FRACTURES OF

FOREARM

Oktya Veny Simbolon

Pattiyah
Prehandini Ayuningtyas
 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
 NAMED FRACTURES
OF FOREARM ,
WRIST & HAND
• Monteggia fracture dislocation
• Galeazzi fracture dislocation
• Colles’ fracture
• Smith’s fracture
• Barton’s fracture
• Chauffer’s fracture
MONTEGGIAFRACTURE
DISLOCATION
• This fracture is named
after Giovanni Battista
Monteggia ,an Italian
surgeon.
MONTEGGIA FRACTURE DISLOCATION

• A fracture of the proximal third of ulna with

dislocation of the head of the radius .
 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
 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
• MOI - Fall on an outstretched hand
- Direct blow on the back of upper
forearm

Classification system – Bado classification ( 4

types )

• 2 major types – Extension type & Flexion type

• TREATMENT
Closed Manual Reduction & AE Slab
Application
( Monitor closely by weekly Check X rays
because there is high chance of redisplacement)

Open Reduction & Internal Fixation using a

plate
COMPLICATIONS

• Malunion (especially if treated conservatively)

• Deformity & limitation of forearm
movements)
 GALEAZZI FRACTURE DISLOCATION
• Named after Ricardio Galeazzi ,an Italian
Orthopaedician .

• A fracture of the distal third of radius with

dislocation or subluxation of the distal radio
ulnar joint .
 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
• MOI - Fall on an
outstretched hand

• A FRACTURE OF
NECESSITY
• TREATMENT

Closed Manual Reduction ( difficult to attain &

maintain except in children)

Open Reduction & Internal Fixation with a

plate
COMPLICATIONS

• Malunion

• Deformity & limitation of supination &

pronation
COLLES’FRACTURE
• Named after Abraham
Colles , Professor
of Anatomy, Surgery
and Physiology at
the Royal College of
Surgeons in Ireland .
 COLLES’FRACTURE
• A fracture at the distal end of the radius , at its
cortico cancellous junction with typical
displacement .
• Commonest fracture in adults above 40 years
of age .

• Common in women because of

postmenopausal osteoporosis
• MOI - Fall on an outstretched hand

• Displacements –

 Impaction of fragments
 Dorsal displacement
 Dorsal tilt
 Lateral displacement
 Lateral tilt
 Supination
• COMMON ASSOCIATED INJURIES

• Fracture of the styloid process of ulna

• Rupture of the ulnar collateral ligament
• Rupture of the triangular cartilage of the ulna
• Rupture of the interosseous radio ulnar
ligament , causing radio ulnar subluxation
• Classical Deformity :
“ Dinner Fork Deformity “
• TREATMENT

• If Undisplaced - Immobilisation in a BE Plaster

Slab / Cast .

• If Displaced - CMR , followed by

immobilisation in Colles’ cast .
• CMR -
 Relaxation of the forearm muscles
 Disimpaction of the fragments
 Correction of the displacement
 Plaster application

• Check X ray

• Encourage active finger movements & elbow &

shoulder movements through their full range
• In Young Individuals ,

o Percutaneous Transfixation using K wires

o External fixator

o Fixation using LCP

• COMPLICATIONS

 Stiffness of joints (Finger stiffness is the

commonest complication)
 Malunion ( Correct malunion by osteotomy if there
is an ugly deformity / if it hampers the day to day
activities of the individual)
 Subluxation of the IRUJ – painful & restriction of
wrist movements ( Excision of the lower end of
ulna – Darrach’s resection – in selected cases)
 Carpal Tunnel Syndrome ( median nerve is compressed
in the carpal tunnel by the encroaching fracture callus)

 Sudeck’s osteodystrophy – Colles’ fracture being the

commonest cause of Sudeck’s osteodystrophy in upper
limb ( Intensive Physiotherapy is required )

 Rupture of EPL - either due to loss of blood supply to

the tendon at the time of injury or due to friction on th
tendon during its movements over the malunited
fracture ( needs tendon transfer)
 SMITH’S FRACTURE
• Named after Robert William Smith ,an Irish
surgeon .
• Reverse of Colles’ fracture
• Uncommon

• Distal fragment
displaces
ventrally & tilts
ventrally

• TREATMENT –
CMR & plaster
immobilsation for
6 weeks
 BARTON’S FRACTURE
• Named after John Rhea Barton ,an American
surgeon.

• An intra articular fracture of the distal end of

radius – the fracture extends from the radius
to either its anterior or posterior cortices .

• 2 types – Volar & Dorsal ( depending on the

displacement of the distal fragment)
• TREATMENT

• Closed Manual Reduction & Plaster

immobilisation

• Open reduction & internal fixation with a plate

( if CMR fails & as a primary choice in young
adults with significantly displaced fractures)
 CHAUFFER’SFRACTURE
( Backfire fracture / Hutchison fracture)

• A fracture of the radial styloid process

• The name originates from
early chauffeurs who
sustained these injuries
when the car back-fired
while the chauffeur
was hand-cranking to start
the car.

• The back-fire forced the

crank backward into the
chauffeur's palm and
produced the characteristic
styloid fracture.
 Principles of Management
Mechanisms of injury
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
Often displaced the diagnosis can easily be
made from the S/S
PE:
1. neurologic evaluation of the motor and
sensory functions
2. Compartment syndrome
3. The soft tissue injury of the elbow and wrist
Galeazzi fracture, Monteggia fracture, Essex-
Lopresti injury
•Rockwood and Green's Fracture in Adult -- 6th Ed
 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
The results are not related with the implants
Plate
used fixation
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
Kirschner Nailing
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
Surgical technique demanding
Can not fulfill the surgical goal of restoration of
normal bowing, adequate rotational stability,
and early mobilization
Lee YH, et al. JBJSA, 2008
Intramedullary Nailing
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

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
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
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
Goal: relocation of the DRUJ, anatomic
Management of Galeazzi Fracture
reduction and rigid fixation of the radial fracture
Dislocation
reduction of the DRUJ: confirmed by images, 2
planes, and by passive rotation of the forearm
 Indications of Possible
DRUJ Instability
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
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
Properly taken radiographs Length of the plate and
Correct diagnosis of the fracture
including classification number of screws
Patient positioning Need for lag screw or
Use of tourniquet
Reduction tools: pointed reduction
prebent plate
clips and bone clamps Kind of approach
Which implant and set: 3.5mm Need of bone graft
implant and 2.7mm screws
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
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
Highly comminuted ulna as a “Bridge plate”
Locked
Helpful Platingbone, non-unions
in osteoporotic
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
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
Pearls and Pifalls---
Plate Fixation
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
Autogenous bone graft did not increase the
Role
union of Bone
rates— AndersonGrafting
,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”
 Complications of Forearm
Fractures
Compartment syndrome
Neurovascular injury
Infection
Nonunion
Malunion
Refracture
Radioulnar Synostosis
Relatively uncommon
Compartment syndrome
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
Revascularization is usually unnecessary in a
Neurovascular
single artery injury injury
Nerve injury
The PIN is most common
 most neurapraxias  wait for 2-4 months
Iatrogenic injury
Immediate plate fixation of open fracture
Infection
 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
Inadequate stability or devascularized bone
Nonunion
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
Significant loss of function, especially in forearm
Malunion
rotation
IM nailing or closed reduction and cast fixation
Malunion osteotomy and rigid plate fixation
 good results
Remove implant  30% refaracture rate
Refracture
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
 SUMMARY
• Monteggia fracture dislocation FRACTURE OF
ULNA

• Galeazzi fracture dislocation FRACTURES OF

• Colles’ fracture RADIUS

• Smith’s fracture