Download Forearm Fractures

20140817 台中榮總 台灣骨科創傷醫學會103年度住院醫師研習營
陳建志
高雄醫學大學附設中和紀念醫院
骨科部
84 year-old male
Crushing injury
paper skin

7 months follow up
Result
Wrist pronation: 80°
Elbow ROM: 0°~130°
Wrist supination: 80°
Learning objectives
 The
principles of management
 The surgical and applied anatomy
 The treatment options
Fractures of the shaft
Galeazzi fracture
Monteggia fracture
Essex-Lopresti injury
 The complications and the outcomes
Introduction
PRUJ and DRUJ pronation and Supination
Muscle origin  inserting to the hand
 the daily activity
Principles of Management
Mechanisms of injury
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

A fall from standing height
A direct blow– fight
isolated fracture of the ulna- nightstick fr.
more stable, esp < 50% displacement
a road traffic accident
Principles of Management
History and Physical Examination


1.
2.
3.
Often displaced the diagnosis can
easily be made from the S/S
PE:
neurologic evaluation of the motor and
sensory functions
Compartment syndrome
The soft tissue injury of the elbow and
wrist
Galeazzi fracture, Monteggia fracture, EssexLopresti injury
•Rockwood and Green's Fracture in Adult -- 6th Ed
Monteggia Fracture- Dislocation
Fracture of the proximal ulna with a concomitant
dislocation of the radial head
 5% - 10% of all forearm fractures
 First described by Monteggia in 1814
 Radial head may be palpable at anterior or
posterior aspect of the elbow
 PIN injury: 17%
-- stretch-- recover spontaneously
-- entrapment-- irreducble Monteggia lesion

Galeazzi Fracture-Dislocation




3% of forearm fractures
Fracture of the radius at
the junction of M/3 and
D/3 associated with a
dislocation of the DRUJ
Reported by Galeazzi in
1934
Large force radial
shaft fracture
interosseous membrane
 TFCC injury and ulnar
head dislocation
Essex-Lopresti injury
Described by Essex-Lopresti in 1951
 Radioulnar dissociation:
A fall on the outstretch hand radial head
fracture disruption of both interosseous
membrane and DRUJ proxial migration
of the radius. Hotchkiss et al. in 1989
 may be associated with Galeaazzi fracture,
radial shaft fracture, and elbow dislocation

Principles of Management
Radiographic Findings
AP + lateral view, including
elbow and wrist
 Oblque view

Principles of Management
Classification
Principles of Management
Epidemiology
Classification of Monteggia Fracture
15-30%
59-79%
Type I
Type III
Bado type 2 fractures
modified by Jupiter and his
colleagues
Type 2a:
the distal part of lecranon and the coronoid
 Type 2 b:
Metaphyseal and diaphyseal junction distal to
coronoid
 Type 2c:
Diapyseal fracture
 Type 2d:
Extended into proximal half of the diaphysis of the
ulna

Classification of Galeazzi
Fracture
Type I:
the distal radial fracture < 7.5cm distal
radial articular surface, 6% DRUJ
instability
 Type II:
> 7.5cm, 55% DRUJ instability

Classification of Essex-Lopresti
injury

Edwards and Jupiter’s Classification
Depends on the type of radial head
fracture
Type 1: large displaced
Type 2: severely comminuted
Type 3: old injuries with irreducible proximal
migration of the radius
Surgical and Applied Anatomy
Bone and joint


5 articular surface
Rotational movement:
Radial bow: sage, 1959
Proximal:

Apex medial:13.10 , Apex anerior: 13.10
Distal
Apex lateral: 9.30 , Apex posterior: 6.40

Ulnar bow : relative straight
Apex posterior
Radial bow
Schemitsch and Richards, JBJSA, 1992
The radial bow : compared to the opposite side
<1.5mm difference
With 9% for the location
better function restoration

Surgical and Applied Anatomy
Interosseous membrane
Central band :
3.5cm in width,
2 or 3 times as thick as the
membranous part
 Stability:
Incision of the TFCC: 8%
poximal to central band:
11%
to central band: 71%

Hotchkiss et al. 1989
Surgical and Applied Anatomy
Anterior Muscle groups
Surgical and Applied Anatomy
Posterior Muscle groups

Pronation muscles:
pronator teres,
pronator quadratus,
flexor carpi radialis

Supination muscles:
Abductor pollicis longus and
brevis
Extensor pollicis longus
Biceps brachii
Surgical and Applied Anatomy
Nerves and arteries


Ulnar nerve
Median nerve
Anterior interosseous
nerve

Radial nerve
Superficial branch
Deep interosseous nerve


Radial artery
Ulnar artery

Anterior Interosseous N. (AIN) AIN
compressed by PT in forearm, injured in supracondylar
fractures
Flexor digitorum profundus [digits 2, 3]
Flexor pollicis longus [FPL]
Pronator Quadratus [PQ]

Posterior Interosseous N.(PIN)- Multiple sites of
compression: 1. fibrous tissue of radial head, 2. leash of Henry,
3. Arcade of Frohse, 4. distal supinator, 5. ECRB
Common Surgical Approaches
Surgical approaches to the Radius
Anterior or Henry Approach
Surgical Exposures in Orthopaedics - The Anatomic Approach 3rd edition.
Common Surgical Approaches
Surgical approaches to the Radius
Thompson Approach
Common Surgical Approaches
Surgical approaches to the ulna
Surgical Exposures in Orthopaedics - The Anatomic Approach 3rd edition.


Regarding implant position and surgical
approach, radioulnar synostosis is
associated with a single incision approach.
A double-incision approach is preferred by
the authors for ORIF of both-bone forearm
fractures. (OKU—11)
Current Treatment Options
Fractures of the forearm
Anatomic reduction, rigid fixation
 PRUJ and DRUJ
Anatomic reduction

 Early range of motion
Nonoperative treatment


Conservative treatment of displaced
forearm shaft fracture  poor functional
outcome, 92%
Isolated ulnar shaft fracture (<50%
displacement, angulation <100)
=> good satisfactory results,
by cast immobilization or functional
bracing
Operative Treatment
Timing of Surgery
As early as possible
 Open fracture: urgent debridement
followed by external or internal fixation
 Major trauma or poor soft tissue condition
 delayed

Plate fixation
Open reduction and plate fixation is the most common
method
Good union rate and functional results
related with the quality of reduction rather than the
types of implant used


The use of plate and screw results in a high union rate,
ranging from 95% to 98%
Dumont CE, et al. J Bone Joint Surg Br 2002
Hertel R, et al. Injury 1996
Mikek M, et al. Arch Orthop Trauma Surg 2004;
Plate fixation

restoration of the radial bow: improved range of
motion and grip strength.
Schemitsch EH, et al. J Bone Joint Surg Am
1992

however, a moderate reduction (30%) in
forearm, wrist, and grip strength has been
reported. Droll KP, et al. J Bone Joint Surg Am.
2007
Plate fixation
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The results are not related with the
implants used
Limited contact dynamic compression
plate (LC-DCP), the point contact fixator
(PC-Fix), locking compression plate (LCP)
The current literature lacks good evidence
to support one plating technique over
another.(OKU-11)
Intramedullary Nailing
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Kirschner wires, steinman pins, Rush pins  20%
nonunion rate, poor range of motion, Smith H, Sage FP,
1957
Sage nail  11% delayed or nonunion, Sage FP, 1959
ForeSight nail 
32 degree loss of rotation, 12.5% infection rate,
Gao et al. 2005
8%, Nonunion rate; 12%, loss of rotation
Weckbach, 2006
Treat Nonunion: 47%, unsatisfactory or poor results
Young Ho Lee,
Lee YH et al. JBJSA, 2008
Intramedullary Nailing
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
Surgical technique demanding
Can not fulfill the surgical goal of
restoration of normal bowing, adequate
rotational stability, and early mobilization
Intramedullary Nailing

Lee YH, et al. JBJSA, 2008
a high rate of osseous consolidation for simple
(noncomminuted) diaphyseal fractures.
81% excellent and 11% good results.
the need for a brace and longer periods of
immobilization
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The indications : pathologic fractures,
segmental fractures, and fractures with poor
soft tissue conditions. (Trauma OKU 4)
Intramedually device should not be used for
fixation of adult Monteggia fractures
External Fixation
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An alternative management of open fracture
In severely injured patient for damage control
16.5% malunion rate, 8.5% delayed or
nonunion rate, Schuind et al, 1991
For temporary fixation : the pins placed at ulna,
seldom necessary at the radius
Caution not to injury the nerve and artery
Management of Monteggia Fracture
Dislocation


Goal: anatomic relocation of the radial
head, with reduction and fixation of the
ulna
The radial head does not reduce after
accurate reduction of the ulna
interposition of the annular ligament 
retract and repair
Management of Monteggia Fracture
Dislocation


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Historically, poor results : 95% permanent
disability, Watson-Jones, 1943
Modern methods of fixation improved the
outcomes: 83% excellent or good results. Ring
D. et al.1998
The poor prognostic factors:
Bado type 2 fractures, Jupiter type 2a fractures,
radial head fracture, coronoid fracture,
ulnohumeral instability
Management of Galeazzi Fracture
Dislocation


Goal: relocation of the DRUJ, anatomic
reduction and rigid fixation of the radial
fracture
reduction of the DRUJ: confirmed by
images, 2 planes, and by passive rotation
of the forearm
Indications of Possible DRUJ
Instability
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Requirement of forceful reduction
A “ mushy” feel of the reduction
Fracture at the base of the ulnar styloid
Persistent incongruity of the distal ulna on a true lateral
view
Shortening (> 5 mm) of the radius (Ring et al. 2006)
Widening of the DRUJ on an AP view
2 Kirschner wires transfixation,
with the forearm in supinatioon
Long arm splint
For 6 weeks
Management of Galeazzi Fracture
Dislocation
If the DRUJ is
irreducible
 ECU, EDM, EDC
interposition
 retract the interposed
tissue , repair the tissue
defect
ORIF for ulnar styloid
fracture

Management of Galeazzi Fracture
Dislocation
Results: Moore et al. 1985
averaged restoration of finger grip strength
was 71%
Complication rate: 39% ,
Nonunion, malunion, infection, refracture
and instability of DRUJ, nerve injury

Management of Essex-Lopresti
Injury

Goals: restoration of the length of the
radius and stabilization of the DRUJ
Radial head fracture
Type 1 : ORIF,
Type 2: prosthesis inserted
 All concomitant injuries should be dealt

Management of Essex-Lopresti
Injury
Early detection and treatment improves the
outcome
 Late diagnosis:
 accurate realignment of the radius and ulna,
radial head replacement
 Distal ulnar shortening or Sauve-Kapandji
procedure
 reconstruction of the central band?? Chloros et
al. 2008

Management of Open Fractures of
the Forearm
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Thorough irrigation and debridement
Immediate internal fixation is considered
Moed et al.1986: 4% deep infection, 12@
nounion
85% good to excellent functional outcome
Chapman et al. 1989: 2% infection
Duncan et al. 1992: recommended immediate
plating in grade I, II, IIIA open fracutre
……
Management of Open Fractures of
the Forearm

Severe comminution: bridging plating

Bone graft : a secondary procedure

Soft tissue coverage for the implants
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Preoperative Planning: Checklist
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Properly taken radiographs
Correct diagnosis of the
fracture including classification
Patient positioning
Use of tourniquet
Reduction tools: pointed
reduction clips and bone
clamps
Which implant and set: 3.5mm
implant and 2.7mm screws
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Length of the plate
and number of screws
Need for lag screw or
prebent plate
Kind of approach
Need of bone graft
Closure technique
Plan of postoperative
rehabilitation
Personality of fracture
-
Soft-tissue damage
- Degree of fracture
displacement
- Degree of comminution
- Degree of joint involvement
- Osteoporosis
- Nerve/blood vessel injury
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Surgical Exposure
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The Henry approach is
used
Thompson approach : if
dorsal soft tissue injury
need debridement
Extrperiosteal dissection
Stripping periosteum
limited to 1-2mm at the
fracture ends
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Reduction and fixation
Direct reduction anatomic reduction
Simple transverse or spiral fractures or in wedge
fracture with large fragments
 Indirect reduction:
AO type C fractures with significant comminution

Author’s Preferred Treatment--Open Reduction and Plate Fixation
Choice of Implant
Conventional plating:
6-7 cortices in each main fragments

Locking plate:
at least 4 cortices in each main fragments
2 bicortical screws or 1 bicortical screw with
2 mono cortical screws

Locked Plating
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Highly comminuted ulna as a “Bridge plate”
Helpful in osteoporotic bone, non-unions
Increased stiffness….. Long term effect
not known
Routine use not appropriate
Bridge Plating
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Closure and aftercare
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Wound closure:
avoiding undue tension at edge
No need to suture the fascial layer
The bone and implant should be covered
Aftercare:
No splint if the stability is achieved
Keep the arm elevated and early active
movement of the elbow and wrist
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Pearls and Pifalls--- Which bone first?

The less comminution first

The same comminution radius first
Author’s Preferred Treatment--Open Reduction and Plate Fixation
Pearls and Pifalls--- Need for Bone
Graft
 Indications
controversial
 “Comminution with > 1/3rd cortical
circumference” Anderson et al., JBJS 1975
 Comminution when interfragmentary screw
fixation cannot be achieved
 Bone loss or defect with open fracture
 Necessity for routine bone grafting recently
questioned
Role of Bone Grafting
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
Autogenous bone graft did not increase
the union rates— Anderson ,1975
Wright et al. (1997) and Wei et al.
(1999)
“.. Acute bone grafting did not affect the
union rate or the time to union”
 “.. Routine use of bone graft in comminuted
forearm fractures is not indicated”
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Complications of Forearm Fractures
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Compartment syndrome
Neurovascular injury
Infection
Nonunion
Malunion
Refracture
Radioulnar Synostosis
Compartment syndrome
Relatively uncommon
 10%, Moed and Fakouri, 1991
 Fracture location is the only significantly risk
factor
In gunshot, proximal third
Young man, distal end of the radius
 Fasciotomy, volar decompression, single
curvilinear incision
 Median nerve compression is common
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Neurovascular injury
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Revascularization is usually unnecessary in
a single artery injury
Nerve injury
The PIN is most common
most neurapraxias  wait for 2-4 months
Iatrogenic injury
Infection
Immediate plate fixation of open fracture
 acceptable risk of infection

If infection does occur,
adequate debridement, copious irrigation
Antibiotics use
Implant removal is not advised if the fixation is
stable and the bone is vascularized

Nonunion
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Inadequate stability or devascularized
bone
IM nail  higher nonunion rate
Inappropriate implants ( one third tubular
plate), plates of inadequate length, failure
of precise reduction, open fracture
Nonunion rate < 2% in plate fixation
nonunion bone grafting
Malunion
Significant loss of function, especially in
forearm rotation
 IM nailing or closed reduction and cast
fixation
 Malunion osteotomy and rigid plate
fixation
 good results

Refracture


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Remove implant  30% refaracture rate
The original fracture site or through an old
screw tract
Higher risk: Excessively large screws, early
removal < 1 year
Radioulnar Synostosis

The incidence: 2-9%
More common with fractures of both
radius and ulna, esp at the same
level
Single one incision to treat both
fractures
Severe local trauma and delayed
ORIF
Head injury

Surgical excision of the
synostosis+ pain control, early
range of motion, Indomethacin
use
Conclusions
 Analysis of fracture mechanism and associated soft-
tissue lesions are vital to allow adequate treatment
planning


Complete reconstruction of anatomy is essential to
restore normal function
Stable fixation with long plates and early movement are
the keys to success
 Plate fixation gives good results
Further directions
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Locking implants
Interlocking nail
Minimal invasive plate osteosynthesis
Reference
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Rockwood and Green's Fracture in Adult -- 7th
Ed
OKU 9
OKU 10
OKU 11
Trauma OKU 4
Master technique in orthopaedics surgery, 2nd
Surgical Exposures in Orthopaedics - The
Anatomic Approach 3rd edition.
Netter's Concise Atlas of Orthopaedic Anatomy,
1st ed