PRESENTED BY: INTERNS 5TH BATCH DR. APARNA MISHRA DR. ADITI MISHRA DR.

SASHMI MANANDHAR

DEPARTMENT OF ORTHOPAEDICS DH - KUTH

CASES PRESENTED AS ..

CASE 1 . . .
HISTORY
9 YRS/ M, SINDHULI ON 30/08/10 FALL INJURY ON THE RIGHT FOREARM 6 HRS BACK PAIN UNABLE TO MOVE RT LIMB KHURKOT HOSPITAL > XRAY & REFERRED NO H/O OTHER INJURIES

CASE 1 . . .
GPE
GC NORMAL VITALS STABLE

L/E

SWELLING ABSENT DEFORMITY PRESENT NO WOUNDS TENDERNESS PRESENT ROM PAINFUL DNVS INTACT

CASE 1 . . . .
INV XRAY RT FOREARM: AP& LAT

CASE 1 . . . .
MANAGEMENT
SPLINT ANALGESICS CR &LAC IN IVA

CASE 2 . . .
HISTORY
9 YRS/M , BARABISE, 30/08/10 FALL INJURY ON LEFT FOREARM 4 HRS BACK PAIN , SWELLING INABILITY TO MOVE HIS FOREARM OPEN WOUND NO H/O OTHER INJURY

CASE 2 . . . .
GPE
GC NORMAL VITALS STABLE

L/E

SWELLING DEFORMITY WOUND 2 *1CM , VOLAR ULNAR ASPECT LT FOREARM TENDERNESS ROM PAINFUL DNVS INTACTROM PAINFUL

CASE 2 . . . .
INV
HB

13.1 gm/dl BT 2 min CT 10 min XRAY LT FOREARM AP &LAT

CASE 2 . . . .
MANAGEMENT
IRRIGATION & DEBRIDEMMENT SPLINT ANALGESICS ANTIBIOTICS CR & RUSH PIN FIXATION RADIUS # OR & RUSH PIN FIXATION ULNA # DRESSING

CASE 3 . . . .
HISTORY
12 YRS / M , KAVRE , 27/08/10 FALL INJURY ON RT FOREARM

CASE 3 . . . .
GPE
GC NORMAL VITALS STABLE

L/E

SWELLING DEFORMITY WOUND 1 *1CM , VOLAR ULNAR ASPECT LT FOREARM TENDERNESS ROM PAINFUL DNVS INTACTROM PAINFUL

CASE 3 . . . .
INV
HB

12.1 gm/dl BLOOD GRP - A + XRAY RT FOREARM AP & LAT

CASE 3 . . . .
MANAGEMENT
SPLINT ANTIBIOTICS ANALGESICS CR ATTEMPTED

BACKGROUND

INTRODUCTION

# of both radius and ulna

AO CLASSIFICATION - A
y A1 Simple fracture, of the ulna, radius

intact y .1 oblique y .2 transverse y .3 with dislocation of the radial head (Monteggia)

y A2 Simple fracture, of the radius, ulna

intact y .1 oblique y .2 transverse y .3 with dislocation of the distal radioulnar joint (Galeazzi)
y y y y

A3 Simple fracture of both bones .1 radius, proximal zone .2 radius, middle zone .3 radius, distal zone

AO CLASSIFICATION - B
B1 Wedge fracture, of the ulna, radius intact y .1 intact wedge y .2 fragmented wedge y .3 with dislocation of the radial head (Monteggia)
y

y B2 Wedge fracture, of the radius, ulna

intact y .1 intact wedge y .2 fragmented wedge y .3 with dislocation of the distal radioulnar joint (Galeazzi)

y B3 Wedge fracture, of the one bone,

simple or wedge fracture of the other y .1 ulna wedge and simple fracture of the radius y .2 radial wedge and simple fracture of the ulna y .3 ulnar and radial wedges

AO CLASSIFICATION - C
y y y y y y y y

C1 Complex fracture, of the ulna .1 bifocal, radius intact .2 bifocal, radius fractured .3 irregular C2 Complex fracture, of the radius .1 bifocal, ulna intact .2 bifocal, ulna fractured .3 irregular

y C3 Complex fracture, of both

bones y .1 bifocal y .2 bifocal of the one, irregular of the other y .3 irregular

# IN DISTAL REGION - I
y INCIDENCE: y Most common y M:F:: 3:1 y 6 12 yrs y CLASSIFICATION: y Physeal fractures (Salter Haris I and II)
y y

Distal radius Distal ulna

y Distal metaphyseal (radius or

ulna)
y y y

Torus (Convex elevation at the # site) Greenstick Complete fractures

y Galeazzi fracture dislocations Dorsal displaced Volar displaced

(Radial shaft # + dislocation of distal radioulnar jt)

y y

# IN DISTAL REGION - II
y MECHANISM OF INJURY: y Fall on outstretched hand y EVALUATION: y Symptoms:
y y

Tenderness, Swelling Silver fork or reverse apex deformity

y XRAY: y Deformity y Rule out the injuries to radioulnar joint and humerus

# IN DISTAL REGION - II
y TREATMENT: y Acceptibility criteria:
y y

50% apposition 1 cm overlap

25 deg angulation

y Non displaced and torus: 4 wks y Sugar tong splint Short arm cast Munster cast y Greenstick #: y Reduction with completion of the # on the concave side + splinting y Displaced # y Reduction before hematoma formation under anaesthesia y Immobilization in the most stable position y Operative: Indication y I/L supracondylar # y Open # y Compartment syndrome y Carpal tunnel syndrome

y COMPLICATIONS: y VIC Cross union of radius and ulna y Tear of triangular fibrocartilage

# IN THE SHAFT - I
y INCIDENCE: y Most common reason for orthopaedic surgery of the forearm y CLASSIFICATION: y Nondisplaced # y Greenstick # y Displaced # y Plastic formation

# IN THE SHAFT - II
y MECHANISM OF INJURY: y Fall on outstretched hand y Plastic deformation (bowing) of radius and ulna y EVALUATION: y Symptoms:
y y y

Tender # site Aggravated on supination and pronation Deformity depending on degree of displacement

y y

XRAY: AP and lateral Asociated injuries:

y y y

Supracondylar humerus # Monteggia # Galeazzi #

# IN THE SHAFT - III

y TREATMENT: y Non displaced: LRC for 4 6 wks y Greenstick:
y y

Correction of rotation and angulation LAC with elbow in flexion

y Displaced: y Reduction and stabilization under anaesthesia y Operative indications: y Open # Segmental # I/L upper extremity injury y Failure of reduction and stabilization y Operative methods: fixation of both # y Plate and screws: Rotational stability y Intramedullary fixation: # must be reducible y External fixation: Soft tissue injury y Plastic: y < 6 yrs: reduction not necessary y > 6 yrs: reduction with 3 point pressure + LAC for 6 wks

y COMPLICATIONS: y Refracture Compartment Syndrome y Cross healing with a creation of radioulnar synostosis y Loss of rotation

MONTEGGIA # - I
y INTRODUCTION: y # of ulna with dislocation of radiocapitellar joint y INCIDENCE: y Age: 7-10 yrs y CLASSIFICATION: (Bado, acc

to disloc of radial head)

y y

Type I: Ant, commonest Type II: Post, common in adults y Type III: Lateral y Type IV: Type I + radial shaft #

MONTEGGIA # - II
y MECHANISM OF INJURY: y Type I: Direct blow on the post aspect of the forearm, hyperpronation, fall on hyper extended elbow y Type II: Elbow flexion y Type III, IV: Unclear y EVALUATION: y Symptoms:
y y

forearm rotation With or without palpable radial head

XRAY: AP and lateral

y

Normal: long axis of the radius intersects the centre of the capitellum

MONTEGGIA # - III
y TREATMENT: y Closed RX: Deformity of ulna reversed and radial head manually reduced + Cast for 4 wks y Open RX:
y y

Removal of interposed tissue + reconstruction of annular ligament ORIF of ulna and fixation of radial head to capitellum

y Delayed Open RX: y Open reduction of radiocapitellar joint and reconstruction of annular ligament

y COMPLICATIONS: y Cubitus Valgus y Collateral ligament instability y Redislocation of radial head y Non union or malunion of ulna y PIN injury

BOTH BONE # OF FOREARM IN ADULTS

y Closed reduction and casting not unacceptable y RX of choice: ORIF with plate and screw fixation y DCS for interfragmentary compression y Bone grafting: Indications y Comminution involving >1/3 diaphyseal cortex at # site y Segmental bony defects y Significant depression of radial articular surface

AND THE JOURNALS SAY

Journal of Pediatric Orthopaedics: May/June 2005

54 operations in 50 patients with both-bones fractures: fractures healed within 8 to 10 weeks, except for two delayed unions and one nonunion Complication rate was 5% for closed treatment, 33% for ORIF, and 42% for IM nailing. More complications with operative techniques ORIF had more major complications

Recent studies
y Prasarn et al reported on a treatment protocol for

repair of infected nonunions of diaphyseal forearm fractures in 15 patients

y patients had at least 50 of supination/pronation and

30-130 of flexion/extension arc (except 3) y average time to union was 13.2 weeks (range, 10-15 weeks).1

y Jan 8 2010: Janos P ertl y Teoh et al compared the differences in

radiographic and functional outcomes of unstable both-bone diaphyseal forearm # after t/t with either IM fixation or plate fixation with screws y Osteomyelitis occur in the IM fixation group y Ulnar never palsy occurred in the plate-fixation group y Nonunion or malunion was not observed

Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius
y 3 April 2000, journal of pediatrics orthopedics y 50 children (5 to 14 years; mean age 11 years) with

unstable diaphyseal forearm #, closed reduction has been unsuccessful

y ORIF of radius only y After anatomical reduction and fixation of the radius

the ulnar fracture had a better alignment

Acceptable Alignment of Forearm Fractures in Children: Open Reduction Indications

y Journal of Pediatric Orthopaedics B: March 2010
y Complex or unstable # / Not maintained in acceptable

alignment- surgical intervention

y angulation is more critical for preservation of forearm

rotation

y 15 degrees angulation is recommended as maximum

angulation for mid-shaft and distal-shaft fractures in children younger than 8 years y 10 degrees is recommended as the maximum acceptable angulation for older children and proximal shaft fractures y fractures with complete displacement will remodel satisfactorily

Hand dominance and gender in forearm fractures in children

y Freih Odeh Abu Hassan november 2008

y 181 children aged 2 15 years presenting with

unilateral forearm fracture were examined over a 6-year period

y . Forearm fractures:

a. more in boys 70.2% b. more common on the left side c. Isolated distal radius fracture is more common 63.3% d. Mean age for boys : 8.97 Mean age for Girls: 5.98

REFERENCE
y Rockwood and Wilkins Fracture in Children y Brinker Review of Orthopaedic Trauma

THANK YOU