Fractures of Upper Extremities:

Radius & UlnaPembimbing: Dr. Husnul Fuad Albar, SpOT

DEPARTMENT OF ORTHOPAEDICS HAM GHFACULTY OF MEDICINE

UNIVERSITAS SUMATERA UTARAMEDAN 2011

1. Fracture of the Forearm

1.1 Fractures Of The Shaft Of Ulna And Radius

• Adult fractures unlike those in children may be markedly displaced with little or no bony contact between the fragments.

• Rotational deformity is common.• Neurovascular injury is checked

carefully. • Closed reduction is difficult and often

fails or is complicated by late slippages. • Fractures are treated with analgesics or

immobilization and refer for ORIF.

Classification of the shaft of radius and ulna fracture

• A1 Simple fracture of the ulna, radius intact 1 oblique 2 transverse 3 with dislocation of the radial head (Monteggia)

• A2 Simple fracture of the radius, ulna intact 1 oblique 2 transverse 3 with dislocation of the distal radio-ulnar joint (Galeazzi)

• A3 Simple fracture of both bones 1 radius, proximal zone 2 radius, middle zone 3 radius, distal zone

• B1 Wedge fracture, of the ulna, radius intact 1 intact wedge 2 fragmented wedge 3 with dislocation of the radial head (Monteggia)

• B2 Wedge fracture, of the radius, ulna intact 1 intact wedge 2 fragmented wedge 3 with dislocation of the distal radio-ulnar joint (Galeazzi)

• B3 Wedge fracture, of the one bone, simple or wedge fracture of the other 1 ulna wedge and simple fracture of the radius 2 radial wedge and simple fracture of the ulna 3 ulnar and radial wedges

•C1 Complex fracture, of the ulna 1 bifocal, radius intact 2 bifocal, radius fractured 3 irregular

•C2 Complex fracture, of the radius 1 bifocal, ulna intact 2 bifocal, ulna fractured 3 irregular

•C3 Complex fracture, of both bones 1 bifocal2 bifocal of the one, irregular of the other 3 irregular

Classification of the shaft of radius and ulna fractures

1.2 Monteggia fracture

•Definition : Fracture of the proximal ulna associated with dislocation of the radial head

•Etiology : Forced pronation of the arm

Bado Classification

Type 1 : anterior dislocation

Type 2: posterior dislocation

Type 3: ;lateral dislocation

Type 4 : anterior with ass.

Both bone fx

Non operative

Operative

Treatment

•Complications:     - PIN or radial nerve palsy from anterior displacement of radial head;   - non union of fracture of ulnar shaft     - radiohumeral ankylosis     - radioulnar synostosis

- recurrent radial head dislocation     - myositis ossificans

2. Fracture of the Radial Head

Epidemiology

•The radial head is fractured in about 20% of cases of elbow trauma, and about 33% of elbow fractures and dislocations including injury to the radial head and or neck.

•Radial head fractures and dislocations are the result of trauma, usually from a fall on the outstretched arm with the force of impact transmitted up the hand through the wrist and forearm to the radial head, which is forced into the capitellum.

Pathophysiology

•The radial head is intra-articular, so the anatomic reduction of the bone fragments is necessary to minimize the risk of lateral post-traumatic arthritis from mechanical grinding. •The intra-articular position also means that soft tissue attacthments to the most proximal portion of the bone are limited, so fractured fragments frequently lose their blood supply, resulting in avascular necrosis and potential nonunion.

•Patients with radial head fracture-dislocations usually presents with a history of a fall on the outstretched hand.

• The wrist, especially the distal radioulnar joint, maybe damaged simultaneously, and the presence of wrist pain, grinding, or swelling can be found.

•Neurovascular symptoms of numbness, tingling, or loss of sensation should be identified to rule out nerve of vascular injury.

• The presence of severe pain should alert the examiner to the possibility of compartment syndrome.

Physical Examination

•Patients with radial head fractures and dislocations present with localized swelling, tenderness, and decreased motion. •Evaluate wounds over the subcutaneous border of the ulna is especially important in fracture-dislocations to avoid missing open fractures.

• Palpation on the elbow, especially the radial head, feeling for deformity, and the wrist, feeling for stability of the distal radioulnar joint.

• The 3 major nerves of the forearm are in danger with elbow fractures and dislocations, carefully assess neurovascular funtion for all of the nerves of the forearm and hand.

• Radial nerve function is especially important to assess with displaced fractures through the neck of the radius. The motor (posterior interosseous) branch provides extension for the fingers and wrist.

• Assess the firmness of all compartments, check for pain with passive stretch, and measure compartment pressures if in doubt to avoid missing compartment syndromes.

• Elbow stability needs to be assessed even with seemingly nondisplaced radial neck fractures.

• The elbow is tested with valgus stress at 30 degrees of flexion to determine the competency of the medial collateral ligament.

The Mason Classification

Management

• The Mason classification is helpful in determining the appropriate treatment for simple radial head and neck fractures.

• Type I fractures are treated with limited immobilization for a few days, followed by early range of motion exercises.

• Type II fractures with acceptable fracture patterns should be treated with open reduction and internal fixation.

• In equivocal situations, particularly if the patient has low-demand occupation, type II injuries can be treated non-operatively, with delayed excision of the radial head if persistent pain or significant limitation of forearm rotation occurs.

• Uncomplicated type III fractures should be treated with excision of the radial head.

• When radial head fractures are associated with dislocation of the elbow and severe ligament injury or disruption of the forearm interosseus, the fragments should be removed and the radial head replaced by prosthesis.

• Results of treatment are uniformly good for type I fractures and often satisfactory for simple type II and type III fractures.

Complications

•Loss of motion•Elbow instability•Post-traumatic arthritis•Myositis issificans•Distal radio-ulnar symptoms

3. Fractures of Diaphyseal of Radius and Ulna

3.1 Galeazzi Fracture

•The Galeazzi fracture-dislocation, also known as reverse Monteggia fracture, is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ); the injury disrupts the forearm axis joint.

Epidemiology

•Galeazzi fractures account for 3-7% of all forearm fractures.

•They are seen most often in males.

Presentation

•Pain and soft-tissue swelling are present at the distal-third radial fracture site and at the wrist joint. This injury is confirmed on radiographic evaluation.

•Forearm trauma may be associated with compartment syndrome.

•Anterior interosseous nerve (AIN) palsy may also be present, but it is often overlooked because there is no sensory component to this finding.

•A purely motor nerve, the AIN is a division of the median nerve. Injury to the AIN can cause paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger, resulting in loss of the pinch mechanism between the thumb and index finger

Management

•Galeazzi fractures are best treated with open reduction of the radius and DRUJ.

•Closed reduction and cast application have led to unsatisfactory results.

•Open forearm fractures constitute a surgical emergency. Immediate stabilization of the radial fracture and the DRUJ is recommended.

•Galeazzi fractures in skeletally immature patients are typically treated with closed reduction and casting because of the enhanced viscoelastic nature of pediatric bone, as well as the presence of a stout periosteal sleeve.

Galeazzi fracture consists of a fracture of the radius with angulation and associated dislocation of the distal

ulna

3.2 Green Stick Fracture• Common in children (usually 6-12 years old)

because a child's bones are softer and more flexible than those of an adult

• The bone cracks but doesn’t break all the way, it looks like a green stick of wood

• Difficult to diagnose, because it may not cause all the classic signs and symptoms of a broken bone.

• Treatment of a greenstick fracture requires immobilization of the child's bone so that the bone will grow back properly.

Definition• An incomplete (green stick) fracture in

the radius and/or ulna, or the fracture may be complete in one bone and incomplete (green stick) in the other

Causes• Usually happens when a child tries to

throw the arms when he/she falls• This is a common reaction to catch

yourself before you fall

     

Symptoms• None, in some cases• Pain• Swelling• Abnormally bent or twisted limb

The intense pain and obvious deformity typical of broken bones may be absent or minimal in greenstick fractures. Additionally, it can be difficult to tell the difference between a greenstick fracture and a soft-tissue injury, such as a sprain or a bad bruise.

The X-Ray result that shows Green Stick Fracture

Management

• Overcorrection of fracture may be required (completing the fracture before aligning it)

•  Acceptable reduction: In infants:                  - up to 30 deg may be accepted;                  - consider reduction with completion of fracture by reversal of deformity if angular > 25-30 deg;  In children:                  - up to 15 deg may be accepted depending on age of patient;                  - there is no need to attempt correction for angulation measuring < 10 deg in children less than 10 yrs of age;  Reduction:          - a volarly angulated greenstick fracture is manipulated with forearm in pronation while a dorsally angulated fracture is manipulated with forearm in supination;       

4. Fractures of Distal Radius

•DefinitionA fracture of the distal radius occurs when the area of the radius near the wrist breaks.

•Epidemiology Osteopenic women(50/60s) : low energy trauma, extra-articular “bending” type injury.

Standard initial radiographs : •A. anteroposterior (AP),•B. lateral (Lat)•C. oblique (Obl)

To reveal the fracture pattern as well as the

extent and direction of the initial displacement.

Classification of distal radius fracture

Type B Type C

Type A

Muller classffication

• Type A Distal radial fractures not involving the articular

surface ( Colles’ and Smith’s fractures) fall into this type.

• Type B This group comparises are distal radial fractures

involving part of the articular surface. These shearing fractures are subdivided into three groups :

B1 : fractures involving injuries in the sagittal plane ( radial atyloid, cuneiform, and lunate facet fractures)

B2 : fractures in the coronal plane affecting the dorsal aspect(Barton’s fracture)

B3 : fractures of the volar aspect, or reverse Barton’s fractures.

 

•Type C

These are distal radial fractures involving a complete articular surface injury.

C1 ; two fragment intraarticular fracture without metaphyseal fragmentation

C2 ; two fragment intraarticular fracture with multifragmented metaphysic

C3 ; fractures with comminution of the articular surface.

Comminution is defined as involvement of more than 50% of the metaphysis as seen on the radiograph.

Treatment Management: a. initial treatment b. definitive

treatment Definitive treatment

Nondisplaced intra- and extraarticular

stable fx

Displaced extraarticukar fx

Open or severely Comminuted

extraarticular fx

Displaced intraarticular fx

Thank You…