Radio-Ulnar Fractures

Forearm

• Main function: – Pronation and supination– Origin of hand muscles

• Fractures in this area cause the most problems in upper extremity function

Mechanisms of Injury

• Significant energy of trauma must be present before the forearm bones can break– Fall from standing height– Direct blow – hit on the arm by hard object, reflex

when protecting self– Vehicular crash

• Nightstick fracture – isolated fracture of the ulnar shaft

Epidemiology

• 0.9% of all fractures• Age: ~40 years• Male/Female: 3:1• Causes:

– Fall 28%– Direct Blow 21%– Sport 18%– Vehicular crash 13%

• OTA Classification:– A: 86%– B: 12%– C: 2%

• Most Common Subgroups:– A1.2 25%– A1.1 25%– A1.3 6.7%– A2.2 6.7%– B1.1 6.7%

History and P.E.

• Signs and Symptoms:– Pain– Deformity– Loss of Function

• Nightstick Fracture – palpate at edge of ulna tenderness at level of fracture

• P.E.– Motor and sensory functions of the radial, median and

ulnar nerve– If swollen and tense: t/c compartment syndrome

Special Lesions

• Monteggia Fracture-Dislocation• Galeazzi Fracture-Dislocation• Essex-Lopresti Injury

Monteggia Fracture-Dislocation

• Fracture of the proximal ulna + dislocation of radial head

• Pain on the elbow and mechanical block to elbow flexion and forearm rotation

• Examine the nerves esp. posterior interosseous nerve injured due to stretching by dislocated radial head

Galeazzi Fracture-Dislocation

• Fracture of the radius at the junction of the middle and distal third + dislocation of the distal radioulnar joint (DRUJ)

• Unstable in nature• Tx: ORIF

Indications of Possible DRUJ Instability

• Requirement for forceful reduction• “Mushy” feel to reduction• Fracture at base of ulnar styloid• Persistent incongruity of the distal ulna on

true lateral radiograph• Shortening (>5mm) of the radius• Widening of the DRUJ on AP radiograph

Essex-Lopresti Injury

• Rare complex injury of the forearm best described as radioulnar dissociation

• FOOSH Fracture in head of radius and disruption of both the interosseous membrane and DRUJ Proximal migration of radius

Assessment

• Radiographs: AP and L are sufficient– Include elbow and wrist– Oblique view taken if there is uncertainty of the

integrity of the proximal or DRUJ• If with DRUJ disruption:– Widening of DRUJ space– AP: Shortening of radius in relation to distal ulna– L: Distal ulna dorsally displaced

Classification of Fractures

Classification of Fractures

• Type A: Unifocal Simple – A1: Isolated ulnar– A2: Isolated radial– A3: Both– Suffix refers to morphology of

fracture• .1: Transverse• .2: Oblique• .3: Monteggia (A1.3), Galeazzi (A2.3)• A3 suffixes: radial fracture position

Classification of Fractures

• Type B: Wedge– B1: Isolated ulnar– B2: Isolated radial– B3: Both– Suffix refers to intact-ness of wedge

• .1: Intact• .2: Fragmented• .3: Fracture-Dislocation (1.3:

Monteggia, 2.3: Galeazzi)• B3 suffixes: radial fracture position

Classification of Fractures

• Type C: Complex – C1: Complex Ulnar

• C1.1: Without radial fx• C1.2: With radial fx• C1.3: Monteggia with complex ulnar,

simple radial

– C2: Complex Radial• C2.1: Without ulnar fx• C2.2: With ulnar fx• C2.3: Galeazzi

– C3: Complex both

Bado’s Classification of Monteggia Lesions

• Type I: Fx of ulnar diaphysis at any level, anterior angulation at fx site, anterior dislocation of radial head

• Type II: Fx of ulnar diaphysis, posterior angulation at fx site, PL dislocation of radial head

• Type III: Fx of ulnar metaphysis with AP or L dislocation of radial head

• Type IV: Fx of the P3 of both radius and ulna with anterior dislocation of radial head

Bado’s Classification of Monteggia Lesions

Non-Operative Treatment Options

• Conservative treatment poor functional outcome due to importance of anatomic relationship of the radius and ulna + difficulty in getting acceptable reduction

• Closed reduction + cast immobilization unsatisfactory results in up to 92% of cases

• If isolated ulnar fx or nightstick fx cast may be used• General Rule: If displacement is <50% of the width of

the bone + angulation < 10 deg, may do functional bracing or cast immobilization

Indications of Surgical Treatment for Forearm Fractures

• Displaced radius and ulna• Isolated fx of either bone with displacement• Monteggia, Galeazzi and Essex Lopresti type• All open fx

Operative Treatment

• Usual method: Open reduction, plate fixation

• Intermedullary Nailing high rate of non-union and poor final range of rotation

• External Fixation Alternative treatment if there is significant bone or soft tissue loss

Management of Monteggia Fracture-Dislocation

• Goal: Anatomic relocation of dislocated radial head together with reduction and fixation of the ulna

• Method: OR, IF with plates

Management ofGaleazzi Fracture Dislocation

• Goal: Relocation of the DRUJ together with a precise reduction of the radial fracture which is rigidly fixed

• Method: Anterior approach to expose fracture than put plate on volar aspect of distal radial shaft

Management of Essex-Lopresti Injury

• Goal: Restoration of the length of the radius and stabilization of the DRUJ

• If radial head is fractured ORIF with miniplates

• If fracture is comminuted use radial head prosthesis

Management of Open Fractures

• Thorough irrigation + Debridement• Stabilize fracture with plate fixation• Implant should be covered with muscles or

other soft tissue• Repeat debridement after 24-48 hours