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Pembimbing: Dr. Husnul Fuad Albar, SpOT
DEPARTMENT OF ORTHOPAEDICS HAM GH FACULTY OF MEDICINE UNIVERSITAS SUMATERA UTARA MEDAN 2011
1. Fracture of the Forearm
1.1 Fractures Of The Shaft Of Ulna And Radius
Adult fractures unlike those in children may be markedly displaced with little or no bony contact between the fragments. Rotational deformity is common. Neurovascular injury is checked carefully. Closed reduction is difficult and often fails or is complicated by late slippages. Fractures are treated with analgesics or immobilization and refer for ORIF.
Classification of the shaft of radius and ulna fracture
A1 Simple fracture of the ulna, radius intact 1 oblique 2 transverse 3 with dislocation of the radial head (Monteggia) A2 Simple fracture of the radius, ulna intact 1 oblique 2 transverse 3 with dislocation of the distal radio-ulnar joint (Galeazzi) A3 Simple fracture of both bones 1 radius, proximal zone 2 radius, middle zone 3 radius, distal zone
radius intact 1 intact wedge 2 fragmented wedge 3 with dislocation of the radial head (Monteggia) B2 Wedge fracture. ulna intact 1 intact wedge 2 fragmented wedge 3 with dislocation of the distal radio-ulnar joint (Galeazzi) B3 Wedge fracture. B1 Wedge fracture. simple or wedge fracture of the other 1 ulna wedge and simple fracture of the radius 2 radial wedge and simple fracture of the ulna 3 ulnar and radial wedges . of the radius. of the one bone. of the ulna.
radius fractured 3 irregular C2 Complex fracture. C1 Complex fracture. of the ulna 1 bifocal. ulna intact 2 bifocal. irregular of the other 3 irregular . of the radius 1 bifocal. radius intact 2 bifocal. ulna fractured 3 irregular C3 Complex fracture. of both bones 1 bifocal 2 bifocal of the one.
Classification of the shaft of radius and ulna fractures .
2 Monteggia fracture Definition : Fracture of the proximal ulna associated with dislocation of the radial head Etiology : Forced pronation of the arm .1.
lateral dislocation Type 4 : anterior with ass.Bado Classification Type 1 : anterior dislocation Type 2: posterior dislocation Type 3: . Both bone fx .
recurrent radial head dislocation . Complications: .radiohumeral ankylosis .radioulnar synostosis . .non union of fracture of ulnar shaft .PIN or radial nerve palsy from anterior displacement of radial head.myositis ossificans .
2. Fracture of the Radial Head .
and about 33% of elbow fractures and dislocations including injury to the radial head and or neck.Epidemiology The radial head is fractured in about 20% of cases of elbow trauma. .
. Radial head fractures and dislocations are the result of trauma. which is forced into the capitellum. usually from a fall on the outstretched arm with the force of impact transmitted up the hand through the wrist and forearm to the radial head.
The intra-articular position also means that soft tissue attacthments to the most proximal portion of the bone are limited.Pathophysiology The radial head is intra-articular. so the anatomic reduction of the bone fragments is necessary to minimize the risk of lateral posttraumatic arthritis from mechanical grinding. so fractured fragments frequently lose their blood supply. resulting in avascular necrosis and potential nonunion. .
maybe damaged simultaneously. . grinding. The wrist. and the presence of wrist pain. especially the distal radioulnar joint. Patients with radial head fracture-dislocations usually presents with a history of a fall on the outstretched hand. or swelling can be found.
tingling. . Neurovascular symptoms of numbness. or loss of sensation should be identified to rule out nerve of vascular injury. The presence of severe pain should alert the examiner to the possibility of compartment syndrome.
. tenderness. Evaluate wounds over the subcutaneous border of the ulna is especially important in fracturedislocations to avoid missing open fractures.Physical Examination Patients with radial head fractures and dislocations present with localized swelling. and decreased motion.
carefully assess neurovascular funtion for all of the nerves of the forearm and hand. . Palpation on the elbow. and the wrist. feeling for stability of the distal radioulnar joint. The motor (posterior interosseous) branch provides extension for the fingers and wrist. feeling for deformity. The 3 major nerves of the forearm are in danger with elbow fractures and dislocations. Radial nerve function is especially important to assess with displaced fractures through the neck of the radius. especially the radial head.
. and measure compartment pressures if in doubt to avoid missing compartment syndromes. check for pain with passive stretch. Assess the firmness of all compartments. The elbow is tested with valgus stress at 30 degrees of flexion to determine the competency of the medial collateral ligament. Elbow stability needs to be assessed even with seemingly nondisplaced radial neck fractures.
The Mason Classification .
Type II fractures with acceptable fracture patterns should be treated with open reduction and internal fixation. type II injuries can be treated non-operatively. particularly if the patient has low-demand occupation. Type I fractures are treated with limited immobilization for a few days. followed by early range of motion exercises.Management The Mason classification is helpful in determining the appropriate treatment for simple radial head and neck fractures. . In equivocal situations. with delayed excision of the radial head if persistent pain or significant limitation of forearm rotation occurs.
Results of treatment are uniformly good for type I fractures and often satisfactory for simple type II and type III fractures. Uncomplicated type III fractures should be treated with excision of the radial head. the fragments should be removed and the radial head replaced by prosthesis. . When radial head fractures are associated with dislocation of the elbow and severe ligament injury or disruption of the forearm interosseus.
Complications Loss of motion Elbow instability Post-traumatic arthritis Myositis issificans Distal radio-ulnar symptoms .
3. Fractures of Diaphyseal of Radius and Ulna .
. is an injury pattern involving a radial shaft fracture with associated dislocation of the distal radioulnar joint (DRUJ).1 Galeazzi Fracture The Galeazzi fracture-dislocation. also known as reverse Monteggia fracture. the injury disrupts the forearm axis joint.3.
They are seen most often in males.Epidemiology Galeazzi fractures account for 3-7% of all forearm fractures. .
Forearm trauma may be associated with compartment syndrome. .Presentation Pain and soft-tissue swelling are present at the distal-third radial fracture site and at the wrist joint. This injury is confirmed on radiographic evaluation.
but it is often overlooked because there is no sensory component to this finding. the AIN is a division of the median nerve. Injury to the AIN can cause paralysis of the flexor pollicis longus (FPL) and flexor digitorum profundus (FDP) to the index finger. Anterior interosseous nerve (AIN) palsy may also be present. A purely motor nerve. resulting in loss of the pinch mechanism between the thumb and index finger .
.Management Galeazzi fractures are best treated with open reduction of the radius and DRUJ. Closed reduction and cast application have led to unsatisfactory results.
. Galeazzi fractures in skeletally immature patients are typically treated with closed reduction and casting because of the enhanced viscoelastic nature of pediatric bone. Immediate stabilization of the radial fracture and the DRUJ is recommended. Open forearm fractures constitute a surgical emergency. as well as the presence of a stout periosteal sleeve.
Galeazzi fracture consists of a fracture of the radius with angulation and associated dislocation of the distal ulna .
it looks like a green stick of wood Difficult to diagnose. because it may not cause all the classic signs and symptoms of a broken bone. .3.2 Green Stick Fracture Common in children (usually 6-12 years old) because a child's bones are softer and more flexible than those of an adult The bone cracks but doesn¶t break all the way. Treatment of a greenstick fracture requires immobilization of the child's bone so that the bone will grow back properly.
or the fracture may be complete in one bone and incomplete (green stick) in the other Causes Usually happens when a child tries to throw the arms when he/she falls This is a common reaction to catch yourself before you fall .Definition An incomplete (green stick) fracture in the radius and/or ulna.
Symptoms None. such as a sprain or a bad bruise. . Additionally. it can be difficult to tell the difference between a greenstick fracture and a soft-tissue injury. in some cases Pain Swelling Abnormally bent or twisted limb The intense pain and obvious deformity typical of broken bones may be absent or minimal in greenstick fractures.
The X-Ray result that shows Green Stick Fracture .
. Reduction: .Management Overcorrection of fracture may be required (completing the fracture before aligning it) Acceptable reduction: In infants: .up to 15 deg may be accepted depending on age of patient.there is no need to attempt correction for angulation measuring < 10 deg in children less than 10 yrs of age. . .up to 30 deg may be accepted.a volarly angulated greenstick fracture is manipulated with forearm in pronation while a dorsally angulated fracture is manipulated with forearm in supination.consider reduction with completion of fracture by reversal of deformity if angular > 25-30 deg. In children: .
4. Fractures of Distal Radius .
Definition A fracture of the distal radius occurs when the area of the radius near the wrist breaks. Epidemiology Osteopenic women(50/60s) : low energy trauma. . extra-articular ³bending´ type injury.
Standard initial radiographs : A. oblique (Obl) To reveal the fracture pattern as well as the extent and direction of the initial displacement. lateral (Lat) C. . B. anteroposterior (AP).
Classification of distal radius fracture .
Type A Muller classffication Type B Type C .
cuneiform. . These shearing fractures are subdivided into three groups : B1 : fractures involving injuries in the sagittal plane ( radial atyloid. Type B This group comparises are distal radial fractures involving part of the articular surface. or reverse Barton¶s fractures. Type A Distal radial fractures not involving the articular surface ( Colles¶ and Smith¶s fractures) fall into this type. and lunate facet fractures) B2 : fractures in the coronal plane affecting the dorsal aspect(Barton¶s fracture) B3 : fractures of the volar aspect.
Type C These are distal radial fractures involving a complete articular surface injury. two fragment intraarticular fracture with multifragmented metaphysic C3 . . fractures with comminution of the articular surface. two fragment intraarticular fracture without metaphyseal fragmentation C2 . Comminution is defined as involvement of more than 50% of the metaphysis as seen on the radiograph. C1 .
initial treatment b.Treatment Management: a. definitive treatment Definitive treatment Nondisplaced intraand extraarticular stable fx Displaced extraarticukar fx Open or severely Comminuted extraarticular fx Displaced intraarticular fx .
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