Fractures of Upper Extremities:

Radius & Ulna

Pembimbing: Dr. Husnul Fuad Albar, SpOT

DEPARTMENT OF ORTHOPAEDICS HAM GH

FACULTY OF MEDICINE
UNIVERSITAS SUMATERA UTARA
MEDAN 2011
1. Fracture of the Forearm
1.1 Fractures Of The Shaft Of Ulna And
Radius
• Adult fractures unlike those in children may be
markedly displaced with little or no bony
contact between the fragments.
• Rotational deformity is common.
• Neurovascular injury is checked carefully.
• Closed reduction is difficult and often fails or is
complicated by late slippages.
• Fractures are treated with analgesics or
immobilization and refer for ORIF.
 Classification of the shaft of radius
and ulna fracture
• A1 Simple fracture of the ulna, radius intact 
1 oblique 
2 transverse 
3 with dislocation of the radial head (Monteggia)

• A2 Simple fracture of the radius, ulna intact 

1 oblique 
2 transverse 
3 with dislocation of the distal radio-ulnar joint (Galeazzi)

• A3 Simple fracture of both bones 

1 radius, proximal zone 
2 radius, middle zone 
3 radius, distal zone
• B1 Wedge fracture, of the ulna, radius intact 
1 intact wedge 
2 fragmented wedge 
3 with dislocation of the radial head (Monteggia)

• B2 Wedge fracture, of the radius, ulna intact 

1 intact wedge 
2 fragmented wedge 
3 with dislocation of the distal radio-ulnar joint
(Galeazzi)

• B3 Wedge fracture, of the one bone, simple

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

• C3 Complex fracture, of both bones 

1 bifocal
2 bifocal of the one, irregular of the other 
3 irregular
Classification of the shaft of radius and ulna fractures
1.2 Monteggia fracture
• Definition :
Fracture of the proximal ulna
associated with dislocation of
the radial head

• Etiology : Forced pronation

of the arm
 Bado Classification

Type 4 : anterior with

Type 1 : anterior Type 2: posterior Type 3: ;lateral
ass.
dislocation dislocation dislocation
Both bone fx
Non operative

Treatment

Operative
• Complications:
     - PIN or radial nerve palsy from anterior
displacement of radial head;
   - non union of fracture of ulnar shaft
     - radiohumeral ankylosis
     - radioulnar synostosis
- recurrent radial head dislocation
     - myositis ossificans
2. Fracture of the Radial Head
Epidemiology

•The radial head is fractured in about 20% of cases

of elbow trauma, and about 33% of elbow fractures
and dislocations including injury to the radial head
and or neck.
• Radial head fractures and dislocations are the
result of trauma, usually from a fall on the
outstretched arm with the force of impact
transmitted up the hand through the wrist and
forearm to the radial head, which is forced into
the capitellum.
Pathophysiology

•The radial head is intra-articular, so the anatomic

reduction of the bone fragments is necessary to
minimize the risk of lateral post-traumatic arthritis
from mechanical grinding.
•The intra-articular position also means that soft
tissue attacthments to the most proximal portion
of the bone are limited, so fractured fragments
frequently lose their blood supply, resulting in
avascular necrosis and potential nonunion.
• Patients with radial head fracture-dislocations
usually presents with a history of a fall on the
outstretched hand.
• The wrist, especially the distal radioulnar joint,
maybe damaged simultaneously, and the
presence of wrist pain, grinding, or swelling can
be found.
• Neurovascular symptoms of numbness, tingling,
or loss of sensation should be identified to rule
out nerve of vascular injury.
• The presence of severe pain should alert the
examiner to the possibility of compartment
syndrome.
Physical Examination

•Patients with radial head fractures and

dislocations present with localized swelling,
tenderness, and decreased motion.
•Evaluate wounds over the subcutaneous border of
the ulna is especially important in fracture-
dislocations to avoid missing open fractures.
• Palpation on the elbow, especially the radial head,
feeling for deformity, and the wrist, feeling for
stability of the distal radioulnar joint.
• The 3 major nerves of the forearm are in danger
with elbow fractures and dislocations, carefully
assess neurovascular funtion for all of the nerves of
the forearm and hand.
• Radial nerve function is especially important to
assess with displaced fractures through the neck of
the radius. The motor (posterior interosseous)
branch provides extension for the fingers and wrist.
• Assess the firmness of all compartments, check
for pain with passive stretch, and measure
compartment pressures if in doubt to avoid
missing compartment syndromes.
• Elbow stability needs to be assessed even with
seemingly nondisplaced radial neck fractures.
• The elbow is tested with valgus stress at 30
degrees of flexion to determine the competency
of the medial collateral ligament.
The Mason Classification
 Management
• The Mason classification is helpful in determining the
appropriate treatment for simple radial head and neck
fractures.
• Type I fractures are treated with limited immobilization
for a few days, followed by early range of motion
exercises.
• Type II fractures with acceptable fracture patterns
should be treated with open reduction and internal
fixation.
• In equivocal situations, particularly if the patient has
low-demand occupation, type II injuries can be treated
non-operatively, with delayed excision of the radial head
if persistent pain or significant limitation of forearm
rotation occurs.
• Uncomplicated type III fractures should be
treated with excision of the radial head.
• When radial head fractures are associated with
dislocation of the elbow and severe ligament
injury or disruption of the forearm interosseus,
the fragments should be removed and the radial
head replaced by prosthesis.
• Results of treatment are uniformly good for type
I fractures and often satisfactory for simple type
II and type III fractures.
Complications
• Loss of motion
• Elbow instability
• Post-traumatic arthritis
• Myositis issificans
• Distal radio-ulnar symptoms
3. Fractures of Diaphyseal of Radius
and Ulna
3.1 Galeazzi Fracture
• The Galeazzi fracture-dislocation, also known as
reverse Monteggia fracture, is an injury pattern
involving a radial shaft fracture with associated
dislocation of the distal radioulnar joint (DRUJ);
the injury disrupts the forearm axis joint.
Epidemiology

• Galeazzi fractures account for 3-7% of all

forearm fractures.
• They are seen most often in males.
Presentation

• Pain and soft-tissue swelling are present at the

distal-third radial fracture site and at the wrist
joint. This injury is confirmed on radiographic
evaluation.
• Forearm trauma may be associated with
compartment syndrome.
• Anterior interosseous nerve (AIN) palsy may
also be present, but it is often overlooked
because there is no sensory component to this
finding.
• A purely motor nerve, the AIN is a division of the
median nerve. Injury to the AIN can cause
paralysis of the flexor pollicis longus (FPL) and
flexor digitorum profundus (FDP) to the index
finger, resulting in loss of the pinch mechanism
between the thumb and index finger
Management

• Galeazzi fractures are best treated with open

reduction of the radius and DRUJ.
• Closed reduction and cast application have led to
unsatisfactory results.
• Open forearm fractures constitute a surgical
emergency. Immediate stabilization of the radial
fracture and the DRUJ is recommended.
• Galeazzi fractures in skeletally immature
patients are typically treated with closed
reduction and casting because of the enhanced
viscoelastic nature of pediatric bone, as well as
the presence of a stout periosteal sleeve.
Galeazzi fracture consists of a fracture of the radius with
angulation and associated dislocation of the distal ulna
3.2 Green Stick Fracture
• Common in children (usually 6-12 years old)
because a child's bones are softer and more flexible
than those of an adult
• The bone cracks but doesn’t break all the way, it
looks like a green stick of wood
• Difficult to diagnose, because it may not cause all
the classic signs and symptoms of a broken bone.
• Treatment of a greenstick fracture requires
immobilization of the child's bone so that the bone
will grow back properly.
Definition
• An incomplete (green stick) fracture in the
radius and/or ulna, or the fracture may be
complete in one bone and incomplete (green
stick) in the other

Causes
• Usually happens when a child tries to throw the
arms when he/she falls
• This is a common reaction to catch yourself
before you fall

   
Symptoms
• None, in some cases
• Pain
• Swelling
• Abnormally bent or twisted limb
The intense pain and obvious deformity typical
of broken bones may be absent or minimal in
greenstick fractures. Additionally, it can be
difficult to tell the difference between a
greenstick fracture and a soft-tissue injury, such
as a sprain or a bad bruise.
The X-Ray result that shows Green Stick Fracture
Management

• Overcorrection of fracture may be required (completing the fracture

before aligning it)
•  Acceptable reduction:
 In infants:
                  - up to 30 deg may be accepted;
                  - consider reduction with completion of fracture by
reversal of deformity if angular > 25-30 deg;
  In children:
                  - up to 15 deg may be accepted depending on age of
patient;
                  - there is no need to attempt correction for angulation
measuring < 10 deg in children less than 10 yrs of age;
  Reduction:
      - a volarly angulated greenstick fracture is manipulated
with forearm in pronation while a dorsally angulated
fracture is manipulated with forearm in supination;
    
4. Fractures of Distal Radius
• Definition
A fracture of the distal radius occurs when the
area of the radius near the wrist breaks.

• Epidemiology
Osteopenic women(50/60s) : low energy
trauma, extra-articular “bending” type injury.
Standard initial radiographs :
• A. anteroposterior (AP),
• B. lateral (Lat)
• C. oblique (Obl)

To reveal the fracture pattern as well as the

extent and direction of the initial displacement.
Classification of distal radius fracture
 Type A

Muller
classffication

Type B Type C
• Type A
Distal radial fractures not involving the articular surface
( Colles’ and Smith’s fractures) fall into this type.

• Type B
This group comparises are distal radial fractures involving
part of the articular surface. These shearing fractures are
subdivided into three groups :
B1 : fractures involving injuries in the sagittal plane
( radial atyloid, cuneiform, and lunate facet fractures)
B2 : fractures in the coronal plane affecting the dorsal
aspect(Barton’s fracture)
B3 : fractures of the volar aspect, or reverse Barton’s
fractures.
 
• Type C

These are distal radial fractures involving a

complete articular surface injury.
C1 ; two fragment intraarticular fracture without
metaphyseal fragmentation
C2 ; two fragment intraarticular fracture with
multifragmented metaphysic
C3 ; fractures with comminution of the articular
surface.
Comminution is defined as involvement of more
than 50% of the metaphysis as seen on the
radiograph.
 Treatment
Management:
a. initial treatment
b. definitive
treatment Definitive treatment

Nondisplaced intra- Open or severely

Displaced Displaced
and extraarticular Comminuted
extraarticukar fx intraarticular fx
stable fx extraarticular fx
Thank You…