Radius and ulnar shaft fx

Radius and ulnar shaft fx

1. FRACTURES OF THE SHAFTS OF THE RADIUS AND ULNA Dr. Mohammad Mahdi Shater Orthopedic Surgery Resident Baqiyatallah University of Medical Sciences بسم الله الرحمن الرحیم Rockwood and Green's Fractures in Adults

2. Introduction Role Radial shaft fractures are defined as those occurring between the radial neck proximally and the junction of the metaphysis and diaphysis distally, approximately 3 cm proximal to the distal articular surface. Ulnar shaft fractures are defined as those occurring between the distal aspect of the coronoid proximally and the ulnar neck distally.

3. Epidemiology Forearm fx are more common in men than women because of higher incidence in men of MCA ,falls,sports participation,… The ratio of open fx to closed fx is higher for the foream than for any other bone except tibia

4. Mechanism of Injury Direct blow is the most common. -road traffic accidents -fights in which the defender uses the forearm for protection. Less frequently may result from falls and sports injuries.

5. Night stick direct blows occur in fights in which the defender uses the forearm for protection a direct blow under these circumstances may cause an isolated ulnar fracture, often called a "night stick“ fracture, or a Monteggia fracture dislocation

6. Signs and Symptoms Pain Swelling Loss of function of the forearm and hand Local tenderness Deformity In closed fractures, a tense swelling and pain on passive stretch of the forearm may suggest compartment syndrome.

7. Associated Musculoskeletal Injuries Muscle Radioulnar joint disruption( Monteggia , Galeazzi )

8. Open Diaphyseal Fractures The frequency of open fractures ranges from less than 10% in isolated radial shaft fractures to 43% of both-bone forearm fractures

9. Compartment Syndrome Swelling ,Pain Pain out of proportion with passive extension of the digits is the most sensitive test to clinically diagnose compartment syndrome Compartmental pressures within 30 mm Hg

10. absolute compartment pressure is an unreliable indicator of the requirement for fasciotomy and that a pressure differential of less than 30 mm Hg between the diastolic blood pressure, and the ompartment pressure indicates that immediate fasciotomy is required

11. Associated Nonmusculoskeletal Injuries Head injury Nerve injuries Artery disruption Abdominal and pelvic trauma

12. Imaging and Other Diagnostic Studies Anterior–posterior (AP) and lateral radiographs of the forearm Tuberosity view Computed tomography ( CT) Magnetic resonance imaging diagnose injuries to the DRUJ and associated TFCC Ultrasound

13. Forearm fractures Classification What bone(s) is (are) fractured? In what location is the fracture (proximal, middle, distal third) What is the fracture pattern (simple transverse, simple oblique, comminuted)? Is there instability at the distal or proximal radioulnar joint? Is the fracture open or closed? Is a previous implant present? Is a previous deformity present? Is the bone stock normal?

14. OTA Classification Type A fractures are simple fractures of the ulna, radius, or both bones. In Al fractures there is a simple fracture of the ulna and the radius is intact. In A2 fractures there is a simple fractures of the radius and the ulna is intact. In both these groups, .1 refers to an oblique fractures, .2 to a transverse fracture, and .3 to a fracture associated with the dislocation. The A1.3 fracture represents a Monteggia fracture dislocation and the A2.3 fracture represents a Galeazzi fracture dislocation. In the A3 group, .1 refers to a radial fracture in the proximal third of the bone, .2 to a radial fracture in the middle third, and .3 to a radial fracture in the distal third.

15. Type B fractures are wedge fractures of either the ulna (Bl), the radius (B2), or both the radius and ulna (B3). In groups Bl and B2, .1 refers to an intact wedge, .2 to a fragmented wedge, and .3 to an associated dislocation with B1.3 fractures being Monteggia fracture dislocations and B2.3 fractures being Galeazzi fracture dislocations. In the B3 group, B3.1 fractures have an ulnar wedge and a simple fracture of the radius, B3.2 fractures have a radial wedge and a simple fracture of the ulna, and B3.3 fractures have radial and ulnar wedges

16. Type C fractures are complex fractures. Cl fractures are complex fractures of the ulna, C2 fractures involve the radius, and C3 fractures involve both the radius and ulna. In Cl.l fractures there is a bifocal fracture of the ulna with an intact radius, in Cl.2 fractures there is a bifocal fracture of the ulna with a radial fracture, and in Cl.3 fractures the ulnar fracture is irregular. In C2.1 fractures the radial fracture is bifocal and the ulna is intact. In C2.2 fractures the radial fracture is bifocal but the ulna is fractured, and in C2.3 fractures the radial fracture is irregular. In C3.1 fractures both bones show a bifocal fracture and in C3.2 fractures there is a bifocal fracture of one bone with an irregular fracture of the other. In the rare C3.3 fracture, both fractures are irregular or comminuted.

17. Monteggia Fracture Fractures between the proximal third of the ulna accompanied by radial head dx. Bado divided Monteggia lesions into four types with the classification depending on the direction of the radial head

18. Bado classification: Type I: An ant. Dx. Of the radial head with associated anterioly angulated fx. Of the ulnar shaft

19. Type II:post. Dx. Radial head with a poteriorly angulated fx of ulna

20. Type III: A lateral or anterolateral dx of the radial head with a fx. Of ulnar metaphysis

21. Type IV: Ant. Dx of radial head with fx radius and ulna

22. Galeazzi Fracture Dislocation or subluxation of the DRUJ in association with a solitary fx. of the radius at the junction of the middle and distal third is called Galeazzi fx. Injuries to the DRUj are generally subdivided into stable, partially unstable (subluxation), and unstable. Open reduction and internal fixation of the radius depends on DRUj stability.

23. Most authorities indicate that : about 60% of Monteggia fracture dislocations are type I 15% are type II 10% are type III (virtually only occur in children) 10% are type IV

24. Anatomy Forearm fractures can be regarded as articular fractures as slight deviations in orientation of the radius and ulna will significantly decrease the forearm's rotation and impair the positioning and function of the hand.

25. Consist of : Ulna : Which is straight Radius: Bowed Interrosseous membrane occupied the space between them The central band is approx, 3.5 cm wide running obliquelyfrom proximal origin on the radius to its distal insertion on the ulna

26. Anatomy Radius Ulna Interosseous Space Triangular Fibrocartilage Complex Proximal Radioulnar Joint Muscles Nerves Arteries

27. CURRENT TREATMENT OPTIONS Nonoperative Treatment Operative Treatment External fixator Intramedullary Nailing Plating

28. Surgical Approach Ulna Radius Volar Approach of Henry Posterior (Thompson) approach

29. Operative Treatment External fixator: There are only a few indications for the use of external fixation in forearm fx: 1- Initial management of open fractures of the radius and ulna associated with extensive soft tissue damage 2-Maintaining the length in fx with severe bone loss 2- multiply-injured patient

30. Intramedullary Nailing intramedullary nails are not as strong and do not maintain forearm reduction as well as plate osteosynthesis Children vs adult Type of Nails Indications/Contraindications

31. Plating Internal fixation with plates allows excellent control of the fracture fragments and therefore permits accurate restoration of the anatomy, which remains the key principle in treating forearm fractures as it preserves maximal forearm function

32. The plates most widely used for internal fixation of forearm fractures are the 3.5 (DCP) and the 3.5 limited contact-dynamic compression plate (LC-DCP) In comparison to the DCP, the contact area between the bone and the LC-OCP is reduced by about 50%

33. The concept of limited contact between the plate and the bone has lead to the development of the point contact-fixator (PC-Fix) in which the contact area between the plate and the underlying bone is reduced to two contact points every 16 mm .Fixation achived between the screws and the bone, like an external fixator.

34. AUTHORS' PREFERRED TREATMENT Nonoperative treatment : -undisplaced fractures -in patients with significant comorbidities Operative treatment : -For the treatment of forearm diaphyseal fractures the best device is plate osteosynthesis(3.5-mm LC-DCP).

35. Pearls and Pitfalls Pearls There is a high incidence of associated musculoskeletal injury. Tense swelling in the forearm suggests compartment syndrome. In type II Monteggia fracture dislocations, an anterior triangular or quadrilateral anterior fragment must be looked for on x-rays. The results of using the 3.5-mm LC-DCPhave not been bettered by more modern plates.

36. Pitfalls Subluxation of dislocation of the DRUJ may develop slowly. Failure to restore the radial bow will restrict forearm rotation. Intramedullary nailing frequently does not restore the radial bow. In initially undisplaced fractures, nonoperative management can be associated with poor results. Minimally invasive techniques are not recommended. Early plate removal may cause refracture. Narrowing of the interosseous space may cause radio-ulnar synostosis.

37. COMPLICATIONS Compartment Syndrome Malunion Nonunion Infection Plate Removal and Refracture Radio-Ulnar Synostosis Nerve palsy(FPL)

38. Compatment syndrome One pathway is tissue hypoxia followed by swelling which further reduces the perfusion pressure at the capillary level, eventually leading to ischemic muscle and myonecrosis. Another more common pathway is direct or indirect muscle damage leading to muscle swelling followed by increased intracompartmental pressure pressure will lead to reduced capillary blood flow, muscle ischemia, and myonecrosis

39. The forearm is the most common site for compartment syndrome in the upper extremity. The three compartments of the forearm include the anterior (or flexor compartment), the posterior (or extensor compartment), and the mobile wad (including brachioradialis and extensor carpi radialis longus and brevis). Flexor digitorum profundus and flexor pollicis longus are the most severely affected muscles because of their deep location.

40. Malunion It seems therefore that early correction yields better results than late correction if osteotomy is required.

41. Nonunion In general, fracture nonunion results from unstable fixation or a compromised blood supply secondary to the severity of the injury or poor surgical technique.

42. Infection If infection does occur, surgical treatment with an adequate debridement is recommended. Implant removal should not be under taken appropriate antibiotic treatment depending on the bacteria involved in the infection.

43. Plate removal It has been suggested that remodeling takes up to 12-18 months to complete 4-6 w brace or splint We do not advocate routine plate removal in the asymptomatic patient

44. General Open fractures Infection Multiply- injuredpatients with head trauma Delayed internal fixation Surgical (less common) Narrowing the interosseous space by nonanatomic reduction Use of too long screws Bone grafting Indomethasin and Radiotherapy Radio-Ulnar Synostosis

45. Assessment of peripheral n. function : Making a fist (median and ulnar n.) Wrist and finger extension (radial n.) Abd. of extended fingers (ulnar n. when radial n.is intact) Extension in the IP joint of the thumb (posterior interosseous n.) Flexion in the IP joint of the thumb (anterior interosseous n.)

46. Assessment of Blood Supply Lesion of the medial collateral ligament complex of the elbow? Lesion of the lateral collateral ligament complex of the elbow? Lesion of radio-carpal ligaments? Pending or established compartment syndrome?

47. Collateral circulation of the forearm in the presence of either isolated radial or ulnar arterial damage is usually sufficient to maintain viability of the hand and forearm. Viability may even be maintained if both the radial and ulnar arteries are damaged because the longitudinally orientated collateral vessels may still provide sufficient blood supply If one major artery is intact and there is adequate perfusion to the hand, the damaged vessel does not have to be repaired. However, in combination with nerve injuries, it has been argued that recovery of the associated nerve lesion will be improved by an enhanced blood supply and vascular repair is therefore advocated.

48. Assessment of Bony Injury Proximal radio-ulnar joint Dislocation or abnormally wide joint space? Direction of the dislocation? Is the annular ligament probably torn or has the radial head just slipped out of the intact annular ligament?

49. Interosseous membrane Is the membrane torn? If so, proximally or distally? Distal radio-ulnar joint Dislocation Abnormal separation Shortening of the radius relative to the ulnar head

50. Nerve injuries in closed forearm fractures are relatively uncommon. posterior interosseous n. most commonly Most nerve injuries are neuropraxias

51. Collateral circulation of the forearm in the presence of either isolated radial or ulnar arterial damage is usually sufficient to maintain viability of the hand and forearm. Viability may even be maintained if both the radial and ulnar arteries are damaged because the longitudinally orientated collateral vessels may still provide sufficient blood supply