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Forearm Fractures
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Anatomy▪ Forearm has very
complex anatomy ▪ 6 articulations ▪ Combination of
hinge, rotatory, and universal joints
▪ Radial bow critical to forearm rotation
▪ Provides stable base for spatial positioning of hand
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Anatomy
▪ Bony stabilizers of elbow ▪ Radiocapitellar articulation ▪ Ulnohumeral articulation
▪ Soft tissue stabilizers of elbow ▪ Medial ulnar collateral ligament (55% valgus
stability at 90) ▪ Lateral ulnar collateral ligament (9-14% varus
stability flx à ext) ▪ Anterior capsule ▪ Annular ligament ▪ Musculature
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Anatomy
▪ Volar and dorsal radioulnar ligaments help stabilize DRUJ ▪ Interosseous membrane allows dynamic
stabilization of radius and ulna during axial compression and somewhat during rotational activities
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Deforming Forces▪ Muscular forces and unique, two-bone
anatomy produce compression, angulation, and rotational deformities ▪ Biceps/supinator – exert rotational (supination)
and angular (flexion) forces on proximal third radius fractures
▪ Pronator teres exerts rotational (pronation) and angular (central) forces across the midshaft level
▪ Pronator quadratus exerts similar forces to PT at the distal third
▪ Proximal muscle mass makes control of proximal fractures difficult
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Deforming Forces▪ Radius fractures occurring
proximal to pronator insertion tend to assume apex volar angulation with proximal supination due to unopposed bicep/supinator pull
▪ Radius fractures occurring distal to pronator insertion tend to maintain the proximal fragment in neutral while the distal fragment pronates
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Deforming Forces▪ Isolated proximal third
ulna fractures tend to assume apex radial deformities which can be very difficult to reduce
▪ Fractures of the distal radius assume ulnarly angulated positions due to the pull of the long forearm and pronator quadratus muscles
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Approaches
▪ Radius ▪ Thompson approach
▪ Dorsal approach to radius ▪ Recommended for approach to
proximal and middle thirds of posterior surface of radius
▪ Deep branch of radial nerve traverses supinator and must be protected
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Approaches ▪ Posterolateral approach ▪ Corresponds to
distal limb of Kocher approach
▪ Best approach for fractures involving radial head
▪ Extensile proximally and distally
▪ PIN fairly safe in this exposure but full pronation provides maximal protection
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Approaches▪ Anterior approach of Henry ▪ Allows access to entire volar
shaft of radius
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Approaches
▪ Boyd approach ▪ Best for access to proximal third
of ulna and fourth of radius ▪ Excellent approach with proximal
ulna fracture and concomitant radial head dislocation (Monteggia)
▪ Provides access to proximal fourth of radius with less risk to deep branch of radial nerve
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Nightstick/Simple Shaft Fractures
▪ Most often occur from direct blow ▪ Generally referred to as “nightstick”
fractures ▪ May be simple or comminuted ▪ Deformity based on level of fracture: ▪ Radial fracture deformation determined by
level proximal/distal to pronator insertion ▪ Ulnar fracture deformation determined by level
proximal/distal to proximal third of bone
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Nightstick Fractures
▪ Treatment ▪ Closed reduction ▪Appropriate for children and for nondisplaced
fractures in adults ▪Alignment of DRUJ, PRUJ, elbow and wrist
articulations must be scrutinized ▪ Long arm cast essential to control rotational forces
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Nightstick Fractures
▪ Treatment ▪ Intramedullary fixation ▪Triangular or star shaped nails with proximal/distal
locking help control rotation ▪Completely internal ▪Discussed more fully in next section
▪ ORIF ▪Rigid fixation ▪ 3.5 DCP +/- locking required for stability
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Nightstick Fractures
▪ Treatment ▪ ORIF ▪Hole diameter must be less that 30% cortical
diameter to reduce stress riser effect ▪Asymptomatic plate removal not recommended due
to increased incidence of fracture ▪Plate removal not recommended prior to 6 months
and preferably after 1-2 years ▪ Immobilization/support required for 6-8 weeks
following plate removal in order to prevent refracture through stress riser effect
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Both Bone Fractures
▪ Occur with significantly more force than isolated fractures ▪ Often comminuted ▪ Soft tissue injury and compartment
syndromes must be anticipated due to increased force transmission
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Both Bone Fractures
▪ Muscle forces and soft tissue injury may produce significant deformity
▪ Must maintain anatomic relationship of elbow, DRUJ, PRUJ, wrist, and interosseous space in order to preserve function
▪ Malunion and non-union more common in this area due to presence of additional pro/supination forces that induce rotational and angular deformities
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Both Bone Fractures
▪ Initial reduction essential for analysis of neurovascular status ▪ X-ray imaging may be difficult to interpret
due to deformity
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Both Bone Fractures
▪ Treatment depends on age and degree of displacement/comminution ▪ Closed reduction ▪Majority of childhood fractures ▪Casting aimed at preservation of interosseous
space through A/P compression ▪Contraindicated in adults with any degree of
displacement ▪ Instability demands fixation
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Both Bone Fractures
▪ Treatment ▪ ORIF
▪ “gold standard” ▪ Rigid plates (3.5 DCP +/- locking)
required to maintain reduction and apposition
▪ Pre-bending necessary to avoid loss of radial bow or length
▪ Larger systems (4.5 DCP or greater) contraindicated due to stress riser effect of large diameter holes
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Both Bone Fractures
▪ Treatment ▪ Intramedullary fixation
▪ Originally described with rounded or rigid nails with dismal results and nonunion rates approaching 20% (Smith/Sage 1957)
▪ Sage Nail developed in 1959 heralded technological breakthrough by using triangular nail with resilient stainless steel
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Both Bone Fractures▪ Intramedullary fixation ▪ Require intact cortex for
stability ▪ Locked and unlocked
devices available ▪ Must resist torsional
stresses ▪ May provide advantage in
segmental fractures
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Both Bone Fractures▪ Intramedullary fixation ▪ Portals for placement in distal
radius and olecranon tip ▪ Less rigid than plating, but
completely internal
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Galeazzi Fracture Dislocation▪ Combination injury
with distal third radial shaft fracture and DRUJ dislocation
▪ Referred to as “fracture of necessity” by Campbell
▪ Often go unrecognized ▪ DRUJ dislocation
should be suspected with any displaced fracture of the distal third radial shaft
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Galeazzi Fracture Dislocation▪ Treatment through closed reduction and
casting has high rate of unsatisfactory results ▪ ORIF through Henry approach
recommended ▪ Fixation with 3.5 DCP is treatment of
choice in adults ▪ Reduction of radial fracture often reduces
DRUJ ▪ Postoperative immobilization in supination
maintains reduction of DRUJ (+/- K-wire in joint)
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Essex-Lopresti Fracture Dislocations
▪ Typically results from hard fall on outstretched hand
▪ Fracture of radial head, DRUJ disruption, and tear of interosseous membrane result
▪ Because of loss of tethering effect of interosseous membrane, subequent radial head resection has devastating consequences
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Essex-Lopresti Fracture Dislocations
▪ Must be suspected prior to performing surgical correction ▪ Pain in the DRUJ with displaced radial
head/neck fracture should alert surgeon ▪ Treatment involves ORIF of radial head/
neck versus replacement ▪ Newest radial head replacements are
vitallium alloy and avoid silastic complications ▪ DRUJ reduced with forearm supination +/-
k-wire
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Monteggia Fracture Dislocations
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Monteggia Fracture Dislocations
▪ Result from combination of ulna fracture with dislocation of radiohumeral articulation with or without radial fracture ▪ Can often be treated conservatively in
children but required ORIF in adults ▪ Divided by Bado into four types based on
ulnar angulation and direction of radius dislocation
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Type I Monteggia Variant
▪ Fracture of the middle or proximal third of ulna
▪ Apex anterior fracture angulation
▪ Anterior dislocation of radial head
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Type II Monteggia Variant
▪ Fracture of middle or proximal third of ulna
▪ Apex posterior angulation of fracture
▪ Posterior dislocation of radial head often includes fracture
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Type III Monteggia Variant
▪ Ulna fracture just distal to coronoid process
▪ Apex radial fracture angulation
▪ Radially dislocated radius
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Type IV Monteggia Variant
▪ Fracture of proximal or middle third of ulna
▪ Fracture of proximal third of radius distal to biceps insertion
▪ Anterior radius dislocation
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Monteggia Fracture Dislocations
▪ Type I variant represents the majority of cases ▪ Treatment ▪ ORIF of ulna fracture ▪ Accurate ulna reduction often allows for
spontaneous or manual closed reduction of radial head
▪ Open reduction of radial head may be required if capsule or annular ligament become interposed
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Monteggia Fracture Dislocations
▪ Treatment ▪ If Open reduction of the radial head dislocation
is required, repair or reconstruction of the annular ligament is required
▪ Old injuries (> 6 weeks) with unreduced radial head dislocations or malreduced ulna fractures leading to recurrent radial head dislocation ▪Best treated with radial head excision/replacement ▪Ulnar fracture reduced or osteotomized with rigid
fixation
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Monteggia Fracture Dislocations
▪ Postoperative management ▪ Long arm posterior mold splint in 90 degrees
or more for two weeks ▪ Following suture removal at two weeks,
another 2-4 weeks of long arm cast immobilization are required
▪ Once cast removed, gentle pro/supination are allowed followed by gradual reintroduction of extension