CASE REPORT APRIL 2014

Closed Fracture Right Neck u!erus

O"e# Fracture 1$% &istal Right Radius 'rade IIIA
Closed Fracture Right (ase )etacar"al Little Fi#ger
Right &R*+ &isru"tio#
(,-
Dian Megawati C 111 09 139
Ad.isors-
dr. Nia Irayati
dr. Mervin Jakarimilena
Su"er.isor-
dr. Zulfan Oktasatria iregar! ". O#
Ort$%"aedi& and #raumat%l%gy De"artment
'asanuddin (niversity
Makassar
)01*
ALA)AN PEN'ESAAN
+ang ,ertandatangan di ,awa$ ini menyatakan ,a$wa -
Nama .%as - &ia# )ega/ati R0 L0 (
NIM - C 111 01 1%1
Judul /a"%ran .asus - Closed Fracture Right Neck Humerus, Open Fracture 1/3 Distal
Right Radius Grade III, Closed Fracture Right !ase "etacarpal
#ittle Finger, Right DR$% Disruption
#ela$ menyelesaikan tugas dalam rangka ke"aniteraan klinik "ada ,agian Ort%"edi dan
#raumat%l%gi! 0akultas .ed%kteran (niversitas 'asanuddin.
Makassar! 1"ril )01*
Mengeta$ui
2em,im,ing
dr0 Nia Ira,ati
dr0 )er.i# +akari!ile#a

Mengeta$ui
u"ervis%r!
dr0 2ul3a# Oktasatria Siregar4 S"0 OT
CONTENTS
CO345 2164
'1/1M1N 24N641'1N.............................................................................ii
CON#4N#........................................................................................................iii
I. C14 542O5#......................................................................................1
II. DIC(ION.........................................................................................7
540454NC4
CASE REPORT
Closed Fracture Right Neck u!erus4 O"e# Fracture 1$% &istal Right
Radius 'rade IIIA4 Closed Fracture Right (ase )etacar"al Little Fi#ger4
Right &R*+ &isru"tio#
A0 PATIENT5S I&ENTIT6
Name Initial - Mr. M
Date %f 8irt$91ge - *3 years %ld
6ender - Male
Date %f 1dmissi%n - 1"ril ))
nd
)01*
5egistrati%n Num,er - 77011:
tatus - (mum
(0 ISTOR6 TA7IN'
Auto a#a!#esis
Chie3 co!"lai#t - ;%und at 5ig$t 0%rearm
uffered sin&e 1< $%urs ,ef%re admitted t% ;a$idin 6eneral '%s"ital due t% m%t%r
ve$i&le a&&ident. 'ist%ry %f un&%ns&i%us =>?! v%mit =>?! nausea =>?.
)echa#is! o3 I#8ur, - ;$ile t$e "atient was riding a m%t%r&y&le suddenly $it ,y a
tru&k fr%m t$e fr%nt. 'e fell t% t$e rig$t side and $is $and ,um"ed t$e as"$alt first. 'e
r%de t$e m%t%r&y&le in l%w s"eed and s% did t$e tru&k. 'e didn@t use $elmet at t$e
time %f t$e in&ident. #$e "atient is a farmer and a rig$t>$anded. 2ri%r treatment at
MamuAu '%s"ital.
C0 P6SICAL E9A)INATION
10 Pri!ar, Sur.e,
1irway and C>s"ine Management- Clear! "atent
8reat$ing- 5es"irat%ry 5ate 1B C9minute! symmetri&! s"%ntane%us!
t$%ra&%a,d%minal ty"e
Cir&ulati%n and 8leeding C%ntr%l- 8l%%d 2ressure 1109:0 mm'g! 'eart rate
B*C9minute! regular! str%ng
Disa,ility- 6C 1< =4*M73<?! "u"ils is%&$%r! diameter )!< mm9)!< mm! lig$t
refleC =D9D?
4nvir%nment- #em"erature 37!B
%
C =1Cillary?
20 Seco#dar, Sur.e,
Right Ar! Regio#
/%%k - Def%rmity =>?! swelling =D?! $emat%ma =D?! stit&$ed w%und
anter%"r%Cimal as"e&t! siEe 1&m
0eel - #enderness =D?! sensi,ility is g%%d! "ulsati%n %f t$e radial artery is
"al"a,le! &a"illary refill time F)G
M%ve - 1&tive and "assive m%vement %f t$e s$%ulder A%int &an@t ,e
evaluated 1&tive and "assive m%vement %f t$e el,%w A%int &an@t ,e
evaluated
Right Forear! Regio#
/%%k - Def%rmity =D? angulati%n ty"e! swelling =D?! $emat%ma =D?! stit&$ed
w%und anteri%r as"e&t siEe 7&m
0eel - #enderness =D?! sensi,ility is g%%d! "ulsati%n %f t$e radial artery is
"al"a,le! &a"illary refill time F)G
M%ve - 1&tive and "assive m%vement %f t$e el,%w A%int &an@t ,e evaluated.
1&tive and "assive m%vement %f t$e wrist A%int &an@t ,e evaluated
Right a#d Regio#
/%%k - Def%rmity =>?! swelling =D?! $emat%ma =D?! stit&$ed w%und d%rsal
as"e&t as level MC2 A%int <t$ finger! siEe )&m
0eel - #enderness =D?! sensi,ility is g%%d! "ulsati%n %f t$e radial artery is
"al"a,le! &a"illary refill time F)G
M%ve - 1&tive and "assive m%vement %f t$e wrist A%int &an@t ,e evaluated
due t% "ain! a&tive and "assive m%vement %f t$e MC2! I2 A%int %f t$e
t$um, are limited! a&tive and "assive m%vement %f t$e MC2! 2I2!
DI2 A%int %f t$e )nd! 3rd! *t$ fingers are limited! a&tive and "assive
m%vement %f t$e MC2! 2I2! DI2 %f <t$ finger &an@t ,e evaluated due
t% "ain
2i&ture 1. Clini&al 2i&ture %f 1rm and 0%rearm =1nteri%r 3iew?
2i&ture ). Clini&al 2i&ture %f 1rm and 0%rearm =/ateral 3iew?
2i&ture 3. Clini&al 2i&ture %f 1rm and 0%rearm =Inferi%r 3iew?
2i&ture *. Clini&al 2i&ture %f 1rm and 0%rearm =2%steri%r 3iew?
2i&ture <. Clini&al 2i&ture %f 'and =1nteri%r 3iew?
2i&ture 7. Clini&al 2i&ture %f 'and 2%steri%r 3iew?
&0 Others E:a!i#atio#
10 La;orator, Fi#di#gs
'emat%l%gy =))9*9)01*?
58C *!0) C 1039mm3
'68 10!7 g9d/
'C# 31!7 H
;8C 13!: C 1039mm3
2/# ):9 C 1039mm3
C# B@00G
8# 3@00@
20 Radiolog, Fi#di#gs
2i&ture :. 21 I>5ay %f &$est taken in Dr. ;a$idin udir%$us%d% '%s"ital
=))90*9)01*?- ;it$in n%rmal limit
2i&ture B. I>5ay %f 12 and /ateral 3iew %f =5? 1rm and 4l,%w J%int taken in Dr.
;a$idin udir%$us%d% '%s"ital =))9*9)01*?- 0ra&ture %f Ne&k 'umerus
2i&ture 9. I>5ay %f 12 and /ateral 3iew %f =5? 0%rearm taken in Dr. ;a$idin
udir%$us%d% '%s"ital =))9*9)01*?- 0ra&ture 193 Distal 5adius
2i&ture 10. I>5ay %f 12 and O,liJue 3iew %f =5? 'and taken in Dr. ;a$idin
udir%$us%d% '%s"ital =))9*9)01*?- 0ra&ture 8ase Meta&ar"al /ittle 0inger!
D5(J Disru"ti%n
E0 RES*)E
Man! *3 years %ld! admitted t% Dr. ;a$idin udir%$us%d% '%s"ital due t%
w%und at t$e rig$t f%rearm eC"erien&ed sin&e 1< $%urs ,ef%re admissi%n. 2ri%r
treatment at MamuAu '%s"ital. Me&$anism %f inAury is w$ile t$e "atient was riding a
m%t%r&y&le suddenly $it ,y a tru&k fr%m t$e fr%nt. 'e fell t% t$e rig$t side and $is
$and ,um"ed t$e as"$alt first. 'e r%de t$e m%t%r&y&le in l%w s"eed and s% did t$e
tru&k. 'e didn@t use $elmet at t$e time %f t$e in&ident.
2$ysi&al eCaminati%n! %n t$e rig$t arm regi%n t$ere is swelling! $emat%ma!
stit&$ed w%und anter%"r%Cimal as"e&t! siEe 1&m! and tenderness. #$e sensi,ility is
g%%d! "ulsati%n %f t$e radial artery is "al"a,le! &a"illary refill time F)G! a&tive and
"assive m%vement %f t$e s$%ulder A%int and t$e el,%w A%int &an@t ,e evaluated due t%
"ain. On t$e rig$t f%rearm regi%n t$ere is def%rmity =angulati%n ty"e?! swelling!
$emat%ma! stit&$ed w%und at anteri%r as"e&t siEe 7&m! and tenderness.
#$e sensi,ility is g%%d! "ulsati%n %f t$e radial artery is "al"a,le! C5# F)G!
a&tive and "assive m%vement %f t$e el,%w A%int and t$e wrist A%int &an@t ,e evaluated
due t% "ain. On t$e rig$t $and t$ere is $emat%m! swelling! and stit&$ed w%und at
d%rsal as"e&t as level MC2 A%int <t$ finger siEe )&m! and tenderness. #$e sensi,ility is
g%%d! d%rsalis "edis artery and ti,ialis "%steri%r artery are "al"a,le! C5# F)G! a&tive
and "assive m%vement %f t$e wrist A%int and t$e MC2! 2I2! DI2 %f <t$ finger &an@t ,e
evaluated due t% "ain! a&tive and "assive m%vement %f t$e MC2! I2 A%int %f t$e
t$um,! and MC2! 2I2! DI2 A%int %f t$e )nd! 3rd! *t$ fingers are limited.
5adi%l%gy findings fr%m I>5ay %f 12 and /ateral 3iew %f =5? 1rm and
4l,%w J%int is 0ra&ture %f Ne&k 'umerus! I>5ay %f 12 and /ateral 3iew %f =5?
0%rearm is 0ra&ture 193 Distal 5adius! and I>5ay %f 12 and O,liJue 3iew %f =5?
'and is 0ra&ture 8ase Meta&ar"al /ittle 0inger! D5(J Disru"ti%n
F0 &IA'NOSE
Cl%sed fra&ture rig$t ne&k $umerus
O"en fra&ture 193 distal rig$t radius grade III1
Cl%sed fra&ture rig$t ,ase meta&ar"al little finger
5ig$t D5(J disru"ti%n
'0 TREAT)ENT
I30D
1nalgesi&
1nti,i%ti&
De,ridement
2lan f%r O5I0
Closed Fracture Right Neck u!erus
A0
INTRO&*CTION
#$e "r%Cimal $umerus &%nsists %f t$e arti&ular surfa&e %f t$e s$%ulder A%int
and t$e atta&$ments %f t$e r%tat%r &uff t% t$e greater and lesser tu,er%sities. M%st
%f t$e ,l%%d su""ly t% t$e $umeral $ead &%mes fr%m t$e anteri%r $umeral
&ir&umfleC ,ran&$ %f t$e aCillary artery. M%re t$an 90H %f "r%Cimal $umeral
fra&tures result fr%m a l%w>energy fall dire&tly %nt% t$e s$%ulder. 2atients wit$
%ste%"%r%ti& ,%ne are at t$e $ig$est risk. In n%n%ste%"%r%ti& "atients! fra&tures
result fr%m $ig$>energy trauma. Neer@s &lassifi&ati%n divides t$e "r%Cimal
$umerus int% * "arts
=1?
-
i. 1rti&ular surfa&e
ii. 6reater tu,er%sity
iii. /esser tu,er%sity
iv. urgi&al ne&k =t$e ,%rder ,etween t$e r%und "r%Cimal meta"$ysis
and t$e dia"$yseal "%rti%n %f t$e ,%ne?
v. 0ra&tures are &lassified as $aving 1KLM* "arts! ,ased %n t$e num,er
%f fragments! wit$ a fragment defined as a "art if it is dis"la&ed N1
&m and9%r angulated N*<OP.
(0
EPI&E)IOLO'6
2r%Cimal $umerus fra&tures &%m"rise *H t% <H %f all fra&tures and re"resent
t$e m%st &%mm%n $umerus fra&ture =*<H?. #$e in&reased in&iden&e in t$e %lder
"%"ulati%n is t$%ug$t t% ,e related t% %ste%"%r%sis. 5isk f%r a "r%Cimal $umeral
fra&ture in&reases wit$ age! "eaking in t$e 9t$ de&ade. #$e )-1 female>t%>male
rati% is likely related t% issues %f ,%ne density0
=1!)?
C0
ANATO)6
#$e s$%ulder $as t$e greatest range %f m%ti%n %f any arti&ulati%n in t$e ,%dyQ
t$is is due t% t$e s$all%w glen%id f%ssa t$at is %nly )<H t$e siEe %f t$e $umeral
$ead and t$e fa&t t$at t$e maA%r &%ntri,ut%r t% sta,ility is n%t ,%ne! ,ut a s%ft
tissue envel%"e &%m"%sed %f mus&le! &a"sule! and ligaments.#$e "r%Cimal
$umerus is retr%verted 3< t% *0 degrees relative t% t$e e"i&%ndylar aCis. #$e f%ur
%sse%us segments =Neer? are t$e $umeral $ead! t$e lesser tu,er%sity! t$e greater
tu,er%sity! and t$e $umeral s$aft.
=)?
Def%rming mus&ular f%r&es %n t$e %sse%us segments - t$e greater tu,er%sity is
dis"la&ed su"eri%rly and "%steri%rly ,y t$e su"ras"inatus and eCternal r%tat%rs! t$e
lesser tu,er%sity is dis"la&ed medially ,y t$e su,s&a"ularis! t$e $umeral s$aft is
dis"la&ed medially ,y t$e "e&t%ralis maA%r! t$e delt%id inserti%n &auses a,du&ti%n
%f t$e "r%Cimal fragment. #$e neur%vas&ular su""ly are fr%m-
=)!3?
a. #$e maA%r ,l%%d su""ly is fr%m t$e anteri%r and "%steri%r $umeral
&ir&umfleC arteries.
,. #$e ar&uate artery is a &%ntinuati%n %f t$e as&ending ,ran&$ %f t$e anteri%r
$umeral &ir&umfleC. It enters t$e ,i&i"ital gr%%ve and su""lies m%st %f t$e
$umeral $ead. mall &%ntri,uti%ns t% t$e $umeral $ead ,l%%d su""ly arise
fr%m t$e "%steri%r $umeral &ir&umfleC! rea&$ing t$e $umeral $ead via
tend%>%sse%us anast%m%ses t$r%ug$ t$e r%tat%r &uff. 0ra&tures %f t$e
anat%mi& ne&k are un&%mm%n! ,ut t$ey $ave a "%%r "r%gn%sis ,e&ause %f
t$e "re&ari%us vas&ular su""ly t% t$e $umeral $ead.
&. #$e aCillary nerve &%urses Aust anter%inferi%r t% t$e glen%$umeral A%int!
traversing t$e Juadrangular s"a&e. It is at "arti&ular risk f%r tra&ti%n inAury
%wing t% its relative rigid fiCati%n at t$e "%steri%r &%rd and delt%id! as well
as its "r%Cimity t% t$e inferi%r &a"sule w$ere it is sus&e"ti,le t% inAury
during anteri%r disl%&ati%n and anteri%r fra&ture>disl%&ati%n.
2i&ture 11. 1nat%my %f 'umerus
=3?
2i&ture 1). 1nat%my %f 2r%Cimal 'umeral 3as&ular
=*?
&0
ETIOPATO)ECANIS)
M%st &%mm%n is a fall %nt% an %utstret&$ed u""er eCtremity fr%m a standing
$eig$t! ty"i&ally in an %lder! %ste%"%r%ti& w%man. +%unger "atients ty"i&ally
"resent wit$ "r%Cimal $umeral fra&tures f%ll%wing $ig$>energy trauma! su&$ as a
m%t%r ve$i&le a&&ident. #$ese usually re"resent m%re severe fra&tures and
disl%&ati%ns! wit$ signifi&ant ass%&iated s%ft tissue disru"ti%n and multi"le
inAuries. /ess &%mm%n me&$anisms in&lude-
=)?
a. 4C&essive s$%ulder a,du&ti%n in an individual wit$ %ste%"%r%sis! in w$i&$
t$e greater tu,er%sity "revents furt$er r%tati%n.
,. Dire&t trauma! usually ass%&iated wit$ greater tu,er%sity fra&tures.
&. 4le&tri&al s$%&k %r seiEure.
d. 2at$%l%gi& "r%&esses- malignant %r ,enign "r%&esses in t$e "r%Cimal
$umerus.
1ss%&iated &%nditi%n t$at may ,ring int% "r%Cimal $umeral fra&ture su&$ as
disl%&ati%n %f t$e glen%$umeral A%int! &%m"lete r%tat%r &uff tears %&&ur in )0H %f
&ases! "arti&ularly greater tu,er%sity fra&tures! aCillary and su"ras&a"ular nerve
inAury! vas&ular inAury t% aCillary vessels %r t$eir ,ran&$es! es"e&ially in t$e
"resen&e %f at$er%s&ler%sis.
=1?
Classi3icatio#
#$e m%st &%mm%nly used &lassifi&ati%n system f%r "r%Cimal $umeral fra&tures
is t$at %f Neer. 1lt$%ug$ limited relia,ility! re"r%du&i,ility am%ng %,servers! and
&%nsisten&y ,y t$e same %,server at different times $ave ,een &ited as limitati%ns
%f t$e Neer system! it remains useful in guiding treatment. Classifi&ati%n is ,ased
%n t$e f%ur>"art anat%my %f t$e "r%Cimal $umerus- t$e $umeral $ead! t$e lesser
and greater tu,er%sities! and t$e "r%Cimal $umeral s$aft. #$e &riteri%n f%r
dis"la&ement is greater t$an 1 &m %f se"arati%n %f "art %r angulati%n %f *<
degrees. Dis"la&ed t$ree>"art and f%ur>"art fra&tures markedly alter t$e arti&ular
&%ngruity %f t$e glen%$umeral A%int and $ave t$e $ig$est likeli$%%d %f disru"ting
t$e maA%r ,l%%d su""ly t% t$e "r%Cimal $umerus. Oste%ne&r%sis is m%st likely
after dis"la&ed f%ur>"art fra&tures.
=*?
2i&ture 13. Neer@s Classifi&ati%n %f 2r%Cimal 'umeral 0ra&ture
=*?
E0
CLINICAL FEAT*RES
2atients ty"i&ally "resent wit$ t$e u""er eCtremity $eld &l%sely t% t$e &$est ,y
t$e &%ntralateral $and! wit$ "ain! swelling! tenderness! "ainful range %f m%ti%n!
and varia,le &re"itus. C$est wall and flank e&&$ym%sis may ,e "resent and s$%uld
,e differentiated fr%m t$%ra&i& inAury. 1 &areful neur%vas&ular eCaminati%n is
essential! wit$ "arti&ular attenti%n t% aCillary nerve fun&ti%n. #$is may ,e assessed
,y t$e "resen&e %f sensati%n %n t$e lateral as"e&t %f t$e "r%Cimal arm %verlying
t$e delt%id. M%t%r testing is usually n%t "%ssi,le at t$is stage ,e&ause %f "ain.
Inferi%r translati%n %f t$e distal fragment may result fr%m delt%id at%nyQ t$is
usually res%lves ,y * weeks after fra&ture! ,ut if it "ersists! it must ,e
differentiated fr%m a true aCillary nerve inAury.
=)?
F0
&IA'NOSTIC TEST
#rauma series! &%nsisting %f 12 and lateral views in t$e s&a"ular "lane as well
as an aCillary view. 1Cillary is t$e ,est view f%r evaluati%n %f glen%id arti&ular
fra&tures and disl%&ati%ns! ,ut it may ,e diffi&ult t% %,tain ,e&ause %f
"ain.3el"eau aCillary- If a standard aCillary &ann%t ,e %,tained ,e&ause %f "ain %r
fear %f fra&ture dis"la&ement! t$e "atient may ,e left in t$e sling and leaned
%,liJuely ,a&kward *< degrees %ver t$e &assette. #$e ,eam is dire&ted &audally!
%rt$%g%nal t% t$e &assette! resulting in an aCillary view wit$ magnifi&ati%n.
C%m"uted t%m%gra"$y is $el"ful in evaluating arti&ular inv%lvement! degree %f
fra&ture dis"la&ement! im"ressi%n fra&tures! and glen%id rim fra&tures. Magneti&
res%nan&e imaging is generally n%t indi&ated f%r fra&ture management! ,ut it may
,e used t% assess r%tat%r &uff integrity.
=)?
2i&ture 1*. I>5ays "r%vide inf%rmati%n a,%ut t$e "%siti%n %f t$e main fra&ture
lines and areas %f arti&ular surfa&e de"ressi%n
=?
2i&ture 13. I>5ay %f 2r%Cimal 'umeral 0ra&tures
=<?
2i&ture 1*. C# &an %f 2r%Cimal 'umeral 0ra&tures
=<?
'0
TREAT)ENT
1.
Minimally dis"la&ed fra&tures
=)?
a. (" t% B<H %f "r%Cimal $umerus fra&tures are minimally dis"la&ed %r
n%ndis"la&ed.
,. ling imm%,iliEati%n %r swat$e f%r &%mf%rt.
&. 0reJuent radi%gra"$i& f%ll%w>u" is im"%rtant t% dete&t l%ss %f fra&ture
redu&ti%n.
d. 4arly s$%ulder m%ti%n may ,e instituted at : t% 10 days if t$e "atient
$as a sta,le %r im"a&ted fra&ture.
e. 2endulum eCer&ises are instru&ted initially f%ll%wed ,y "assive range>
%f>m%ti%n eCer&ises.
f. 1t 7 weeks! a&tive range>%f>m%ti%n eCer&ises are started.
g. 5esistive eCer&ises are started at 1) weeks
).
#w%>"art
=<!7?
5e"air %f t$e dis"la&ed tu,er%sity wit$ sutures %r tensi%n ,and wiringQ surgi&al
ne&k fra&tures &an n%rmally ,e managed n%n%"eratively. (nsta,le! unim"a&ted
fra&tures may ,e treated wit$ &l%sed redu&ti%n wit$ "er&utane%us "inning
=C522?. Immediate "$ysi&al t$era"y during n%n%"erative management results
in faster re&%very.
Surgical neck fracture. #$e fragments are gently mani"ulated int%
alignment and t$e arm is imm%,iliEed in a sling f%r a,%ut f%ur weeks %r until
t$e fra&ture feels sta,le and t$e C>ray s$%ws s%me signs %f $ealing. 4l,%w and
$and eCer&ises are en&%uraged t$r%ug$%ut t$is "eri%dQ s$%ulder eCer&ises are
&%mmen&ed at a,%ut f%ur weeks. #$e results %f &%nservative treatment are
generally satisfa&t%ry! &%nsidering t$at m%st %f t$ese "atients are %ver 7< and
d% n%t demand "erfe&t fun&ti%n. '%wever! if t$e fra&ture &ann%t ,e redu&ed
&l%sed %r if t$e fra&ture is very unsta,le after &l%sed redu&ti%n! t$en fiCati%n is
reJuired. O"ti%ns in&lude "er&utane%us "ins! ,%ne sutures! intramedullary "ins
wit$ tensi%n ,and wiring %r a l%&ked intramedullary nail. 2late fiCati%n
reJuires a wider eC"%sure and t$e newer l%&king "lates %ffer a sta,le fiCati%n
wit$%ut t$e need f%r eCtensive "eri%steal stri""ing.
Greater tuberosity fractures 0ra&ture %f t$e greater tu,er%sity is %ften
ass%&iated wit$ anteri%r disl%&ati%n and it redu&es t% a g%%d "%siti%n w$en t$e
s$%ulder is rel%&ated. If it d%es n%t redu&e! t$e fragment &an ,e re>atta&$ed
t$r%ug$ a small in&isi%n wit$ inter%sse%us sutures %r! in y%ung $ard ,%ne!
&an&ell%us s&rews.
Anatomical neck fractures #$ese are very rare. In y%ung "atients t$e
fra&ture s$%uld ,e fiCed wit$ a s&rew. In %lder "atients "r%st$eti& re"la&ement
=$emiart$r%"lasty? is "refera,le ,e&ause %f t$e $ig$ risk %f avas&ular ne&r%sis
%f t$e $umeral $ead.
3.
#$ree>"art
=<!7?
#$ese usually inv%lve dis"la&ement %f t$e surgi&al ne&k and t$e greater
tu,er%sityQ t$ey are eCtremely diffi&ult t% redu&e &l%sed. In a&tive individuals
t$is inAury is ,est managed ,y %"en redu&ti%n and internal fiCati%n. #$ere is
little eviden&e t$at %ne te&$niJue is ,etter t$an an%t$er alt$%ug$ t$e newer
im"lants wit$ l%&ked "lating and nailing are ,i%me&$ani&ally su"eri%rin
%ste%"%r%ti& ,%ne.
>O"en redu&ti%n wit$ internal fiCati%n =O5I0? f%r y%ung "atients! wit$ re"air
%f t$e tu,er%sities %r r%tat%r &uff
>'emiart$r%"lasty f%r %lder "atients! wit$ re"air %f t$e r%tat% &uff9 tu,er%sities
*.
0%ur>"arts
=<!7?
#$e surgi&al ne&k and ,%t$ tu,er%sities are dis"la&ed. #$ese are severe inAuries
wit$ a $ig$ risk %f &%m"li&ati%ns! su&$ as vas&ular inAury! ,ra&$ial "leCus
damage! inAuries %f t$e &$est wall and =later? avas&ular ne&r%sis %f t$e $umeral
$ead. #$e C>ray diagn%sis is diffi&ult =$%w many fragments are t$ere! and are
t$ey dis"la&edR?. Often t$e m%st %ne &an say is t$at t$ere are Smulti"le
dis"la&ed fragments@! s%metimes t%get$er wit$ glen%$umeral disl%&ati%n. In
y%ung "atients an attem"t s$%uld ,e made at re&%nstru&ti%n. In %lder "atients!
&l%sed treatment and attem"ts at %"en redu&ti%n and fiCati%n &an result in
&%ntinuing "ain and stiffness and additi%nal surgi&al treatment &an
&%m"r%mise t$e ,l%%d su""ly still furt$er. If t$e fra&ture "attern is su&$ t$at
t$e ,l%%d>su""ly is likely t% ,e &%m"r%mised! %r t$at re&%nstru&ti%n and
internal fiCati%n will ,e eCtremely diffi&ult! t$en t$e treatment %f &$%i&e is
"r%st$eti& re"la&ement %f t$e "r%Cimal $umerus. #$e results %f
$emiart$r%"lasty are s%mew$at un"redi&ta,le. 1nat%mi&al redu&ti%n! fiCati%n
and $ealing %f t$e tu,er%sities are "rereJuisites f%r a satisfa&t%ry %ut&%meQ
even t$en! se&%ndary dis"la&ement %f t$e tu,er%sities may result in a "%%r
fun&ti%nal %ut&%me. In additi%n t$e "r%st$eti& im"lant s$%uld ,e "erfe&tly
"%siti%ned. 8e warned T t$ese are %"erati%ns f%r t$e eC"ert.
2i&ture 1<. #reatment %f 2r%Cimal 'umeral fr&atures
=<?
0
CO)PLICATIONS
<2=
3as&ular inAury- #$is is infreJuent =<H t% 7H?Q t$e aCillary artery is t$e m%st &%mm%n
site ="r%Cimal t% anteri%r &ir&umfleC artery?. #$e in&iden&e is in&reased in %lder
individuals wit$ at$er%s&ler%sis ,e&ause %f t$e l%ss %f vessel wall elasti&ity.
Neural inAury
o 8ra&$ial "leCus inAury- #$is is infreJuent =7H?.
o 1Cillary nerve inAury- #$is is "arti&ularly vulnera,le wit$ anteri%r fra&ture>
disl%&ati%n ,e&ause t$e nerve &%urses %n t$e inferi%r &a"sule and is "r%ne t%
tra&ti%n inAury %r la&erati%n. C%m"lete aCillary nerve inAuries t$at d% n%t
im"r%ve wit$in ) t% 3 m%nt$s may reJuire ele&tr%my%gra"$i& evaluati%n and
eC"l%rati%n.
C$est inAury- Intrat$%ra&i& disl%&ati%n may %&&ur wit$ surgi&al ne&k fra&ture>
disl%&ati%nsQ "neum%t$%raC and $em%t$%raC must ,e ruled %ut in t$e a""r%"riate
&lini&al setting.
My%sitis %ssifi&ans- #$is is un&%mm%n and is ass%&iated wit$ &$r%ni& unredu&ed
fra&ture>disl%&ati%ns and re"eated attem"ts at &l%sed redu&ti%n.
$%ulder stiffness- It may ,e minimiEed wit$ an aggressive! su"ervised "$ysi&al
t$era"y regimen and may reJuire %"en lysis %f ad$esi%ns f%r re&al&itrant &ases.
Oste%ne&r%sis- #$is may &%m"li&ate 3H t% 1*H %f t$ree>"art "r%Cimal $umeral
fra&tures! 13H t% 3*H %f f%ur>"art fra&tures! and a $ig$ rate %f anat%mi& ne&k
fra&tures.
N%nuni%n- #$is %&&urs "arti&ularly in dis"la&ed tw%>"art surgi&al ne&k fra&tures wit$
s%ft tissue inter"%siti%n. Ot$er &auses in&lude eC&essive tra&ti%n! severe fra&ture
dis"la&ement! systemi& disease! "%%r ,%ne Juality! inadeJuate fiCati%n! and infe&ti%n.
It may ,e addressed wit$ O5I0 wit$ %r wit$%ut ,%ne graft %r "r%st$eti& re"la&ement.
Maluni%n- #$is %&&urs after inadeJuate &l%sed redu&ti%n %r failed O5I0 and may
result in im"ingement %f t$e greater tu,er%sity %n t$e a&r%mi%n! wit$ su,seJuent
restri&ti%n %f s$%ulder m%ti%n.
O"e# Fracture 1$% &istal Right Radius 'rade IIIA
A0 INTRO&*CTION
O"en fra&tures are defined as situati%ns in w$i&$ t$e fra&ture site &%mmuni&ates
wit$ t$e %utside envir%nmentQ t$e ,%ne d%es n%t need t% "r%trude fr%m t$e skin f%r t$e
inAury t% ,e an %"en fra&ture! any full>t$i&kness skin la&erati%n in t$e E%ne %f fra&ture
inAury is &%nsidered an %"en fra&ture. O"en fra&tures &an ,e &lassified ,y t$e 6ustil%>
1nders%n system-
=7?
o #y"e I- /%w>energy fra&ture wit$ a &lean w%und F1 &m l%ng
o #y"e II- /%w> t% medium>energy fra&ture wit$ a la&erati%n N1 &m l%ng ,ut
wit$%ut eCtensive s%ft>tissue damage
o #y"e III-
'ig$>energy fra&ture
egmental fra&tures! guns$%t inAuries
M%re eCtensive s%ft>tissue devitaliEati%n t$an in ty"e II
#y"e III1- 1deJuate s%ft>tissue &%verage %f ,%ne
#y"e III8- InadeJuate s%ft>tissue &%verage %f ,%ne! fra&tures t$at need
r%tati%nal %r free fla" &%verage
#y"e IIIC- 0ra&ture wit$ an arterial inAury
0%rearm fra&tures inv%lve t$e ,%nes %f t$e f%rearm =t$e radius and ulna?! and
s%metimes t$e fra&tures are ass%&iated wit$ el,%w and wrist inAuries. In additi%n t% t$e
,%ne inAury! s%ft>tissue inAuries may in&lude &%m"artment syndr%me! neura"raCia! and
vas&ular damage. 1dults are m%re sus&e"ti,le t$an &$ildren t% m%re severe inAuries
and als% reJuire a m%re eCa&t redu&ti%n ,e&ause t$ey $ave less "%tential f%r ,%ny
rem%deling! and t$e fra&tures $ave n% innate sta,ility. C$ildren F1) years %ld d% n%t
reJuire anat%mi& redu&ti%n %f f%rearm fra&tures. Classifi&ati%n-
=7?
o Multi"le &lassifi&ati%n s&$emes
o Im"%rtant fa&t%rs in&lude-
0ra&ture l%&ati%n
0ra&ture &%nfigurati%n
2resen&e %f any radi%ulnar %r radi%$umeral arti&ular inv%lvement
Is%lated ulna s$aft fra&tures are &alled nig$t sti&k fra&tures ,e&ause
t$ey %ften are &aused ,y ,lunt trauma.

EPI&E)IOLO'6
0%rearm fra&tures are m%re &%mm%n in men t$an w%menQ se&%ndary t% t$e
$ig$er in&iden&e in men %f m%t%r ve$i&le a&&idents! &%nta&t at$leti& "arti&i"ati%n!
alter&ati%ns! and falls fr%m a $eig$t. #$e rati% %f %"en fra&tures t% &l%sed fra&tures is
$ig$er f%r t$e f%rearm t$an f%r any %t$er ,%ne eC&e"t t$e ti,ia.
=)?

ANATO)6
#$e f%rearm a&ts as a ringQ a fra&ture t$at s$%rtens eit$er t$e radius %r t$e ulna
results eit$er in a fra&ture %r a disl%&ati%n %f t$e %t$er f%rearm ,%ne at t$e "r%Cimal %r
distal radi%ulnar A%int. Nig$tsti&k inAuries are an eC&e"ti%n. #$e ulna! w$i&$ is
relatively straig$t! a&ts as an aCis ar%und w$i&$ t$e laterally ,%wed radius r%tates in
su"inati%n and "r%nati%n. 1 l%ss %f su"inati%n and "r%nati%n may result fr%m radial
s$aft fra&tures in w$i&$ t$e lateral &urvature $as n%t ,een rest%red. #$e inter%sse%us
mem,rane %&&u"ies t$e s"a&e ,etween t$e radius and ulna. #$e &entral ,and is
a""r%Cimately 3.< &m wide running %,liJuely fr%m its "r%Cimal %rigin %n t$e radius
t% its distal inserti%n %n t$e ulna. e&ti%ning %f t$e &entral ,and al%ne redu&es sta,ility
,y :1H. 0ra&ture l%&ati%n di&tates def%rming f%r&es-
o
5adial fra&tures distal t% t$e su"inat%r mus&le inserti%n ,ut "r%Cimal t% t$e
"r%nat%r teres inserti%n tend t% result in su"inati%n %f t$e "r%Cimal fragment
%wing t% un%""%sed "ull %f t$e su"inat%r and ,i&e"s ,ra&$ii mus&les.
o
5adial fra&tures distal t% t$e su"inat%r and "r%nat%r teres mus&les tend t%
result in neutral r%tati%nal alignment %f t$e "r%Cimal fragment.
=)?
2i&ture 17. 1nat%my %f 5adial and (lna
=3?
2i&ture 1:. 1nat%my %f #$e Mus&les at 0%rearm
=3?

ETIOPATO)ECANIS)
#$ese are m%st &%mm%nly ass%&iated wit$ m%t%r ve$i&le a&&idents! alt$%ug$
t$ey are als% &%mm%nly &aused ,y dire&t trauma =w$ile "r%te&ting %ne@s $ead?!
guns$%t w%unds! and falls eit$er fr%m a $eig$t %r during at$leti& &%m"etiti%n
2at$%l%gi& fra&tures are un&%mm%n. #reatment %f %"en fra&tures is ,ased %n
"reventing infe&ti%n and sta,iliEing t$e inAured ,%ne. Infe&ti%n is "r%m%ted ,y
,a&terial &%ntaminati%n %f w%und! devitaliEed mus&le and ,%ne! dead s"a&e! and
f%reign material.
=)!7?
2i&ture 1B. Me&$anism %f InAury %f 0%rearm
=3?
2i&ture 19. 6ustil% and 1nders%n@s Classifi&ati%n %f O"en 0ra&ture
=7?
Classifcation:
=7?
Type I: no periosteal stripping, minimum soft tissue damage, small
skin wound (1 cm)
Type II:little periosteal stripping, moderate muscle damage, skin
wound (1-10 cm)
Type III!contaminated wound ("ig"-energy guns"ot wound, farm
in#ury, s"otgun) or e$tensi%e periosteal stripping wit" large skin
wound (&10 cm)
Type III'!same as III (ut will re)uire *ap co%erage
Type IIIC!same as III (ut wit" %ascular in#ury t"at re)uires repair

CLINICAL FEAT*RES
2atients ty"i&ally "resent wit$ gr%ss def%rmity %f t$e inv%lved f%rearm! "ain!
swelling! and l%ss %f $and and f%rearm fun&ti%n. 1 &areful neur%vas&ular
eCaminati%n is essential! wit$ assessment %f radial and ulnar "ulses! as well as
median! radial! and ulnar nerve fun&ti%n. One must &arefully assess %"en w%unds
,e&ause t$e ulna ,%rder is su,&utane%us! and even su"erfi&ial w%unds &an eC"%se
t$e ,%ne. 4C&ru&iating! unremitting "ain! tense f%rearm &%m"artments! %r "ain %n
"assive stret&$ %f t$e fingers s$%uld raise sus"i&i%ns %f im"ending %r "resent
&%m"artment syndr%me. C%m"artment "ressure m%nit%ring s$%uld ,e "erf%rmed!
wit$ emergen&y fas&i%t%my indi&ated f%r diagn%sed &%m"artment syndr%me.
=)?
Ph,sical E:a!
<>=
#$e "$ysi&ian must diagn%se t$e %"en fra&ture and t$en f%ll%w a general
fra&ture "$ysi&al eCaminati%n.
Diagn%sing an %"en fra&ture-
o 8%ne "r%truding fr%m skin =n%t reJuired?
o 0at %r ,l%%d %%Eing fr%m a la&erati%n
/a&erati%n in t$e E%ne %f inAury! w$i&$ &an ,e large in $ig$>energy
fra&tures
6eneral eCaminati%n f%r fra&tures-
2al"ate A%int a,%ve and ,el%w inAury as well as every %t$er A%int in
,%dy.
o 1ssess vas&ular via,ility %f lim, and damaged s%ft tissues.
2ulses %r arterial ,ra&$ial indi&es
C%l%r and &a"illary refill %f &%ntused skin and mus&le
o 2resen&e %r a,sen&e %f-
2eri%steal stri""ing
6r%ss &%ntaminati%n wit$ f%reign material
C%m"artment syndr%me
o Neur%l%gi& m%t%r and sens%ry eCaminati%ns

&IA'NOSTIC TEST
1nter%"%steri%r =12? and lateral views %f t$e f%rearm s$%uld ,e %,tained! wit$
%,liJue views %,tained as ne&essary f%r furt$er fra&ture definiti%n. 5adi%gra"$i&
evaluati%n s$%uld in&lude t$e i"silateral wrist and el,%w t% rule %ut t$e "resen&e
%f ass%&iated fra&ture %r disl%&ati%n. #$e radial $ead must ,e aligned wit$ t$e
&a"itellum %n all views. C# s&an is indi&ated f%r s%me fra&ture "atterns ,ut s$%uld
n%t delay surgi&al de,ridement and sta,iliEati%n.
=)!7?

TREAT)ENT
<?=
1nti,i%ti&s. #$e w%und s$%uld ,e ke"t &%vered until t$e "atient
rea&$es t$e %"erating t$eatre. In m%st &ases &%>am%Ci&lav %r &efur%Cime =%r
&lindamy&in if "eni&illin allergy is an issue? is given as s%%n as "%ssi,le!
%ften in t$e 1&&ident and 4mergen&y de"artment. 1t t$e time %f
de,ridement! gentami&in is added t% a se&%nd d%se %f t$e first anti,i%ti&.
8%t$ anti,i%ti&s "r%vide "r%"$ylaCis against t$e maA%rity %f 6ram>"%sitive
and 6ramnegative ,a&teria t$at may $ave entered t$e w%und at t$e time %f
inAury. Only &%>am%Ci&lav %r &efur%Cime =%r &lindamy&in? is &%ntinued
t$ereafterQ as w%unds %f 6ustil% grade I fra&tures &an ,e &l%sed at t$e time %f
de,ridement! anti,i%ti& "r%"$ylaCis need n%t ,e f%r m%re t$an )* $%urs.
;it$ 6ustil% grade II and III1 fra&tures! s%me surge%ns "refer t% delay
&l%sure after a Sse&%nd l%%k@ "r%&edure. Delayed &%ver is als% usually
"ra&tised in m%st &ases %f 6rade III8 and IIIC inAuries. 1s t$e w%unds $ave
n%w ,een "resent in a $%s"ital envir%nment f%r s%me time! and t$ere are data
t% indi&ate infe&ti%ns after su&$ %"en fra&tures are &aused m%stly ,y
$%s"ital>a&Juired ,a&teria and n%t seeded at t$e time %f inAury! gentami&in
and van&%my&in =%r tei&%"lanin? are given at t$e time %f definitive w%und
&%ver. #$ese anti,i%ti&s are effe&tive against met$i&illin>resistant
ta"$yl%&%&&us aureus and 2seud%m%nas! ,%t$ %f w$i&$ are near t$e t%" %f
t$e league ta,le %f res"%nsi,le ,a&teria. #$e t%tal "eri%d %f anti,i%ti& use f%r
t$ese fra&tures s$%uld n%t,e greater t$an :) $%urs.
De,ridement. #$e %"erati%n aims t% render t$e w%und free %f f%reign
material and %f dead tissue! leaving a &lean surgi&al field and tissues wit$ a
g%%d ,l%%d su""ly t$r%ug$%ut. (nder general anaest$esia t$e "atient@s
&l%t$ing is rem%ved! w$ile an assistant maintains tra&ti%n %n t$e inAured lim,
and $%lds it still. #$e dressing "revi%usly a""lied t% t$e w%und is re"la&ed
,y a sterile "ad and t$e surr%unding skin is &leaned. #$e "ad is t$en taken
%ff and t$e w%und is irrigated t$%r%ug$ly wit$ &%"i%us am%unts %f
"$ysi%l%gi&al saline. #$e w%und is &%vered again and t$e "atient@s lim, t$en
"re""ed and dra"ed f%r surgery. Many surge%ns "refer t% use a t%urniJuet as
t$is "r%vides a ,l%%dless field. '%wever t$is indu&es is&$aemia in an already
,adly inAured leg and &an make it diffi&ult t% re&%gniEe w$i&$ stru&tures are
devitaliEed. 1 &%m"r%mise is t% a""ly t$e t%urniJuet ,ut n%t t% inflate it
during t$e de,ridement unless a,s%lutely ne&essary. 8e&ause %"en fra&tures
are %ften $ig$>energy inAuries wit$ severe tissue damage! t$e %"erati%n
s$%uld ,e "erf%rmed ,y s%me%ne skilled in dealing wit$ ,%t$ skeletal and
s%ft tissuesQ ideally t$is will ,e a A%int eff%rt ,y %rt$%"aedi& and "lasti&
surge%ns.
;e generally "refer n%t t% use internal fiCati%n initially in ty"e III %"en
fra&tures %f t$e f%rearm. ;e ,elieve t$at &%m"li&ati%ns are fewer if t$e
w%und is initially &ared f%r wit$ irrigati%n and dU,ridement. #$is all%ws t$e
w%und eit$er t% reveal itself infe&ted %r t% $eal. If t$e w%und is &lean at < t%
: days! t$e a""r%"riate internal fiCati%n &an ,e "erf%rmed. 1nders%n et al.
re"%rted eC"erien&e in treating %"en fra&tures wit$ t$is delayed met$%d %f
%"en redu&ti%n and internal fiCati%n using t$e &%m"ressi%n "late. N%
infe&ti%ns %&&urred in 3B %"en fra&tures treated in t$is manner. In many ty"e
I and ty"e II w%unds! internal fiCati%n &an ,e "erf%rmed "rimarily wit$%ut
w%und $ealing "r%,lems! ,ut we ,elieve it is safer t% delay t$e fiCati%n in
ty"e III w%unds in m%st &ases. In single>,%ne fra&tures %f t$e f%rearm! a &ast
t$at is wind%wed %ver t$e %"en w%und "r%vides suffi&ient eCternal fiCati%n
until t$e w%und $as $ealed and internal fiCati%n &an ,e inserted. $%rtening
fr%m %verriding %f single>,%ne fra&tures resulting fr%m delay in inserting
internal fiCati%n is n%t a "r%,lem. #% "revent s$%rtening in ,%t$>,%ne
fra&tures ass%&iated wit$ %"en w%unds! "ins t$r%ug$ t$e "r%Cimal ulna and
t$r%ug$ t$e ,ases %f t$e se&%nd and t$ird meta&ar"als &an ,e used t% a""ly
tra&ti%n and rest%re lengt$. #$e "ins are in&%r"%rated in a "laster &ast t$at
&an ,e wind%wed a""r%"riately t% treat and ins"e&t t$e w%unds. 4Cternal
fiCati%n devi&es als% are satisfa&t%ry f%r redu&ti%n and skeletal fiCati%n w$en
eCtensive s%ft>tissue w%unds reJuire "r%&edures su&$ as skin grafting! and
we $ave $ad eC&ellent eC"erien&e wit$ t$em. If t$e s%ft>tissue w%und is
massive! making skin grafting and re&%nstru&tive "r%&edures inevita,le! and
t$ese "r%&edures are n%t managea,le t$r%ug$ a wind%w in a tra&ti%n ty"e %f
&ast! an intramedullary nail in t$e ulna &an ,e used t% sta,iliEe t$e f%rearm.
kin grafting and similar "r%&edures %n t$e s%ft tissues are alm%st
im"%ssi,le t% &arry %ut unless t$e f%rearm is sta,iliEed ,y eit$er eCternal %r
internal means. #$e te&$niJue f%r t$e tra&ti%n &ast is des&ri,ed in t$e neCt
se&ti%n.
Current treatment trends fav%r immediate %"en redu&ti%n and internal
fiCati%n %f all %"en f%rearm fra&tures. Dun&an et al. re"%rted 90H a&&e"ta,le
results in 103 6ustil% ty"e I! ty"e II! %r ty"e III1 %"en dia"$yseal f%rearm
fra&tures treated wit$ immediate dU,ridement and &%m"ressi%n "late and
s&rew fiCati%n. #$eir results wit$ ty"e III8 and ty"e IIIC inAuries were "%%r!
$%wever. J%nes re"%rted << g%%d results in a small series %f ty"e III8 and
ty"e IIIC inAuries treated in a similar fas$i%n. #w% %f t$ree "atients wit$ ty"e
IIIC inAuries $ad "%%r results after immediate dU,ridement and &%m"ressi%n
"late and s&rew fiCati%n. Immediate %"en redu&ti%n and internal fiCati%n %f
ty"e I and ty"e II %"en dia"$yseal f%rearm fra&tures is a""r%"riate if
t$%r%ug$ dU,ridement is "erf%rmed. #reatment %f ty"e III inAuries s$%uld ,e
individualiEed! wit$ &%nsiderati%n given t% t$e me&$anism and f%r&e %f
inAury! ass%&iated inAuries! and t$e &%nditi%n %f t$e "atient ,ef%re and after
inAury. ;e &%ntinue t% delay %"en redu&ti%n and internal fiCati%n until t$ere
is n% eviden&e %f infe&ti%n. In a &riti&ally inAured "atient! multi"le returns t%
t$e %"erating r%%m may n%t ,e "%ssi,le! and early definitive treatment may
,e ne&essary.
2i&ture )0. #reatment f%r 5adial 0ra&ture
=7?

CO)PLICATIONS
<2=

N%nuni%n and maluni%n- #$ese are un&%mm%n! m%st %ften related t% infe&ti%n and
err%rs %f surgi&al te&$niJue. 2atients may reJuire rem%val %f $ardware! ,%ne grafting!
and re"eat internal fiCati%n.

Infe&ti%n- #$e in&iden&e is %nly 3H wit$ %"en redu&ti%n and internal fiCati%n. It
ne&essitates surgi&al drainage! de,ridement! &%"i%us irrigati%n! w%und &ultures! and
anti,i%ti&s. If internal fiCati%n is f%und t% ,e sta,le! it d%es n%t ne&essarily need t% ,e
rem%ved ,e&ause m%st fra&tures will unite des"ite infe&ti%n. Massive infe&ti%ns wit$
severe s%ft tissue and %sse%us &%m"r%mise may ne&essitate eCternal fiCati%n wit$
w%unds left %"en and serial de,ridements.

Neur%vas&ular inAury- #$is is un&%mm%n! ass%&iated wit$ guns$%t inAury %r iatr%geni&

&auses. Nerve "alsies &an generally ,e %,served f%r 3 m%nt$s! wit$ surgi&al
eC"l%rati%n indi&ated f%r failure %f return %f nerve fun&ti%n. InAuries t% t$e radial %r
ulnar arteries may ,e addressed wit$ sim"le ligati%n if t$e %t$er vessel is "atent.

3%lkmann is&$emia- #$is devastating &%m"li&ati%n f%ll%ws &%m"artment syndr%me.

Clini&al sus"i&i%n s$%uld ,e f%ll%wed ,y &%m"artment "ressure m%nit%ring wit$
emergen&y fas&i%t%my if a &%m"artment syndr%me is diagn%sed.

2%sttraumati& radi%ulnar syn%st%sis- #$is is un&%mm%n =3H t% 9H in&iden&e?Q t$e

risk in&reases wit$ massive &rus$ inAuries %r &l%sed $ead inAury. It may ne&essitate
surgi&al eC&isi%n if fun&ti%nal limitati%ns %f su"inati%n and "r%nati%n result! alt$%ug$
a n%narti&ular syn%st%sis eC&isi%n is rarely su&&essful in t$e "r%Cimal f%rearm.
2%st%"erative l%w>d%se radiati%n may de&rease t$e in&iden&e %f re&urren&e.
Closed Fracture Right (ase )etacar"al Little Fi#ger
A0
INTRO&*CTION
1 fra&ture %f t$e meta&ar"al ,%ne! t$e small tu,ular ,%ne in t$e $and..
Meta&ar"al fra&tures are &lassified a&&%rding t% t$eir anat%mi& l%&ati%n =at t$e
$ead! ne&k! s$aft! %r ,ase?. Meta&ar"al fra&tures %f t$e t$um, are &lassified int% *
"atterns =s%me e"%nym%us?! a&&%rding t% w$et$er t$ey are intra>arti&ular %r eCtra>
arti&ular and ,y t$e am%unt %f &%mminuti%n. #$e 8ennett fra&ture $as a v%lar li"
fragment %f varia,le siEe at t$e CMC A%int! and t$e remainder %f t$e ,ase is
dis"la&ed fr%m t$e A%int. #$e 5%land% fra&ture is a +>s$a"ed intra>arti&ular
fra&ture.
=1?
8%ra and DidiEian &alled attenti%n t% a "%tentially disa,ling intraarti&ular
fra&ture at t$e ,ase %f t$e fift$ meta&ar"al. If t$e inAury is n%t redu&ed "r%"erly! a
maluni%n may result in weakness %f gri" and a "ainful A%int. #$e A%int &%nsists %f
t$e ,ase %f t$e fift$ meta&ar"al arti&ulating wit$ t$e $amate and t$e adA%ining
f%urt$ meta&ar"al. #$e eCtens%r &ar"i ulnaris tend%n atta&$es "r%Cimally t% t$e
fift$ meta&ar"al d%rsal ,ase. #$e A%int "ermits a""r%Cimately 30 degrees %f
n%rmal fleCi%n and eCtensi%n and t$e r%tati%n ne&essary in gras" and in "almar
&u""ing. #$is dis"la&ed intraarti&ular fra&ture mig$t ,e &%m"ared wit$ a 8ennett
fra&ture ,e&ause t$e "ull %f t$e eCtens%r &ar"i ulnaris $as a great tenden&y t%
dis"la&e t$e meta&ar"al s$aft "r%Cimally! similar t% t$e t$um, meta&ar"al
dis"la&ement in a 8ennett fra&ture ,y t$e a,du&t%r "%lli&is l%ngus.
=*?
(0
EPI&E)IOLO'6
Meta&ar"al and "$alangeal fra&tures are &%mm%n! &%m"rising 10H %f all
fra&turesQ N<0H %f t$ese are w%rk related. #$e 199B (nited tates Nati%nal '%s"ital
1m,ulat%ry Medi&al Care urvey f%und "$alangeal =)3H? and meta&ar"al =1BH?
fra&tures t% ,e t$e se&%nd and t$ird m%st &%mm%n $and and f%rearm fra&tures
f%ll%wing radius fra&tures. #$ey &%nstitute anyw$ere fr%m 1.<H t% )BH %f all
emergen&y de"artment visits! de"ending %n survey met$%ds. /%&ati%n- 8%rder digits
are m%st &%mm%nly inv%lved wit$ a""r%Cimate in&iden&e as f%ll%ws distal "$alanC
=*<H?! meta&ar"al =30H?! "r%Cimal "$alanC =1<H?! middle "$alanC =10H?. Male>t%>
female rati%s run fr%m 1.B-1 t% <.*-1! wit$ $ig$er rati%s seen in t$e age gr%u"s
ass%&iated wit$ t$e greatest in&iden&e =s"%rts inAuries in t$e early t$ird de&ade and
w%rk"la&e inAuries in t$e fift$ de&ade?.
=)?
C0
ANATO)6
@
2i&ture )1. 1nat%my %f 'and
=3?
)etacar"als
#$ey are ,%wed! &%n&ave %n "almar surfa&e.
#$ey f%rm t$e l%ngitudinal and transverse ar&$es %f t$e $and.
#$e indeC and l%ng finger &ar"%meta&ar"al arti&ulati%n is rigid.
#$e ring and small finger &ar"%meta&ar"al arti&ulati%n is fleCi,le.
#$ree "almar and f%ur d%rsal inter%sse%us mus&les arise fr%m meta&ar"al s$afts
and fleC t$e meta&ar"%"$alangeal =MC2? A%ints.
#$ese mus&les &reate def%rming f%r&es in t$e &ase %f meta&ar"al fra&tures!
ty"i&ally fleCing t$e fra&ture =a"eC d%rsal angulati%n?.
Phala#ges

2r%Cimal "$alanC fra&tures usually angulate int% eCtensi%n =a"eC v%lar?.

o #$e "r%Cimal fragment is fleCed ,y t$e inter%ssei.
o #$e distal fragment is eCtended ,y t$e &entral sli".

Middle "$alanC fra&tures are un"redi&ta,le.

Distal "$alanC fra&tures usually result fr%m &rus$ inAuries and are &%mminuted tuft
fra&tures.
=)?
&0
ETIOPATO)ECANIS)
<2=
1 $ig$ degree %f variati%n in me&$anism %f inAury a&&%unts f%r t$e ,r%ad
s"e&trum %f "atterns seen in skeletal trauma sustained ,y t$e $and.
1Cial l%ad %r inAuries are freJuently sustained during ,all s"%rts %r sudden
rea&$es made during everyday a&tivities su&$ as t% &at&$ a falling %,Ae&t.
2atterns freJuently resulting fr%m t$is me&$anism are s$earing arti&ular
fra&tures %r meta"$yseal &%m"ressi%n fra&tures.
1Cial l%ading al%ng t$e u""er eCtremity must als% make %ne sus"i&i%us %f
ass%&iated inAuries t% t$e &ar"us! f%rearm! el,%w! and s$%ulder girdle.
Dia"$yseal fra&tures and A%int disl%&ati%ns usually reJuire a ,ending
&%m"%nent in t$e me&$anism %f inAury! w$i&$ &an %&&ur during ,all $andling
s"%rts %r w$en t$e $and is tra""ed ,y an %,Ae&t and is una,le t% m%ve wit$ t$e
rest %f t$e arm.
Individual digits &an easily ,e &aug$t in &l%t$ing! furniture! %r w%rk"la&e
eJui"ment t% sustain t%rsi%nal me&$anisms %f inAury! resulting in s"iral
fra&tures %r m%re &%m"leC disl%&ati%n "atterns.
Industrial settings %r %t$er envir%nments wit$ $eavy %,Ae&ts and $ig$ f%r&es
lead t% &rus$ing me&$anisms t$at &%m,ine ,ending! s$earing! and t%rsi%n t%
"r%du&e uniJue "atterns %f skeletal inAury and ass%&iated s%ft tissue damage.
E0
CLINICAL FEAT*RES
<2=
o 'ist%ry- a &areful $ist%ry is essential as it may influen&e treatment. #$is
s$%uld in&lude t$e "atient- 1ge! $and d%minan&e! %&&u"ati%n! systemi&
illnesses! me&$anism %f inAury- &rus$! dire&t trauma! twist! tear! la&erati%n! et&!
time %f inAury =f%r %"en fra&tures?! eC"%sure t% &%ntaminati%n- ,arnyard!
,ra&kis$ water! animal9 $uman ,it! treatment "r%vided- &leansing! antise"ti&!
,andage! t%urniJuet! finan&ial issues- w%rkers &%m"ensati%n.
o 2$ysi&al eCaminati%n in&ludes digital via,ility =&a"illary refill s$%uld ,e F)
se&%nds?! neur%l%gi& status =d%&umented ,y tw%>"%int dis&riminati%n Vn%rmal
is 7 mmW and individual mus&le testing?! r%tati%nal and angulat%ry def%rmity!
range %f m%ti%n =d%&umented ,y g%ni%meter?! malr%tati%n at %ne ,%ne
segment is ,est re"resented ,y t$e alignment %f t$e neCt m%re distal segment.
#$is alignment is ,est dem%nstrated w$en t$e intervening A%int is fleCed t% 90
degrees. C%m"aring nail "late alignment is an inadeJuate met$%d %f
evaluating r%tati%n.
F0
&IA'NOSTIC TEST
In additi%n t% t$e r%utine anter%"%steri%r and lateral views! a radi%gra"$
s$%uld ,e made wit$ 30 degrees %f "r%nati%n t% give a ,etter view %f t$e
arti&ular surfa&e f%r a&&urate diagn%sis.
2i&ture )). 12! O,liJue! and /ateral 3iew %f 'and
=*?
'0
TREAT)ENT
0ra&tures %f t$e ,ase %f t$e se&%nd! t$ird! and f%urt$ fingers are generally
minimally dis"la&ed and are ass%&iated wit$ ligament avulsi%n. #reatment is ,y
s"linting and early m%ti%n in m%st &ases.#$e reverse 8ennett fra&ture is a fra&ture>
disl%&ati%n %f t$e ,ase %f t$e fift$ meta&ar"al9$amate.
o
#$e meta&ar"al is dis"la&ed "r%Cimally ,y t$e "ull %f t$e eCtens%r &ar"i
ulnaris.
o
#$e degree %f dis"la&ement is ,est as&ertained via radi%gra"$ wit$ t$e $and
"r%nated 30 degrees fr%m a fully su"inated =anter%"%steri%r? "%siti%n.
o
#$is fra&ture %ften reJuires surgi&al interventi%n wit$ O5I0.
=)?
0 CO)PLICATIONS

Maluni%n- 1ngulati%n &an distur, intrinsi& ,alan&e and als% &an result in "r%minen&e
%f meta&ar"al $eads in t$e "alm wit$ "ain %n gri""ing. 5%tati%nal %r angulat%ry
def%rmities! es"e&ially %f t$e se&%nd and t$ird meta&ar"als! may result in fun&ti%nal
and &%smeti& distur,an&es! em"$asiEing t$e need t% maintain as near anat%mi&
relati%ns$i"s as "%ssi,le.

N%nuni%n- #$is is un&%mm%n! ,ut it may %&&ur wit$ eCtensive s%ft tissue inAury and
,%ne l%ss! as well as wit$ %"en fra&tures wit$ gr%ss &%ntaminati%n and infe&ti%n. It
may ne&essitate de,ridement! ,%ne grafting! %r fla" &%verage.

Infe&ti%n- 6r%ssly &%ntaminated w%unds reJuire meti&ul%us de,ridement and

a""r%"riate anti,i%ti&s de"ending %n t$e inAury setting =e.g.! ,arnyard &%ntaminati%n!
,ra&kis$ water! ,ite w%unds?! l%&al w%und &are wit$ de,ridement as ne&essary! and
"%ssi,le delayed &l%sure.

Meta&ar"al>"$alangeal A%int eCtensi%n &%ntra&ture- #$is may result if s"linting is n%t

in t$e "r%te&ted "%siti%n =i.e.! MC2 A%ints at N:0 degree? %wing t% s%ft tissue
&%ntra&ture.

/%ss %f m%ti%n- #$is is se&%ndary t% tend%n ad$eren&e! es"e&ially at t$e level %f t$e
2I2 A%int.

2%sttraumati& %ste%art$ritis- #$is may result fr%m a failure t% rest%re arti&ular

&%ngruity.
=)?
&R*+ &isru"tio#
A0
INTRO&*CTION
(0
EPI&E)IOLO'6
C0
ANATO)6
&0
ETIOPATO)ECANIS)
E0
CLINICAL FEAT*RES
F0
&IA'NOSTIC TEST
'0
TREAT)ENT
0
CO)PLICATIONS
REFFERENCES
1. 0rassi&a! 0rank J! 2aul D! J%$n ';. #$e <>Minute Ort$%"aedi& C%nsult. )
nd
ed.
New +%rk- /i""in&%tt ;illiams X ;ilkinsQ )00:. ". *01>).
). .%val .eneat$ J. Zu&kerman J%se"$ D. 'and,%%k %f fra&ture! 3nd editi%n. New
+%rk- /i""in&%tt ;illiams X ;ilkinsQ )007. ". 177>1:1.
3. #$%m"s%n JC. /eg and .nee. Netter C%n&ise Ort$%"aedi& 1nat%my. )nd ed.
aunders 4lsevier. ". B*! 111! 1*1! 173.
*. Canale #erry! et all. Cam",ell@s O"erative Ort$%"aedi&s. 4levent$ 4diti%n.
2$iladel"$ia - M%s,y 4lsevier. )00:.
<. %l%m%n /! ;arwi&k D! Nayagam . 2rin&i"le %f 0ra&ture. 1"leyYs ystem %f
Ort$%"aedi&s and 0ra&tures. 9t$ ed. /%nd%n- '%dder 1rn%ldQ )010. ". :)7>:! :**>
:.
7. Miller MD! te"$en 5#! Jennifer 1'. 5eview %f Ort$%"aedi&s. 7
t$
ed. 4lsevier
aunders. )01). ". :01!9>11.