Injuries of the forearm
By : Dr.Sanjeev
Monteggia Fracture Dislocation.
• Fracture upper third of ulna with dislocation head
of the radius .
Mechanism:
• More common in children
• fall on outstretched hands either in hyperpronation
or in hyperextension .
• C / F : - Pain , Swelling, deformity, severe loss of
forearm movement.
• Radiology : AP, lateral.
.
• Fig : -
Classification
• Type 1 (60%) : anterior dislocation of head of the
radius with fracture ulna at upper third and with
anterior angulation.
• Type 2 (5%) : posterior dislocation head of the
radius and fracture proximal ulna with posterior
angulation.
• Type 3 (20%) : lateral dislocation head of the radius
and fracture proximal ulna with lateral angulation.
• Type 4 (15%) : fracture radius and ulna in their upper
one – third and anterior dislocation of head of the
radius with anterior angulation.
Cont..
• Fig : - Type 1:
Cont..
• Fig : - Type 2 :
Cont..
• Fig : - Type 3
Cont..
• Fig : Type - 4
Clinical symptoms :
Type 1 , Type 2 , Type 3 and Type 4 :
• Marked pain and tenderness about the elbow
• No flexion , extension , pronation , and
supination.
• Paralysis of the interosseous nerve may occur.
Clinical signs
Type 1 : - HOR felt anteriorly
- Anterior angulation
Type 2 : - HOR posterior
- Posterior angulation of ulna
- Shortening of forearm
Type 3 : - HOR is lateral
- Lateral angulation
Type 4 : - HOR is anterior
- Deformity is at the fracture level
(HOR = HEAD OF RADIUS)
TREATMENT : In children
• Type 1 :
• Closed reduction (if fails)
• OR of fracture ulna + CR of HOR (if fails)
• OR of fracture ulna with OR of head of the radius
Type 2 :
• CR (closed reduction )
• OR (open reduction
Type 3 : - CR
CONT..
Type 4 :
• CR (if fails )
• OR rigid IF with plate and screws
IN ADULTS : (type 1, 2, 3 and 4)
•
•
•
•
OR + IF of fracture ulna with plate and screws
CR of HOR (if fails)
OR ,HOR +IF fracture ulna
If fracture more than 6 weeks excision HOR is
done.
Complications
•
•
•
•
•
Posterior interosseous nerve palsy .
Radial head instability
Nonunion of fracture ulna.
Malunion of fracture ulna.
Myositis ossificans
Galeazzi fracture dislocation
• Fracture of the radial shaft at the junction of middle
and distal third with associated subluxation or
dislocation of the distal radioulnar joint.
• Reverse Monteggia
• Also known as fracture of necessity (which requires
ORIF)
Forces causing loss of reduction and difficulty in
reduction :
• Insertion of pronator quadratus pulls the
distal fragment in proximal and volar direction
• Brachioradialis uses the distal radioulnar joint
as a pivot and causes shortening
Mechanism of injury : .
- Direct blow on the dorsolateral side
of the forearm
- Fall on an outstretched hand with
marked pronation of the forearm .
Clinical features :
•
•
•
•
Pain,
swelling,
Deformity of the lower end of the forearm
Pronation and supination are severely
restricted.
• Neurovascular injury is rare.
Radiological :
AP view :
• Fracture radius ,
transverse or short
oblique
• Distal radioulnar joint is
dislocated
• Radius appears short
Lateral view :
• Radius is angulated
dorsally
• Head of the ulna is
prominent dorsally.
CONT..
FIG : AP - VIEW
Cont…
FIG : - LATERAL VIEW
Treatment
• ORIF(Plate and screw fixation).
• Distal radio – ulnar joint stability..?
– Yes plaster ,
– No K wire fixation.
Complications
• Malunion loss of supination/ pronation.
(osteotomy).
• Nonunion bone grafting.
• Compartment syndrome.
• Angulation of the fracture and subluxation of
the distal radioulnar joint.
Barton’s fracture
• Fracture line extends from the distal articular
surface of the radius.
• Dislocation or subluxation usually associated.
• Most are unstable.
• ORIF.
Cont..
• Fig : -
Radial styloid fracture
• Also known as chauffeur’s fracture;
Hutchinson fracture.
• Posterior marginal fracture of the radius
• Avulsion fracture of the radiocarpal ligament
• Seen in motorcycle accidients , and fall from
heights
Cont ..
• Fig : Radial styloid fracture
Clinical features
•
•
•
•
Pain
Swelling
Tenderness over the radial styloid process
Movement of the wrist, especially radial
deviation , is painful
Radiology :
• AP – shows transverse fracture
Treatment
• Closed reduction and above elbow plaster cast
Unstable fractures :
• percutaneous with K - wire
Cont..
• Fig : long armed cast