Fracture forearms and carpal bones

1. FRACTURES OF THE FOREARM
AND CARPAL BONES
Dr. Ritesh Chaudhary
Fellowship in Emergency Medicine
BP Koirala Institute of Health Sciences,
Dharan, Nepal

2. Radial head fractures
• Occur frequently, usually as a result of a fall onto an
outstretched hand or, less frequently, following a direct
blow to the lateral side of the elbow.
• Usually, there is swelling and tenderness over the radial
head.
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3. • Elbow extension and forearm rotation are limited.
• Severely comminuted fractures may have proximal
displacement of the radius, which can be associated with
disruption of the interosseous membrane and subluxation
of the distal radioulnar joint.
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4. Imaging
• Standard anteroposterior (AP) and lateral X-rays of the
elbow are required.
• The presence of an anterior fat pad sign alone on X-ray is
associated with an underlying radial head or neck fracture
in up to 50% of patients.
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5. A subtle radial head fracture with associated positive sail sign
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6. Classification
Mason–Hotchkiss classification of radial
head fractures.
The Mason classification is as
follows:
1.Mason type I, displaced <2 mm.
2.Mason type II,displacement >2
mm.
3.Mason type III, comminuted
fractures of the entire radial head.
4.Mason type IV, radial head
fracture with associated elbow
dislocation.
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7. Treatment
• All non-displaced (type I) radial head fractures and those
type II fractures without mechanical block may be
managed with a bandage and sling.
• Mobilization should be started as early as possible.
• If there is severe pain, a posterior splint may be useful but
should not be applied for more than 2 days. Prognosis is
good, but full extension may not be possible for many
months.
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8. • Mechanical block can be difficult to assess acutely due to
pain.
• Intra-articular injection of bupivacaine may assist early
assessment or assessment may be deferred until pain
has settled.
• Surgical options include open reduction and internal
fixation and excision of the radial head with or without
implantation of a prosthesis.
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9. • Displaced or complex radial head fractures (type II or III)
may be treated in the acute setting with a sling or
posterior splint.
• These patients should have early orthopaedic review
(within days).
• Radial neck fractures with up to 20° tilts can be managed
conservatively. More severe tilt can be reduced using
intra-articular local aneasthesia.
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10. • The forearm is pronated until the most prominent part of
the radial head is felt.
• Then traction is applied to the forearm and pressure
applied to the radial head.
• Open reduction is indicated if closed methods fail or
displacement is severe.
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11. Complications
• Complications relate to disturbance of the relationships of
the proximal radio-ulnar and radiocapitellar articular
surfaces causing limitation of movement.
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12. Shaft fractures
• This type of injury requires great force, typically from a
motor-vehicle accident, a fall from a height or a direct
blow.
• These fractures are commonly open and nearly always
displaced.
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13. Examination
• The forearm is swollen and tender and may be angulated
and rotated.
• Look for an open wound, local neurovascular
compromise, compartment syndrome or
musculotendinous injury.
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14. Clinical investigations
Imaging
• AP and lateral X-rays of the forearm, including the wrist
and elbow joints, are needed.
• Displacement and angulation are easily determined, but
torsional deformity may be subtle.
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15. • The ulna and radius are rectangular in cross-section
rather than circular, a change in bone width at the fracture
site indicates rotation.
• The radial and ulnar styloid processes normally point in
opposite directions to the bicipital tuberosity and coronoid
process, respectively.
• A change in this alignment also suggests torsion.
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16. Treatment
• Adult forearm fractures are less stable than those in
children and lack of remodelling limits tolerance to
incomplete reduction.
• Undisplaced fractures may be managed with an above-
elbow cast, but must be reviewed at 1 week for
displacement and angulation.
• Most fractures, however, are displaced and require open
reduction and internal fixation.
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17. Complications
• Early complications include wound infection,
osteomyelitis, neurovascular injury and compartment
syndrome.
• Later, non-union, malunion, reduced forearm rotation and
reflex sympathetic dystrophy are possible complications.
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18. Specific fracture types
Isolated fracture of the ulnar shaft
• Direct blow to the ulna, often when raised in defence;
hence they are also known as ‘nightstick’ fractures.
• Patients present with localized pain and swelling. AP and
lateral X-rays delineate the location of the fracture and
degree of angulation.
• Look for associated dislocation of the radial head if
displacement is present (Monteggia fracture dislocation).
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19. • Fractures displaced less than 50% of the ulna width heal
well with a non-union rate of 0–4%.
• Traditional treatment involves fixing the forearm in mid-
pronation with a plaster cast, extended above elbow if the
middle or proximal thirds of the ulna are fractured.
• The cast is removed once union occurs, usually in about 8
weeks.
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20. • Other proven options include a below-elbow plaster
(BEPOP) for proximal fractures, early mobilization with
bandage after 1–2 weeks in BEPOP or functional bracing
after 3–5 days, which allows movement at wrist and
elbow.
• Fractures with more than 10° of angulation or displaced
more than 50% of the diameter of the ulna require
surgical intervention.
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21. Monteggia fracture dislocation
• This is a rare fracture of the proximal ulna with dislocation
of the radial head.
• It occurs either through a fall onto the outstretched hand
with hyperpronation or through a force applied to the
posterior aspect of the proximal ulna.
• Patients present with pain, swelling and reduced elbow
movement. The forearm may appear shortened and the
radial head may be palpable in the antecubital fossa.
• Associated posterior interosseous nerve injury is
common.
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22. • On X-ray the fracture is obvious, but the dislocation is
commonly missed.
• Check that a line through the radial shaft bisects the
capitellum on both views.
• There are four types of Monteggia fracture depending
upon displacement of the radial head (Bado
classification).
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24. • All Monteggia fractures require open reduction and
internal fixation.
• Common complications include malunion and non-union
of the ulnar fracture and an unstable radial head.
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25. Isolated radial shaft fracture
• Isolated fractures of the proximal two-thirds of the radial
shaft are uncommon and are usually displaced.
• Rare undisplaced fractures can be treated similarly to
isolated ulnar shaft fractures.
• Displaced fractures require open reduction and internal
fixation.
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26. Galeazzi fracture dislocation
• Fractures of the distal third of the radial shaft occur as a
result of a fall onto the outstretched hand or a direct blow.
• There may be an associated subluxation or dislocation of
the distal radioulnar joint (DRUJ), known as the Galeazzi
fracture dislocation.
• Patients have pain and swelling at the radial fracture site.
• Those with a Galeazzi injury will also have pain and
swelling at the DRUJ and a prominent ulnar head.
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27. The Galeazzi fracture dislocation.
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X-rays show the radial fracture,
which is tilted ventrolaterally.
Widening of the DRUJ space on
the AP X-ray and dorsal
displacement of the ulnar head
on the lateral X-ray are seen.
An ulnar styloid fracture is seen
in 60% of cases.

28. • All Galeazzi fracture dislocations require surgical
management.
• Complications include malunion or non-union of the radial
fracture and subsequent instability of the DRUJ.
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29. Fractures of the distal radius and ulna
• Fractures of the distal radius and ulna are common,
particularly in children and elderly women.
• Fractures in the latter group are indications for evaluation
of bone-mineral density.
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30. Clinical features
History and examination
• Fractures usually occur after a fall onto the outstretched hand
resulting in bending, shearing or impaction forces being applied
to the distal metaphysis, or from a direct blow.
• Pain, tenderness and variable degrees of swelling and
deformity.
• Examine for associated injuries to carpal bones, radial and
ulnar shafts, elbow and shoulder joints, for median nerve injury,
vascular compromise and for extensor tendon injury.
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31. Clinical investigations
Imaging
• Anteroposterior and lateral X-rays of the wrist
demonstrate most injuries.
• For patients with significant symptoms or signs and a
normal X-ray, consider an occult undisplaced fracture or
ligamentous injury.
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32. Treatment
• Prompt attention to analgesia, splinting and elevation is
essential while awaiting X-rays.
• Reduction is indicated in the following circumstances to
improve long-term function:
1.Visible deformity of the wrist
2.Loss of volar tilt of the distal radial articular surface beyond neutral
3.Loss of>5° of the radial inclination of the distal radius (normally
approximately 20°)
4.Intra-articular step of>2 mm
5.Radial shortening>2–3 mm.
• Greater deformity can be accepted in low-demand, elderly
patients.
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33. • Anaesthetic options for reduction include haematoma
block, Bier’s block and procedural sedation.
• Reduction is traditionally maintained with an encircling
plaster cast moulded to oppose displacement forces and
extending from volar metacarpal crease to proximal
forearm for 6 weeks.
• Weekly X-rays for 2–3 weeks with orthopaedic follow up
are recommended for all displaced fractures, those with
intra-articular extension and potentially unstable fractures.
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34. Indications for operative management
1.Comminuted, displaced, intra-articular fractures
2.Open fractures
3.Associated carpal fractures
4.Associated neurovascular or tendon injury
5.Failed conservative treatment (failed reduction or
unstable after reduction)
6.Bilateral fractures/impaired contralateral extremity.
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35. Complications
• Median nerve injury
• Malunion with chronic wrist pain, arthritis and secondary
radioulnar and radiocarpal instability.
• Long-term complications include osteoarthritis, residual
disability and complex regional pain syndrome (CRPS).
1% to 22%.
• Prophylactic vitamin C may reduce the incidence of
CRPS, the advised dose is 500 mg/day for 50 days
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36. Specific fractures
Colles’ fracture
• Colles’ fracture is a metaphyseal bending fracture.
• The wrist has a classic ‘dinner-fork’ appearance, often
with significant swelling of the soft tissues.
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37. Colles’ fracture. A fracture of the distal
radial metaphysis
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38. • There is often associated damage to the radio-ulnar
fibrocartilage.
• There may be comminution, commonly dorsally, which
can extend into the radiocarpal or radio-ulnar joints.
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39. • The commonly accepted cast immobilization position is
with the wrist joint in 15° palmar flexion, 10–15° ulnar
deviation and slight pronation.
• However, some evidence suggests better outcomes are
achieved with the wrist in dorsiflexion and mid-supination.
• The cast must be carefully moulded over the dorsum of
the distal fragment and the anteromedial forearm.
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40. Smith’s fracture
• This metaphyseal bending fracture of the distal radius
occurs through a direct blow or fall onto the back of the
hand or a fall backward onto the outstretched hand in
supination.
• AP and lateral X-rays of the wrist show a ‘reverse Colles’
fracture’ with a similar AP appearance, but with volar
displacement and tilt on the lateral X-ray view.
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41. Smith’s fracture ( Frontal and lateral )
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42. • Closed reduction to achieve anatomical radial length and
volar tilt should be attempted.
• Traction is first applied to restore length, followed by
dorsal pressure over the volar surface of the distal radius
to reverse displacement and angulation.
• A full above-elbow cast is applied with the wrist in
supination and dorsiflexion to prevent loss of reduction.
• However, most Smith’s fractures are unstable and require
operative management. Early orthopaedic follow up is
mandatory.
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43. Barton’s fracture
• Barton’s fractures are dorsal or volar intra- articular
fractures of the distal radial rim.
• The mechanisms of injury are similar to those seen with
Colles’ and Smith’s fractures, respectively.
• There is often significant soft-tissue injury and the carpus
is usually dislocated or subluxed along with the distal
fragment.
• These fractures are complicated by arthritis of the
radiocarpal joints and carpal instability.
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44. 3/8/2016 Forearm fracture and carpal bones 44

45. Barton’s fracture
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46. • Minimally displaced fractures involving less than 50% of
the joint surface and without carpal displacement may be
reduced along the lines of a Colles’ or Smith’s fracture.
• Immobilization should occur with wrist flexed for dorsal
Barton’s and extended for volar Barton’s.
• However, most fractures are unstable and potentially
disabling, requiring early operative management,
especially in younger patients.
• Early orthopaedic follow up is mandatory.
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47. Radial styloid (Hutchison’s or chauffeur’s)
fracture
• Oblique intra-articular fracture of the radial styloid.
• Caused by a direct blow or fall onto the hand.
• Displacement is associated with carpal instability and
long-term arthritis.
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48. Radial styloid (Hutchison’s or chauffeur’s) fracture
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49. • Undisplaced fractures can be treated with a cast for 4–6
weeks.
• Displaced fractures should be referred to an orthopaedic
surgeon for anatomical reduction and fixation.
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50. Ulnar styloid fracture
• An isolated fracture can occur through forced radial
deviation, dorsiflexion, rotation or a direct blow.
• fractures involving the base of the ulnar styloid disrupt the
major stabilizing ligaments of the distal ulna and the
triangular fibrocartilage complex (TFCC) and may lead to
subsequent distal radio- ulnar joint (DRUJ) instability.
• Fractures should be treated with a splint or cast with the
wrist in mid-supination and ulnar deviation, patients
should be referred to an orthopaedic surgeon to assess
DRUJ stability
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51. Normal P/A view of wrist joint
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1. The carpal bones are arranged in two rows forming three smooth arcs (Gilula lines). 2. The carpal
bones are separated by a uniform 1- to 2-mm space. 3. The scaphoid (S) is elongated. 4. The radius
has an ulnar inclination of 13 to 30 degrees. 5. The radial styloid projects 8 to 18 mm. 6. Half the
lunate articulates with the radius, with equal length over the ulna (neutral ulnar variance). C = capitate;
H = hamate; L = lunate; P = pisiform; Tm = trapezium; Tq = triquetrum; Tz = trapezoid.

52. Normal Wrist Axis
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Normal wrist. Axis of the radius (R), lunate
(L), and capitate (C) are collinear (three C’s
sign).
The capitolunate (CL) angle is <10 to 20
degrees. The scapholunate (SL) angle is
between 30 and 60 degrees. The radial
volar tilt is 10 to 15 degrees
Dorsal intercalated segment instability.
Volar intercalated segment instability.

53. Scaphoid fracture
• The most common mechanism of injury is a fall on the
outstretched hand with the wrist in radial deviation.
• Wrist pain and local swelling and tenderness over the
scaphoid.
• Imaging with AP, lateral and scaphoid views will detect at
most 70% of all scaphoid fractures.
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54. • Stable fractures are undisplaced with little comminution
and unstable fractures are displaced with considerable
comminution.
• Stable fractures are generally treated with a below-elbow
cast for 10–12 weeks.
• Unstable fractures require surgical intervention.
• Complications include non-union and avascular necrosis
of the proximal segment.
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55. Imaging
• Early primary CT, magnetic resonance imaging (MRI) or
bone scintigraphy.
• All of these imaging modalities have their advantages and
shortcomings.
• Bone scintigraphy is recommended as a useful diagnostic
modality to rule out occult scaphoid fractures.
• Bone scintigraphy can rule out scaphoid fracture with a
sensitivity close to 100% but with the disadvantage of up
to 25% false positives.
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56. Dislocations of the wrist
• Dislocations involving the wrist usually result from high-
energy falls on the outstretched hand (such as from a
height) that result in forced hyperextension.
• Clinical features include mechanism of injury, wrist pain,
swelling and tenderness and possibly reduced grip
strength.
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57. Imaging
• Imaging requires PA and lateral X-rays. The normal PA
view should show two rows of carpal bones in a normal
anatomic position with uniform joint spaces of no more
than 1–2 mm.
• No overlap should be seen between the carpal bones or
between the distal ulna and the radius.
• On the lateral film, a longitudinal axis should align the
radius, the lunate, the capitate and the third metacarpal
bone.
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58. Lunate dislocation
• On the usual PA image, the lunate has a triangular shape
rather than its usual trapezoidal shape.
• On the lateral film, the lunate has a ‘C-’ or ‘half-moon’
shape.
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59. Perilunate dislocation
• On the PA film, crowding is evident between the proximal
and distal carpal bones.
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60. 3/8/2016 Forearm fracture and carpal bones 60
Perilunate dislocation.
A. Posteroanterior view shows obliteration of the three smooth arcs as bones overlap one
another (white hash marks).
B. Lateral view shows capitate dorsal to lunate, disrupting the “three C’s” (arrow).

61. Scapholunate dislocation
• On a PA radiograph, the scapholunate space is greater
than 4 mm (also known as the Terry-Thomas sign).
• The scaphoid rotates, producing the classic signet-ring
sign.
• Associated carpal fractures, especially of the scaphoid,
may be evident.
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62. 3/8/2016 Forearm fracture and carpal bones 62
'Terry Thomas sign' - in
homage to the well
known British actor

63. Treatment
• All wrist dislocations require orthopaedic consultation and
prompt reduction.
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64. Wrist Radiography
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