Radio-Ulnar Fractures

Forearm Main function: Pronation and supination Origin of hand muscles Fractures in this area cause the most problems in upper extremity function

Mechanisms of Injury Significant energy of trauma must be present before the forearm bones can break Fall from standing height Direct blow – hit on the arm by hard object, reflex when protecting self Vehicular crash Nightstick fracture – isolated fracture of the ulnar shaft

Epidemiology 0.9% of all fractures Age: ~40 years Male/Female: 3:1 Causes: Fall 28% Direct Blow 21% Sport 18% Vehicular crash 13% OTA Classification: A: 86% B: 12% C: 2% Most Common Subgroups: A1.2 25% A1.1 25% A1.3 6.7% A2.2 6.7% B1.1 6.7%

History and P.E. Signs and Symptoms: Pain Deformity Loss of Function Nightstick Fracture – palpate at edge of ulna  tenderness at level of fracture P.E. Motor and sensory functions of the radial, median and ulnar nerve If swollen and tense: t/c compartment syndrome

Special Lesions Monteggia Fracture-Dislocation Galeazzi Fracture-Dislocation Essex-Lopresti Injury

Monteggia Fracture-Dislocation Fracture of the proximal ulna + dislocation of radial head Pain on the elbow and mechanical block to elbow flexion and forearm rotation Examine the nerves esp. posterior interosseous nerve  injured due to stretching by dislocated radial head

Galeazzi Fracture-Dislocation Fracture of the radius at the junction of the middle and distal third + dislocation of the distal radioulnar joint (DRUJ) Unstable in nature Tx: ORIF

Indications of Possible DRUJ Instability Requirement for forceful reduction “Mushy” feel to reduction Fracture at base of ulnar styloid Persistent incongruity of the distal ulna on true lateral radiograph Shortening (>5mm) of the radius Widening of the DRUJ on AP radiograph

Essex-Lopresti Injury Rare complex injury of the forearm best described as radioulnar dissociation FOOSH  Fracture in head of radius and disruption of both the interosseous membrane and DRUJ  Proximal migration of radius

Assessment Radiographs: AP and L are sufficient Include elbow and wrist Oblique view  taken if there is uncertainty of the integrity of the proximal or DRUJ If with DRUJ disruption: Widening of DRUJ space AP: Shortening of radius in relation to distal ulna L: Distal ulna dorsally displaced

Classification of Fractures

Classification of Fractures Type A: Unifocal Simple A1: Isolated ulnar A2: Isolated radial A3: Both Suffix refers to morphology of fracture .1: Transverse .2: Oblique .3: Monteggia (A1.3), Galeazzi (A2.3) A3 suffixes: radial fracture position

Classification of Fractures Type B: Wedge B1: Isolated ulnar B2: Isolated radial B3: Both Suffix refers to intact-ness of wedge .1: Intact .2: Fragmented .3: Fracture-Dislocation (1.3: Monteggia, 2.3: Galeazzi) B3 suffixes: radial fracture position

Classification of Fractures Type C: Complex C1: Complex Ulnar C1.1: Without radial fx C1.2: With radial fx C1.3: Monteggia with complex ulnar, simple radial C2: Complex Radial C2.1: Without ulnar fx C2.2: With ulnar fx C2.3: Galeazzi C3: Complex both

Bado’s Classification of Monteggia Lesions Type I: Fx of ulnar diaphysis at any level, anterior angulation at fx site, anterior dislocation of radial head Type II: Fx of ulnar diaphysis, posterior angulation at fx site, PL dislocation of radial head Type III: Fx of ulnar metaphysis with AP or L dislocation of radial head Type IV: Fx of the P3 of both radius and ulna with anterior dislocation of radial head

Bado’s Classification of Monteggia Lesions

Non-Operative Treatment Options Conservative treatment  poor functional outcome due to importance of anatomic relationship of the radius and ulna + difficulty in getting acceptable reduction Closed reduction + cast immobilization  unsatisfactory results in up to 92% of cases If isolated ulnar fx or nightstick fx  cast may be used General Rule: If displacement is <50% of the width of the bone + angulation < 10 deg, may do functional bracing or cast immobilization

Indications of Surgical Treatment for Forearm Fractures Displaced radius and ulna Isolated fx of either bone with displacement Monteggia, Galeazzi and Essex Lopresti type All open fx

Operative Treatment Usual method: Open reduction, plate fixation Intermedullary Nailing  high rate of non-union and poor final range of rotation External Fixation  Alternative treatment if there is significant bone or soft tissue loss

Management of Monteggia Fracture-Dislocation Goal: Anatomic relocation of dislocated radial head together with reduction and fixation of the ulna Method: OR, IF with plates

Management of Galeazzi Fracture Dislocation Goal: Relocation of the DRUJ together with a precise reduction of the radial fracture which is rigidly fixed Method: Anterior approach to expose fracture than put plate on volar aspect of distal radial shaft

Management of Essex-Lopresti Injury Goal: Restoration of the length of the radius and stabilization of the DRUJ If radial head is fractured  ORIF with miniplates If fracture is comminuted  use radial head prosthesis

Management of Open Fractures Thorough irrigation + Debridement Stabilize fracture with plate fixation Implant should be covered with muscles or other soft tissue Repeat debridement after 24-48 hours