Friday, November 12, 2010

Forearm Fractures



transverse + oblique
fracture / dislocations


If undisplaced ® immobilise elbow for 3 - 4 weeks in a sling
If displaced (disruption or extensor mechanism) ® TBW
TBW with double twist ® strongest method of internal fixation for these fractures however a dorsal plate (positioned in tension) is also effective


reduced ROM - up to 50% have some loss of ROM - only ~ 3% have functional loss from this
post traumatic OA- rare as is a non wght bearing jt
Nonunion - ~5%
If high demand pt - ORIF/ BG
If low demand pt - may not need to do anything. Can excise the olecranon fragment with very good results ( as long as the coronoid and ant soft tissues are intact to provide stability)

Radial Head Fractures

Usually due to a fall onto the outstretched hand and may be associated with dislocation of the elbow
Over half of radial head fractures are associated with other injuries about the elbow

Classification: (Mason)

ref: Mason, M.L. "Some observations on fractures of the head of the Radius With a Review of 100 cases" Br J Surg 42: 123-132, 1954

Marginal fracture with displacement
Comminuted fracture with whole head involvement
Fracture of the radial head associated with dislocation of the elbow
NB: Type IV not described by Mason

Note that Essex- Lopresti (ALRUD) lesions can coexist


AP/ lat views of the elbow usually sufficient
fat pad sign
if no fracture seen but fat pad sign present - Radiocapitellar views with the forearm in neutral rotation and the XRay tube angled 45 deg cephalad



Acceptable angulation of 30o in young children as ® remodels with growth (15o in older children ie more than 10) and can expect 10o correction
If greater angulation than 30o ® either;
Manipulation under GA
Open reduction if more than 45o and irreducible
Never ® radial head excision in the young as ® ulna overgrowth



nonoperative - early motion as soon as comfortable
without Essex- Lopresti
without mechanical block as for type 1
with mechanical block excise or ORIF
with Essex- Lopresti ORIF if at all possible ie retain head
May need to pin radius + ulna
without Essex- Lopresti or dislocation excise
with Essex- Lopresti aim to retain the head if at all possible
may need to transfix the radius and ulna to prevent translation
if the ant band of the MCL is disrupted need to repair primarily
aim to retain the radial head if at all possible


if head is salvageable do so
if Essex- Lopresti - save head, or if excise pin radius and ulna for 4-6/52
if elbow unstable ie MCL torn - save head, repair ligament if excise or not
In adults operation indicated if
Angulation more than 30o Depression of articular surface of more than 3mm
Greater than 1/3 of radial head involved


Reduced motion
Radial head overgrowth
Premature physeal closure
Non union
Avascular necrosis of the radial head
Alteration in the carrying angle
Neuromuscular problems (ie ® valgus with ulna nerve problems)
Radio/ulna synostosis
Myositis ossificans


The results of initial conservative management of Mason II and III fractures are no different to early excision
Also the results of delayed excision of the radial head are satisfactory giving some justification for the initial closed treatment of these fractures with delayed excision of the radial head to be considered at a later date if needed as symptoms develop

Fractures of Radius and Ulna

Galleazi fracture

fracture of distal 1/3 of radius with dislocation of the distal radioulnar jt ( Galleazi - 1934)


ORIF in adults
CR/POP in children
aim to reduce accurately to ensure DRUJ reduction

Monteggia fracture

fracture of proximal ulna with dislocation of the prox radius ( Monteggia - Milan, 1814 )


( Bado)

ant dislocation of radial head
post or posterolat dislocation of the radial head
lat or anterolat dislocation of the radial head
ant dislocation of the radial head with fracture of both radius and ulna at the diaphysis


ORIF in adults
CR/POP in children
aim to reduce ulna - this reduces the prox jt

Nightstick Fracture

fracture ulnar diaphysis alone from a direct blow


AEPOP or functional brace stopping supination/ pronation



union in ~ 10 wks
nonunion - rare

Fracture of Shaft of Radius Alone



AEPOP or functional brace stopping supination/ pronation


Fracture of Both Bones of Forearm

Classification based on the location in the forearm (proximal, middle or distal 1/3)



CR/POP - note the deforming forces of muscles at different levels of fracture
ORIF if unable to obtain or maintain reduction
Can accept 1cm overriding as long as the bones are correctly aligned and rotated
Can accept up to 20o angulation at the fracture in the skeletally immature (ie less than 10 years) ® no significant loss of pronation or supination providing the rotation of the individual bones is correct
Correction of angulation has been reported up to 18o (Larsen, 1988) mainly due to change in the orientation of the epiphyseal plate and appositional bone formation and resorption If close to cessation of growth require an anatomical reduction

No comments:

Post a Comment