Fractures of radius and ulna .

Different types of fractures (radius & ulna). Open and close fractures. Monteggia & Galeazzi fractures. Classification system for fractures. Fasciotomy.

1. FRACTURES MSS CASE 4a

2. OUTLINE Introduction Fractures of radius and ulna Carpal fractures (scaphoid) Fasciotomy Indications

3. INTRODUCTION Fracture: Break in the structural continuity of the bone More often the break is complete and the bone fragments are displaced Closed (or simple)  overlying skin remains intact Open (or compound)  skin or one of the body cavities is breached

4. FRACTURES OF THE RADIUS AND ULNA

5. MONTEGGIA FRACTURE 1814, Giovanni Battista Monteggia Fracture to the proximal third of the ulna Anterior dislocation of radial head Description based on history of injury and physical examination findings

6. BADO CLASSIFICATION Type I - Fracture of the proximal or middle third of the ulna with anterior dislocation of the radial head

7. Type II - Fracture of the proximal or middle third of the ulna with posterior dislocation of the radial head

8. Type III - Fracture of the ulnar metaphysis with lateral dislocation of the radial head

9. Type IV - Fracture of the proximal or middle third of the ulna and radius with anterior dislocation of the radial head

10. ETIOLOGY Fall on an outstretched hand with forced pronation If the elbow is flexed, the chance of a type II or III lesion is greater High-energy trauma & low-energy trauma

11. PROGNOSIS In 1991, Anderson and Meyer used the following criteria to evaluate forearm fractures and their prognosis: Excellent - Union with less than 10° loss of elbow and wrist flexion/extension and less than 25% loss of forearm rotation Satisfactory - Union with less than 20° loss of elbow and wrist flexion/extension and less than 50% loss of forearm rotation Unsatisfactory - Union with greater than 30° loss of elbow and wrist flexion/extension and greater than 50% loss of forearm rotation Failure - Malunion, nonunion, or chronic osteomyelitis

12. CLINICAL FEATURES Elbow pain Depending on the type of fracture and severity Elbow swelling, deformity, crepitus and paresthesia or numbness X-ray Isolated fractures of ulna Forward dislocation of radial head, fracture of the upper 3 rd of ulna with forward bowing Posterior or Lateral ulna bowing  with posterior or lateral displacement of radial head

13. TREATMENT Aim  Restore the length of fractured ulna Adults Via a posterior approach Ulna fracture reduction with bone restoration to full length (fixation with plate and screws) Radial head reduction Stability testing  full range of flexion and extension Radial head doesn’t reduce: Perform open reduction

14. TREATMENT Children Features are similar to those in adults Ulnar fracture may be incomplete (greenstick) If undetected & corrected  chronic subluxation of radial head Incomplete ulnar fractures Close reduction Complete fractures Open reduction & fixation (intramedullary rod/small plate)

15. GALEAZZI FRACTURE Described in 1934 by Galeazzi More common than Monteggia fracture Usually caused by a fall on a hyperpronated forearm Radial fracture (lower third), inferior radio-ulnar joint dislocation

16. CLINICAL FEATURES Pain and soft tissue swelling Anterior interosseous nerve palsy Loss of pinch mechanism

17. TREATMENT Restore the length of fractured bone Open reduction of radius and distal radioulnar joint “Fracture of necessity” X-ray is taken to ensure that the distal radioulnar joint is reduced 3 possibilities: D istal radio-ulnar joint is reduced and stable Distal radio-ulnar joint is reduced but unstable Distal radio-ulnar joint is irreducible

18. a) Monteggia fracture b) Galeazzi fracture X-ray Galeazzi type before and after reduction & plating

19. COLLES’ FRACTURE Described in 1814 by Abraham Colles Transverse fracture above the wrist with dorsal displacement of distal fragment Common in older people

20. CLINICAL FEATURES Dinner fork deformity Tenderness on the back of the wrist and a depression anteriorly Patients with less deformity: Local tenderness and pain on wrist movements X-ray Transverse fracture of radius ( corticocancellous junction) Ulnar styloid is broken off

21. TREATMENT Undisplaced fractures Dorsal splint for a day or two until swelling has resolved, then the cast is completed X-ray is taken at 10-14 days Displaced fractures Comminuted fractures

22. SMITH’S FRACTURE Reversed Colles’ Transverse fracture of radius above the wrist with anterior displacement of distal fragment Caused by a fall on the back of the hand

23. CLINICAL FEATURES Wrist injury but no dinner-fork deformity Garden-spade deformity X-ray Fracture via distal radial metaphysis Lateral view  distal fragment is displaced and tilted anteriorly

24. TREATMENT Reduced by traction, supination and extension of wrist Forearm is immobilized in a cast for 6 weeks X-ray taken at 7-10 days to ensure the fracture hasn’t slipped Unstable fractures Fixed with percutaneous wires or a plate

25. FRACTURED SCAPHOID Account for 75% of all carpal fractures Usually caused by a fall on the dorsiflexed hand Most scaphoid fractures are stable; with unstable fractures the fragments may become displaced Humpback deformity Flexion of distal fragment and dorsal tilting of proximal fragment with lunate (a Dorsal Intercalated Segment Instability (DISI) deformity) Blood supply  diminishes proximally 1% distal fractures, 20% middle third fractures and 40% proximal fractures result in nonunion or avascular necrosis of the proximal fragment

26. CLINICAL FEATURES T enderness in the anatomical snuffbox X-ray Fracture is transverse via the narrowest part of the bone (waist) Look for subtle signs of displacement E .g.: obliquity and opening of the fracture line, angulation of the distal fragment and foreshortening of the scaphoid image Few weeks after the injury the fracture may be more obvious; if union is delayed, cavitation appears on either side of the break Old, un-united fractures have ‘hard’ borders Relative sclerosis of proximal fragment  avascular necrosis

27. TREATMENT Scaphoid tubercle fracture No splintage required Treated ass a wrist sprain Apply crepe bandage and encourage movement Undisplaced fractures No reduction required Treated in plaster Cast is applied from the upper forearm to metacarpo-phalangeal joints of fingers including proximal phalanx of thumb Wrist is held dorsiflexed and the thumb forwards in the ‘glass holding’ position Cast is retained for 8 weeks,

28. Displaced fractures Can also be treated in plaster Open reduction  increases the likelihood of union and reduce immobilization time

29. INDICATIONS FOR FASCIOTOMY

30. FASCIOTOMY A surgical procedure where the fascia is cut to relieve tension or pressure commonly to treat the resulting loss of circulation to an area of tissue or muscle. Performed through a volar approach, a dorsal approach or both. In the forearm, the volar compartment, dorsal compartment, and mobile wad compartment are interconnected

31. INDICATIONS Based on clinical impression. 4 signs & symptoms (4 Ps) Pain that is out of proportion to clinical findings Pain with passive stretch of involved muscles Pain with palpation of involved compartment Pressure increase within the compartment as measured In a patient who can’t express pain or paresthesias clinical examination, monitoring of compartment pressure Masquelet Whenever diastolic pressure minus tissue pressure is less than 30 mmHg

32. REFERENCE "Fasciotomy: Overview, Preparation, Technique". Emedicine.medscape.com. N.p., 2017. Web. 18 Apr. 2017. Louis, S, Warwick, D & Nayagam, S. (2010). Apley’s System Of Orthopaedics and Fractures. Euston Road, London: Hachette UK Company. "Monteggia Fracture Treatment & Management: Approach Considerations, Medical Therapy, Surgical Therapy". Emedicine.medscape.com. N.p., 2017. Web. 19 Apr. 2017.

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