Fracture of radius and ulna

Dr. Ghadeer Hikmat

 Fracture of radius and ulna
• Age:
 common in children & adult.
• Mechanism;
 either direct producing fracture at the same
level or
indirect causing fractures at different levels.
• Deformity:
 displacement in the forearm comes
from the fact that the muscles attached
to the radius will act as deforming force
because the supinator is attached to the
proximal 1/3 , pronator teres to
middle 1/3 & pronator quadratus to the
lower 1/3.
• clinical features:
pain, swelling, deformity , loss of function.

• Note:
The bleeding& swelling in the forearm can
cause compartment syndrome because of
tight fascia.
 Compartement syndrome:
• Fracture of forearm can give rise to pressure
ischemia even if there's no damage to blood
vessels.
• bleeding, edema or inflammation increase the
pressure within the osteofascial compartment
with reduced capillary blood flow which leads to
muscle ischemia that after few hours leads to
necrosis of muscles or nerves within the
compartment.
• The nerve is capable of regeneration but the
muscle once infarcted is replaced by inelastic
fibrous tissue (VolKmann's ischemic contracture).
The classical features of ischemia are five Ps:
1- pain,
2- pallor,
3- paralysis,
4- pulselessness,
5- parasthesia.
• The earliest feature is pain especially on
hyperextension of fingers,
• next altered sensibility,
• & the presence of pulse does not exclude the
diagnosis.
• In doubtful cases diagnosis is made by
measuring the intra-compartment pressure.
• Clinicaly in case of suspicion we should remove
the cast bandage or any dressing & Keep the
limb elevated.
• if no improvement is obtained in 1-2. hours we
do fasciotomy to decompress the forearm.
• x-ray:Ap & lateral we always take one joint above
& one joint below.
• The fracture pattern can be transverse, spiral,
oblique or comminuted.
Treatment of ulna and radius fracture
• A) children:
l. Undisplaced: above elbow POP to the wrist,
elbow is flexed in 90°, the forearm is supinated for
upper 1/3rd fracture; neutral rotation for middle
1/3rd fracture &- pronated for lower l/3rd fracture.
2. Displaced: MUA; the tough periosteum will
help align the fracture.
3, If it couldn't be reduced or maintained reduced
then we do ORIF & the cast is Kept for 6-8 weeks
with regular X-ray check up.
• B)Adults:
I. Perfect reduction is vital otherwise it ends with limited
rotation of forearm.
2. If undisplaced: we apply above elbow cast to the wrist
& the elbow & the forearm are in the positions previously
mentioned. Time of healing in adults is about 12 weeks.
3. If displaced: ORIF with rush nail, plate & screws or
external fixator for compound fracture.
• Complications:
Delayed union, non-union malunion &-compartment
syndrome.
Fractures of Single Forearm Bone:
• It is uncommon, usually caused by a direct trauma
producing fracture of one bone.
• Clinical features: PST.
• X-Pay: AP lateral should include one joint below
& one above to exclude fellow bone fracture or
dislocation.
• Treatment:
• fractured ulna usually undisplaced & can be
treated by casting for 8 weeks but if displaced then
surgical fixation is needed.
• Fractured radius usually displaced by rotation
because of deforming force of muscle
attachment so surgical fixation is needed but if it
is undisplaced then conservative treatment is
needed.
Monteggia Fracture –Dislocation of Ulna
• This is fracture of ulna with dislocation of radio
-capitellar joint.
• Types:
1- Anterior (extension) type: head of radius dislocates
anteriorly & a pex. of angulation of ulnar fracture is
anterior.
2- Posterior (flexion) type: head of radius dislocates
posteriorly & the apex of angulation of fractured ulna is
posterior.
3- Lateral: head of radius dislocates laterally & apex of
angulation of ulnar fracture is laterally.
• Clinical Features: PSDTLf
• X-Ray: AP & lateral of forearm.
• Treatment:
• Restoration of full length of ulna leads to
spontaneous stable reduction of radius head.
• This is achieved by open reduction & IF.
• If there's bone loss we put bone graft to restore full
length.
• This is followed by X-ray check to ensure the
reduction of radial head & put a back slab for 4-6
weeks.
• In children because of tough periosteum there's
incomplete break of ulna that can be reduced by
MUA then slab in supination & elbow is flexed in
90° for 3 weeks.
• If it's displaced in a way that can't be reduced by
closed method perfectly then treated like adult
by ORIF.
• Complications:
• Malunion: the head of radius stays out & limits
rotation.
• Non-union: ORIF with bone graft plus OR. of
head of radius dislocation, or in neglected long
standing cases by fixation of ulna & excision of
head of radius; this is done only in adults.

 Never excise radial head in child.

Galeazzi Fracture-Dslocation of Radius
• Mechanism: fall on an outstretched hand with rotation,
• it is a transverse or oblique fracture of lower 1/3 of
radius with
• subluxation or dislocation of inferior radioulnar joint.

• Clinical Features: PSTD.

• We can demonstrate inferior radioulnar joint by
balloting the lower end fracture of ulna (the Piano-Key
signs).
• X-Pay: AP & lateral.
 Treatment:
• The Key is to restore the full length of radius.
• In children it can be achieved usually
conservatively by MUA & POP above elbow,
• elbow flexed in f 90° & forearm supinated.
• In adults & children that can't be reduced
perfectly it is treated by OPIF we do
postoperative check X-ray to ensure reduction of
inferior radioulnar joint.
Complications:
• Delayed union,
• non-union,
• malunion,
• ulnar nerve injury is common in this type of
injury & should be looked for in the clinical
examination.
 Fractured Distal Radius:

• The distal end of radius is subjected to 6 distinct types of

factures:
• 1- Colles' fracture: low energy, osteoporotic fracture in
postmenopausal women.
• 2- Smith's fracture: similar to Colles' but displaced
anterior rather than posterior (reversed Colles).
• 3- Distal forearm fracture in children.
• 4- Radial styloid fracture: intra-articular to the wrist joint.
• 5- barton's fracture: fracture-subluxation of the wrist.
• 6- Comminuted intra-articular fracture in adults. 
1- Colles’ Fracture:
• This is a transverse fracture of the cortico-
cancellous junction of the lower inch of radius
with or without avulsion of styloid process of ulna.
• The distal piece will go into impaction, lateral
rotation, lateral displacement, dorsal
displacement rotation with supination.
• Mechanism:
• A fall on an outstretched hand in usually middle
age but it can be seen frequently in adults.
• Clinical features:
• pain, swelling, tenderness, with dinner-fork
deformity.
• X-Ray:AP & lateral.
•  Treatment:
Undisplaced: treated by POP below elbow for 4-
6 weeks with regular check X-Ray.
Displaced: MUA by disimpaction & palm flexion,
pronation, ulnar deviation & cast for 4-6 weeks.
Complications:
• Early:
1. Circulation to the fingers: it should be
checKed, the bandage holding the slab may
need to be splinted or loosened.
2 Nerve injury: usually median nerve, injury is
rare but compression is common. If symptoms
are mild treat it conservatively but if severe
then we do surgical decompression.
Complication:

3. Reflex sympathetic dystrophy: there's swelling

of fingers, pain,
stiffness, due to vasomotor instability.
4. TFCC: triangular Fibro - Cartilaginous Complex
injury.
• Late complication:
• l. Malunion.
• 2. Delayed union.
• 3. joint stiffness (shoulder, elbow, wrist, fingers).
• 4- Non-union.
• 5- Spontaneous rupture of tendon of extensor
pollicis longus.
2- Smith Fracture:
• Mechanism: fall on the back of the hand.
• Deformity: distal piece displaces anteriorly (reversed
Colles).
• Clinical features: PST,
• X-Ray: AP & lateral.
• Treatment:
• 1.Undisplaced: treated by POP for 6 weeks.
• 2-Displaced: MUA by traction in extension POP for
6 weeks.
• 3- Regular check X-Ray is taken post-reduction.
3- Distal Forearm Fracture in children
• The distal radius & ulna are among the commonest
sites of fracture in children. They occur through
distal physis or in the metapbysis of one or both
bones. Metaphyseal fractures are incomplete.
• Mechanism:
• Fall on an outstretched hand with the wrist in
extension causing the distal piece to go posteriorly
• If the wrist is in flexion the fracture will angulate
anteriorly.
• clinical features: PSTD.
• X-Ray: AP & lateral.
• Treatment:
1-Undisplaced: cast for 2-4 weeks above elbow,
elbow flexed.
2-Displaced: MUA&POP.
3-If it cannot be reduced or maintained reduced
then we do ORIF by wire.
4-Regular X-Ray check.
• Complications:
• Malunion,
• compartment syndrome,
• redioulnar discrepancy (due to premature fusion
of epiphysis).
4- Radio-Carpal fractures:
• (fractured styloid process of radius)
• Mechanism: fall on an outstretched hand with
radial deviation
• causing transverse fracture that starts at the
articular surface & goes laterally.
• Clinical features: PST.
• X-Ray: AP & lateral.
• Treatment:
• Undisplaced: POP above elbow with ulnar
deviation for 4-0 weeks.
• Displaced: MUA & POP & if can't be reduced
then OR& K-wire fixation.
 5- Barton's Fracture:
• This is an oblique fracture through the lower end of
radius into the wrist joint. It is of twe types.
• I. Volar barton's: passes through the volar lip of radius
with volar subluxation of carpus.
• 2. Dorsal Barton's: passes through the dorsal lip of
radius with dorsal subluxation of carpus.
• clinical features: FDTD.
• X-Ray: AP& lateral.
• Treatment:
• This an unstable intra-articular fracture that is best
treated by ORIF for both types.
6- Comminuted Intra-articular Fractures in Adults:

• Mechanism: high energy trauma.

• Clinical Features: PSTD
• X-Ray: AP, lateral, oblique to show the medial
cortex.
• Treatment:
1. Undisplaced: By POP
 2 .Displaced: MUA&POP.
3. If anatomy cannot be restored then OR & internal
or external fixation is done with or without bone
graft.
 THE END

Dr. Ghadeer Hikmat