Fracture of Forearm Bones
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This document discusses fractures of the forearm and wrist. It begins by describing olecranon fractures, classifying them based on displacement and stability. It notes that undisplaced fractures are treated nonoperatively while displaced fractures require operative fixation. Radial head and neck fractures as well as fractures of the radius and ulna shaft are also discussed. Distal radius fractures are classified using the AO system and treatment may involve closed or open reduction. Specific fractures of the wrist like scaphoid and Bennett fractures are outlined along with treatment principles for metacarpal and phalangeal injuries. Overall, the summary provides an overview of different forearm, wrist and hand fractures and guidelines for nonoperative and operative management.
Fracture of Forearm Bones
- 1. Fractures of forearm bones
- 2. anatomy
- 3. Elbow joint
- 6. CLASSIFICATION(The Mayo classification of olecranon fractures) • Type I fractures are nondisplaced or minimally displaced and are subclassified as either noncomminuted (type 1A) or comminuted (type 1B). Treatment is nonoperative. • Type II fractures have displacement of the proximal fragment without elbow instability; these fractures require operative treatment. – Type IIA fractures, which are noncomminuted, can be treated by tension band wire fixation. – Type IIB fractures are comminuted and require plate fixation. • Type III fractures feature instability of the ulnohumeral joint and require surgical treatment
- 8. Mechanism of Injury • Direct: A fall on the point of the elbow or direct trauma to the olecranon typically results in a comminuted olecranon fracture. • Indirect: A fall on to the outstretched upper extremity accompanied by a strong, sudden contraction of the triceps typically results in a transverse or oblique fracture. • A combination of these may produce displaced, comminuted fractures, or, in cases of extreme violence, fracture-dislocation with anterior displacement of the distal ulnar fragment and radial head
- 10. Examination • The patient will present with a painful swelling over the olecranon and a hemorrhagic effusion. The patient will be unable to actively extend the forearm against gravity or resistance due to the inadequacy of the triceps mechanism. It is of critical importance that the initial examination includes documentation of ulnar nerve function. It is not uncommon for comminuted fractures to result in compromise of ulnar nerve function
- 11. TREATMENT OBJECTIVES • Restoration of the articular surface • Restoration and preservation of the elbow extensor mechanism • Restoration of elbow motion and prevention of stiffness • Prevention of complications
- 12. Nondisplaced • Nondisplaced fractures are those fractures with <2 mm of separation or articular incongruity. Treatment begins with immobilization in a long-arm splint with the elbow flexed at 50В° to 90В° and the forearm in a neutral position. A cast is used for definitive management, and should be well molded posteriorly and supported with a collar and cuff. Finger and shoulder range of motion exercises should be started as soon as possible with repeat radiographs obtained in 5 to 7 days to exclude displacement. Union is complete in 6 to 8 weeks, but the cast may be removed by the orthopedist as early as 1 week in adults to avoid chronic stiffness.
- 13. Displaced • Displaced fractures of the olecranon include those with displacement of a transverse fracture, a comminuted fracture, an avulsion fracture, or an epiphyseal fracture. These fractures are intraarticular and necessitate anatomic reduction through operative fixation
- 18. COMPLICATIONS • Implant symptoms occur in 22% to 80% of patients. – From 34% to 66% require implant removal. • Implant failure occurs in 1% to 5%. • Infection occurs in 0% to 6%. • Pin migration occurs in 15%. • Ulnar neuritis occurs in 2% to 12%. • Heterotopic ossification occurs in 2% to 13%. • Nonunion occurs in 5%. • Decreased range of motion: This may complicate up to 50% of cases, particularly loss of elbow extension, although most patients note little if any functional limitation
- 19. Radial Head and Neck Fractures
- 20. Mechanism of Injury • The most common mechanism is a fall on the outstretched hand (indirect) • It is frequently associated with injury to the ligamentous structures of the elbow. • It is less commonly associated with fracture of the capitellum
- 22. Examination • Tenderness will be present over the radial head with swelling secondary to a hemarthrosis. Pain is exacerbated by supination and associated with reduced mobility • Wrist pain associated with a fracture of the radial head suggests disruption of the distal radioulnar joint and the radioulnar interosseous membrane
- 23. Examination
- 24. Imaging • Visualization of radial head and neck fractures often requires oblique views. Impact fractures of the neck are best seen on the lateral projection. If a radial head fracture is suspected, but not seen, additional views in varying degrees of radial rotation should be obtained
- 25. Visualization of radial head and neck fractures
- 26. oblique views
- 27. CLASSIFICATION • Type I:Nondisplaced fractures • Type II:Marginal fractures with displacement (impaction, depression, angulation) • Type III:Comminuted fractures involving the entire head • Type IV:Associated with dislocation of the elbow (Johnston)
- 28. CLASSIFICATION
- 29. CLASSIFICATION • Type I small marginal fractures(<2 mm displacements) • Type II includes two part fracture(>2mm displacements) • Type III Highly comminuted fractures
- 30. Treatment
- 31. Nondisplaced • Marginal radial head fractures with displacement of <2 mm (marginal fractures or minimal depression fractures) are treated with a sling or a long-arm posterior splint. If splinted, the splint should remain in place for no more than 3 to 4 days. Early motion exercises are recommended if they can be tolerated (pain).
- 33. Displaced • When there is displacement or depression of >2 mm with over one-third of the articular surface involved, operative treatment is required
- 36. Radius and Ulna Shaft • The forearm is a very complex part of the apper limb.The forearm consists of 2 bones(ulna,radia).The length of these two bones are practically indentical.The neurovascular structures dispose next to musculs,fascie and bone of the forearm. If one bone has a fracture another bone is blocked,when a patient has a fracture both these bones,the displacement can be major becausу of different direction of muscul tractions.After the fracture a patient often has some very difficalt neurovascular injuries.
- 37. Mechanism of Injury • These are most commonly associated with motor vehicle accidents, although they are also commonly caused by direct trauma , gunshot wounds, and falls either from a height or during athletic competition. • Pathologic fractures are uncommon
- 39. Clinical Evaluation • Patients typically present with gross deformity of the involved forearm, pain, swelling, and loss of hand and forearm function. • A careful neurovascular examination is essential, with assessment of radial and ulnar pulses, as well as median, radial, and ulnar nerve function. • One must carefully assess open wounds because the ulna border is subcutaneous, and even superficial wounds can expose the bone
- 40. Classification
- 41. Classification
- 42. Nonoperative • There are, nondisplaced fracture of both the radius and the ulna may be treated with a well-molded, long arm cast in neutral rotation with the elbow flexed to 90 degrees
- 44. Operative • Principles of plate fixation: – Restore ulnar and radial length (prevents subluxation of either the proximal or distal radioulnar joint). – Restore rotational alignment. – Restore radial bow (essential for rotational function of the forearm).
- 50. Treatment
- 52. Distal Radius Fractures -AO Comprehensive Classification -Biomechanics of a Colles‘(Smith's) fracture -NONOPERATIVE TREATMENT -SURGICAL MANAGEMENT
- 53. Anatomy of the wrist and hand
- 64. COMPLICATIONS • Persistent deformity or malunion • Sudek’s atrophy(syndrome) • Carpal tunnel(median nerve compression) • Persisting stiffness • Associated scaphoid fracture
- 65. Wrist
- 66. SPECIFIC FRACTURES Scaphoid • Fractures of the scaphoid are common and account for about 50% to 80% of carpal injuries • The most common mechanism is a fall on to the outstretched hand that imposes a force of dorsiflexion, ulnar deviation, and intercarpal supination
- 67. Types of scaphoid fractures • Patients present with wrist pain and swelling, with tenderness to palpation overlying the scaphoid in the anatomic snuffbox
- 68. Classification • Based on displacement • Stable: nondisplaced fractures with no step-off in any plane • Unstable: displacement with 1 mm or more step-off scapholunate angulation >60 degrees or radiolunate angulation >15 degrees
- 69. Classification • Based on location • Tuberosity: 17% to 20% • Distal pole: 10% to 12% • Waist: 66% to 70% – Horizontal oblique: 13% to 14% – Vertical oblique: 8% to 9% – Transverse: 45% to 48% • Proximal pole: 5% to 7%
- 70. Treatment • Indications for nonoperative treatment • Nondisplaced distal third fracture • Tuberosity fractures Operative treatment • Indications for surgery – Fracture displacement >1 mm – Radiolunate angle >15 degrees – Scapholunate angle >60 degrees
- 72. General indications for surgery include • Open fractures. • Unstable fractures. • Irreducible fractures. • Multiple fractures. • Fractures with bone loss. • Fractures with tendon lacerations
- 73. Metacarpal and phalangeal fractures are common, comprising 10% of all fractures • Location: • Distal phalanx (45%) • Metacarpal (30%) • Proximal phalanx (15%) • Middle phalanx (10%)
- 74. Metacarpal and phalangeal injuries • “Boxer's fracture” • Bennett fracture • Phalanges fracture
- 75. General principles of initial fracture management • Careful assessment History Physical examination Skeletal examination Stability testing Skin examination Vascular examination Neurologic examination Tendon examination Radiographs Immobilization Pain management
- 76. Clear descriptors for metacarpal and phalangeal fractures • Nondisplaced • Stable • Reducible • Extraarticular • Simple • Closed • Displaced • Unstable • Irreducible • Intraarticular • Comminuted • Open
- 77. Bennett fracture • Bennett fracture: fracture line separates major part of metacarpal from volar lip fragment, producing a disruption of the first carpometacarpal (CMC) joint; first metacarpal is pulled proximally by the abductor pollicis longus
- 78. Displacement of Bennett fractures
- 83. Metacarpal and phalangeal injuries (Operative treatment)