Radius Fracture

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  • Fractures of the forearm bones
  • The radius and ulna are commonly fractured together – termed fracture of ‘both bones of the forearm’. (MCQ)
  • Cause of fracture
    • indirect force such as a fall on the hand
    • direct force such as a ‘lathi’ blow to the forearm. (MCQ)
  • Displacements
    • In children, these fractures are often undisplaced, or minimally displaced {greenstick fractures
    • In adults they are notoriously prone to severe displacement.
      • Angulation – commonly medial and anterior
      • Shift – in any direction
      • Rotation – the proximal and distal fragments lie in different positions of rotations (e.g., the proximal fragment may be supinated and the istal pronated).
    • Treatment
      • Conservative treatment is sufficient in most cases.
      • For adults with displaced fractures, operative treatment is often required.
      • Conservative treatment:
        • closed reduction by manipulation under general anaesthesia, and immobilisation in an above-elbow plaster cast. (MCQ)
        • Weekly X-rays should be taken for 3 weeks, for early detection of redisplacement. (MCQ)
      • Open reduction and internal fixation:
        • The radius and ulna should be approached through separate incisions to avoid cross union.
        • Compression plating is the preferred method. (MCQ)
        • The other method is intra-medullary nailing.
        • Additional bone grafting should be used in fractures older than three weeks.
        • The limb should be mobilised depending upon rigidity of the fixation.
        • External fixation is used in some compound fracture for ease of dressing.
        • Complications
        • Infection – osteomyelitis
        • Volkmann’s ischaemia: (MCQ)
      • This occurs within 8 hours of injury
      • Occur as a result of ischaemic damage to the muscles of the flexor compartment of the forearm
        • Delayed union and non-union: (MCQ)
      • delayed union is particularly that of ulnar shaft at the junction of the middle and lower-thirds
      • The cause of non-union is usually inadequate immobilization
      • Treatment:
        • Treatment of non-union of these bones is open reduction and internal fixation using plates, and bone grafting.
        • In a non-union involving the distal 5 cm of the ulna, good functions can be achieved by simply excising the short distal fragment.
  • Malunion:
  • This results from failure to achieve and maintain a good reduction
  • Treatment is open reduction and internal fixation using plates, and bone grafting.
    • Cross union:
  • When radius and ulna fractures are joined to each other by a bridge of callus
  • It is likely to develop in a case where the two fractures are at the same level (MCQ)
  • It result in a complete limitation of forearm rotations
  • Treatment:
    • If the cross union is in mid-pronation, the position most suitable for function, it is left as it is(MCQ)
    • If it occurs in excessive pronation or supination, operative treatment may be required. (MCQ)
    • The cross union is undone, mal-alignment corrected, and the fracture internally fixed.
  • Monteggia fracture-dislocation (A Very High yield topic in PG Medical entrance)
    • This is a fracture of the upper-third of the ulna with dislocation of the head of the radius. (MCQ)
    • Mechanism of fracture
      • It is caused by a fall on an out-stretched hand(MCQ)
      • It may also result from a direct blow on the back of the upper forearm. (MCQ)
    • Types
      • These fall into two main categories depending upon the angulation of the ulna fracture -extension and flexion type.
      • Extension type
        • commoner of the two types (MCQ)
        • ulna fracture angulates anteriorly (extends) and the radial head dislocates anteriorly.
      • Flexion type
        • ulna fracture angulates posteriorly (flexes)
        • radial head dislocates posteriorly
      • Clinical vignette :
        • In a case with an isolated fracture of the ulna in its upper half a dislocation of the head of the radius should be carefully looked for (MCQ)
      • Treatment
        • This is a very unstable injury, frequently redisplacing even if it has been reduced once.
        • One attempt at reduction under general anaesthesia is justified.
        • If reduction is successful, a close watch is kept by weekly check X-rays for the initial 3-4 weeks(MCQ)
        • open reduction and internal fixation using a plate -indications
          • In case, the reduction is not possible
          • if redisplacement occurs
        • The radial head automatically falls into position, once the ulna fracture is reduced.
      • Complications
        • Malunion (MCQ)
          • occurs commonly in cases treated conservatively,
          • occurs because of an undetected re-displacement within the plaster.
        • Galeazzi fracture-dislocation
          • a fracture of the lower third of the radius with dislocation or subluxation of the distal radio-ulnar joint(MCQ)
          • It commonly results from a fall on an out stretched hand.
          • Displacement
            • The radius fracture is angulated medially and anteriorly (MCQ)
            • The distal radio-ulnar joint is disrupted, resulting in dorsal dislocation of the distal end of the ulna.
          • Clinical vignette :
            • In an isolated fracture of the distal-half of the radius, the distal radio-ulnar joint must be carefully evaluated for subluxation or dislocation.
          • Treatment
            • Most adults require open reduction and internal fixation of the radius with a plate. The dislocated radio-ulnar joint may automatically fall back in place or may require open reduction.
          • Complication –Malunion
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