MANAGEMENT OF FOREARM

FRACTURES

DR.M.S.GOUDPROFESSOR

DEP.OF ORTHOPAEDICSA.P.GENERAL &CHEST HOSPITAL

HYDERABAD

• Forearm represents a “critical anatomic unit” of upper limb,permits the hand , the effector organ of upper limb to be placed in any position to either group or support an object.

• It maintains a stable link between elbow and wrist serving as an organ for the many muscles that insert on the hand

• Radius rotates on ulna , stability depends on radioulnar joint proximally and distally and in the middle by interosseous membrane.

• Rotation of fore arm is an important evolution among hominids.

INTRODUCTION

OSTEOLOGY• THE FIVE JOINTS ULNOHUMERAL

,RADIO HUMERAL ,PROXIMAL RADIOULNAR , DISTAL RADIOULNAR ,AND RADIO CARPAL CONSTITUTE A DELICATELY ARRANGED MECHANISM WITH MUSCLES NERVES AND VESSELS FORM FOREARM

• THE ULNA ,RELATIVELY STRAIGHT,HAS STABLE ARTICULATION WITH DISTAL HUMERUS AT ELBOW RUNS SUBCUTANEOUSLY TO ULNAR STYLOID

• THE RADIUS , BOWED ALONG

ITS LENGTH WIDENED DISTAL END ARTICULATES TO CARPUS,TO JUST DISTAL TO BICEPETAL TUBEROSITY

• THE STRUT LIKE RADIUS SWEEPS AND ROTATES AROUND THE RELATIVELY FIXED ULNA WITH MOTIONS OF PRONATION AND SUPINATION

DEFORMING FORCES AFTER FORE ARM FRACTURES

The biceps and supinator muscles through their insertions exert rotational forces on fracture s of the proximal third of radius. Distally tha pronator teres inserting on the mid shaft and the pronator quadratus exert rotational and angulatory forces.

•Isolated fractures of ulna in its proximal third are angulated towards radius and are difficult to reduce•Fractures of distal radius are angulated towards ulna because of pull of long forearm muscles and pronator quadratus.

STABILITY OF THE FOREARM•Antero posterior view of radius and ulna with forearm in full supination has double curvature of each bone in this plane,even minor alterations in this curvature can interfere with fore arm rotation.

•Radio ulnar association is maintained by 3 groups of soft tissue structures annular and quadrate ligament proximally ,the interosseous membrane portion ,TFCC distally .

•Viewing laterally the ulna has posterior bow where as radius again has double curvature.

CLASSIFICATIONFOR DESCRIPTIVE PURPOSE DIVEIDED IN TO #

OLECRANON ,

#RADIAL HEAD,# BOTH BONE FOREARM,#DISTAL END

OF RADIUSALONG WITH THERE

ARE TWO COMPLEX INJURIES NAMELY MONTEGGIA

AND GALAZZI

PERFECT ALIGNMENT AND MAINTAING THE LENGTH

OF BONE IS KEY FOR SUCCESS

POP IMMOBILISATION FOR 6 WEEKS AFTER INJURY

HELPS IN HEALING LIGAMENTS

INJURY AT RADIO ULNAR JOINT

PLATE FIXATION IS IDEAL

MONTEGGIA #

GALAZZI #

CLASSIFICATIONAO CLASSIFICATION

BONE =RADIUS AND ULNA=2

SEGMENT =DIAPHYSEAL=2TYPES:A:SIMPLE FRACTUREB:WEDGE FRACTUREC:COMPLEX FRACTURE

Groups:A1:simple # of ulna,radiusIntactA2:simple# radius,ulna IntactA3:simple # both bonesB1:wedge #ulna, radius intactB2: wedge # radius,ulna intactB3:wedge# of one bone/simple Or wedge# of other boneC1:complex # ulnaC2:complex# radiusC3:complex # both bones

BADO PROPOESD A CLASSIFICATION OFMONTEGGIA FRACTURES BASED ON DIRECTION AND DISPALCEMENT OF RADIALHEAD AND ANGULATION ATFRACTURE

TYPE 1:ANTERIOR ANGULATED ULNA ASSOCIATED WITH ANTERIOR DISLOCATION OFRADIAL HEAD

TYPE 2: POSTRIOR ANGULATED FRACTURE WITH POSTERIOR DISLOCATION OF RADIAL HEAD

TYPE 3:FRACTURE ULNAR METAPHYSIS WITH ANT./LAT DISLOCATION OF RADIAL HEAD

TYPE 4:FRACTURE OF PROXIMAL 3RD RADIUS AND ULNA WITH DISLOCATION OF RADIAL HEAD

ESSEX LOPRESTI LESION

ESSEX LOPRESTI LESION REFERS TO LONGITUDINAL DISRUPTION OF RADIOULNAR INTEROOSUES MEMBRANE AND PROXIMAL MIGRATION OF THE RADIUSASSOCIATED WITH FRACTURES INVOLVING THE PROXIMAL RADIO ULNAR JOINT,THE DISTAL RADIO ULNAR JOINT OR BOTH SITES

MODE OF INJURY :OF THE MANY MECHANISMS OF INJURY THAT CAUSE FRACTURES OF RADIUS AND ULNA , A DIRECTBLOW IS MOST COMMON-> FREQUANTLY ASSOCIATED WITH R.T.A S->FALL ON OUT STRETCHED HAND->OTHER DIRECT BLOWS MAY CAUSE NIGHT STICK FRACTURES ->BLAST INJURIES AND GUN SHOT INJURIES

ASSESMENT :

EXTENSION OF HAND AND FINGERS(RADIAL NERVE)

MAKING A O.K{KILOH _NEVIN SIGN}(MEDIAN NERVE)

MAKING A FIST(MEDIAN AND ULNAR NERVE)

EXTENSION OF INTERPHALANGEAL JOINTS OF THUMB(POST.INTERROSSEOUS NERVE)FLEXION OF INTER PHALANGEAL JOINTS OF THUMB(ANT. INTEROSSOUS NERVE

ASSESMENT OF BONY INJURY ,BLOOD SUPPLY AND NERVE INJURY TO BE ONECHECK WETHER INTEROSSEUS MEMBRANE IS TORN OR NOTCHECK WETHER ANY RADIO ULNAR JOINT DISRUPTION(ABNORMAL TENDERNESS OVER THE JOINT IS A CLUE)

RATIONALE FOR TREATMENT

•10 DEGREES OF ANGULATION OF ONE OR BOTH BONES RESULTED IN LOSS OF ROM 20 DEGREE PRONATION AND SUPINATION•WITH 20 DEGREE OF ANGULATION SIGNIFICANT RESTRICTION IN PASSIVE ROTATION IS OBSERVEDSIGNIFICANTLY GREATER LOSS OF ROM IN M/3 DEFORMITIES THAN WITH DISTAL 3RD DEFORMITIS,MORE SUPINATION IS BEING LOST THAN PRONATION

PLATE OSTEOSYN

THESIS

INTRA MEDULLA

RY NAILING

NONOPERATIV

E TREATME

NT

NO CONTROL OF FRACTURE FRAGMENTSHIGH RATE OF SECONDARY DISPLACEMENTSUNCERTAIN TIME TO UNION POOR FUNCTIONAL RESULTS

POOR CONTROL OF FRACTURE FRAGMENTSANATOMICAL RE ALIGNMENT IS DIFFICULT MORE DIFFICULT TO EXPLORE NEURO VASCULARSTRUCTURESHIGH RATE OF NON UNION

EXCELLENT CONTROL OF FRACTURE FRAGMENTSPERFECT ANATOMICAL REALIGNMENT IS POSSIBLEPOSSIBILITY OF TREATING CONCOMITANT INJURIESCAN EXPLORE NEUROVASCULAR STRUCTURESVERY LOW RATE OF NON UNIONEXCELLENT FUNCTIONAL RESULTS

TREATMENT OPTIONS:

NON OPERATIVE TREATMENT

INDICATIONS OF NON OPERATIVE TREATMENT

•ISOLATED UN DISPLACED FRACTURES OF THE ULNA

•POOR GENERAL CONDITION

SURGICAL APPROCHES

FOUR BASIC EXPOSURES RECOMMENDED:

1. STRAIGHT ULNAR APPROACH TO ULNAR SHAFT

2.VOLAR ANTECUBITAL APPROACH TO PROXIMAL RADIUS

3.DORSOLATERAL APPROACH TO RADIAL SHAFT FROM RADIAL HEAD TO DISTAL QUARTER OF THE SHAFT

4.PALMAR APPROACH TO DISTAL 3RD RADIUS

ANTERIOR (HENRY APPROACH) TO RADIUS

INCISION FROM LATERAL SIDE OF BICEPS DOWN TO RADIAL STYLOIDINTERNERVOUS

PLANE OF BARCHIORADIALIS(R.N.)FLEXOR CARPI RADIALIS(M.N.)

POSITION

APPROACH FOR ULNA(SUBCUTANEOUS)

POSITION MAKING A LONGITUDINAL INCISIONON SUB CUTANEOUS BORDEROF ULNA

INTERNERVOUS PLANE BETWEEN EXT.CARPI ULNARIS(P.I.N.) AND FLEX. CARPI.ULNARIS(U.N.)

POSTERIOR APPROACH TO THE RADIUS(THOMSON)

POSITIONINCISION FROM JUST ANT. TO LATERAL EPICONDYLE OF HUMERUS TO JUST DISTAL TO ULNAR SIDE OF LISTERS TUBERCLE AT WRISTINTERNERVOUS PLANE OF EXT. CARPI RADIALIS BREVIS(R.N)EXT.DIGIT.COMMUNIS(P.I.N.)

NAILING VS PLATING

INTRA MEDULLARY NAILS ARE NOT AS STRONG AND DO NOT MAINTAIN FORE ARM AS WELL AS PLATE OSTEOSYNTHESIS.

MORE OVER THE USE OF INTRAMEDULLARY NAILSIS LIMITED BY THE CONFIGURATION OF THE FRACTURE AND THE PRESENCE AND SEVERITY OF ASSSOCIATED INJURIES

SELECTION OF CORRECT LENGTH AND DIAMETER OF THE NAIL WITH REFERRENCE TO THE CONFIGURATION OF THE FRACTURE IS CRITICAL.

THE ANATOMIC REDUCTION CANNOT BE AS ACCURAE AS ACHIEVED WITH PLATING

WE DO NOT ADVOCATE ITS USE IN DISPLACED AND UNSTABLE FORE ARM FRACTURES IN ADULTS.

PLATINGFIXATION WITH A STANDARD LENGTH COMPRESSION PLATE AND FOUR

CORTICES ON EITHER SIDE OF THE FRACTURE SEEMS TO BE STABLE CONSTRUCT

FOR DIAPHYSEAL FRACTURES.

A RETROSPECTIVE STUDY IN 78 FRACTURED BONES PLATED USING MINIMAL

SCREW TECHNIQUE USING LESS THAN SIX SCREWS SHOWS THAT UNION RATE OF

91% AND ALL NON UNIONS WERE ATROPHIC OCCURRED IN OPEN FRACTURES

WITH BONE LOSS.

IN GENERAL , USE 3.5 MM DYNAMIC COMPRESSION PLATES WITH

3.5 MMCORTICAL SCREWS WITH 1.25 PITCH THREADS

TIMING OF PLATE REMOVAL

:->HIGH RATE OF REFRACTURE AFTER PLATE REMOVAL 4% TO 25% IN VARIOUS STUDIES->THE BONE SHOULD BE ALLOWED TO REMODEL BEFORE THE PLATE IS REMOVED->IT HAS BEEN SUGGETED THAT PLATING REMOVAL @ 21 MONTHS->IT HAS BEEN SUGGESTED THAT REMODELLING TAKES AFTER 21 MONTHS TO COMPLETE->DO NOT ADVOCATE ROUTINE PLATE REMOVAL IN ASYMPTOMATIC PATIENTS

OPERATIVE TREATMENT/INTRAMEDULLARY NAILING

1. SAGE F.P. DEVISED TRIANGULAR INTRA MEDULARY NAILS

2. NON UNION OCCURRED IN 6.2 % OF PTS WITH DELAYED UNION IN 4.1%

3. HIGH INCIDENCE OF MAL UNION AND POOR FUNCTION

4. IN THOSE FRACTURES THAT UNITED

INTRA MEDULLARY NAILING(STATICK LOCKING NAIL)

ZENAR ET AL REPORTED UNION RATES ARE 93% AND 97% IN A TOTAL OF 339 #SCRENSHAW STATON REPORTED 100% UNION IN 37 % FRACTURESTHE AVERAGE TIME TO FRACTURE UNION WAS 14 WEEKSADVANTAGES OF I.L NAIL SYSTEM ARE TECHNICALLY STRAIGHT FORWARD AS IT ALLOWS HIGH RATE OF CONSOLIDATION REQUIRES LESS SURGICAL EXPOSUREAND OPERATIVE TIME THAN PLATE OSTEO SYNTHESIS

INTRA MEDULLARY NAILING

INDICATIONS:

SEGMENTAL FRACTURES

POOR SKIN CONDITIONS (BURNS)

SELECTED NON UNIONS OF FAILED COMPRESSION PLATING

MULTIPLE INJURIES

DIAPHYSEAL FRACTURES IN OSTEOPAENIC PATIENTS

SELECTED TYPE 1 AND TYPE 2 DIAPHYSEAL FRACTURES

MASSIVE COMPOUND INJURIES FOR WHICH NON REAMED ULNAR NAILS CAN BE

USED AS A INTERNAL SPLINT TO MAINTAIN FOREARM LENGTH WHILE EXTESIVE

SOFT TISSUE LOSS IS TREATED

ALMOST ANY DIAPHYSEAL FRACTURE CAN BE REPAIRED WITH INTRA MEDULLARY NAIL

CONTRAINDICATIONS

ACTIVE INFECTION

A MEDULLARY CANAL SMALLER THAN 3MM AN OPEN PHYSIS

OPEN FRACTURES OF FOREARM

Q.WHAT NEEDS TO BE DONE?Q.DEFINATIVE SURGERY EARLY OR LATE?

MANAGEMENT PROTOCOL FOR OPEN FRACTURES

1. PIN AND PLASTER2. EXTERNAL FIXATOR3. ULNAR NAILING-REQUIRING FLAP OR GRAFT4. CAST AND WINDOW-SINGLE BONE COMPOUND #S

•ANDESON ETAL

OPEN FRACTURES OF FOREARM

DUNCAN ETAL REPORTED 90% ACCEPTABLE RESULTS IN 103 GUSTILO TYPE 1 ,TYPE2 ,OR TYPE 3A OPEN FRACURES TREATED IMMEDIATE WITH DEBRIDEMENT AND COMPRESSION PLATING AND SCREW FIXATION

THEIR RESULTS WITH TYPE 3B AND TYPE 3C WERE POOR

TREATMENT OF TYPE 3 INJURIES SHOULD BE INDIVIDUALISED,WITH CONSIDERATION GIVEN TO MECHANISM AND FORCE OF INJURYY,ASSOCIATED INJURIES AND COND’N OF PATIENT BEFORE AND AFTER SURGERY DELAYED INTERNAL FIXATION USING COMPRESSION PLATING IN TYPE 3

COMPLICATIONS

INFECTIONCOMPARTMENT SYNDROMEMALUNIONSTNOSTOSIS /CROSSUNIONNONUNIONNERVE /VESSEL INJURIES

HOW TO DEAL WITH SYNOSTOSIS

1.TREATMENT OF RADIO ULNAR SYNASTOSIS BY RADICAL EXCISION AND INTERPOSITION OF RADIALADIPOFASCIAL FLAP

2.TREATMENT OF SYNOSTOSIS WITH THE USE OF MEDICATION(INDOMETHACIN)OR INTEREPOSITION OF SILICONE,FAT,OR MUSCLE

3.SURGICAL RESECTION WITH ADJUVANT RADIOTHERPAY MAY TRIED

>SYNOSTOSIS MOST COMMON FOLLOWING BOTH BONES FRACTURE AT SAME LEVELPARTICULARLY WHEN PLATE FIXATION PERFORMED HEMATOMA BETWEEN THE BOTH BONES COMMUNICATES.

>MATURATION REQUIRES 12 MONTHS

>ONLY SURGICAL REMOVAL ASSOCIATED WITH RECURRENCE

HOW TO DEAL WITH COMPARTMENTSYNDROME

FOREARM CONTAINS MUSCLE COMPARTMENTS CONSTRAINED BY STONG FASCIA FRACTURE BLEEDS AND RISES THE PRESSURE IN COMPARTMENTVENOUUS RETURN DECREASES MUSCLE ISCHAEMIASWELLINGFURTHER COMPARTMENT SYNDROME

TO DECOMPRESS FLEXOR COMAPRTMENTMAKE A LONGITUDINAL INCIISIONFROM LATERAL SIDE OF ELBOW CREASE TO RADIAL STYLOID PROCESS

CLOSE ONLY SUB CUTANEOUS LAYER AND SKINDO APPLY SPLINT POST OPERATIVELY

THANK YOU