fracture radius ulna

1. TeamV
AG/WM/LA/RE
MOD: SG
SUPV: dr. Dewi Kurniati, M.Kes, Sp.OT
BAGIAN ORTOPEDI &TRAUMATOLOGI FAKULTAS KEDOKTERAN UNHAS MAKASSAR

2.  Epidemiology
 men > women
 ratio of open to closed fractures is higher than for any
other bone except tibia
 Mechanism
 direct trauma
▪ often while protecting one's head
 indirect trauma
▪ motor vehicle accidents
▪ falls from height
▪ athletic competition orthobullets

3.  Associated conditions
 elbow injuries
 evaluate DRUJ
 Compartement syndrome
 Prognosis
 functional results depend on restoration of radial
bow
orthobullets

7.  Symptoms
 gross deformity, pain, swelling
 loss of forearm and hand function
 Physical exam
 inspection
 open injuries
 check for tense forearm compartments
 neurovascular exam
 assess radial and ulnar pulses
 document median, radial, and ulnar nerve function
 pain with passive stretch of digits
 alert to impending or present compartment syndrome orthobullets

8.  recommended views
AP and lateral views
 additional views
 oblique forearm views
▪ for further fracture definition
 ipsilateral wrist and elbow
▪ to evaluate for associated fractures or dislocation
orthobullets

9.  functional fx brace with good interosseous
mold
 indications
 isolated nondisplaced OR distal 2/3 ulna shaft fx
(nightstick fx) with
▪ < 50% displacement and
▪ < 10° of angulation
orthobullets

10.  ORIF without bone grafting
 indications
 displaced distal 2/3 isolated ulna fxs
 proximal 1/3 isolated ulna fxs
 all radial shaft fxs (even if nondisplaced)
 both bone fxs
 Gustillo I, II, and IIIa open fractures may be treated
with primary ORIF
orthobullets

11.  ORIF with bone grafting
 indications
 cancellous autograft is indicated in radial and
ulnar fractures with bone loss
 bone loss that is segmental or associated with
open injury
 nonunions of the forearm
orthobullets

12.  external fixation
 indications
 Gustillo IIIb and IIIc open fractures
 IM nailing
 indications
 poor soft-tissue integrity
 not preferred due to lack of rotational and axial
stability and difficulty maintaining radial bow (higher
nonunion rate) orthobullets

14.  SAE09TR. A 12-year-old girl falls in gymnastics and
sustains comminuted midshaft radius and ulna fractures.
Closed reduction and cast immobilization are attempted
but fracture redisplacement with 20 degrees of angulation
occurs. Surgical treatment includes closed reduction and
intramedullary fixation of both bones. What is the most
common long-term complication for this fracture?
 1. Infection
 2. Malunion
 3. Loss of forearm rotation
 4. Refracture
 5. Delayed union/nonunion

15.  PREFERRED RESPONSE 3
 Healing of forearm fractures in skeletally immature patients is the
usual outcome. The use of intramedullary fixation has been
reported to result in a lower frequency of refractures when
compared to plate osteosynthesis due to the absence of diaphyseal
holes after plate removal, which are considered stress risers.
Regardless of implant technique, malunion and infection are
infrequent. Loss of forearm pronation and supination is a common
occurrence in surgically treated fractures due to the higher degree
of soft-tissue injury, and periosteal stripping leads to fracture site
instability and fracture comminution.

16. OBQ05.178) A 42-year-old male sustains a closed, isolated ulna shaft
fracture with 2mm displacement and 3 degrees valgus angulation. He
is treated conservatively with early range of motion but presents at
one year with a painful atrophic nonunion.What treatment is
indicated at this time?
 1. Dynamic splinting
 2. Open autogenous cancellous bone grafting
 3. Open reduction internal fixation with autogenous bone grafting
 4. Closed reduction and percutaneous pinning
 5. Use of an implantable ultrasound device

17.  PREFERRED RESPONSE 3
 Appropriate treatment of an atrophic nonunion of the ulna includes open
reduction and internal fixation with autogenous bone grafting. The
atrophic nature of the nonunion reveals that biology, and not necessarily
stability, is the major issue of the nonunion. The referenced article by Ring
et al reviews a case series of these patients and found that even in the
face of significant preoperative bone resorption, good clinical outcomes
and union rate is possible with open plating and grafting. The article by
Street reviews intramedullary nailing/pinning of the forearm, and found a
7% nonunion rate with this technique.

18. OBQ15.139)Which of the following post-reduction forearm fractures
patterns may be treated non-operatively in an otherwise healthy 22-
year old male?
 1. Displaced diaphyseal fracture of the radius
 2. Non-displaced diaphyseal fracture of the radius, displaced
diaphyseal fracture of the ulna
 3. Displaced diaphyseal fractures of both bones of the forearm,
with less than 10 degrees angulation after closed reduction
 4. An isolated mid-shaft ulna fracture translated 20%, with less
than 5 degrees of angulation
 5. Gustilo grade II open fracture of the radius

19. PREFERRED RESPONSE 4
In adults, minimally displaced fractures of the ulna may be treated non-operatively. Even in the setting of
minimal displacement, fractures involving the radial diaphysis, or both bones of the forearm, are at high risk
of displacing further and progressing to malunion or nonunion. Given the potential for a resulting loss of
forearm rotation, open reduction internal fixation is indicated for almost all adult diaphyseal radius and both
bone fractures.
Schulte et al. review the management of both bone forearm fractures in adults. They review biomechanics,
fixation techniques, outcomes and complications. They note that the goals of fixation in simple patterns are
'cortical opposition, compression, and restoration of forearm geometry.' Anderson et al. treated 330 acute
diaphyseal forearm fractures with compression plating from 1960 to 1970. At 4 months to 9 years follow up,
they achieved a 97.9% union rate for the radius and 96.3% union rate for the ulna. Illustration A shows
measurement of radial bow. A dotted line perpendicular to the line drawn from the radial tuberosity to the
ulnar aspect of the distal radius can be used to measure radial bow when drawn at the point of maximum
distance to the ulnar edge of the radius.