Fractures of the Radius and Ulna Shaft PDF

FRACTURES OF THE RADIUS AND ULNAR SHAFT Prepared by Dr. Sahar Mowad  The radius and ulna make up the bones of the forearm and the movement and articulation changes moving from the wrist to the elbow. The ulna can mostly be considered to be a straight bone w...

FRACTURES OF THE RADIUS AND ULNAR SHAFT Prepared by Dr. Sahar Mowad  The radius and ulna make up the bones of the forearm and the movement and articulation changes moving from the wrist to the elbow. The ulna can mostly be considered to be a straight bone while the radius has a curvature to it called the radial bow. A strong interosseous membrane holds the two bones together. Some fractures of the forearm are coupled with a dislocation of the joint proximal or distal to the fracture Monteggia fracture dislocation Galeazzi fracture dislocation A fracture A fracture of of the ulna the radius with a with a disruption/ dislocation dislocation of the radial of the distal head radioulnar joint Mechanism of injury and pathology Fractures of the shafts of both forearm bones occur quite commonly. A twisting force (usually a fall on the hand) produces a spiral fracture with the bones broken at different levels. An angulating force causes a transverse fracture of both bones at the same level.  A direct blow causes a transverse fracture of just one bone, usually the ulna.  Additional rotation deformity may be produced by the pull of muscles attached to the radius: they are the biceps and supinator muscles to the upper third, the pronator teres to the middle third, and the pronator quadratus to the lower third.  Bleeding and swelling of the muscle compartments of the forearm may cause circulatory impairment Clinical features usually quite obvious the pulse must be felt and the hand examined for circulatory or neural deficit Repeated examination is necessary in order to detect an impending compartment syndrome  X-RAY :Both bones are broken obliquely with the radial fracture transversely and at the same level usually at a higher level. Fractured radius and ulna in children In adults, displacement may occur in any direction – shift, overlap, tilt or twist. In low-energy injuries, the fracture tends to be transverse or oblique in high-energy injuries it is comminuted or segmental  Treatment In children, closed treatment is usually successful because the tough periosteum tends to guide and then control the reduction. The fragments are held in a well-moulded full-length cast, from axilla to metacarpal shafts (to control rotation). The cast is applied with the elbow at 90 degrees. If the fracture is proximal to pronator teres, the forearm is supinated if it is distal to pronator teres, then the forearm is held in neutral  The position is checked by x-ray after a week and, if it is satisfactory, splintage is retained until both fractures are united (usually 6–8 weeks). Throughout this period hand and shoulder exercises are encouraged. The child should avoid contact sports for a few weeks to prevent re-fracture. Occasionally an operation is required, either if the fracture cannot be reduced or if the fragments are unstable.  Fixation with intramedullary rods is preferred, but they should be inserted with great care to avoid injury to the growth plates Alternatively, a plate or K-wire fixation can be used.  Childhood fractures usually remodel well, but not if there is any rotational deformity or an angular deformity of more than 15 degrees in children under 6 years or 10 degrees in children between 6 and 12. In those over 12 years old even slight angular deformities are unlikely to remodel satisfactorily ADULTS most surgeons opt for open reduction and internal fixation from the outset. The fragments are held by inter fragmentary compression with plates and screws. Bone grafting is advisable if there is commination.  After the operation the arm is kept elevated until the swelling subsides, and during this period active exercises of the hand are encouraged If the fracture is not comminuted and the patient is reliable, early range of movement exercises are commenced but lifting and sports are avoided. It takes 8–12 weeks for the bones to unite. With comminuted fractures or unreliable patients, immobilization in plaster is safer  Complications EARLY LATE Delayed union and non-  Compartment syndrome union  Nerve injury : posterior Malunion interosseous nerve Complications of plate removal Fractured radius and ulna – cross- union Physical therapy rehabilitation Phase I: (Weeks 0–2) Patient is placed into a splint and surgical incisions are protected Sutures or staples are removed at week two. Elevation of extremity encouraged Edema control and ROM of fingers Gentle grade I or II distraction and oscillation techniques in the resting position may inhibit pain and move synovial fluid for nutrition in the involved joints  Educate the Patient Inform the patient regarding the anticipated length of acute symptoms and teach methods of joint protection Instruct the patient to avoid excessive fatigue by performing exercises frequently during the day but limiting the number of repetitions during each bout (set) of exercises Phase II: (Weeks 2–6) Active and active-assisted ROM of elbow, forearm, and wrist No repetitive forearm twisting 5-pound weight restriction though some surgeons prefer strict non weight bearing Multiple-angle muscle setting of elbow flexors, extensors, pronators, and supinators and wrist flexors and extensors in pain-free positions Phase III: (Weeks 6 and Beyond) Lifting and twisting restrictions lifted once union has been achieved Work on regaining preoperative motion if not already achieved. It is crucial to communicate with the treating surgeon regarding when union has been achieved and when restrictions may be removed or surgeon preference regarding weight lifting limits despite lack of full union. passive stretching and muscle inhibition techniques  Initiate stretching cautiously and note the joint and tissue response. Vigorous stretching should not be undertaken until the chronic stage of healing high-intensity stretching of the elbow flexors is contraindicated following trauma because of the potential for development of heterotopic bone formation. Passive joint mobilization techniques To progress joint mobility in the terminal ranges of flexion and extension, it may be necessary to emphasize the accessory motions of varus and valgus, respectively. This is accomplished with medial and lateral gliding techniques or with a varus or valgus physiological stretch at the elbow. Common fractures around elbow joint Prepared by Dr. Sahar Mowad Lecture in Orhopedic physical therapy department BNS University  Fractures around the elbow in adults – especially those of the distal humerus – are often high-energy injuries associated with vascular and nerve damage Some can be reduced and stabilized only by complex surgical techniques; and the tendency to stiffness of the elbow are common. The AO-ASIF Group have defined three types of distal humeral fracture : Type A – an extra-articular supracondylar fracture Type B – an intra-articular unicondylar fracture (one condyle sheared Off) Type C – bicondylar fractures with varying degrees of commination. TYPE A – SUPRACONDYLAR FRACTURES These are among the commonest fractures in children. The distal fragment may be displaced either posteriorly or anteriorly These extra-articular fractures are rare in adults. When they do occur They are usually displaced and unstable.  Mechanism of injury Posterior angulation or displacement (95 per cent of all cases) suggests a hyperextension injury usually due to a fall on the outstretched hand. The humerus breaks just above the condyles. The distal fragment is pushed backwards and (because the forearm is usually in pronation) twisted inwards. The jagged end of the proximal fragment pokes into the soft tissues anteriorly sometimes injuring the brachial artery or median nerve.  Classification Type I is an undisplaced fracture. Type II is an angulated fracture with the posterior cortex still in continuity. IIA – a less severe injury with the distal fragment merely angulated. IIB – a severe injury; the fragment is both angulated and malrotated. Type III is a completely displaced fracture (although the posterior periosteum is usually still preserved, which will assist surgical reduction).  Clinical features pain and the elbow is swollen; with a posteriorly displaced fracture the S-deformity of the elbow is usually obvious and the bony landmarks are abnormal. essential to feel the pulse and check the capillary return; passive extension of the flexor muscles should be pain- free. The wrist and the hand should be examined for evidence of nerve injury.  X-ray seen most clearly in the lateral view In an undisplaced fracture the ‘fat pad sign’ should raise suspicions: there is a triangular lucency in front of the distal humerus, due to the fat pad being pushed forwards by a haematoma. In the common posteriorly displaced fracture the fracture line runs obliquely downwards and forwards and the distal fragment is tilted backwards and/or shifted backwards An anteroposterior view is often difficult to obtain without causing pain and may need to be postponed until the child has been anaesthetized.  It may show that the distal fragment is shifted or tilted sideways, and rotated (usually medially). Measurement of Baumann’s angle is useful in assessing the degree of medial angulation before and after reduction.  Treatment TYPE I: UNDISPLACED FRACTURE TYPE II A: POSTERIORLY ANGULATED FRACTURE MILD TYPES II B AND III: ANGULATED AND MALROTATED OR POSTERIORLY DISPLACED TREATMENT OF ANTERIORLY DISPLACED FRACTURES  TYPE I: UNDISPLACED FRACTURE The elbow is immobilized at 90 degrees and neutral rotation in a light-weight splint or cast and the arm is supported by a sling. It is essential to obtain an x-ray 5–7 days later to check that there has been no displacement. The splint is retained for 3 weeks and supervised movement is then allowed. The capitulum normally angles forward about 30 degrees; if the capitulum is in a straight line with the humerus on the lateral x-ray, it will still remodel. Even with Type I fractures, care must be taken to recognise any medial tilt of the distal fragment on the anteroposterior x-ray, otherwise cubitus varus can result. Measure Baumann’s angle. TYPE II A: POSTERIORLY ANGULATED FRACTURE MILD Traction for 2–3 minutes in the length of the arm with counter-traction above the elbow Correction of any sideways tilt or shift and rotation (in comparison with the other arm) Gradual flexion of the elbow to 120 degrees, and pronation of the forearm, while maintaining traction and exerting finger pressure behind the distal fragment to correct posterior tilt. If the acutely flexed position cannot be maintained without disturbing the circulation, or if the reduction is unstable, (and most of these fractures are unstable!) the fracture should be fixed with percutaneous crossed K- wires. TYPES II B AND III: ANGULATED AND MALROTATED OR POSTERIORLY DISPLACED These are usually associated with severe swelling, are difficult to reduce and are often unstable There is a considerable risk of neurovascular injury or circulatory compromise due to swelling The fracture should be reduced under general anesthesia as soon as possible, by the method of type I. Then held with percutaneous crossed K-wires; this obviates the necessity to hold the elbow acutely flexed Smooth wires should be used (this lessens the risk of physeal injury) Great care should be taken not to injure the ulnar, radial and median nerves.  ANTERIORLY DISPLACED FRACTURES Reduced by pulling on the forearm with the elbow semi-flexed, applying thumb pressure over the front of the distal fragment and then extending the elbow fully. Crossed percutaneous pins are used if unstable. A posterior slab is bandaged on and retained for 3 weeks. Thereafter, the child is allowed to regain flexion gradually.  Complications LATE EARLY Malunion Vascular injury Elbow stiffness and Nerve injury myositis ossifficans  FRACTURED HEAD OF RADIUS Radial head fractures are common in adults but are hardly ever seen in children  Mechanism of injury A fall on the outstretched hand with the elbow extended and the forearm pronated causes impaction of the radial head against the capitulum. The radial head may be split or broken. In addition, the articular cartilage of the capitulum may be bruised or chipped This cannot be seen on x-ray but is an important complication. The radial head is also sometimes fractured during elbow dislocation  Clinical features tenderness on pressure over the radial head pain on pronation and supination should suggest the diagnosis.  CLASSIFICATION Type I An undisplaced vertical split in the radial head Type II A displaced single fragment of the head Type III The head broken into several fragments (comminuted ). Type IV Radial head fracture with dislocation  X-ray Special radial head views, rather than simple PA and lateral views are needed to fully assess the fracture. The wrist also should be x-rayed to exclude a concomitant injury of the distal radioulnar joint, which would signify damage to the interosseous membrane (acute longitudinal radioulnar dissociation).  Treatment An undisplaced split (Type I) : pain relief can be achieved by aspirating the haematoma and injecting local anaesthetic. The arm is held in a collar and cuff for 3 weeks; active flexion, extension and rotation are encouraged. The prognosis for this injury is very good, although there is often some loss of elbow extension.  Treatment A single large fragment (Type II) If the fragment is displaced, it should be reduced and held with one or two small headless screws. A comminuted fracture (Type III) This is a challenging injury. Always assess for an associated soft tissue injury:  Rupture of the medial collateral ligament;  Rupture of the interosseous membrane (Essex Lopresti lesion)  Combined fractures of the radial head and coronoid process plus dislocation of the elbow – the ‘terrible triad’  Treatment If any of these is present, excision of the radial head is contra-indicated; this may lead to intractable instability of the elbow or forearm. The head must be meticulously reconstructed with small headless screws or replaced with a metal spacer. A medial collateral rupture, if unstable after replacing or fixing the radial head, should be repaired. Radial head excision usually gives a good long-term result if there are no contra-indications wrist pain from ulnar head impaction, valgus instability of the elbow and trochleo-olecranon arthritis can develop  Complications Joint stiffness Myositis ossificans Recurrent instability of the elbow  Common Functional Limitations/Disabilities Difficulty turning a doorknob or key in the ignition Difficulty or pain with pushing and pulling activities,such as opening and closing doors Restricted hand-to-mouth activities for eating and drinking and hand-to-head activities for personal grooming and using a telephone Difficulty or pain with pushing self up from a chair Inability to carry objects with a straight arm Limited reach Physical Therapy Management  Protection Phase Educate the Patient Gentle grade I or II distraction and oscillation techniques in the resting position may inhibit pain and move synovial fluid for nutrition in the involved joints. Passive or active-assistive ROM within limits of pain, including flexion/extension and pronation/supination Multiple-angle muscle setting of elbow flexors, extensors, pronators, and supinators and wrist flexors and extensors in pain-free positions Shoulder, wrist, and hand ROM and activities should be encouraged within the tolerance of the individual. If edema develops in the hand, the arm should be elevated whenever possible and distal-to-proximal massage techniques applied.  Controlled Motion Phase If joint hypo mobility exists, ROM is increased by utilizing joint mobilization techniques as well as passive stretching and muscle inhibition techniques Increase Soft Tissue and Joint Mobility by Initiate stretching cautiously and note the joint and tissue response. Vigorous stretching should not be undertaken until the chronic stage of healing. high-intensity stretching of the elbow flexors is contraindicated following trauma because of the potential for development of heterotopic bone formation Passive joint mobilization techniques.  Manual stretching and self-stretching begin wearing an adjustable, dynamic splint that applies a low-intensity stretch force over an extended period of time Home instructions Improve Joint Tracking of the Elbow Improve Muscle Performance and Functional Abilities  Return to Function Phase Improve Muscle Performance Restore Functional Mobility of Joints and Soft Tissues