Injuries of the forearm By : Dr.Sanjeev Monteggia Fracture Dislocation. Fracture upper third of ulna with dislocation head of the radius . Mechanism:
More common in children fall on outstretched hands either in hyperpronation or in hyperextension . C / F : - Pain , Swelling, deformity, severe loss of forearm movement. Radiology : AP, lateral.
. Fig : - Classification Type 1 (60%) : anterior dislocation of head of the
radius with fracture ulna at upper third and with anterior angulation. Type 2 (5%) : posterior dislocation head of the radius and fracture proximal ulna with posterior angulation.
Type 3 (20%) : lateral dislocation head of the radius and fracture proximal ulna with lateral angulation. Type 4 (15%) : fracture radius and ulna in their upper one third and anterior dislocation of head of the radius with anterior angulation.
Cont.. Fig : - Type 1: Cont.. Fig : - Type 2 :
Cont.. Fig : - Type 3 Cont.. Fig : Type - 4
Clinical symptoms : Type 1 , Type 2 , Type 3 and Type 4 : Marked pain and tenderness about the elbow No flexion , extension , pronation , and supination. Paralysis of the interosseous nerve may occur.
Clinical signs Type 1 : - HOR felt anteriorly - Anterior angulation Type 2 : - HOR posterior - Posterior angulation of ulna - Shortening of forearm
Type 3 : - HOR is lateral - Lateral angulation Type 4 : - HOR is anterior - Deformity is at the fracture level (HOR = HEAD OF RADIUS)
TREATMENT : In children Type 1 : Closed reduction (if fails) OR of fracture ulna + CR of HOR (if fails) OR of fracture ulna with OR of head of the radius
Type 2 : CR (closed reduction ) OR (open reduction Type 3 : - CR
CONT.. Type 4 : CR (if fails ) OR rigid IF with plate and screws IN ADULTS : (type 1, 2, 3 and 4)
OR + IF of fracture ulna with plate and screws
CR of HOR (if fails) OR ,HOR +IF fracture ulna If fracture more than 6 weeks excision HOR is done. Complications
Posterior interosseous nerve palsy . Radial head instability Nonunion of fracture ulna. Malunion of fracture ulna. Myositis ossificans Galeazzi fracture dislocation
Fracture of the radial shaft at the junction of middle and distal third with associated subluxation or dislocation of the distal radioulnar joint. Reverse Monteggia Also known as fracture of necessity (which requires
ORIF) Forces causing loss of reduction and difficulty in reduction : Insertion of pronator quadratus pulls the
distal fragment in proximal and volar direction Brachioradialis uses the distal radioulnar joint as a pivot and causes shortening Mechanism of injury : . - Direct blow on the dorsolateral side
of the forearm - Fall on an outstretched hand with marked pronation of the forearm . Clinical features :
Deformity of the lower end of the forearm Pronation and supination are severely restricted. Neurovascular injury is rare. Radiological :
AP view : Fracture radius , transverse or short oblique Distal radioulnar joint is dislocated
Radius appears short Lateral view : Radius is angulated dorsally Head of the ulna is prominent dorsally.
CONT.. FIG : AP - VIEW Cont FIG : - LATERAL VIEW
Treatment ORIF(Plate and screw fixation). Distal radio ulnar joint stability..? Yes plaster , No K wire fixation.
Complications Malunion loss of supination/ pronation. (osteotomy). Nonunion bone grafting. Compartment syndrome.
Angulation of the fracture and subluxation of the distal radioulnar joint. Bartons fracture Fracture line extends from the distal articular surface of the radius.
Dislocation or subluxation usually associated. Most are unstable. ORIF. Cont.. Fig : -
Radial styloid fracture Also known as chauffeurs fracture; Hutchinson fracture. Posterior marginal fracture of the radius Avulsion fracture of the radiocarpal ligament
Seen in motorcycle accidients , and fall from heights Cont .. Fig : Radial styloid fracture
Clinical features Pain
Swelling Tenderness over the radial styloid process Movement of the wrist, especially radial deviation , is painful Radiology : AP shows transverse fracture
Treatment Closed reduction and above elbow plaster cast Unstable fractures : percutaneous with K - wire
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