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Fractures of The Radius and Ulna

ORTHOPEDY AND TRAUMATOLOGY DEPARTEMENT


WAHIDIN SUDIROHUSODO HOSPITAL
HASANUDDIN UNIVERSITY
Essential Anatomy

•  The radius and the ulna can be thought of conceptually as


two cones lying next to each other pointing in opposite
directions

•  The radius and the ulna lie parallel to each other and thus
permitting supination and pronation as the radius "rolls"
around the ulna.

§ Because of their close proximity, injury forces


typically disrupt both bones and their
ligamentous attachments.
Axiom :
A fracture of one of the paired bones,
especially when angulated or displaced, is
usually accompanied by a fracture or
dislocation of its "partner."
The shafts of the radius and the ulna are surrounded by four primary
muscle groups whose pull frequently results in fracture displacement or
nullification of an adequate reduction

1. Proximal: The biceps brachii and the supinator insert on the proximal
radius and exert a supinating force.

2. Midshaft: The pronator teres inserts on the radial shaft and exerts a
pronating force.

3. Distal: Two groups of muscles insert on the distal radius.


A. The pronator quadratus exerts a pronating force, which may cause
displacement.
B. The brachioradialis and abductor pollicis longus and brevis produce
deforming forces. Of these, the brachioradialis exerts the predominant
displacing force.
Radius fractures
Can be divided into three groups on the basis of muscular
attachments and consequent fragment displacement after a
fracture :
1. The proximal one-third of the radial shaft just distal to
the insertion of the supinator and the biceps brachii. Both of
these muscles exert a supinating force and will result in
displacement of the proximal radius if a fracture occurs
2. The middle one-third of the radial shaft where the
pronator teres exerts a pronating force
3. The distal one-third of the radius. In this area the
pronator quadratus exerts a pronating force on the fracture
fragment
Examination
Tenderness over the distal radioulnar joint
may be secondary to subluxation or
dislocation and should alert the physician
to the possibility of a Galeazzi fracture.
Imaging
Routine anteroposterior (AP) and lateral
views of the forearm are usually
adequate

Axiom: Isolated fracture of the radial


shaft without an ulnar fracture is an
unusual injury and the physician must
suspect injury to the distal radioulnar joint
when treating these
Galeazzi fracture
Associated Injuries
•  A distal radial shaft fracture associated with
a distal radioulnar dislocation (Galeazzi
fracture)
•  Acute compartment syndrome
Treatment
Nondisplaced Proximal One-Third

•  Application of splints
•  The elbow should be in 90° of flexion with the forearm in supination.
Supination of the forearm is required with this fracture because of the
supinating forces of the supinator and biceps muscles that insert on the
proximal portion of the radius

Displaced Proximal One-Third


Treatment of choice is open reduction and internal
fixation
Nondisplaced Midshaft One-Third
•  The elbow should be in 90° of flexion and the
forearm in moderate supination

Displaced Midshaft One-Third


•  The treatment of choice is open reduction and
internal fixation
Nondisplaced Midshaft Distal One-Third
•  The elbow should be in 90° of flexion and the
forearm in pronation.
•  Application of splints

Displaced Midshaft Distal One-Third


•  Open reduction with internal fixation is the treatment
of choice
Complications

1. Malunion or non-union may be secondary to inadequate reduction


or immobilization.
2. Rotational deformities must be detected and treated early in the
management of these fractures.
3. Distal radioulnar joint subluxation or dislocation
4. Neurovascular injuries
Ulnar Shaft Fractures
•  Ulnar shaft fractures can be classified into
three groups:

(1) Nondisplaced,
(2) Displaced (>5 mm),
(3) Monteggia fractures
•  Monteggia fractures are displaced fractures of
the proximal one-third of the ulnar shaft combined
with a radial head dislocation.
•  Radial head dislocations can only occur if
there is complete rupture of the annular
ligament.
Monteggia fractures are classified into four types:

1. Ulnar shaft fracture with an anterior dislocation of the radial


head. There is usually anterior angulation of the distal
fragment.
2. Ulnar shaft fractures with a posterior or posterior-lateral
dislocation of the radial head
3. Ulnar metaphyseal fractures with lateral or anterolateral
dislocation of the radial head.
4. Ulnar and radial shaft fracture (proximal one-third) and
anterior dislocation of the radial head.
Two mechanisms of injury frequently result in
fractures of the ulna :
1. A direct blow (nightstick fracture)
2. Excessive pronation or supination

Examination
•  Swelling and tenderness
•  Pronation and supination will be mildly
painful
•  Monteggia fractures often will reveal
shortening of the forearm due to
angulation
•  Radial head may be palpable in the
antecubital fossa following anterior
dislocations
Imaging
•  AP and lateral views of the forearm
•  elbow and wrist views should be added to
exclude articular injury, subluxation, or
dislocation
•  Any fracture of the ulna, especially proximal
fractures, evaluate the radiocapitellar line on
the lateral radiograph.
•  A line drawn down the center of the shaft
and head of the radius should intersect the
middle of the capitellum.
•  If this intersection does not occur, the
proximal radioulnar joint is disrupted
Associated Injuries
Axiom: Displaced ulnar fractures are
frequently associated with radial fractures or
dislocations of the radial head

• Paralysis of the deep branch of the radial


nerve can occur
• Acute compartment syndrome
Treatment

Nondisplaced / minimally Displaced (<5


mm) Ulnar shaft fractures

• Can be treated with a long-arm cast with the elbow in 90°


of flexion and the forearm neutral was recommended

• After 1 week the splint or cast be replaced by a


prefabricated functional brace
Treatment
Displaced (>5 mm) Ulnar shaft fractures

•  Open reduction with internal fixation


•  Monteggia Fracture In adults, Surgical correction is
indicated
•  Monteggia Fracture In children, Closed reduction of the
ulnar fracture is then typically carried out under general
anesthesia, followed by relocation of the radial head by
direct pressure during supination of the forearm
Complications
Monteggia fractures require emergent referral because
of a high incidence of complications, including :

1. Paralysis of the deep branch of the radial nerve is


usually secondary to a contusion and typically heals
without treatment.

2. Non-union may be due to an inadequate reduction


or may be secondary to inadequate immobilization.

3. Recurrent dislocation or subluxation of the


radial head due to an unrepaired tear in the annular
ligament is common after closed reductions
Combined
Radius and Ulna Fractures
Two mechanisms result in fractures of the
forearm shaft

•  A direct blow
•  Fall on an outstretched arm (the most
common mechanism )
Examination
•  Pain, swelling, deformity
•  Examination of the elbow and wrist is important to
detect possible injury to the proximal or distal
ligamentous structures
•  Deficits of the radial, median, and ulnar nerves are
uncommonly seen, but must be excluded by careful
physical examination and documentation
Imaging
•  Plain foto of the forearm AP and lateral views
•  Wrist and elbow views should also be obtained and
evaluated for fracture, dislocation, or subluxation
AP and lateral radiographs demonstrating
greenstick fractures of the distal radius and
ulna in a child.
Associated Injury
•  Injury to the proximal and distal radioulnar
joints
•  Acute compartment syndrome
Treatment
Nondisplaced Radius and Ulna Fractures

•  This is an uncommon injury

•  If neither bone is displaced or angulated, the patient can


be treated with anteroposterior splints, with the elbow in
90° of flexion and the forearm neutral

•  Definitive management includes a well-molded long-arm


cast

•  Caution: Repeat radiographs are required as delayed


displacement is common
Treatment
Displaced Radius and Ulna Fractures

•  Attempts at closed reductions in adults


generally fail in achieving and maintaining
proper alignment and rotational corrections
•  The treatment of choice is open reduction
with internal fixation
Greenstick Fractures

•  Initially treated with immobilization in a long-


arm splint
•  The definitive treatment with a long-arm
cast for 4 to 6 weeks

Combined Proximal One-Third Fractures

with Radial Head Dislocation Require open


reduction and internal fixation.
Complications
1. Infection is commonly seen with open fractures.
2. Nerve damage is uncommon in closed injuries, but is frequently
seen with open fractures.
3. Vascular compromise is an uncommon complication because
of the presence of arterial collaterals.
4. Non-union or malunion may be secondary to inadequate
reduction or inadequate immobilization.
5. Compartment syndromes
6. Synostosis (bone fusion) of the radius and ulna may complicate
the management of combined shaft fractures.
7. Pronation and supination may be impaired if fractures are
poorly managed