Fractures of the Fractures of the Shaft of Radius Shaft of Radius

and Ulnaand Ulna

ByBy

Dr. sajid Manzoor Dr. sajid Manzoor PG-trainee Orthopedics PG-trainee Orthopedics

LGH LahoreLGH Lahore

Fractures of the Shaft of Fractures of the Shaft of Radius and UlnaRadius and Ulna

Regard as articular fracturesRegard as articular fractures Present specific problems in Present specific problems in

addition to those common to addition to those common to other long bone shaft other long bone shaft fractures. fractures.

slight deviation in spatial slight deviation in spatial orientation will significantly orientation will significantly decrease forearm rotational decrease forearm rotational amplitude and thus impair amplitude and thus impair hand position and functionhand position and function

Mechanism of injuryMechanism of injury

Direct blow associated with Direct blow associated with

Road traffic accident Road traffic accident

Fight when forearm used for Fight when forearm used for protectionprotection

Fall from hight Fall from hight Gunshot injuries Gunshot injuries Sports injuries (rarely)Sports injuries (rarely)

Signs & SymptomsSigns & Symptoms

– Usually displaced with Usually displaced with obvious deformityobvious deformity

– Pain,swelling, loss of Pain,swelling, loss of functionfunction

– Neuro deficits Neuro deficits uncommonuncommon

– Vascular statusVascular status– Compartment syndromeCompartment syndrome

ImagingImaging– Minimum of 2 viewsMinimum of 2 views– Low energy – transverse, short obliqueLow energy – transverse, short oblique– High energy – comminuted, segmentalHigh energy – comminuted, segmental– Must include elbow & wrist (Must include elbow & wrist (Both PRUJ Both PRUJ

& DRUJ injuries can coexist )& DRUJ injuries can coexist )– Attention to displacement, angulation, Attention to displacement, angulation,

shortening, & comminutionshortening, & comminution– Radial head in line with capitellumRadial head in line with capitellum– CT scanCT scan

DRUJ & PRUJ subluxation at extremes of DRUJ & PRUJ subluxation at extremes of rotationrotation

– USUS – interosseous membrane – interosseous membrane

ClassificationClassification

– Open or Closed, level, pattern, Open or Closed, level, pattern, displacement, presence of displacement, presence of comminution or segmental losscomminution or segmental loss

– Determined by status of PRUJ & DRUJDetermined by status of PRUJ & DRUJ

Surgical anatomySurgical anatomy Radius and ulna function Radius and ulna function

as a unitas a unit They are parallel bones They are parallel bones

connecting by proximal connecting by proximal and distal radio-ulnar and distal radio-ulnar joints which articulate joints which articulate closely with elbow and closely with elbow and wrist jointswrist joints

Interasseos membrane Interasseos membrane spans the space between spans the space between radio-ulnar joints its fibers radio-ulnar joints its fibers runs obliquely upward runs obliquely upward from ulna to radiusfrom ulna to radius

BiomechanicsBiomechanics Ulna Ulna

– Relatively straightRelatively straight– around which radius rotatesaround which radius rotates

Radial Bow Radial Bow – Rotation decreased if Rotation decreased if

increase/decrease bowincrease/decrease bow Interosseous SpaceInterosseous Space

– Central Band – longitudinal support of Central Band – longitudinal support of radius, prevents proximal migrationradius, prevents proximal migration

10 degree angulation of any one or 10 degree angulation of any one or both bones results loss of 20* both bones results loss of 20* pronation and supination while pronation and supination while 20*angulation show significant loss 20*angulation show significant loss of ROMof ROM

Angulation in middle 3Angulation in middle 3rdrd Significant loss of ROM of forearm Significant loss of ROM of forearm due to loss of radial bow where due to loss of radial bow where two bones overlap at extremes of two bones overlap at extremes of pronation and supinationpronation and supination

Rotatory and Angulatory Rotatory and Angulatory ForcesForces

Biceps and supinator Biceps and supinator through their insertion act through their insertion act as rotational force on as rotational force on proximal 3proximal 3rdrd radius fractures radius fractures

Pronator teres inserted on Pronator teres inserted on mid shaft exert both mid shaft exert both rotational and angulatory rotational and angulatory forcesforces

pronator quadratus on distal pronator quadratus on distal 4th exert both rotational and 4th exert both rotational and angulatory forcesangulatory forces

Proximal ulna angulate toward Proximal ulna angulate toward the radius by muscle mass in the radius by muscle mass in proximal forearm proximal forearm

Malunion and nonunion occur Malunion and nonunion occur more frequently because of more frequently because of difficulty in reducing and difficulty in reducing and maintaining the reduction of maintaining the reduction of two parallel bones in presence two parallel bones in presence of these angulating and of these angulating and rotational influencesrotational influences

Current treatment options Current treatment options

Nonoperative treatment Nonoperative treatment Operative treatmentOperative treatment

1) Open reduction and plate & 1) Open reduction and plate &

screw fixationscrew fixation

2) Intramedullary nailing 2) Intramedullary nailing

3) External fixation3) External fixation Aim should be Anatomic Aim should be Anatomic

reduction, Rigid fixation, Early reduction, Rigid fixation, Early mobilizationmobilization

Nonoperative TreatmentNonoperative Treatment

Long-arm cast in neutral i.e. Long-arm cast in neutral i.e. in supination in proximal 3in supination in proximal 3rdrd shaft fracture, midprone shaft fracture, midprone position in middle third position in middle third fractures and in pronation in fractures and in pronation in distal 3distal 3rdrd fractures with 90º fractures with 90º elbow flex positionelbow flex position

Indications Indications Undisplace ulna fracture Undisplace ulna fracture Unicortical fractures Unicortical fractures Patient not fit for surgeryPatient not fit for surgery

Drawbacks of nonoperative Drawbacks of nonoperative treatmenttreatment

No control on fracture fragmentsNo control on fracture fragments High rate of secondary displacement High rate of secondary displacement Poor functional resultsPoor functional results Uncertain time of unionUncertain time of union long healing time> elbow stiffnesslong healing time> elbow stiffness

Indications of operative Indications of operative treatment in fracture shaft of treatment in fracture shaft of

radius and ulnaradius and ulna All displaced fractures of radius and ulna in adultsAll displaced fractures of radius and ulna in adults All isolated displaced fractures of radiusAll isolated displaced fractures of radius All isolated fractures of ulna with angulation more All isolated fractures of ulna with angulation more

than 10 degreethan 10 degree All Monteggia fractures All Monteggia fractures All Galleazi fracturesAll Galleazi fractures Open fracturesOpen fractures Fracture associated with compartment syndrome Fracture associated with compartment syndrome

regardless of degree of displacementregardless of degree of displacement Multiple fractures of same extremity Multiple fractures of same extremity Pathologic fractures Pathologic fractures

Plate and screw fixationPlate and screw fixation

Can used for Can used for displaced fracture at displaced fracture at any level but any level but especially distal 3especially distal 3rdrd or or proximal 4proximal 4thth of radius of radius and proximal 3and proximal 3rdrd of of ulna shaftulna shaft

rigidity of fixation rigidity of fixation should be sufficient to should be sufficient to avoid postoperative avoid postoperative cast immobilizer cast immobilizer

If both bones are fractured both Fx If both bones are fractured both Fx should be exposed and reduced should be exposed and reduced temporarily and than fix one by onetemporarily and than fix one by one

Plate must be centered and of Plate must be centered and of sufficient length to permit minimum sufficient length to permit minimum 4 and preferably six cortices on each 4 and preferably six cortices on each side of the fractureside of the fracture

No screws within 1 cm of fractureNo screws within 1 cm of fracture Lag screws for butterfly fragmentLag screws for butterfly fragment

Choices of surgical approach Choices of surgical approach for radius fracturesfor radius fractures

If fracture is of distal half of the If fracture is of distal half of the radius, expose it through anterior radius, expose it through anterior Henry approach and apply plate on Henry approach and apply plate on volar surfacevolar surface

If fracture is of proximal half of radius, If fracture is of proximal half of radius, expose it through dorsal Thompson expose it through dorsal Thompson approach and apply plate on dorsal approach and apply plate on dorsal surfacesurface

For fracture middle 3For fracture middle 3rdrd of radius, of radius, either approach can used either approach can used

Anterior approach Anterior approach (Henry) (Henry)

Landmarks for skin Landmarks for skin incisionsincisions

Proximally, from the biceps Proximally, from the biceps tendon and The distal end of tendon and The distal end of the incision is the radial styloid the incision is the radial styloid processprocess

Superficial dissectionSuperficial dissection

Dissect the interval between Dissect the interval between the brachioradialis and flexor the brachioradialis and flexor carpi radialis muscles. The carpi radialis muscles. The radial artery should be radial artery should be identified and protected identified and protected beneath the brachioradialis beneath the brachioradialis

Deep Deep dissectiondissection

proximal third:proximal third: forearm should be fully forearm should be fully supinated supinator supinated supinator muscle should be muscle should be incised in its most incised in its most medial part. The plate medial part. The plate is inserted below the is inserted below the detached supinator detached supinator muscle. muscle.

Deep dissectionDeep dissection

middle third:middle third: The forearm should be The forearm should be

fully pronated to expose fully pronated to expose the radial border of the the radial border of the pronator teres muscle. If pronator teres muscle. If required detach the required detach the pronator teres off the pronator teres off the radius. radius.

Deep dissectionDeep dissection

distal third: distal third:

Pronating the forearm will Pronating the forearm will expose the border of the expose the border of the radius just lateral to the radius just lateral to the edge of the flexor pollicis edge of the flexor pollicis longus and the pronator longus and the pronator quadratusquadratus

Dorsolateral Dorsolateral

(Thompson)(Thompson) Skin incisionSkin incision The skin The skin

incision lies straight down incision lies straight down the dorsal aspect of the the dorsal aspect of the forearm, from the anterior forearm, from the anterior side of lateral humeral side of lateral humeral epicondyle, and distally to epicondyle, and distally to the dorsal aspect of the the dorsal aspect of the styloid process of the styloid process of the radius.radius.

Plane of dissectionPlane of dissection The The plane of dissection lies plane of dissection lies between the between the extensor extensor carpi radialis breviscarpi radialis brevis which should be retracted which should be retracted radially, and the radially, and the extensor extensor digitorum communisdigitorum communis which should be retracted which should be retracted ulnarly. ulnarly.

Dorsolateral Dorsolateral (Thompson)(Thompson)

supinator wraps the upper 3rd of supinator wraps the upper 3rd of the radius.the radius.

posterior interosseous nerve runs posterior interosseous nerve runs through its substance. The nerve through its substance. The nerve must be identified and protected must be identified and protected

The incision in the muscle should The incision in the muscle should be made on the ulnar border of the be made on the ulnar border of the radius and the muscle should be radius and the muscle should be elevated sub periostealy and apply elevated sub periostealy and apply plate below the supinatorplate below the supinator

less suited for distal radius shaft less suited for distal radius shaft fractures as abductor pollicis fractures as abductor pollicis longus and extensor pollicis brevis longus and extensor pollicis brevis crosses the surgical field crosses the surgical field

precautionsprecautions

Strip periostium from bone with muscles Strip periostium from bone with muscles and apply plate beneath the periostium to and apply plate beneath the periostium to protect blood supply and avoid necrosisprotect blood supply and avoid necrosis

Release tourniquet and secure all major Release tourniquet and secure all major bleeders before skin closure bleeders before skin closure

Do not close deep fascia to avoid Do not close deep fascia to avoid Volkmann contracturesVolkmann contractures

If bone graft is required, avoid applying it If bone graft is required, avoid applying it to the interosseous border to prevent to the interosseous border to prevent synostosissynostosis

Approach for ulna fracture Approach for ulna fracture

Ulna: incision Ulna: incision directly on the directly on the subcutaneous subcutaneous border and extend border and extend between ECU & between ECU & FCUFCU

plate is applied plate is applied anteriorly or anteriorly or posteriorlyposteriorly

AftercareAftercare

Non-comminuted: no splint is Non-comminuted: no splint is required and advise early motion required and advise early motion

Comminuted & unreliable patient: Comminuted & unreliable patient: removable splint x 6 weeksremovable splint x 6 weeks

Intramedullary NailsIntramedullary Nails

Interlocking nailsInterlocking nails Rush pins and Flexible nailRush pins and Flexible nail

Rush pins and Flexible nailRush pins and Flexible nail

poor results due to poor results due to poor rotation poor rotation control and lack of control and lack of rigid fixation rigid fixation

Interlocking NailsInterlocking Nails IndicationIndication - Segmental fx- Segmental fx - Open fx with soft - Open fx with soft

tissue or bone losstissue or bone loss - Pathologic bone- Pathologic bone - Failed plating- Failed plating - Multiple injuries- Multiple injuries ContraindicationContraindication - Active infection- Active infection - Medullary canal - Medullary canal

smaller than 3mmsmaller than 3mm - An open physis - An open physis

Interlocking nailsInterlocking nails

Triangular & Triangular & Square nailsSquare nails

Bent nails for radial Bent nails for radial bowbow

Difficult to beat the Difficult to beat the results of plate results of plate fixationfixation

Portal of entry for IM Portal of entry for IM nail of ulna is made in nail of ulna is made in proximal ulnaproximal ulna

Radial portal of entry Radial portal of entry is variableis variable

Different steps of IM locking Different steps of IM locking nailing nailing

Interlocking nailsInterlocking nails

Adventages Adventages - - little or no periosteal strippinglittle or no periosteal stripping - smaller operative wound - smaller operative wound - bone grafting is generally not - bone grafting is generally not requiredrequired - after nail removal less chances - after nail removal less chances

of of refracture refracture

Interlocking nailsInterlocking nails

ComplicationsComplications– SizeSize

Side-to-side & rotary movementsSide-to-side & rotary movements Explode the shaftExplode the shaft

– Inadequate fixationInadequate fixation– Injury to PIN with locking screwsInjury to PIN with locking screws

Open fractureOpen fracture

Common with high Common with high energy trauma)energy trauma)

Usually Gustillo I or IIUsually Gustillo I or II Can plate primarilyCan plate primarily Ex-fix for soft tissue Ex-fix for soft tissue

loss, maintain lengthloss, maintain length

Monteggia Monteggia

Monteggia fracture Monteggia fracture

In 1814 Monteggia described In 1814 Monteggia described fracture of proximal 3fracture of proximal 3rdrd of ulna in of ulna in combination with anterior combination with anterior dislocation of proximal radio-dislocation of proximal radio-ulnar joint ulnar joint

In1967 Bado named it as In1967 Bado named it as Monteggia fracture and Monteggia fracture and described four different types described four different types

Bado classification of Bado classification of Monteggia fracture Monteggia fracture

Type lType l radial head is dislocated radial head is dislocated anteriorly (60%)anteriorly (60%)

Type llType ll radial head is dislocated radial head is dislocated posteriorly(15%)posteriorly(15%)

Type lllType lll radial head is dislocated radial head is dislocated laterally(10%)laterally(10%)

Type lVType lV radial head dislocation in any radial head dislocation in any direction with fracture of both radius and direction with fracture of both radius and ulna shaft (10%)ulna shaft (10%)

Treatment objectiveTreatment objective

The radial head must always line up The radial head must always line up with the capitellum in all views and in with the capitellum in all views and in all positions of limb all positions of limb

Ulna fracture should be fixed rigidly Ulna fracture should be fixed rigidly to prevent angulation at fracture site to prevent angulation at fracture site and thus future subluxation or and thus future subluxation or dislocation of radial head dislocation of radial head

Treatment PlanTreatment Plan For acute injuriesFor acute injuries, close reduction of radial , close reduction of radial

head dislocation should be attempted and ulna head dislocation should be attempted and ulna fracture should be fixed rigidly fracture should be fixed rigidly

For acute injuries,For acute injuries, in which close reduction of in which close reduction of radial head failed due to interposition of annular radial head failed due to interposition of annular ligament or capsule open reduction with repair or ligament or capsule open reduction with repair or reconstruction of annular ligament should be reconstruction of annular ligament should be perform followed by rigid fixation of ulna perform followed by rigid fixation of ulna

For old injuries (6 weeks or more)For old injuries (6 weeks or more) in which in which radial head has never been reduced or radial head has never been reduced or insufficient fixation of ulna leads to redislocation , insufficient fixation of ulna leads to redislocation , excision of radial head with rigid fixation of ulna excision of radial head with rigid fixation of ulna donedone

NightstickNightstick

Ulna onlyUlna only Usually direct blowUsually direct blow Usually non/minimally displacedUsually non/minimally displaced Splint 7-10 days, Fracture Brace 4-6 weeks Splint 7-10 days, Fracture Brace 4-6 weeks

(allow elbow/wrist motion)(allow elbow/wrist motion) Displaced - PlateDisplaced - Plate

Galeazzi Fracture Galeazzi Fracture

In 1934, Galeazzi In 1934, Galeazzi described dislocation or described dislocation or subluxation of distal subluxation of distal radio-ulnar joint in radio-ulnar joint in association with solitary association with solitary fracture of distal 3fracture of distal 3rdrd of of radial shaft (named as radial shaft (named as Galeazzi fracture) Galeazzi fracture)

Campbell called it as Campbell called it as ““fracture of necessity” fracture of necessity”

Galeazzi FractureGaleazzi Fracture Injuries to DRUJ are subdivided to Injuries to DRUJ are subdivided to

:: - Stable - Stable - Partially unstable - Partially unstable (subluxation)(subluxation) - Unstable (dislocation)- Unstable (dislocation)

If close reduction DRUJ is not If close reduction DRUJ is not possible open exploration for a possible open exploration for a trapped tendon or soft tissue trapped tendon or soft tissue may be required may be required

Treatment Treatment Close reduction and cast Close reduction and cast

immobilization has a high rate of immobilization has a high rate of unsatisfactory results unsatisfactory results

Open reduction and internal fixation Open reduction and internal fixation with 3.5mm DCP is treatment of with 3.5mm DCP is treatment of choice choice (fracture is usually too (fracture is usually too distal to be fixed with distal to be fixed with intramedullary nail)intramedullary nail)

Rigid anatomical fixation of radius Rigid anatomical fixation of radius usually reduce DRUJ dislocation, if not usually reduce DRUJ dislocation, if not than open exploration and reduction than open exploration and reduction should be achieved and stable with a should be achieved and stable with a K-wire for 6 wks K-wire for 6 wks

ComplicationsComplications InfectionInfection Nerve injuryNerve injury - Uncommon- Uncommon

– if neuro deficit exists; explore at time of debridement; if if neuro deficit exists; explore at time of debridement; if divided, ends tagged togetherdivided, ends tagged together

– Clean transection - 1º repair if wound clean, soft tissue Clean transection - 1º repair if wound clean, soft tissue adequateadequate

– IatrogenicIatrogenic Incomplete – observeIncomplete – observe Complete – explore within a few daysComplete – explore within a few days

– AIN palsy caused by constrictive dressingAIN palsy caused by constrictive dressing Vascular injuryVascular injury

– either radial or ulnareither radial or ulnar Compartment syndrome (rare)Compartment syndrome (rare)

– ,crush injuries,crush injuries

Radioulnar SynostosisRadioulnar Synostosis– UncommonUncommon– Highest risk – proximal Highest risk – proximal

fx’s treated w/ 1 incisionfx’s treated w/ 1 incision– Heterotopic ossification in Heterotopic ossification in

interosseous memebrane interosseous memebrane in response to screws in response to screws being too longbeing too long

– Resection> interposition Resection> interposition w/ muscle or silicone w/ muscle or silicone sheet> early mobilizationsheet> early mobilization

– Nonarticular synostosis in Nonarticular synostosis in distal or middle 1/3 has distal or middle 1/3 has best chancebest chance

MalunionMalunion– Corrective Corrective

osteotomy if loss osteotomy if loss of rotationof rotation

NonunionNonunion– UncommonUncommon

THANK YOUTHANK YOU