Tuesday, June 23, 2009

Fracture of the Radius and Ulna

Fracture of the Radius and Ulna


By Dr. KM Liau


A 19 years old boy was involved in a road traffic accident. He fell down from the motorcycle and landed on outstretched hands. He complaint of pain and deformity over his right forearm. No other injury noted.

Anterior-Posterior view of right forearm.

Simple transverse fracture over distal end of right radius and ulna.

No dislocation of proximal or distal radioulnar joint.

Lateral view of right forearm

Both the distal segment of radius and ulna displaced dorsally.

Rule of forearm fracture:

They either fracture together (both radius and ulna)

or

associated with dislocation of either proximal or distal radio-ulnar joint when only a single forearm bone is fractured - Monteggia, Galeazzi or Essex-Lopresti fracture dislocation.

Monteggia fracture-dislocation

Monteggia fracture-dislocation refers to fracture of the ulna with dislocation of the radial head.

It is named for Giovanni Battista Monteggia.

Due to high risk of displacement causing malunion open reduction and internal fixation is typically done - this is also referred as fracture of necessity (which means necessary to fix internally)

Galeazzi fracture-dislocation

Galeazzi fracture-dislocation refers to a fracture of the shaft of the radius associated with dislocation of the distal radioulnar joint.

Ulnar plus variance (= radial shortening) of >10 mm implies complete disruption of interosseous membrane means complete instability of distal radioulnar joint.

Due to the high incidence of malunion if treated conservatively, it is necessary to fix this fracture internally as well (another fracture of necessity)

Essex-Lopresti lesion

Essex-Lopresti lesion refers to longitudinal disruption of the radioulnar interosseous membrane and proximal migration of the radius associated with fractures involving the proximal radioulnar joint, the distal radioulnar joint, or both sites.

Closed manipulative reduction (CMR)

CMR was attempted but the fracture reduction was not acceptable. The patient was informed for open reduction and plating of both the fractures under general anaesthesia.

Preoperative assessment and preparation

1. Full Blood Count:

Hb 13.3g%
TWC 6,400
Platlet 354,000

2. BUSE

Na 139 mmol/l
K 4.3 mmol/l
Urea 6.0 mmol/l

3. Group Screen and Hold (GSH) 2 pint packed cell.

Open reduction and internal fixation (ORIF)

Indication of ORIF :

Both forearm bone fracture is an injury that almost always requires surgery in an adult patient.

Without surgery, the forearm is generally unstable and there is no ability to cast this type of fracture in a proper orientation.

They are most commonly treated by placing a metal plate and screws on both the radius and ulna bones.

These bones must each be approached through a separate incision.

Skin incision for radius fracture

Incision was made lateral to flexor carpi radialis tendon to approach the radius volarly.

Deep dissection

Deep fascia is incised between Brachioradialis (BR) & Flexor Carpi Radialis;

The superficial branch of the radial nerve lies along the undersuface of the BR. It is protected by lateral retraction of BR.

Periosteum elevated

The periosteum was elevated to expose the fracture site over the radius

Currettage of the fracture end

Soft tissue was curretted off the fracture end.

Fracture reduced

The fracture was reduced using Kern bone holding forcep

Anatomical reduction

Perfect anatomical reduction achieved.

Plate insertion

Six hole 3.5 mm dynamic compression plate was used to hold the reduced fracture.

Drilling

Screw holes were drilled with 2.7 mm drill bit to accommodate 3.5 mm screw

Skin closure

Drain was inserted and the skin was closed.

Ulna fracture

Ulna fracture was approached dorsally due to its subcutaneous location.

Reduction of ulna fracture

The ulna fracture was reduced easily using Kern bone holding forcep.

Plating of Ulna fracture

The fracture was plated with a 6 hole 1/3 tubular plate.

Post-op X-ray

The post-op x-ray showed plates and screws in-situ over the radius and ulna. The fracture reduction was acceptable with maintenance of the radial height and palmar inclination of the radius.

Discussion

These fractures are relatively more common in children than adults because of differences in diaphyseal bone mechanics. Because of this, both bone forearm fractures in adults are more likely to be high energy open fractures than those seen in children.

Traditionally, both bone forearm fractures in children are treated closed much more often than both bone forearm fractures in adults.

In general, complications are more common and prognosis is worse for displaced fractures and for open fractures.

On the average, nondisplaced fractures take six to eight weeks to heal, and displaced fractures take three to five months.

Satisfactory functional end results may be expected in about eight out of ten patients with nondisplaced fractures and about one half of those with displaced fractures.

Function may be most obviously affected with loss of pronation / supination, and as many as half of patients with both bone forearm fractures will have obvious loss of forearm pronation, which may or may not be functionally significant.

Loss of forearm rotation is most likely when fractures occur in the middle third of the forearm.

Early protected motion appears to improve the odds of satisfactory final motion.

Synostosis between the radius and ulna is much more common in proximal than in distal forearm fractures, occurring in about one out of fifteen patients with proximal fractures.

Synostosis is also more likely in children, with open fractures, with single incision access to both to and forearm bones, and following high energy injuries.

Nonunion occurs in as many as one out of ten patients.

Postsurgical infection may occur in as many as one out of twenty patients.

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