The document summarizes the case of a 19-year-old Thai man who presented to the emergency department after being assaulted with a knife. He sustained a large laceration and open fracture of both the radius and ulna in his right forearm. Physical examination revealed the injuries as well as decreased sensation and inability to extend his wrist and fingers. X-rays confirmed the open, oblique fractures of both forearm bones. The patient was taken to the operating room for wound debridement, tendon repair, and application of a splint.

1. Extern Conference
Extern Nannapin Paitoon

2. Patient profile
• ผู้ป่ ยชายไทยคู่ อายุ 19 ปี ัญชาติ ไทย า นา พุทธ
• ภูมิลาเนา อ.พิมาย จ.นครราช ีมา
• ิทธิการรัก า บัตรทอง
Chief complaint
• ถูกทาร้ายร่างกาย 2 hr.PTA

3. Present illness
2hr. PTA ถูกทาร้ายร่างกายโดยใช้มีดฟันที่แขนข า มีแผลขนาดใ ญ่ มีแขนผิด
รูปทันที รู้ ึกชาที่ปลายนิ้ กระดกข้อมือไม่ได้ จึงมารพ.

4. Physical examination
Primary survey
• GA: A Thai man, good consciousness
• HEENT: No pale conjunctiva,
anicteric sclera
• Heart: Normal S1S2, no murmur
• Lungs: Normal and equal breath
sound
• MSK:
Physical examination
• A: Can speak, c-spine not
tender
• B: CCT neg., Normal breath
sound both
• C: BP 119/55 PR 87 RR 20 T36.8
• D: E4V5M6, pupils 2 mmRTLBE
• E: Laceration wound 15x10 cm.
just below to Rt. elbow

5. Physical examination
• Laceration
wound 15x10
cm. just below
to Rt. elbow
• Deep to muscle
and tear
• Cap refill <2
• Radial pulse 2+
• Decrease
pinprick
sensation
• Can’t extent
wrist and finger

8. Secondary survey
AMPLE
• A : None
• M : No current medication
• P: No U/D
• L: NPO time22.00
• E:

9. Investigation
• Film Rt. forearm
AP, Lat. : Seen
fracture at
proximal radius
and ulnar bone
open
oblique

10. Investigation
• Film Rt. elbow AP,
Lat. : Seen
fracture at
proximal radius
and ulnar bone
and no joint
dislocate
open oblique

11. Investigation(Pre-op)
• CBC
WBC 9400 HGB 12 Hct37.6
MCV86 Plt 229,000 NE 86
LYM 11
• Coag
PT 11 INR 0.93 PTT 23 TT 18.8
• Imm
Anti-HIV neg. Anti-HCV neg.
Anti-HBV neg. HBsAg neg

12. Diagnosis
• Open fracture at both bone Rt. Forearm
• Complete tear ECRL ECRB EDC ECU muscle
Management
• Set OR for debridement with repair tendon with slab
-
his ,
!uMkeq9u-complete impair supination
I I 1 : I branchia radial is
Extensor Carpi Extensor Carpi Extensor Carpi ulnar is
radial is lig.
radial is brevis
I
extensor digitorum

13. Management
• Film Rt. forearm
AP, Lat.

14. Fracture of the both bone
forearm

15. Fracture of the both bone forearm

16. Fracture of the both bone forearm
Epidemiology
• More common in men than
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

17. Fracture of the both bone forearm
Associated conditions
• Elbow injury
• Evaluate DRUJ and elbow for
Galeazzi, Monteggia
• Compartment syndrome
• evaluate compartment pressures
if concern for compartment
syndrome
Prognosis
• functional results depend
on restoration of radial bow
Distal radial ulnar joint
on .
his mi until miioiasioiw

18. Classification
Descriptive
• Closed versus open
• Location
• Comminuted, segmental,
multifragmented
• Displacement
• Angulation
• Rotational alignment
OTA classification
• radial and ulna diaphyseal
fractures
Type A
simple fracture of ulna (A1), radius
(A2), or both bones (A3)
Type B
wedge fracture of ulna (B1), radius
(B2), or both bones (B3)
Type C
complex fractures

19. Presentation
Symptom
• 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

20. Imaging
Radiographs
•Recommended views
• AP and lateral views of the forearm
• Additional views
• oblique forearm views for further fracture definition
• ipsilateral wrist and elbow
• to evaluate for associated fractures or dislocation
• radial head must be aligned with the capitellum on all views

21. Treatment
• Non-operative
• functional fx brace with good interosseous mold
• Indications
isolated non displaced or distal 2/3 ulna shaft fx (nightstick fx) with
• < 50% displacement and
• < 10° of angulation
• Outcomes
• union rates > 96%
• acceptable to fix surgically due to long time to union
Entwines HW non displaced /
+

22. Treatment
• Operative
ORIF without bone grafting
• indications
-displaced distal 2/3 isolated ulna fx
-proximal 1/3 isolated ulna fx
-all radial shaft fx (even if nondisplaced)
-both bone fx
-Gustillo I, II, and IIIa open fractures may be
treated with primary ORIF
Outcomes
• most important variable in functional
outcome is to restore the radial bow
• Operative
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(delayed
grafting in open injuries
-nonunions of the forearm
I both bone and .
.
. .

23. Treatment
• 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)
Intramedullary nail
MINNY Srf

24. Complications
• Infection
• Compartment syndrome
• Nonunion
• Malunion
• Neurovascular injury
• Refracture

25. Thanks you