Fractures of the Forearm Bones 2012 Muzahem M.Taha Ass.Prof. in Ortho.and Spine surgery FICMS,Iraq. Diploma in spine surgery.SanDiego,USA. Felloship in Arthroplasty, StolzAlpe,Austria AOSpine officer ME AIMIS spine member

Causes Falling on outstretched arm Direct blow Mountain biking Skateboarding Trauma Automobile accidents Child abuse

Types of Fractures Isolated bone fracture.(radius or ulna) e.g. nightstick fracture –Defined as an isolated midshaft ulnar fracture Monteggia fracture –Defined as a fracture of the ulna (usually proximal one third) with dislocation of the radial head. Galeazzi fracture –Defined as a fracture of the distal one third of the radius with dislocation of the distal radioulnar joint (DRUJ).

Types Cont. Essex-Lopresti fracture –This is defined as a fracture of the radial head and dislocation of DRUJ, with partial or complete disruption of radioulnar interosseous membrane.

Pediatric Forearm Fracture Types Plastic Deformation –No cortical disruption –Stress higher than elastic limit of bone Incomplete “Greenstick” Fractures –One cortex intact –Include buckle or torus type fractures Complete Fractures –No cortex intact –Most unstable

Plastic deformation

Incomplete (Greenstick) Fracture

Complete Fracture

Signs and Symptoms Most of the time you will know if you have a broken arm Snap or cracking sound Area will be tender and swollen Obvious deformity Decreased sensation or inability to move the limb, which may indicate nerve damage

Goals of Treatment Restore alignment and clinical appearance Limit injury to local soft tissues Prevention of further injury Pain relief Regain functional forearm rotation

Treatment options External fixation methods –plaster and fiberglass casts –cast-braces –splints Internal fixation methods –metal plates –Pins –screws

children most of the fractures are treated conservatively if can achieve the acceptable alignment. Full length cast from axilla to metacarpal shafts with the elbow flexed at 90 degree. If the # proximal to pronator teres, the forearm is supinated; if it is distal to pronator teres. Then the forearm is held in neutral. The position is checked by x-ray until # is united usually 6-8 weeks.

Indications for Internal Fixation Open fractures Compartment syndrome Inability to maintain acceptable reduction Multi-trauma Floating elbow Neurologic/vascular compromise Re-fracture with displacement

Closed Reduction Method Conscious sedation/Bier block/general anesthesia Traction/counter-traction Reproduce/exaggerate deformity to unlock fragments Reduce/lock fragments using periosteal hinge Correct rotational deformity

Closed Reduction Method Maintain cast for 4 to 6 weeks or until radiographic evidence of union Conversion to a short arm cast at 3 to 4 weeks if healing adequate Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees

How Much Angulation is too Much? Depends on fracture, location, age, stability Closed reduction should be attempted for any angulation greater than 20 degrees in children. Angulation encroaching on interosseous space may limit rotation Any angulation that is clinically apparent

Rotational Malunion Remember, these will not remodel…

Adults Isolated bone fracture in adult can be treated conservatively if can achieve alignment; If not ORIF. Radial #s are prone to rotary displacement; to achieve reduction the forearm needs to be supinated for upper third #,neutral for middle third # and pronated for lower third. For both bone fractures unless the fragments are undisplaced, most surgeons prefer ORLF from the outset.

Forearm Fractures - Complications Malunion –Most common Refracture Compartment syndrome Synostosis –very rare Neurologic injury If headed for malunion… Do not hesitate to stabilize.

Intramedullary Fixation

Plate Fixation

Open Fractures Immediate operative stabilization of open fractures in both adults and children does not increase the infection rate Timing of antibiotics very important –Closer to time of injury = less risk of infection

Galeazzi fracture dislocation of the radius Fall on the hand with rotational force. The radius fractured in its distal third with dislocation or subluxation of the distal R-U joint. Deformity of the radius and tenderness over the distal R-U joint, instability of the joint can be elicited by (piano key sign) by balloting the distal ulna. If the bone length restored, the joint will relocated. In adults usually needs ORIF if the distal joint not reduced or unstable than open joint reduction is important.

Galeazzi Fracture

Monteggia fracture – dislocation Fracture of the shaft of the ulna including trans olecranon f, with associated dislocation of the proximal R-U joint or radio – capitillar joint. the f. is angulated and may be green stick in children. Obvious deformity of the ulna, with swelling of the proximal R-U joint. The wrist and hand examined to exclude radial n. injury. X-ray shows the #. and the radial head not points any more to the capitulum.

Treatment The clue to successful treatment is to restore the length of the fractured ulna; only then can the dislocated joint be fully reduced and remain stable. In adult this mean ORIF. Complications include: nerve injury, malunion and non-union.