INJURIES OF THE FOREARM AND WRIST

What is this dorsal tilt called?

'dinner-fork deformity'.

Complications

- Circulatory impairment - Nerve injury - Compression of carpal tunnel -> Median nerve - Malunion - Associated radioulnar and carpal injuries - Tendon rapture - extensor pollicis longus tendon - Joint stiffness - Complex regional pain syndrome

Types of fractures in the distal radius

1. COLLES' FRACTURE 2. SMITH'S FRACTURE 3.BARTON'S FRACTURE

Signs

1. Ulnar fractures that bows forward 2. Radial head dislocation

Signs and symptoms

1. there may be pain and swelling but little or no deformity. 2. Displaced fractures produce a distinctive dorsal tilt just above the wrist

Causes

A twisting force (usually a fall on the hand) produces spiral fractures with the bones broken at different levels. A direct blow or an angulating force causes transverse fractures of one or both bones at the same level.

Treatment

As with the Monteggia fracture, the important step is to restore the length of the fractured bone In children, closed reduction is often successful In adults, reduction is best achieved by open operation and compression plating of the radius.

FRACTURE-SUBLUXATION OF THE WRIST (BARTON'S FRACTURE)

Barton's injury is an oblique fracture which runs from the volar surface of the distal end of the radius into the wrist joints.

Buckle fractures

Buckle fractures require no more than 2 weeks in plaster, followed by another 2 weeks of restricted activity.

More sensitive imaging

CT

Complications of distal radial fractures

Carpal instability Secondary osteoarthritis

Treatment in children

Closed reduction

Treatment for displaced

Displaced fractures must be reduced under anaesthesia (haematoma block, Bier's block or axillary block).

Complex regional pain syndrome , symptoms

Early signs are swelling and tenderness of the finger joints By the time the plaster is removed, the hand is stiff and painful and there are signs of vasomotor instability. X-rays show osteoporosis and there is increased activity on the bone scan.

Signs and symptoms

Following a fall patient complains of pain in the wrist, swelling Tenderness can often be localized to a particular spot, providing a clue to the diagnosis Movements are likely to be restricted and painful.

Complications

Forearm swelling Malunion

Greenstick fractures

Greenstick fractures are usually easy to reduce - but apt to re-displace in the cast! Some degree of angulation can be accepted: in children under the age of 10 years, up to 30 degrees, and in children over 10 years, up to 15 degrees. If the deformity is greater, the fracture is reduced by thumb pressure and the arm is immobilized in a full-length cast

Comminuted and unstable Colles' fractures

If plaster immobilization alone cannot hold the fracture, then surgery is considered. Options include percutaneous K-wire fixation For very unstable fractures and osteoporotic bone, external fixation may be added to prevent collapse around the wires.

Complication

If the CMC joint is seriously damaged or subluxated, osteoarthritis may ensue.

Treatment for Undisplcaed fracture

If the fracture is undisplaced a dorsal splint is applied for 1-2 days until the swelling has resolved, then the cast is completed.

Principle of diagnosis

If the initial x-rays seem to be normal but the clinical signs suggest a carpal injury, a splint or plaster should be applied and the x-ray examination repeated 2 weeks later;

Treatment

If the styloid fragment is displaced, it should be reduced and held with screws or K-wires.

SMITH'S FRACTURE

In this injury the distal fragment is displaced and tilted anteriorly (which is why it is sometimes called a 'reversed Colles'). It is caused by a fall on the back of the hand.

Treatment

Internal fixation

Treatment

It can be held in a plaster cast but it usually slips so it is best to fix the fracture with a simple percutaneous wire or screw

Epidemiology

It is the most common of all fractures in older people onset of postmenopausal osteoporosis. older woman gives a history of falling on her outstretched hand.

Definite diagnosing imaging

MRI

Complications

Nerve injury Compartment syndrome Non-union - High energy and open fractures Malunion - after closed reduction

Causes of an single forearm bone fracture

Nightstick fracture

Complications

Non-union Avascular necrosis Osteoarthritis

Treatment in adults

ORIF

Treatment - Physeal fractures

Physeal fractures are reduced, under anaesthesia, by pressure on the distal fragment. These fractures do not interfere with growth.

Displaced fractures

Plaster Reduction and compression with screws

Signs and symptoms

Prominence or tenderness over the lower end of the ulna is the striking feature. It is important also to test for an ulnar nerve lesion, which is common.

Most common carpal fracture

Scaphoid fractures account for almost 75%

Complex regional pain syndrome, also called

Sudeck's atrophy or reflex sympathetic dystrophy

Treatment Isolated fracture of the ulna

Surgical fixation

Epidemiology

The Galeazzi fracture is much more common than the Monteggia

The break may occur through

The distal radial physis or in the metaphysis of one or both bones.

Complete fractures

The fracture is manipulated in much the same way as a Colles' fracture

X-ray

The radius is fractured at the corticocancellous junction, about 2 cm from the wrist often the ulnar styilod is also fractured. Characteristically, the distal fragment is shifted and tilted both dorsally and towards the radial side

Treatment

The secret of successful treatment is to restore the length of the fractured ulna; only then can the dislocated proximal radioulnar joint be fully reduced and remain stable. In adults, this means an operation.

Treatment

The simplest option is a manipulation and cast immobilization but only if a perfect reduction is achieved

Cause of carpal fracture

The usual mechanism is a fall on the hand with wrist extended. The critical movement is probably a combination of dorsiflexion and radial deviation,

Signs and symptoms

The wrist is painful, and often quite swollen; sometimes there is an obvious 'dinner-fork deformity'.

FRACTURE OF THE RADIAL STYLOID PROCESS

This injury is caused by forced radial deviation of the wrist, usually the result of a fall. The fracture line is transverse, just proximal to the radial styloid process.

BENNETT'S FRACTURE-SUBLUXATION OF THE FIRST METACARPAL

This is a fracture at the base of the thumb metacarpal with extension into the CMC joint. It is an unstable injury

What single forarmbone fracture is usually missed

Ulnar fractures

Epidemiology

Uncommon If it happens most likely due to an disruption of the proximal or distal radioulnar joint.

Complications

Unreduced dislocation

X-ray

X-rays should offer anteroposterior, lateral and two oblique

The usual injury is

a fall on the outstretched hand with the wrist in extension; the distal fragment is usually forced posteriorly (this is often called a 'juvenile Colles' fracture').

GALEAZZI FRACTURE is

a fracture of the distal third of the radius and dislocation or subluxation of the distal radioulnar joint.

Its associated with

disruption of the proximal radioulnar joint and dislocation of the radiocapitellar joint.

commonest sites of childhood fractures.are

distal radius and ulnar fractures

MONTEGGIA FRACTURE is

fracture of the shaft of the ulna the term includes also fractures of the olecranon combined with radial head dislocation.

Proximal pole fractures

have such a poor rate of healing that unless the patient is prepared to spend a long time in plaster --> percutaneous screw.

COMMINUTED INTRA-ARTICULAR FRACTURES IN YOUNG ADULTS its a

high-energy injury

Metaphyseal fractures are often

incomplete or greenstick.

Colles fracture is

is a transverse fracture of the radius just above the wrist, with dorsal displacement of the distal fragment.

Undisplaced fractures of the waist

need no reduction and can be treated in plaster; 90% should heal.

Isolated fracture of the radius

rigid internal fixation with a compression plate and screws is preferred.

Signs and symptoms

slight fullness in the anatomical snuffbox; precisely localized tenderness in the same place examination must also include: 1. pressure backwards over the scaphoid tubercle, 2. palpation over the proximal pole and 3.telescoping of the thumb base.

Fracture of the scaphoid tubercle

usually needs no splintage and should be treated as a wrist sprain; a crepe bandage is applied and movement is encouraged.

If the scaphoid is tender, or the fracture still visible on x-ray

when non-operative treatment is chosen, the cast is re-applied and retained for a further 6 weeks. If, at that stage, there are signs of delayed union (bone resorption and cavitation around the fracture), healing can be hastened by bone grafting and internal fixation.