Forearm Fractures

Anatomy

 

Radial bow radius

- important for rotation

 

Interosseous membrane

- Z pattern

- proximal radius to distal ulna

 

Mechanism

 

Direct blow

- ulna / night stick

 

Ulna Fracture Night Stick

 

Indirect

 

Monteggia

- Proximal 1/3 ulna fracture with radial head dislocation

 

Elbow Monteggia FractureElbow Monteggia Fracture ORIF

 

Monteggia Variant

- proximal 1/3 ulna fracture with radial head / neck fracture

 

Monteggia Variant APMonteggia Variant Lateral

 

Galleazzi

- distal 1/3 radial fracture with DRUJ disruption

 

Galleazzi APGalleazzi LateralGalleazzi Xray APGalleazzi Xray Lateral

 

Associated Injuries

 

Ulna can be compound

Compartment Syndrome

 

Compound Ulna

 

X-ray

 

Joint above and below

 

Elbow

- always assess radial capitellar line on two views

 

DRUJ disruption

- widened space between R & U

- radial shortening > 5 mm

- ulna styloid fracture

 

Classification

 

Isolated single bone

 

Both bone

 

Fracture of one bone with ligament rupture

- Galleazzi, Monteggia

 

Fractures of bone bones with ligament rupture

 

Non operative Management

 

Indications

 

Ulna

- < 10o angulation

 

Ulna Fracture Undisplaced

 

Radius

- completely undisplaced

- maintenance radial bow

 

Operative Management

 

Options

 

Intramedullary fixation

- children (good remodelling potential)

- prophylaxis to prevent pathological fracture

 

Ulna Intramedullary Wire

 

External Fixation

- severe injury / compound

 

Plate fixation

 

Ulna Plating

 

Goals

 

Anatomical reduction with absolute stability

- length

- rotation

- radial bow (need to bend plate for long fractures)

 

Approach

 

Forearm Fractures Plate LateralForearm Fractures Plate AP

 

Ulna

- approach between ECU / FCU

 

Radius

 

Distal

- between FCR and radial artery

 

Proximally

- between BR and pronator teres

- supinate forearm

- elevate supinator from ulna to radial

 

Galleazzi

 

Incident DRUJ instability

- up to 50% if fracture radius < 7.5 cm to distal articular surface

- < 5% if > 7.5 cm

 

Galleazzi ORIF 1Galleazzi ORIF 2

 

Plate distal radius

- assess DRUJ stability

- if stable, early ROM

- unstable, splint in supination

- if still unstable, ensure that radius is anatomical

- may have to repair TFCC / ORIF ulnar styloid

- if still unstable, may rarely have to K wire ulna to radius

 

Galleazzi ORIF APGalleazzi ORIF Lateral

 

Complications

 

Nonunion

- 2%

- exclude infection

 

Radial Fracture Non Union CTUlna Non Union

 

Malunion

 

Problem

- > 10o angulation leads to loss of ROM

 

Management

- osteotomy

 

Radial Fracture Malunion Radial Fracture Malunion 2Radial Osteotomy Radial Osteotomy Lateral

 

Infection

 

Management

 

Initial

- excise non union 

- debridement

- ABx cement spacer + external fixator

- eliminate infection

 

Obtain union

- BG and plate

 

Compartment syndrome

- don't close fascia

- good haemostasis

 

Synostosis

 

Risk factors

- fractures at same level / Monteggia

- proximal fractures

- open fractures

- head injuries

- bone grafting

- ORIF through single incision

- delayed surgery > 2 weeks

 

Management

 

Excision

- usually posterior approach

- elevate ECU from ulna

- exposes synostosis and radius

- application of bone wax to bone after debridement

- +/- irradiation / indomethacin especially in head injured patients

- worst results with proximal synostosis