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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
FRACTURES OF THE RADIUS AND ULNA
Mechanism of injury and pathology
Fractures of the shafts of both forearm bones occur quite commonly.
A twisting force (usually a fall on the hand) produces a spiral fracture with the bones
broken at different levels.
An angulating force causes a transverse fracture of both bones at the same level.
A direct blow causes a transverse fracture of just one bone, usually the ulna.
Additional rotation deformity may be produced by the pull of muscles attached to the
radius: they are the biceps and supinator muscles to the upper third, the pronator teres to
the middle third, and the pronator quadratus to the lower third.
Bleeding and swelling of the muscle compartments of the forearm may cause circulatory
impairment.
Clinical features
The fracture is usually quite obvious, but the pulse must be felt and the hand examined
for circulatory or neural deficit.
Repeated examination is necessary in order to detect an impending compartment
syndrome.
X-RAY
Both bones are broken, either transversely and at the same level or obliquely with the
radial fracture usually at a higher level.
In children, the fracture is often incomplete (greenstick) and only angulated.
In adults, displacement may occur in any direction – shift, overlap, tilt or twist.
In low-energy injuries, the fracture tends to be transverse or oblique; in high-energy
injuries it is comminuted or segmental.
Treatment
CHILDREN
In children, closed treatment is usually successful because the tough periosteum tends
to guide and then control the reduction.
The fragments are held in a well-moulded full-length cast, from axilla to metacarpal
shafts (to control rotation).
The cast is applied with the elbow at 90 degrees.
If the fracture is proximal to pronator teres, the forearm is supinated; if it is distal to
pronator teres, then the forearm is held in neutral.
The position is checked by x-ray after a week and, if it is satisfactory, splintage is
retained until both fractures are united (usually 6–8 weeks).
Throughout this period hand and shoulder exercises are encouraged.
The child should avoid contact sports for a few weeks to prevent re-fracture.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Occasionally an operation is required, either if the fracture cannot be reduced
or if the fragments are unstable.
Fixation with intramedullary rods is preferred.
Alternatively, a plate or K-wire fixation can be used.
Childhood fractures usually remodel well, but not if there is any rotational deformity
or an angular deformity of more than 15 degrees in children under 6 years or 10
degrees in children between 6 and 12. Inthose over 12 years old even slight angular
deformities are unlikely to remodel satisfactorily.
ADULTS
Unless the fragments are in close apposition, reduction is difficult and re-displacement in
the cast almost invariable.
So predictable is this outcome that most surgeons opt for open reduction and internal
fixation from the outset.
The fragments are held by interfragmentery compression with plates and screws.
Bone grafting is advisable if there is comminution.
The deep fascia is left open to prevent a build-up of pressure in the muscle compartments,
and only the skin is sutured.
After the operation the arm is kept elevated until the swelling subsides, and during this
period active exercises of the hand are encouraged.
If the fracture is not comminuted and the patient is reliable, early range of movement
exercises are commenced but lifting and sports are avoided.
It takes 8–12 weeks for the bones to unite.
With comminuted fractures or unreliable patients, immobilization in plaster is safer.
OPEN FRACTURES
Open fractures of the forearm must be managed meticulously.
Antibiotics and tetanus prophylaxis are given as soon as possible; the wounds are
copiously washed and nerve function and circulation are checked.
At operation the wounds are excised and extended and the bone ends are exposed and
thoroughly cleaned.
The fractures are primarily fixed with compression screws and plates; if the wounds are
absolutely clean, the soft tissues can be closed.
If bone grafting is necessary, this is best deferred until the wounds are healed.
If there is major soft-tissue loss, the bones are better stabilized by external fixation.
The aim is to obtain skin cover as soon as possible; if plastic surgery services are
available, these should be enlisted from the outset.
If there is any question of a compartment syndrome, the wounds should be left open and
closed 24–48 hours later, with a skin graft if needed.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
Complications
EARLY
o Nerve injury Nerve injuries are rarely caused by the fracture, but they may be
caused by the surgeon!
Exposure of the radius in its proximal third risks damage
to the posterior interosseous nerve where it is covered by the superficial part of
the supinator muscle.Surgical technique is particularly important here; the anterior
Henry approach is safest.
o Vascular injury Injury to the radial or ulnar artery seldom presents any problem,
as the collateral circulation is excellent.
o Compartment syndrome Fractures (and operations) of the forearm bones are
always associated with swelling of the soft tissues, with the attendant risk of a
compartment syndrome. The threat is even greater, and the diagnosis more
difficult, if the forearm is wrapped up in plaster. A distal pulse does not exclude
compartment syndrome!
o
The byword is ‘watchfulness’; if there are any signs of circulatory embarrassment,
treatment must be prompt and uncompromising.
LATE
o Delayed union and non-union: Most fractures of the radius and ulna heal within 8–
12 weeks; high energy fractures and open fractures are less likely to unite. Delayed
union of one or other bone (usually the ulna) is not uncommon; immobilization may
have to be continued beyond the usual time. Non-union will require bone grafting and
internal fixation.
o Malunion With closed reduction there is always a risk of malunion, resulting in
angulation or rotational deformity of the forearm.
o Cross-union of the fragments, or shortening of one of the bones and disruption of the
distal radio-ulnar joint.
o Complications of plate removal Removal of plates and screws is often regarded as a
fairly innocuous procedure. Beware! Complications are common and they include
damage to vessels and nerves, infection and fracture through a screw-hole.
THANK YOU
DR.JAMAL AL-SAIDY
M.B.CH.B..…… F.I.C.M.S