnawith ma0or s&in and softtiss(e loss. 1n these cases, se+eral operati+e proced(res ma-/e necessar-, incl(din' initial de/ridement and sta/ili8ation, s&in 'raftin', pedicle orfreeflap applications,4#@5 late reconstr(ction of the /ones, and, fre3(entl-, tendontransfers.

Histor-

Nondisplaced diaph-seal fract(res of the shafts of /oth /ones of the forearm are rare,and the deformit- is often o/+io(s, with the patient s(pportin' the deformed and in0(redlim/ with the other hand. )he s-mptoms incl(de pain, deformit-, and loss of f(nction of

the forearm. 1n these cases, e*cessi+e manip(lation of the arm sho(ld /e a+oided topre+ent f(rther dama'e to the soft tiss(es.

=h-sical E*amination

Clinical e*amination sho(ld incl(de a caref(l ne(rolo'ic e+al(ation of the motor andsensor- f(nctions of the radial, median, and (lnar ner+es. Chec& the +asc(lar stat(sand amo(nt of swellin' in the forearm. 2 tense compartment with ne(rolo'ic si'ns orstretch pain sho(ld aro(se the s(spicion of compartment s-ndrome 6see the first ima'e/elow7, and compartment press(res sho(ld /e meas(red and monitored. )his ma- /eof si'nificance in pol-tra(ma patients or in comatose or o/t(nded patients. 2 lowthreshold sho(ld /e maintained when decidin' whether a fasciotom- is needed in

patients with impendin' compartment s-ndrome.

Closed fract(re of the forearm in the middlethird area is complicated /- compartment s-ndrome,with earl- /listers and a tense compartment.

Open fract(res, especiall- those res(ltin' from '(nshot wo(nds, fre3(entl- ha+eassociated ner+e and ma0or /lood +essel in+ol+ement. )his in+ol+ement m(st /ecaref(ll- e+al(ated. Ur'ent treatment is re3(ired for open fract(res. 2 sterile dressin'sho(ld /e placed o+er the wo(nd, and formal de/ridement sho(ld /e reser+ed for theoperatin' room.


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)he presence of ipsilateral fract(res sho(ld /e e*cl(ded, and a preliminar- secondar-s(r+e- sho(ld /e performed to r(le o(t other s&eletal in0(ries.

1ma'in' St(dies

)he confi'(ration of midshaft fract(res of the radi(s and (lna +aries dependin' on themechanism of in0(r- and the de'ree of +iolence in+ol+ed. Gowener'- fract(res tend to

/e trans+erse or short o/li3(e, whereas hi'hener'- in0(ries are fre3(entl- e*tensi+el-

commin(ted or se'mented, often with e*tensi+e softtiss(e in0(ries.

Radiography

2t least two radio'raphic pro0ections 6ie, anteroposterior and lateral7 of the forearm m(st

/e o/tained. )hese show the fract(re, the e*tent of displacement, and the e*tent of

commin(tion. 2ttention sho(ld /e directed toward findin' an- forei'n /odies in open

fract(res and '(nshot in0(ries.

2lso imperati+e is to incl(de the el/ow and wrist 0oint in the radio'raphs of forearm

fract(res to ens(re that radial head and distal radio(lnar 0oint in0(ries are not missed. 2

line thro('h the center of the radial shaft, nec&, and head sho(ld pass thro('h the

center of the capitell(m in an- +iew of the el/ow.

2 t(/erosit- +iew ma- help ascertain the rotational displacement of the fract(re. )his

wo(ld help in plannin' how m(ch s(pination or pronation is needed to achie+e acc(rate

anatomic red(ction. )he (lna is laid flat on the cassette with its s(/c(taneo(s /order incontact with the cassette the *ra- t(/e is tilted toward the olecranon /- "!9. )his

radio'raph is then compared with a standard set of dia'rams that show the prominence

of the radial t(/erosit- in +ario(s de'rees of pronation and s(pination in order to

determine the scope of the rotational deformit-.

Computed tomography

Comp(ted tomo'raph- 6C)7 is (sef(l in distal radi(s fract(res and radio(lnar 0oint

patholo'ies. One st(d- e*amined whether the location of distal fract(res of the radi(s

correlate with the areas of attachment of the wrist li'aments. 4#$5 Usin' data from C)scans of ac(te intraartic(lar distal radi(s fract(res, the st(d- noted that artic(lar

fract(res of the distal radi(s were statisticall- more li&el- to occ(r at the inter+als

/etween the li'ament attachments than at the li'ament attachments. )he most common

fract(re sites were the center of the si'moid notch, /etween the short and lon'

radiol(nate li'aments, and the central and (lnar aspects of the scaphoid fossa dorsall-.


6/16

)hese res(lts s(''est that C) ma- /e (sed to identif- the s(/se3(ent propa'ation of

the fract(re and the li&el- site of the impaction of the carp(s on the distal radi(s artic(lar

s(rface.

Other modalities

Ma'netic resonance ima'in' 6MR17 is of limited (tilit- in radio(lnar in0(ries and is not

indicated in (ncomplicated forearm fract(res. 2n'io'raph- or +asc(lar Doppler

(ltrasono'raph- is (sef(l to determine the le+el of +asc(lar in0(r- in selected cases in

which +asc(lar in0(r- is s(spected.

2pproach Considerations

2ll displaced ad(lt forearm fract(res sho(ld /e sta/ili8ed /eca(se no other means of

mana'ement is a+aila/le that pro+ides a compara/le res(lt. )he followin' are specificindications for operati+e treatment:

• Fract(re of /oth /ones 6ie, radi(s and (lna7

• Fract(re dislocations, Monte''ia fract(re dislocations, and >alea88i fract(re dislocations

• 1solated radi(s fract(res

• Displaced (lnar shaft fract(res

• Dela-ed (nion or non(nion

• Open fract(res

• Fract(res associated with a compartment s-ndrome, irrespecti+e of the e*tent of

displacement•

M(ltiple fract(res in the same e*tremit-, se'mental fract(res, and floatin' el/ow• =atholo'ic fract(res

2 medicall- fit patient has few contraindications to operati+e fi*ation of a forearm

fract(re. Hi'hl- contaminated compo(nd fract(res, partic(larl- with /one loss, ma- /e

mana'ed with temporar- e*ternal fi*ation followed /- de/ridement and dela-ed internal

fi*ation.

Medical )herap-

1n children, the (s(al plan is to attempt closed red(ction followed /- cast immo/ili8ation.4#B5 Childhood o/esit- appears to increase the ris& of malred(ction and s(/se3(ent

manip(lations with closed red(ction and castin'. 4#5 1n ad(lts, treatment with

immo/ili8ation in a molded lon' arm cast can /e (sed in those rare occasions of a

nondisplaced fract(re of /oth /ones of the forearm.

http://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1231438-overviewhttp://emedicine.medscape.com/article/1231438-overviewhttp://emedicine.medscape.com/article/1239331-overviewhttp://emedicine.medscape.com/article/1239331-overviewhttp://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1231438-overviewhttp://emedicine.medscape.com/article/1239331-overview


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)he cast sho(ld /e applied with the el/ow in ?!9 fle*ion. )he sta/le position of

pronation or s(pination can /e fo(nd /- screenin' on the ima'e intensifier, /(t in

'eneral, fract(res of the pro*imal third are sta/le in s(pination, fract(res of the middle

third are sta/le in ne(tral position, and fract(res of the distal third are sta/le in

pronation. Follow(p of these patients with radio'raph- in /oth planes at wee&l-

inter+als for the first @ wee&s is mandator- to detect earl- displacement of the fract(re.

Sarmiento et al reported the res(lts of a closed method of treatment for nondisplaced

fract(res of one or /oth /ones of the forearm. 4#


8/16

Osteos-nthesis (sin' a d-namic compression plate for a closed midshaft fract(re of /oth /ones of

the forearm.

)he 'eneral r(le is that /one 'raftin' is recommended when more than one third of the

circ(mference of the /one is commin(ted. 1f this is instit(ted, it sho(ld /e performed

awa- from the interosseo(s mem/rane to decrease the ris& of s-nostosis. 1n their

re+iew of #?< forearm fract(res, ri'ht et al reported compara/le res(lts in (nion in

commin(ted forearm fract(res treated with /one 'raftin' and witho(t /one 'raftin'.

4""5

1n a st(d- of $? cases of shaft fract(re of /oth forearm /ones, Kim et al s(''ested that

a com/ination of plate fi*ation and intramed(llar- nailin', tho('h not 'enerall-

prefera/le to plate fi*ation alone, mi'ht /e a (sef(l option for these fract(res when

treatment with platin' /- itself is not feasi/le. 4"5

!ntramedullary nailing

)he first widel- (sed and s(ccessf(l med(llar- forearm nail s-stem was de+eloped /-

Sa'e in #?$?.4#"5

)he pre/ent radial nail maintains the radial /ow, and the trian'(larcrosssectional shape pre+ents rotational insta/ilit- 6see the ima'e /elow7.

1nternal fi*ation (sin' s3(are nails for a se'mental fract(re of /oth /ones of the forearm.


9/16

hen intramed(llar- de+ices are (sed in persons with a fract(re of /oth /ones, fi*ation

of the radi(s m(st /e sta/le eno('h to pre+ent collapse of the radial /ow otherwise,

elon'ation of the radi(s and distraction of the (lnar fract(re can occ(r, res(ltin' in

non(nion in either or /oth /ones. )he entr- point for intramed(llar- nailin' of the (lna is

made in the pro*imal (lna. )he radial portal is (s(all- into the radial st-loid process

/etween the e*tensor carpi radialis lon'(s and the e*tensor pollicis /re+is. 2ll radial

nails sho(ld /e well seated to a+oid fra-in' of the tendon and possi/le r(pt(re. 4"@, "$, "B5

)he indications for intramed(llar- nailin' are as follows:

• Se'mental fract(res

• =oor s&in condition

• Selected non(nions or failed compression platin's 4", "(stilo t-pe 1 and t-pe 11 open diaph-seal forearm

fract(res is appropriate, pro+ided that thoro('h de/ridement is performed. 4"?5 D(ncan et

al reported ?!; accepta/le res(lts in persons with >(stilo t-pe 1, t-pe 11, or t-pe 1112

open diaph-seal fract(res treated in this manner howe+er, their res(lts with 111% and

111C in0(ries were poor.4!, #5

"rocedural details

Fract(res are /est internall- fi*ed as soon after the in0(r- as is practical, prefera/l-

/efore the onset of swellin'. ith dela-ed fract(re presentation, /listers secondar- to

swellin' can de+elop. R(pt(red fract(re /listers or a/rasions older than B< ho(rs ma-

/e a contraindication for s(r'er-. 2t least #! da-s ma- /e re3(ired for a/raded s&in

and fract(re /listers to heal and for swellin' to s(/side.

Ulnar approach

2n interne(ral approach /etween the e*tensor carpi (lnaris and the fle*or carpi (lnaris

is (sed. )he plate can /e (sed on either the posterior or the anterior s(rface, tho('h the

posterior s(rface is preferred /eca(se it is the tension side of the (lna. Care sho(ld /e

ta&en to a+oid dama'e to the dorsal sensor- /ranch of the (lnar ner+e in the distal part

of the incision.


10/16

Palmar approach of Henry

)he palmar approach of Henr- is the most common approach for fi*ation of the shaft of

the radi(s. 1t (ses the interne(ral inter+al /etween the /rachioradialis 6radial ner+e7 and

the pronator teres 6or the fle*or carpi radialis distall-, inner+ated /- the median ner+e7.

For deep dissection, the arterial /ranches of the radial arter- s(ppl-in' the

/rachioradialis are caref(ll- li'ated. Rotation of the forearm enhances the +iew d(rin'

this approach.

Dorsolateral approach

2ccess to the radial shaft r(ns in the sept(m /etween the e*tensor carpi radialis /re+is

and the e*tensor di'itor(m m(scles. 1t can /e (sef(l for fract(res of the pro*imal and

middle thirds of the radi(s and to address in0(ries to the pro*imal radio(lnar 0oint. )he

dorsolateral approach 6also called the )hompson approach7 potentiall- in+ol+es less

softtiss(e strippin' than the palmar approach, and patients ma- e*perience a more

rapid ret(rn of wrist and hand f(nction. )he two ner+es +(lnera/le to in0(r- with this

approach are the followin':

• )he s(perficial radial ner+e in the distal part of the incision alon' the /rachioradialis

crossin' the a/d(ctor pollicis lon'(s in the s(/c(taneo(s la-er • )he posterior interosseo(s ner+e r(nnin' thro('h the s(pinator in the pro*imal e*pos(re

Reduction techniques

=eriosteal strippin' sho(ld /e limited to a minim(m, and circ(mferential strippin' is to/e strictl- a+oided. =lates of .$ mm ha+e /een pro+ed to /e the ideal si8e for the

forearm /ones. )he p(rpose of the plate is to ne(trali8e the torsional forces, and

p(rchase sho(ld /e o/tained at no fewer than si* cortices in each main fra'ment in

order to achie+e this o/0ecti+e. 1nterfra'mentar- la' screws, inserted either

independentl- or thro('h a plate hole, sho(ld /e (sed to stren'then the fi*ation if the

fract(re confi'(ration allows it.

Closure

Of (tmost importance is to close onl- the s(/c(taneo(s tiss(e and s&in. 1f the deepfascia is s(t(red ti'htl-, edema and hemorrha'e ma- ca(se increased press(re in the

forearm compartments, which can lead to ischemic contract(re. 2 s(ction drain can /e

(sed to decrease the hematoma and res(ltant swellin'. )he drain is remo+ed in #""@

ho(rs.


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"ostoperati#e care

1f the ri'idit- of the fi*ation is s(fficient, limited postoperati+e cast immo/ili8ation is

(sed. 2 posterior splint can /e applied for #" wee&s for comfort. =atients are

enco(ra'ed to perform /oth acti+e and acti+eassisted ran'eofmotion 6ROM7

e*ercises of the sho(lder and hand. El/ow ROM and pronations(pination e*ercises

sho(ld /e'in as soon as remission of pain and swellin' of the forearm permits after the

plaster splint is remo+ed. Howe+er, in the case of a noncompliant patient, e*ternal

immo/ili8ation 6(s(all- an a/o+etheel/ow cast7 is essential, alon' with s(per+ised

ph-siotherap- (ntil the fract(re is deemed (nited on the /asis of radio'raphic findin's.

Complications

$onunion and malunion

Non(nion of fract(res of the shafts of the radi(s and (lna is relati+el- (ncommon.

2ndersons series of forearm fract(res treated with compression plates incl(ded nine

non(nions 6".;7 and fo(r dela-ed (nions 6#.";7 in ! fract(res. 4##5 2lmost all of the

non(nions and dela-ed (nions appeared to ha+e /een ca(sed /- infection or errors in

s(r'ical techni3(e 6see the ima'es /elow7. 2cc(rate open red(ction and ri'id internal

fi*ation pre+ent most of these complications.4"5

Non(nion of the radi(s and (lna d(e to an error in s(r'ical techni3(e.


12/16

Non(nion treated with resection of appro*imatel- " cm of /one from /oth the radi(s and the (lna,

alon' with compression platin'.

!nfection

Stern et al reported a .#; rate of osteom-elitis in forearm fract(res /oth instances

occ(rred in patients with massi+e cr(sh in0(ries 6see the ima'e /elow7. 45ith 'ood

techni3(e and a contemporar- operatin' en+ironment, the rate is c(rrentl- m(ch lower.

Se3(estr(m of the pro*imal radi(s. Se3(ela to an open fract(re of the radi(s and (lna and m(ltiple

s(r'eries.

S(perficial infections respond well to appropriate anti/iotics. )he 'eneral principles of

s(r'ical de/ridement and copio(s irri'ation are &e- in treatin' deep infections. )he


13/16

internal fi*ation can /e left in sit( while the infection is /ein' treated, and most fract(res

proceed to (nion. )he metal can /e remo+ed after (nion of the fract(re.

2''ressi+e treatment is re3(ired for late infections, when fi*ation has /een lost and

non(nion has de+eloped. Metal sho(ld /e remo+ed alon' with an- non+ia/le /one. )he

wo(nd can /e left open for dressin' chan'es, or an irri'ations(ction s-stem can /e

instit(ted.

1f an intercalar- defect res(lts, it can /e spanned with a lon' plate and /one 'raftin'

when the wo(nd is health- and after a period of dressin' chan'es. Serial e*aminations

of the wo(nd are re3(ired to determine the appropriate timin' for the /one'raftin'

proced(re. 1f the intercalar- defect is lar'e 6IB cm7, a +asc(lari8ed fi/(lar /one 'raft

sho(ld /e considered to /rid'e the defect 6see the ima'e /elow7.

1nfected non(nion of a compo(nd fract(re, treated pre+io(sl- with /one 'raftin' and replatin'. )he

plates were remo+ed and dead, infected /one was de/rided, lea+in' a 'ap of $.$ cm in the radi(s.)emporar- e*ternal fi*ation was applied to the radi(s. Fo(r wee&s later, a free fi/(lar 'raft was (sed

to reconstr(ct the radi(s, and the (lna was replated.

Compartment syndrome

Compartment s-ndromes 6see the ima'e /elow7 can occ(r in the forearm either after

tra(ma or after s(r'er-. Eaton et al reported #? patients with Jol&mann ischemia,


14/16

res(ltin' from a +olar compartment s-ndrome of the forearm. 4@5 2n important earl- si'n

is pain o(t of proportion to the in0(r- and pain (pon passi+e e*tension of the fin'ers.

)he presence of the radial p(lse is not a relia/le dia'nostic indicator the radial p(lse

was a/sent in onl- fi+e of their #? patients. %e aware that the presence of a palpa/le

radial p(lse does not r(le o(t the presence of a compartment s-ndrome.

Closed fract(re of the forearm in the middlethird area is complicated /- compartment s-ndrome,

with earl- /listers and a tense compartment.

1n conscio(s patients, the dia'nosis of compartment s-ndrome is made on the /asis of

clinical findin's. Compartment press(res can /e meas(red to confirm the dia'nosis of

compartment s-ndrome, pro+ided that treatment is not dela-ed. Meas(rement is

especiall- +al(a/le when ma&in' the dia'nosis of compartment s-ndrome in

(nconscio(s or o/t(nded patients.

S(r'ical treatment sho(ld /e performed earl- and sho(ld incl(de fasciotom- from the

el/ow to the wrist, incl(din' di+ision of the lacert(s fi/rosis pro*imall- and the

trans+erse carpal li'ament distall- 6see the ima'e /elow7. Dela-ed clos(re of the wo(ndis performed later. 2 resid(al defect ma- re3(ire splitthic&ness s&in 'raftin'.

)he same patient as in ima'e a/o+e, with fasciotom- and e*ternal fi*ation to the radi(s and

intramed(llar- nailin' of the (lna.

Closed compartment s-ndromes that follow operations in the forearm are (s(all- d(e to

inade3(ate hemostasis or clos(re of the deep fascia. )he- can (s(all- /e a+oided /-

releasin' the to(rni3(et /efore wo(nd clos(re to ma&e s(re hemostasis is ade3(ate

and /- closin' onl- the s(/c(taneo(s tiss(e and s&in.


15/16

!mplant remo#al and refractures after implant remo#al

Remo+al of implants is not mandator- and is rarel- indicated in an as-mptomatic patient

/eca(se of the ris& of complications, incl(din' ne(ro+asc(lar in0(r- and refract(re. 1f

indicated, implants sho(ld not /e remo+ed for at least #< months to " -ears after

internal fi*ationand e+en then, onl- after caref(l consideration /- an e*perienced

s(r'eon.

Remo+al of forearm fract(re plates after healin' is not a /eni'n proced(re. )he rate of

refract(re is .$"$;. E+idence indicates that the (se of the .$mm plate has

considera/l- red(ced the rate of refract(re. Commin(ted fract(res, open fract(res, /one

defects, technical fail(re 6e*cessi+e strippin', inade3(ate compression7, and earl- plate

remo+al within # -ear after internal fi*ation increase the ris& of refract(re. 4$5

Once a plate has /een remo+ed, the forearm sho(ld /e protected /- a splint for Bwee&s. 1t sho(ld then /e protected from se+ere stress and torsion for B months. =atients

(nder'oin' electi+e remo+al of implants sho(ld /e warned of the potential for refract(re

e+en later than B months. Mih et al reported an ##; refract(re rate in B" patients, with a

mean time to refract(re of B months.4B5

Synostosis

%a(er et al reported that the hi'hest ris& of s-nostosis is associated with internal fi*ation

of fract(res in+ol+in' the pro*imal third of /oth the radi(s and the (lna. 45E*tensi+e soft

tiss(e dissection d(rin' e*pos(re, the de+elopment of a radio(lnar hematoma, the ris&of interosseo(s dama'e, and occasional malpositionin' of the dorsal plate if the %o-d

approach is (sed also contri/(te to an enhanced ris& of postosteos-nthetic s-nostosis

6see the ima'e /elow7. 1n cases in which /oth /ones are fract(red, separate s(r'ical

approaches for the radi(s and the (lna ha+e /een shown to minimi8e the ris& of

radio(lnar s-nostosis.

=ostosteos-nthetic s-nostosis.

Gon')erm Monitorin'

http://emedicine.medscape.com/article/1240467-overviewhttp://emedicine.medscape.com/article/1240467-overview


16/16

Follow(p radio'raphs are ta&en re'(larl- d(rin' the postoperati+e phase (ntil

pro'ressi+e healin' is doc(mented. Determinin' when a ri'idl- plated fract(re of the

forearm has healed on the /asis of radio'raphic findin's is diffic(lt, partl- /eca(se +er-

little e*ternal call(s res(lts when fract(res are sta/ili8ed in a ri'id manner as is the case

for plateandscrew fi*ation of radi(s and (lnar fract(res. Stren(o(s acti+it- m(st /e

prohi/ited (ntil /one tra/ec(lae cross the fract(re.

forearm fractures medscape

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