Different types of fractures (radius & ulna). Open and close fractures. Monteggia & Galeazzi fractures. Classification system for fractures. Fasciotomy.

1. FRACTURES
MSS CASE 4a

2. OUTLINE
 Introduction
 Fractures of radius and ulna
 Carpal fractures (scaphoid)
 Fasciotomy
 Indications

3. INTRODUCTION
Fracture:
 Break in the structural continuity of the bone
 More often the break is complete and the bone fragments are
displaced
 Closed (or simple)  overlying skin remains intact
 Open (or compound)  skin or one of the body cavities is breached

4. FRACTURES OF THE RADIUS
AND ULNA

5. MONTEGGIA FRACTURE
 1814, Giovanni Battista Monteggia
 Fracture to the proximal third of the ulna
 Anterior dislocation of radial head
 Description based on history of injury and physical examination
findings

6. BADO CLASSIFICATION
 Type I - Fracture of the proximal or middle third of the ulna with anterior
dislocation of the radial head

7.  Type II - Fracture of the proximal or middle third of the ulna with
posterior dislocation of the radial head

8.  Type III - Fracture of the ulnar metaphysis with lateral dislocation of
the radial head

9.  Type IV - Fracture of the proximal or middle third of the ulna
and radius with anterior dislocation of the radial head

10. ETIOLOGY
 Fall on an outstretched hand with forced pronation
 If the elbow is flexed, the chance of a type II or III lesion is
greater
 High-energy trauma & low-energy trauma

11. PROGNOSIS
 In 1991, Anderson and Meyer used the following criteria to
evaluate forearm fractures and their prognosis:
 Excellent - Union with less than 10° loss of elbow and wrist flexion/extension
and less than 25% loss of forearm rotation
 Satisfactory - Union with less than 20° loss of elbow and wrist
flexion/extension and less than 50% loss of forearm rotation
 Unsatisfactory - Union with greater than 30° loss of elbow and wrist
flexion/extension and greater than 50% loss of forearm rotation
 Failure - Malunion, nonunion, or chronic osteomyelitis

12. CLINICAL FEATURES
 Elbow pain
 Depending on the type of fracture and severity
Elbow swelling, deformity, crepitus and paresthesia or numbness
 X-ray
 Isolated fractures of ulna
 Forward dislocation of radial head, fracture of the upper 3rd of ulna with
forward bowing
 Posterior or Lateral ulna bowing  with posterior or lateral displacement of
radial head

13. TREATMENT
 Aim  Restore the length of fractured ulna
 Adults
 Via a posterior approach
 Ulna fracture reduction with bone restoration to full length (fixation with
plate and screws)
 Radial head reduction
Stability testing full range of flexion and extension
 Radial head doesn’t reduce:
 Perform open reduction

14. TREATMENT
 Children
 Features are similar to those in adults
 Ulnar fracture may be incomplete (greenstick)
 If undetected & corrected chronic subluxation of radial head
 Incomplete ulnar fractures
 Close reduction
 Complete fractures
 Open reduction & fixation (intramedullary rod/small plate)

16. GALEAZZI FRACTURE
 Described in 1934 by Galeazzi
 More common than Monteggia fracture
 Usually caused by a fall on a hyperpronated forearm
 Radial fracture (lower third), inferior radio-ulnar joint
dislocation

17. CLINICAL FEATURES
 Pain and soft tissue swelling
 Anterior interosseous nerve palsy
 Loss of pinch mechanism

18. TREATMENT
 Restore the length of fractured bone
 Open reduction of radius and distal radioulnar joint
 “Fracture of necessity”
 X-ray is taken to ensure that the distal radioulnar joint is reduced
 3 possibilities:
Distal radio-ulnar joint is reduced and stable
Distal radio-ulnar joint is reduced but unstable
Distal radio-ulnar joint is irreducible

19. a) Monteggia
fracture
b) Galeazzi fracture
X-ray
Galeazzi type
before and after
reduction &
plating

20. COLLES’ FRACTURE
 Described in 1814 by Abraham Colles
 Transverse fracture above the wrist with dorsal displacement
of distal fragment
 Common in older people

21. CLINICAL FEATURES
 Dinner fork deformity
 Tenderness on the back of the wrist and a depression
anteriorly
 Patients with less deformity:
 Local tenderness and pain on wrist movements
 X-ray
 Transverse fracture of radius (corticocancellous junction)
 Ulnar styloid is broken off

23. TREATMENT
 Undisplaced fractures
 Dorsal splint for a day or two until swelling has resolved, then the cast
is completed
 X-ray is taken at 10-14 days
Displaced fractures
Comminuted fractures

24. SMITH’S FRACTURE
Reversed Colles’
Transverse fracture of radius above the wrist with
anterior displacement of distal fragment
Caused by a fall on the back of the hand

25. CLINICAL FEATURES
 Wrist injury but no dinner-fork deformity
 Garden-spade deformity
 X-ray
 Fracture via distal radial metaphysis
 Lateral view  distal fragment is displaced and tilted anteriorly

26. TREATMENT
 Reduced by traction, supination and extension of wrist
 Forearm is immobilized in a cast for 6 weeks
 X-ray taken at 7-10 days to ensure the fracture hasn’t slipped
 Unstable fractures
 Fixed with percutaneous wires or a plate

27. FRACTURED SCAPHOID
 Account for 75% of all carpal fractures
 Usually caused by a fall on the dorsiflexed hand
 Most scaphoid fractures are stable; with unstable fractures the
fragments may become displaced
 Humpback deformity
 Flexion of distal fragment and dorsal tilting of proximal fragment with lunate
(a Dorsal Intercalated Segment Instability (DISI) deformity)
 Blood supply  diminishes proximally
 1% distal fractures, 20% middle third fractures and 40% proximal fractures
result in nonunion or avascular necrosis of the proximal fragment

29. CLINICAL FEATURES
 Tenderness in the anatomical snuffbox
 X-ray
 Fracture is transverse via the narrowest part of the bone (waist)
 Look for subtle signs of displacement
 E.g.: obliquity and opening of the fracture line, angulation of the distal fragment
and foreshortening of the scaphoid image
 Few weeks after the injury the fracture may be more obvious; if union is
delayed, cavitation appears on either side of the break
 Old, un-united fractures have ‘hard’ borders
 Relative sclerosis of proximal fragment  avascular necrosis

30. TREATMENT
 Scaphoid tubercle fracture
 No splintage required
 Treated ass a wrist sprain
 Apply crepe bandage and encourage movement
 Undisplaced fractures
 No reduction required
 Treated in plaster
 Cast is applied from the upper forearm to metacarpo-phalangeal joints of
fingers including proximal phalanx of thumb
 Wrist is held dorsiflexed and the thumb forwards in the ‘glass holding’
position
 Cast is retained for 8 weeks,

31.  Displaced fractures
 Can also be treated in plaster
 Open reduction  increases the likelihood of union and reduce
immobilization time

32. INDICATIONS FOR
FASCIOTOMY

33. FASCIOTOMY
 A surgical procedure where the fascia is cut to relieve
tension or pressure commonly to treat the resulting loss of
circulation to an area of tissue or muscle.
 Performed through a volar approach, a dorsal approach or
both.
 In the forearm, the volar compartment, dorsal
compartment, and mobile wad compartment are
interconnected

34. INDICATIONS
 Based on clinical impression.
 4 signs & symptoms (4 Ps)
 Pain that is out of proportion to clinical findings
 Pain with passive stretch of involved muscles
 Pain with palpation of involved compartment
 Pressure increase within the compartment as measured
 In a patient who can’t express pain or paresthesias
 clinical examination, monitoring of compartment pressure
 Masquelet
 Whenever diastolic pressure minus tissue pressure is less than 30 mmHg

35. REFERENCE
 "Fasciotomy: Overview, Preparation, Technique".
Emedicine.medscape.com. N.p., 2017. Web. 18 Apr. 2017.
 Louis, S, Warwick, D & Nayagam, S. (2010). Apley’s System
Of Orthopaedics and Fractures. Euston Road, London:
Hachette UK Company.
 "Monteggia Fracture Treatment & Management: Approach
Considerations, Medical Therapy, Surgical Therapy".
Emedicine.medscape.com. N.p., 2017. Web. 19 Apr. 2017.

36. THANK YOU 