1. Radio-Ulnar Fractures

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

3. 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

4. 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%
A %
A %
B %

5. 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

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

7. 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

8. 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

9. 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

10. 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

11. 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

12. Classification of Fractures

13. 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

14. 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

15. 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

16. 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

17. Bado’s Classification of Monteggia Lesions

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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 hours