forearm fractures need understanding of principles for ... · forearm fractures need understanding...
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Forearm fractures need understanding of principles for diaphyseal and articular fractures
Andreas Panagopoulos, MD, PhD
Assistant Professor, Patras University Hospital
AOT Basic Principles Course
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Learning outcomes
• Review the concept of the forearm as a “joint”
• Describe the assessment, problems and treatment
options of forearm fractures
• Review the options for surgical approaches
• Discussion complications and outcomes
Understand why it is not “just another shaft fracture”
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Introduction
Common injury
Often high velocity
Soft tissue injury
Significant functional issues
Multiple configurations
Work as functional unit
Never injured in isolation
Never injury one without
affecting the other
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The radial bow and the relations
between the proximal and distal
radio-ulnar joints comprise a
complex 3-dimensional functional
unit.
Even small deformities caused by
fracture malunion can result in
significant functional impairment
Functional unit
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Function: position hand in space
Requires:
Mobility
Stability
Alignment
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Anatomy
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Articulations
Ulno-humeral
Radio-capitellar
Proximal radio-ulnar
Distal radio-ulnar
Radio-carpal
Interosseous membrane
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Extrinsic stabilizers DRUJ
(1) dynamic tensioning of the ECU
(2) semirigid sixth dorsal compartment
(3) pronator quadratus,
(4) interosseous ligament
Intrinsic stabilizers
(1) superficial (green) & deep (blue) radioulna fibers
(2) 2 disc-carpal ligaments (lunate and triquetral)
(3) central articular disc (white).
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DRUJ is a diarthrodial, synovial articulation
It acts as the link between radius and ulna and a pivot for prono-supination.
The ulna is the stable unit of the forearm
90° of forearm supination, at which point the two forearmbones are essentially parallel and the interosseous space widest
90° of pronation, at which point the radius has rotated acrossthe anterior surface of the fixed ulna
Motion
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Muscle forces
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Consequences of injury
Shortening
Angulation
Radial bow loss
Loss of aligment
Loss of relationship
Dysfunction of unit
Disability
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Fracture mechanisms
Axial compression
Bending
Rotation
Direct trauma
Determines
Fracture configuration
Displacement
Soft tissue injury
Associated injuries
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Clinical evaluation
Soft tissue
- Wounds
- Swelling
- Blisters
Neurological
- Careful exam
- Document
Vascular
- Pulses
- Compartment syndrome
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Radiographic evaluation
Full length AP & lateral
- elbow
- wrist
Ct scan
- selected articular fractures
MRI
- ligament injury
Angiography
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Classification
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Monteggia type
Ulnar shaft fracture with
dislocated radial head
Types I-IV depending on
direction of radial head
dislocation fracture
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Monteggia type
Line drawn through radial
head and shaft should line up
with capitellum in all views
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Galleazzi type
Radial shaft fracture with
dislocated distal ulna
Multiple variant in location
of radius fracture
Can be very subtle
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Signs of DRJU Injury
ulnar styloid fx
widening of joint on AP view
dorsal or volar displacement (lateral view)
radial shortening (≥5mm)
if radial fracture is <7.5 cm from articular surface unstable in 55%
if radial fracture is >7.5 cm from articular surface unstable in 6%
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Personality of fracture
Soft tissue damage
Fracture displacement
Osteoporosis
Comminution
Joint involvement
Neuro/vascular injury
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Goals of treatment
Restore
- relative length
- rotation
- radial bow
Reduce joints
- stabilize if needed
Repair soft tissues
Stabilize the fracture
- absolute or relative
Early functional movement
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Conservative treatment?
3 weeks 12 weeks
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Surgical indications
All unstable bone fractures
Displaced isolated fractures
- 10 degrees of angulation
- 50% of displacement
Monteggia and Galeazzi
Every open fracture
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Preoperative decisions
Timing of surgery?
Surgical approach
- Henry (palmar)
- Thompson (dorsolateral)
- Boyd (proximal ulna)
Ulna/radius first?
Type of reduction
Type of fixation
Bone graft?
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Timing of surgery
Splint and elective surgery for simple
closed displaced fractures
- Reasonable alignment
- Joints reduced
Immediate fixation for:
- open fractures
- impending open fractures
- compartment syndrome
- unreducible dislocations
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ApproachesThompson Henry
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Articular
Anatomic reduction
- open
Interfragmentary compression
Stable fixation
Diaphyseal
Realigment
- length & rotation
Bridge plating
Relative stability
Characteristics
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Reduction/fixation
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Reduced “simpler” fracture
Provisional fixation:
- clamps
- plate with few screws
Reduce more complex fracture
- provisional fixation
Confirm alignment/rotation
Definite fixation
Surgical tactics
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The gold standard treatment for
more diaphyseal forearm fractures
Stable, strong anatomical fixation
Union rates more than 95%
Plate fixation
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Postoperative care
Temporary splinting
Avid prolonged immobilization
- if you fix internally, do not fix it externally
Immobilize the minimum time needed to
protect soft tissues
- Dislocations or instability may require more time of
immoblzation
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Complications
nonunion 2-4%
Infection 1-2%
Hardware irritation
Synostosis
Malunion
Compartment syndrome
Refracture
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Intramedullary fixation
Relative indications
Children
Single fractures
Bad soft tissues
Pathologic fracture
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Take-home messages
Complete understanding of injury
Understand functional unit
Both bony and soft injuries must be addresses
Combination of articular & diaphyseal principles
ORIF with plates is standard