Fractures Of The Shaft Of Radius And Ulna

Fractures of the Shaft of Radius and Ulna By Dr. sajid Manzoor PG-trainee Orthopedics LGH Lahore

Fractures of the Shaft of Radius and Ulna  

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Regard as articular fractures Present specific problems in addition to those common to other long bone shaft fractures. slight deviation in spatial orientation will significantly decrease forearm rotational amplitude and thus impair hand position and function

Mechanism of injury  Direct

blow associated with

Road traffic accident Fight when forearm used for protection Fall from hight  Gunshot injuries  Sports injuries (rarely)

Signs & Symptoms – Usually displaced with obvious deformity – Pain,swelling, loss of function – Neuro deficits uncommon – Vascular status – Compartment syndrome

 Imaging

– – – –

Minimum of 2 views Low energy – transverse, short oblique High energy – comminuted, segmental Must include elbow & wrist (Both PRUJ & DRUJ injuries can coexist ) – Attention to displacement, angulation, shortening, & comminution – Radial head in line with capitellum – CT scan  DRUJ & PRUJ subluxation at extremes of rotation

– US – interosseous membrane

Classification

– Open or Closed, level, pattern, displacement, presence of comminution or segmental loss – Determined by status of PRUJ & DRUJ

Surgical anatomy  

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Radius and ulna function as a unit They are parallel bones connecting by proximal and distal radio-ulnar joints which articulate closely with elbow and wrist joints Interasseos membrane spans the space between radio-ulnar joints its fibers runs obliquely upward from ulna to radius

Biomechanics 

Ulna

– Relatively straight – around which radius rotates

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Radial Bow

– Rotation decreased if increase/decrease bow

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Interosseous Space

– Central Band – longitudinal support of radius, prevents proximal migration

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10 degree angulation of any one or both bones results loss of 20* pronation and supination while 20*angulation show significant loss of ROM Angulation in middle 3rd  Significant loss of ROM of forearm due to loss of radial bow where two bones overlap at extremes of pronation and supination

Rotatory and Angulatory Forces 

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Biceps and supinator through their insertion act as rotational force on proximal 3rd radius fractures Pronator teres inserted on mid shaft exert both rotational and angulatory forces

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pronator quadratus on distal 4th exert both rotational and angulatory forces Proximal ulna angulate toward the radius by muscle mass in proximal forearm Malunion and nonunion occur more frequently because of difficulty in reducing and maintaining the reduction of two parallel bones in presence of these angulating and rotational influences

Current treatment options  

Nonoperative treatment Operative treatment 1) Open reduction and plate & screw fixation 2) Intramedullary nailing 3) External fixation

 Aim

should be Anatomic reduction, Rigid fixation, Early mobilization

Nonoperative Treatment Long-arm cast in neutral i.e. in supination in proximal 3rd shaft fracture, midprone position in middle third fractures and in pronation in distal 3rd fractures with 90º elbow flex position Indications  Undisplace ulna fracture  Unicortical fractures  Patient not fit for surgery 

Drawbacks of nonoperative treatment  No control on fracture fragments  High rate of secondary displacement  Poor functional results  Uncertain time of union  long healing time> elbow stiffness

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Indications of operative treatment in fracture shaft of radius and ulna All displaced fractures of radius and ulna in adults All isolated displaced fractures of radius All isolated fractures of ulna with angulation more than 10 degree All Monteggia fractures All Galleazi fractures Open fractures Fracture associated with compartment syndrome regardless of degree of displacement Multiple fractures of same extremity Pathologic fractures

Plate and screw fixation 

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Can used for displaced fracture at any level but especially distal 3rd or proximal 4th of radius and proximal 3rd of ulna shaft rigidity of fixation should be sufficient to avoid postoperative cast immobilizer

 If

both bones are fractured both Fx should be exposed and reduced temporarily and than fix one by one  Plate must be centered and of sufficient length to permit minimum 4 and preferably six cortices on each side of the fracture  No screws within 1 cm of fracture  Lag screws for butterfly fragment

Choices of surgical approach for radius fractures  If

fracture is of distal half of the radius, expose it through anterior Henry approach and apply plate on volar surface  If fracture is of proximal half of radius, expose it through dorsal Thompson approach and apply plate on dorsal surface  For fracture middle 3rd of radius, either approach can used

Anterior approach (Henry) Landmarks for skin incisions Proximally, from the biceps tendon and The distal end of the incision is the radial styloid process Superficial dissection Dissect the interval between the brachioradialis and flexor carpi radialis muscles. The radial artery should be identified and protected beneath the brachioradialis

Deep dissection 

proximal third: forearm should be fully supinated supinator muscle should be incised in its most medial part. The plate is inserted below the detached supinator muscle.

Deep dissection

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middle third: The forearm should be fully pronated to expose the radial border of the pronator teres muscle. If required detach the pronator teres off the radius.

Deep dissection 

distal third: Pronating the forearm will expose the border of the radius just lateral to the edge of the flexor pollicis longus and the pronator quadratus

Dorsolateral (Thompson) 

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Skin incision The skin incision lies straight down the dorsal aspect of the forearm, from the anterior side of lateral humeral epicondyle, and distally to the dorsal aspect of the styloid process of the radius. Plane of dissection The plane of dissection lies between the extensor carpi radialis brevis which should be retracted radially, and the extensor digitorum communis which should be retracted ulnarly.

Dorsolateral (Thompson)  

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supinator wraps the upper 3rd of the radius. posterior interosseous nerve runs through its substance. The nerve must be identified and protected The incision in the muscle should be made on the ulnar border of the radius and the muscle should be elevated sub periostealy and apply plate below the supinator less suited for distal radius shaft fractures as abductor pollicis longus and extensor pollicis brevis crosses the surgical field

precautions 

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Strip periostium from bone with muscles and apply plate beneath the periostium to protect blood supply and avoid necrosis Release tourniquet and secure all major bleeders before skin closure Do not close deep fascia to avoid Volkmann contractures If bone graft is required, avoid applying it to the interosseous border to prevent synostosis

Approach for ulna fracture 

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Ulna: incision directly on the subcutaneous border and extend between ECU & FCU plate is applied anteriorly or posteriorly

Aftercare

 Non-comminuted:

no splint is required and advise early motion  Comminuted & unreliable patient: removable splint x 6 weeks

Intramedullary Nails

 Interlocking

nails  Rush pins and Flexible nail

Rush pins and Flexible nail

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poor results due to poor rotation control and lack of rigid fixation

Interlocking Nails 

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Indication - Segmental fx - Open fx with soft tissue or bone loss - Pathologic bone - Failed plating - Multiple injuries Contraindication - Active infection - Medullary canal smaller than 3mm - An open physis

Interlocking nails   

Triangular & Square nails Bent nails for radial bow Difficult to beat the results of plate fixation

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Portal of entry for IM nail of ulna is made in proximal ulna

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Radial portal of entry is variable

Different steps of IM locking nailing

Interlocking nails  Adventages

- little or no periosteal stripping - smaller operative wound - bone grafting is generally not required - after nail removal less chances of refracture

Interlocking nails  Complications

– Size  Side-to-side & rotary movements  Explode the shaft – Inadequate fixation – Injury to PIN with locking screws

Open fracture  Common

with high energy trauma)  Usually Gustillo I or II  Can plate primarily  Ex-fix for soft tissue loss, maintain length

Monteggia

Monteggia fracture  In

1814 Monteggia described fracture of proximal 3rd of ulna in combination with anterior dislocation of proximal radioulnar joint  In1967 Bado named it as Monteggia fracture and described four different types

Bado classification of Monteggia fracture

 Type l radial head is dislocated anteriorly (60%)  Type ll radial head is dislocated posteriorly(15%)  Type lll radial head is dislocated laterally(10%)  Type lV radial head dislocation in any direction with fracture of both radius and ulna shaft (10%)

Treatment objective  The

radial head must always line up with the capitellum in all views and in all positions of limb  Ulna fracture should be fixed rigidly to prevent angulation at fracture site and thus future subluxation or dislocation of radial head

Treatment Plan 

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For acute injuries, close reduction of radial head dislocation should be attempted and ulna fracture should be fixed rigidly For acute injuries, in which close reduction of radial head failed due to interposition of annular ligament or capsule open reduction with repair or reconstruction of annular ligament should be perform followed by rigid fixation of ulna For old injuries (6 weeks or more) in which radial head has never been reduced or insufficient fixation of ulna leads to redislocation , excision of radial head with rigid fixation of ulna done

Nightstick

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Ulna only Usually direct blow Usually non/minimally displaced Splint 7-10 days, Fracture Brace 4-6 weeks (allow elbow/wrist motion) Displaced - Plate

Galeazzi Fracture  In

1934, Galeazzi described dislocation or subluxation of distal radio-ulnar joint in association with solitary fracture of distal 3rd of radial shaft (named as Galeazzi fracture)  Campbell called it as “fracture of necessity”

Galeazzi Fracture 

Injuries to DRUJ are subdivided to : - Stable - Partially unstable (subluxation) - Unstable (dislocation)

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If close reduction DRUJ is not possible open exploration for a trapped tendon or soft tissue may be required

Treatment  

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Close reduction and cast immobilization has a high rate of unsatisfactory results Open reduction and internal fixation with 3.5mm DCP is treatment of choice (fracture is usually too distal to be fixed with intramedullary nail) Rigid anatomical fixation of radius usually reduce DRUJ dislocation, if not than open exploration and reduction should be achieved and stable with a Kwire for 6 wks

Complications  

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Infection Nerve injury - Uncommon – if neuro deficit exists; explore at time of debridement; if divided, ends tagged together – Clean transection - 1º repair if wound clean, soft tissue adequate – Iatrogenic  Incomplete – observe  Complete – explore within a few days – AIN palsy caused by constrictive dressing Vascular injury – either radial or ulnar Compartment syndrome (rare) – ,crush injuries

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Radioulnar Synostosis – Uncommon – Highest risk – proximal fx’s treated w/ 1 incision – Heterotopic ossification in interosseous memebrane in response to screws being too long – Resection> interposition w/ muscle or silicone sheet> early mobilization – Nonarticular synostosis in distal or middle 1/3 has best chance

 Malunion

– Corrective osteotomy if loss of rotation  Nonunion

– Uncommon

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