Fracture of the Radius and Ulna
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.
No dislocation of proximal or distal radioulnar joint.
Lateral view of right forearm
Rule of forearm fracture:
They either fracture together (both radius and ulna)
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.
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)
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)
Closed manipulative reduction (CMR)
Preoperative assessment and preparation
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)
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
The superficial branch of the radial nerve lies along the undersuface of the BR. It is protected by lateral retraction of BR.
Currettage of the fracture end
Reduction of ulna fracture
Plating of Ulna fracture
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.