both bone fractures of forearm Monteggia & Galeazzi.pptx

Both bone fractures of forearm Monteggia & Galeazzi's fracture dislocations

1. Topic – Both bone forearm fractures, Monteggia and Galeazzi’s Fracture dislocations Moderator – Dr. Satish Presenter – Dr. Karthik M V

2. Radial shaft fractures - occurring between the radial neck proximally and approximately 3 cm proximal to the distal articular surface Ulnar shaft fractures - occurring between the distal aspect of the coronoid proximally and the ulnar neck distally

3. Four-fifths of forearm shaft fractures occur in children Above the age of 20, yearly incidence of forearm shaft fractures remains below 2 per 10,000 people Direct trauma - high-energy trauma such as motor vehicle accidents or sports injuries Indirect trauma – Bending or Torsional forces

4. MECHANISM OF INJURY

5. The frequency of open fractures ranges from less than 10% in isolated radial shaft fractures to 43% of fractures affecting both forearm bones Type I according to the Gustilo classification skin disruption from within, in which the sharp fracture edges pierce through the skin in an inside-out fashion

6. DEFORMING FORCES

7. CLINICAL EVALUATION Pain Swelling Deformity Skin condition Neuro vascular injury Compartment syndrome

8. ASSOCIATED INJURIES DRUJ injuries Radial Head Injuries Elbow Dislocation Wrist Injuries Contralateral Forearm Fractures. Distal Biceps rupture Traumatic Rotator Cuff Tears

9. INVESTIGATIONS X-rays AP and lateral views of the forearm - These must include both the elbow and wrist joint. CT —rarely indicated

10. MACLAUGHLIN’S LINE:

11. Radiographic signs for disruption of the DRUJ Dorsal displacement of the distal ulna Change in ulnar variance of more than 5mm widening of the DRUJ on the PA view Dislocation of the ulna seen on the lateral view

12. AO/OTA classification

13. Night stick fracture Isolated ulnar shaft fractures Occurring due to direct injury to the ulnar shaft as the arm is raised to protect the body from a blow subcutaneous location of the ulnar shaft

14. Essex- Lopresti Injuries Radial head or neck fracture with DRUJ injury, and intraosseous membrane (IOM) injury Wrist examination and imaging mandatory for elbow fractures Treatment- surgical fixation or radial head arthroplasty DRUJ stabilization as needed Avoid radial head excision – proximal migration of radius and ulnar positivity at the wrist Outcomes Good, when injury detected and treated.

15. Principles of Treatment of Diaphyseal Fractures of the Radius and Ulna Obtain adequate reduction Achieve and maintain fracture reduction while Preserving biology and allowing Early range of motion.

16. Cadaver studies have shown that ulnar shaft fractures with displacement of greater than 50% have concomitant interosseous membrane disruption leading to fracture instability Non operative – Above elbow slab for 3 weeks - Later convert to functional brace

17. Anterior approach to radius – Henry’s

18. Dissection proceeds between brachioradialis and the PT proximally and brachioradialis and FCR distally

19. Access to the proximal third of the radial shaft is gained by releasing the supinator muscle from the radius In order to protect the PIN, the forearm is fully supinated, thereby rotating the PIN into a posterior position. The supinator muscle is then released from its radial origin.

20. The Middle third of the radial shaft is accessed by pronating the forearm and incising the radial origins of the PT and FDS distal to the supinator muscle The distal third of the radius is accessed by sweeping the FPL ulnarly and exposing the underlying PQ muscle, supinating the forearm, the PQ can be released from its radial origin and reflected ulnarly.

21. Posterior Approach to the Radius (Thompson) It allows exposure of the dorsum of the radius Most frequently used for proximal and mid third fractures The incision is performed on a line from the lateral epicondyle toward Lister tubercle. Proximally, the approach gains access to the radius between ECRB medially and EDC laterally, Distally, access is gained between ECRB and EPL

22. No true internervous plane exists in this approach. ECRB is innervated by the deep branch of the radial nerve and EDC and EPL by the PIN, which branches off the deep branch of the radial nerve

23. Approach to Ulna

24. The internervous plane lies between the extensor carpi ulnaris (posterior interosseous nerve) and the flexor carpi ulnaris (ulnar nerve).

25. IMPLANT SELECTION GOLD STANDARD : OPEN REDUCTION AND INTERNAL FIXATION WITH PLATING 3.5 MM DCP, LC DCP IS THE IDEAL SIZE

26. Open Reduction with Plate and Screw Fixation Gold standard of operative treatment of forearm fractures Removal of soft tissue interposed at the fracture site and anatomic reduction of the fracture Restoration of the radial bow In Galeazzi and Monteggia fracture dislocations, anatomic reduction of the radius and ulna respectively will in most instances lead to stable reduction of the associated dislocated radioulnar joints

27. Fracture location will determine what type of approach will be performed on the radius. Distal half fractures will most likely be fixed through a volar approach While proximal half fractures are best managed using a dorsal approach.

28. Which Bone to Fix first ? When both Ulna and Radius fractured, We generally approach Less comminuted bone first If both bone fractures are Simple, Ulna us fixed first If both bone fractures are comminuted, ORIF of Ulna first, then the Radius

29. INTRAMEDULLARY NAILS INDICATIONS : Segmental fractures Open fractures with a poor soft tissue envelope polytrauma Osteopenic bone COMPLICATIONS- Infection Non-Union Radioulnar Synostosis Compartment Syndrome. Contraindication

30. INTRAMEDULLARY NAILS Currently available implants for intramedullary nailing of forearm shaft fracture include elastic titanium nails and Intra medullary rods. Elastic nails rely entirely on interference fit based on the principle of three-point fixation. Elastic nailing is recommended for pediatric fracture fixation

31. TENS

32. TENS Also called as Nancy Nails 3 Point fixation – Entry Point - Fracture zone - Far end in the distal metaphyseal area Indication Age – 3 years to 15 years

33. Nail Diameter Measure the isthmus of Medullary cavity on X-ray in AP view The Diameter of Nail should be - 60% of isthmus diameter if one TENS nail is used - 40% of isthmus diameter(for each nail) if two TENS nails are used

34. Complications Infection Non Union Malunion Radio Ulnar Synostosis Re-fracture Compartment syndrome

35. COMPLICATIONS : NON UNION 0-10 % Causes: Biomechanics problem - Unstable fixation, nails giving no rotational stability Biology problem - Infection, Soft tissue stripping, Open fractures

36. COMPLICATIONS: RADIOULNAR SYNOSTOSIS 1-6 % More in patients with a head injury Same level fracture with comminution Post-bone grafting CLASSIFICATION : Jupiter and Ring, proximal radioulnar synostosis Distal to the bicipital groove Involving radial head and PRUJ Extending to the distal humerus Management with interposition fat grafting

37. COMPLICATIONS: NEURAL INJURIES Most common PIN palsy – posterior Thompson approach FPL weakness in volar approach Generally spontaneous recovery

38. COMPLICATIONS :IMPLANT REMOVAL AND REFRACTURE <10 % plates require removal Ulna implant removal done (subcutaneous) Risk of refracture Usually done after 2 years

39. GALEAZZI FRACTURE : INTRODUCTION : The injury was first described in 1934 by Galleazzi . The usual cause is a fall on the hand, probably with a superimposed rotation force. The combination of fracture of the distal or middle third of the shaft of the radius and dislocation of the distal radioulnar joint was called “ the fracture of necessity” by Campbell . Similar to Monteggia fracture-dislocations, Galeazzi fracture dislocations often go unrecognized.

40. MECHANISM OF INJURY

41. Ring et al established that in the setting of isolated radial shaft fractures, associated distal radioulnar joint injury is present in 10 out of 36 cases widening of the DRUJ on the PA view Dorsal displacement of the ulna seen on the lateral view Change in ulnar variance of more than 5mm Base of Ulnar styloid fracture suggests an injury to the DRUJ

42. Type 1 fractures occur within 7.5 cm of the articular surface of the distal radius Type 2 more proximally type 1- associated with a significantly higher rate of instability of the DRUJ, frequently requiring open repair of this joint. Simple dislocations readily reduce after radial alignment has been restored Complex dislocations are those in which the DRUJ is irreducible after anatomic reduction of the radial shaft fracture

43. MANAGEMENT Poor results with nonoperative treatment inadequate control of deforming forces- Pronator quadratus , brachioradialis Open reduction and internal fixation with Plate and screw fixation is the preferred mode of fracture stabilization.

44. After fixation of the radial shaft, the DRUJ should be assessed for stability Stable injuries are routinely immobilized for 3 to 6 weeks in a long arm splint or cast Unstable DRUJ- pinning of the DRUJ using Kirschner wires with or without open repair of the TFCC

45. DRUJ translation is examined at different positions of forearm rotation. The position that allows the least amount of translation is selected and two 2 mm Kirschner wires are placed from the ulna into the radius. The most distal pin is placed just proximal to the distal ulnar facet of the radius . The second pin is placed 1 cm proximal to the first pin . Pins are then bent and cut and the forearm immobilized in a long arm splint without changing forearm rotation

46. MONTEGGIA FRACTURE Fracture of ulna associated with proximal radioulnar joint and radio capitellar joint dislocation. Most common age: 4-10 YEARS Giovanni Batista Monteggia in 1814

47. BADO CLASSIFICATION

48. BADO CLASSIFICATION : TYPE 1 RADIUS ULNA ANTERIOR Ulnar diaphyseal fracture with apex anterior M/c in children, might be associated with soft tissue interposition

49. BADO CLASSIFICATION : TYPE 2 RADIUS ULNA Posterior/posterolateral Ulnar diaphyseal/metaphyseal with apex posterior M/c in adult

50. BADO CLASSIFICATION : TYPE 3 RADIUS ULNA Lateral Fracture of proximal ulna with apex lateral 2nd M/C in children, m/c a/w soft tissue interposition between radio capitellar

51. BADO CLASSIFICATION : TYPE 4 RADIUS ULNA Anterior Radius + ulna fracture

52. DORMANS AND RANG Extended BADO classification by adding a type 5 Intermittent and habitual dislocation of radio capitellar joint and proximal radioulnar joint

53. LETTS CLASSIFICATION Classified monteggia fracture in children based on the direction of radial head dislocation and ulnar fracture BADO type 1 is subdivided in three sub types TYPE A – anterior bowing of ulna (Plastic deformation) and anterior Dislocation of radial head TYPE B – Greenstick fracture of ulna TYPE C – Complete fracture of ulna TYPE D – same like BADO type 2 TYPE E – same like BADO type 3

54. MECHANISM OF INJURY TYPE 1 Direct trauma : direct blow on posterior aspect of forearm - ulnar fracture and anterior dislocation of radial head. B . Hyperextension theory : Tompkins -1971 FOOSH leading to hyper-extension of elbow - pull of biceps leading to radial head dislocation

55. HYPERPRONATION THEORY: Evans – 1949 Sudden hyperpronation causes Rotation of radius over ulna Anterior directed force on radial head leading to anterior dislocation of radial head or fracture of proximal third of ulna.

56. TYPE 2 60 degree of elbow flexion with applied longitudinal traction resulting in posterior elbow dislocation. Also in patients with weaker ulna than its surrounding ligaments, bone gives away earlier than the ligament hence the fracture occurs.

57. TYPE 3 Varus stress at the level of elbow in combination with outstretched hand planted firmly against a fixed surface. Often produces a green stick fracture with tension failure radially and compression medially.

58. MONTEGGIA EQUIVALENTS

59. MONTEGGIA EQUIVALENTS

60. ASSOCIATED INJURIES WITH MONTEGGIA : Distal radial and ulnar fractures Galeazzi fractures Radial head and neck fractures Distal humerus lateral condyle FACTORS A/W POORER OUTCOME: Intra-articular injury Coronoid fracture Comminuted ulna fracture Comminuted radial head fracture

61. CLINICAL FINDINGS BADO TYPE 1 Skin tenting and ecchymosis on anterior aspect of skin. Fullness on anterior aspect of elbow. Valgus positioning of elbow

62. CLINICAL FINDINGS BADO TYPE 2 Swelling in posterolateral aspect of radial head. Posterior tenting of skin. Radial nerve and Posterior interosseous nerve injury is common

63. CLINICAL FINDINGS BADO TYPE 3 Lateral swelling Varus deformity Loss of rom (mainly supination)

64. CLINICAL FINDINGS BADO TYPE 4 Similar to type 1 but more severe injury Risk of compartment syndrome Increased risk of neurovascular injury

65. RADIOLOGY Xray elbow ap and lateral Xray full length forearm with wrist ap and lateral (ipsilateral)

66. LIGAMENTS 1.Annular ligament (orbicular ligament) Prime stabiliser of PRUJ Get tightens in supination. Encircles radial neck from its origin and its insertion on proximal ulna. Confluent with the remainder of LCL and provides stability to radio capitellar joint and PRUJ also resists varus stress.

67. MUSCULATURE Biceps brachii Deforming force in type 1 lesion, hence elbow is to be kept flexed in type 1 lesion to prevent recurrent anterior dislocation of radial head Anconeus Dynamic stabiliser of elbow joint and provides a valgus moment at the joint during pronation and extension Surgical exposures of proximal radioulnar joint and radio capitellar joint is performed through anconeus and ECU interval

68. NERVES Radial nerve Passes through interval between biceps and brachialis Close proximity to radial head makes it susceptible to injury in monteggia fractures ( specifically in type 2) Posterior interosseous nerve: Associated with injury in type 1 and type 3 Monteggia fracture Leads to partial or complete loss of finger extension, thumb abduction and sensory loss over dorsum of hand of lateral three and half fingers Ulnar nerve Associated with injury in type 2 Monteggia because of stretched associated with varus deformity and in chronic monteggia where it is associated with ulnar lengthening

69. TREATMENT Goals of treatment: Restoration of radio capitellar joint congruency Maintain ulnar length and fracture stability Anatomical correction of ulnar deformity

70. NON OPERATIVE TREATMENT Reserved for Paediatric population Reduction is maintained in flexion by above elbow cast for 6 to 8 weeks duration Degree of flexion depends upon the radial head dislocation

71. TYPE 1 Close reduction manoeuvre

72. TYPE 2 Closed reduction via longitudinal traction and an anteriorly directed force in 60 degree flexion. Slab applied in 60 degree flexion or complete extension. Osteonecrosis and non union are complications

73. TYPE 3 Closed reduction: longitudinal traction along with valgus stress to reduce radial head.

74. TYPE 4 Aim is to do closed reduction and convert type 4 lesion into type 1 by fixing radial shaft fractures.

75. OPERATIVE TREATMENT Indication for operative intervention Failure of ulnar reduction Can be reduced but difficult to maintain because of obliquity of fractures, hence ORIF is necessary Failure of radial head reduction This is due to interposed soft tissue (radial nerve/annular ligament) within the radio capitellar joint.

76. COMPLICATIONS: NEGLECTED MONTEGGIA FRACTURE NERVE INJRIES PERIARTICULAR OSSIFICATION COMPARTMENT SYNDROME RADIAL HEAD INSTABILITY NON UNION – MOST OFTENLY BADO TYPE 2

77. NEGLECTED MONTEGGIA FRACTURE Uncommon Frequently missed in children Chronic neglected monteggia > 1month Can lead to – Limited ROM Radial head deformation Radioulnar synostosis Malunion shortening of Ulna

78. NEGLECTED MONTEGGIA FRACTURE Criteria for surgical Repair (1). Normal concave radial head articular and convex capitulum (2). Progressive deformity (3). Normal shape of radius and ulna (Deformity of either correctable by osteotomy) Best when corrected within 6 months of injury Better outcome up to 10 years of age

79. SURGICAL PROCEDURE Open reduction Ulnar osteotomy alone or in combination with ligament reconstruction Annular ligament repair or reconstruction Radial osteotomy Radial head excision

80. ULNAR OSTEOTOMY Aim – to restore radio-ulnar relation and interosseous membrane Mc location is at level of Proximal Ulna Posterior bending overcorrection osteotomy – ulnar lengthening Bone grafting Fix with either plate and screws or Using gradual lengthening technique temporary stabilization with external fixation followed by gradual lengthening Some patient might need ALR if unstable.(check for stability intra-op)

81. They did z shaped sagittal osteotomy, distracted, angulated and fixed with one medio-lateral screw Post op immobilised in AE slab for 6 weeks followed by gradual mobilization

82. ANNULAR LIGAMENT RECONSTRUCTION Approaches for ALR Kocher approach Boyds approach

83. APPROACHES: KOCHER Kocher approach: Skin incision over the lateral epicondyle and continue distally and obliquely directly over the lateral epicondyle up to proximal ulna Inter nervous plane: b/w anconeus and ECU Forearm in pronation in order to protect PIN

84. BOYD APPROACH: Incision: extends from lateral border of triceps to lateral condyle and extending along the radial side of proximal ulna. This incision is carried under the anconeus and ECU in an extra periosteal manner elevating the fibres of supinator from ulna. Advantages: Approach proximal fourth of radius Access radio capitellar joint Fixation of ulna

85. ANNULAR LIGAMENT RECONSTRUCTION: Bell tawse: Used the central portion of triceps tendon passed through a drill hole and around he radial neck to stabilise the reduction and immobilised the elbow in long arm cast in extension

86. BUCKNILLAND LLYOD ROBERTS: Modified bell tawse approach where they used the lateral portion of triceps tendon with a transcapitellar pin for stability. Elbow was immobilised in flexion THOMPSON AND LIPSCOMB: Utilized fasica lata for the same approach. Radial head excision & Radius osteotomies Poor outcomes osteotomies Poor out

87. MONTEGGIA FRACTURE IN ADULTS Treatment of choice ORIF of ulna fracture with 3.5 mm DCP or Intramedullary nailing (less favoured ) in paediatric patients Plate on tension side of ulna Close reduction of radial head once ulnar length is achieved Failure of close reduction of radial head – open reduction of radial head and pinning Posterior elbow splint or AE slab Post op f/b physiotherapy

88. TAKE HOME MESSAGE HIGH INDEX OF SUSPICION ALWAYS GET XRAY OF IPSILATERAL WRIST AND ELBOW CONSERVATIVELY MANAGED PATIENT TO BE FOLLOWED UP EVERY WEEKLY FOR SEQUENTIAL CHECK XRAYS CHECK FOR RADIAL NERVE AND POST INTEROSSEOUS NERVE PALSY LOOK FOR SIGNS OF COMPARTMENT SYNDROME FAILURE TO MAKE DIAGNOSIS CAN LEAD TO CHRONIC MONTEGGIA LESION

89. REFERNCES ROCKWOOD AND GREENS : ADULT FRACTURES 9 TH EDITION ROCKWOOD AND WILKINS : PEDIATRIC FRACTURE 9 TH EDITION CAMPBELL OPERATIVE ORTHOPAEDICS 14 TH EDITION HANDBOOK OF FRACTURES KOVAL 6 TH EDITION AO PRINCIPLES OF FRACTURES MANAGEMENT 3 RD EDITION .

90. THANK YOU