SURGERY LITERATURE REVIEW

FOREARM FRACTURE

Submitted for completing task of stage Surgery Faculty of Medicine Diponegoro

University

Author:
Putri Java Islami Yuntoharjo
22010117220127

Mentor :
dr. Kamal Adib, M.Kes, Sp.OT

FACULTY OF MEDICINE UNIVERSITY OF DIPONEGORO

SEMARANG
2019

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 VALIDATION SHEET

Name : Putri Java Islami Yuntoharjo

NIM : 22010117220127

Topic : Forearm Fracture

Mentor : Dr. Kamal Adib, M.Kes, SpOT

Batang, 2 May 2019

Dr. Kamal Adib, M.Kes, Sp.OT

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 INTRODUCTION

With the increasing mobility in the traffic sector and the factor of human negligence as one of
the most frequent causes of accidents that can cause fractures. Other causes can be due to workplace
accidents, sports and households. Antebrachial fractures often occur in the distal area which is
generally caused by direct fracture forces when falling with a hyperextension hand position. This can
be explained because of the fall reflex mechanism where the arm holds the body with the elbow
slightly bent like the style of the fall of an athlete or paratrooper.

Fracture is a disorder of bone continuity with or without location. changes in the location of
bone fragments. According to Lane and Cooper, a fracture or fracture is a complete or incomplete
damage to tissue or bone which results in the affected bone losing its continuity with or without the
distance that causes the fragmen.

Fractures that occur can affect both adults and children. Fractures that affect the forearm in
children are about 82% in the metaphysical area of the distal radius, and the distal ulna, whereas
fractures in the diaphysis region occur as invoices for green-stick types. Radius fracture can occur in
1/3 proximal, 1/3 middle or 1/3 distal.

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 LITERATURE REVIEW

Definition

Anatomy of forearm

Figure 1. Os Radius
The radius is an extension of the hand. It has an apex lateral bow, which, if allowed to heal
unrestored (i.e., straightened) after a fracture, will result in loss of forearm rotation. The shaft of the
radius is triangular in cross section. with its ulnar comer serving as the attachment of the interosseous
membrane. The blood supply of the diaphyseal cortex of the radius is through periosteal and
intramedullary vessels. The intramedullary vessels originate from a single nutrient artery that enters
the radius through a foramen on the anterior surface of the radius in its proximal third.

The radius articulates in four places:

 Elbow joint – Partly formed by an articulation between the head of the radius, and the
capitulum of the humerus.
 Proximal radioulnar joint – An articulation between the radial head, and the radial notch of
the ulna.
 Wrist joint – An articulation between the distal end of the radius and the carpal bones.
 Distal radioulnar joint – An articulation between the ulnar notch and the head of the ulna.
1. Proximal Region of the radius
The proximal end of the radius articulates in both the elbow and proximal radioulnar joints.
Important bony landmarks include the head, neck and radial tuberosity:
 Head of radius – A disk shaped structure, with a concave articulating surface. It is
thicker medially, where it takes part in the proximal radioulnar joint.
 Neck – A narrow area of bone, which lies between the radial head and radial
tuberosity.
 Radial tuberosity – A bony projection, which serves as the place of attachment of the
biceps brachii muscle.

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 2. Shaft of the radius
The radial shaft expands in diameter as it moves distally. Much like the ulna, it is triangular in
shape, with three borders and three surfaces.
The three surfaces: Anterior, posterior and lateralis
The three: posterior, interosseous and anterior
In the middle of the lateral surface, there is a small roughening for the attachment of the
pronator teres muscle.
3. Distal of radius
The distal region, the radial shaft expands to form a rectangular end. The lateral  side projects
distally as the styloid process. In the medial surface, there is a concavity, called the ulnar
notch, which articulates with the head of ulna, forming the distal radioulnar joint.
The distal surface of the radius has two facets, for articulation with the scaphoid and lunate
carpal bones. This makes up the wrist joint. Consist of:
 Articular surface: Carpal surface for the joint with scaphoid and lunate bones, ulnar
notch for the joint with the head of the ulna
 Non- articular surface: anterior, posterior, lateral

Figure 2. Os Ulna
The ulna is an extension of the arm; it has a slight posterior curve at its apex. The proximal
half of the ulna has an apical dorsolateral curve, and the distal half has an apical volar curve. The
radial border of the ulna serves as the attachment of the interosseous membrane. The posterior, or
subcutaneous, surface is the origin of the deep fascia of the forearm. The blood supply of the ulna is
through periosteal and intramedullary vessels, which originate from a single nutrient artery entering
the ulna through a foramen on its anterior surface just proximal to its midpoint.

1. Proximal of Ulna
The proximal end of the ulna articulates with the trochlea of the humerus. To enable movement at
the elbow joint, the ulna has a specialised structure, with bony prominences for muscle
attachment.
Important landmarks of the proximal ulna are the olecranon, coronoid process, trochlear notch,
radial notch and the tuberosity of ulna:

 Olecranon – a large projection of bone that extends proximally, forming part of trochlear
notch. It can be palpated as the ‘tip’ of the elbow. The triceps brachii muscle attaches to
its superior surface.
 Coronoid process  – this ridge of bone projects outwards anteriorly, forming part of the
trochlear notch.

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  Trochlear notch – formed by the olecranon and coronoid process. It is wrench shaped,
and articulates with the trochlea of the humerus.
 Radial notch  – located on the lateral surface of the trochlear notch, this area articulates
with the head of the radius.
 Tuberosity of ulna –  a roughening immediately distal of the coronoid process. It is
where the brachialis muscle attaches.
2. Shaft of Ulna

The ulnar shaft is triangular in shape, with three borders and three surfaces. As it moves
distally, it decreases in width.
The three surfaces:

Anterior – site of attachment for the pronator quadratus muscle distally.

Posterior – site of attachment for many muscles. three consecutive muscle attachments
can be seen in descending order just below the attachment of the interosseous membrane
as it travels down the shaft and they are:the abductor pollicis longus muscle,The extensor
pollicis longus muscle and The extensor indicis muscle.
 Medial : ¾ proximal attachment m. flexor digitorum profundus.
The three borders:

 Posterior – palpable along dorsal olecranon dan end in dorsal processus styloideus
ulnae
 Interosseous – site of attachment for the interosseous membrane, which spans the
distance between the two forearm bones. Start from 2 convergen line from incisura
radialis and become one and end in caput ulnae
 Anterior – start from medial procesus coronoideus and end in front of procecus
styloideus . separates medial and anterior surface

The muscles of the forearm are divided into flexor and extensor compartments .The flexors
are further divided into superficial flexors originating from the humerus and deep flexors originating
from the radius, ulna, and interosseous membrane. The superficial group includes the pronator teres
and the flexors carpi radialis, palmaris longus, carpi ulnaris, and digitorum superficialis. The deep
flexor group includes the ftexors digitorum profundus, pollicis longus, and pronator quadratus. All the
ftexors are innervated by the median nerve or its anterior interosseous branch except the flexor carpi
ulnaris and the ulnar side of the flexor digitorum profundus. These are innervated by the ulnar nerve.

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 Figure 3. Muscles of forearm
The interosseous nerve arises from the posterior aspect of the median nerve in the proximal
forearm and supplies the flexor pollicis longus and digitorum profundus, part of the flexor
superficialis , and the pronator quadratus . It has terminal sensory fibers to the joints that make up the
wrist. Injury to the anterior interosseous nerve is usually indicated by weakness or lost of
interphalangeal joint flexion of the thumb and index finger.

The extensor compartment is divided into superficial and deep groups. The muscles of the
superficial group originate from the humerus and common extensor tendon. The superficial group
include the brachioradialis, extensor carpi radialis longus and brevis, extensor digitorum, extensor
digiti minimi, and extensor carpi ulnaris. The deep extensor group includes the supinator, abductor
pollicis longus, extensor pollicis longus and brevis and extensor indicis. With the exception of the
supinator the muscles of the deep extensor group originate from the radius, ulna and interosseous
membrane. The muscles of the extemor compartement are innervated by the radial nerve or its
terminal muscular branch. The posterior interosseous nerve.

In the anterior compartment, they are split into three categories; superficial, intermediate and
deep. In general, Muscles in the anterior compartment of the forearm perform flexion at the wrist and
fingers, and pronation.

Figure 4. Anterior Muscle Groups

A. Superficial Compartment
The superficial muscles in the anterior compartment are the flexor carpi ulnaris, palmaris
longus, flexor carpi radialis and pronator teres. They all originate from a common tendon,
which arises from the medial epicondyle of the humerus.
Flexor Carpi Ulnaris:
 Attachment: Originates from the medial epicondyle with the other superficial flexors.
It also has a long origin from the ulna. It passes into the wrist and attaches to the
pisiform carpal bone.
 Action: flexion and adduction at the wrist

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  Innervation: ulnar nerve

Palmaris Longus

 Attachment: Originates from the medial epicondyle, attaches to the flexor

retinaculum of the wrist.
 Action: Flexion at the wrist
 Innervation: Median Nerve

Flexor Carpi Radialis

 Attachment: Originates from the medial epicondyle, attaches to the base of

metacarpals II and III
 Action: Flexion and abduction at the wrist
 Innervation: Median nerve

Pronator Teres

The lateral border of the pronator teres forms the medial border of the cubital fossa,
an anatomical triangle located over the elbow.
 Attachment: It has two origins, one from the medial epicondyle, and the other from
the coronoid process of the ulna. It attaches laterally to the mid-shaft of the radius.
 Actions: Pronation of the forearm
 Innervation: Median nerve

B. Intermediate Compartment
The flexor digitorum superficialis is the only muscle of the intermediate compartment.
The muscle is a good anatomical landmark in the forearm – the median nerve and ulnar artery
pass between its two heads, and then travel posteriorly.
 Attachments: It has two heads – one originates from the medial epicondyle of the
humerus, the other from the radius. The muscle splits into four tendons at the wrist,
which travel through the carpal tunnel, and attaches to the middle phalanges of the
four fingers.
 Actions: Flexes the metacarpophalangeal joints and proximal interphalangeal joints
at the 4 fingers, and flexes at the wrist.
 Innervation: Median nerve.
C. Deep compartment
There are three muscles in the deep anterior forearm; flexor digitorum profundus, flexor
pollicis longus, and pronator quadratus.

Flexor Digitorum Profundus

 Attachment : Originates from the ulna and associated interosseous membrane. At the
wrist, it splits into four tendons, that pass through the carpal tunnel and attach to the
distal phalanges of the four fingers.
 Action: It is the only muscle that can flex the distal interphalangeal joints of the
fingers. It also flexes at metacarpophalangeal joints and at the wrist
 Innervation: The medial half (acts on the little and ring fingers) is innervated by the
ulnar nerve. The lateral half (acts on the middle and index fingers) is innervated by
the anterior interosseous branch of the median nerve.

Flexor Pollicis Longus

This muscle lies literally to the flexor digitorum profundus

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  Attachment: Originates from the anterior surface of the radius and surrounding
interosseous membrane. Attaches to the base of the distal phalanx of the thumb.
 Action: Flexes the interphalangeal joint and metacarpophalangeal joint of the thumb.
 Innervation: Median nerve (anterior interosseous branch)

Pronator Quadratus

A square shaped muscle, found deep to the tendons of the Flexor Digitorum Profundus and
Flexor Pollicis Longus

 Attachment: Originates from the anterior surface of the ulna, and attaches to the
anterior surface of the radius.
 Pronates the forearm
 Innervation: Median nerve (anterior interosseous branch)

Figure 5. Posterior Muscle Groups

The muscles in the posterior compartment of the forearm are commonly known as the
extensor muscles. The general function of these muscles is to produce extension at the wrist and
fingers. They are all innervated by the radial nerve.

Anatomically, the muscles in this compartment can be divided into two layers; deep and
superficial. These two layers are separated by a layer of fascia.

A. Superficial Muscles
The superficial layer of the posterior forearm contains seven muscles. Four of these muscles –
extensor carpi radialis brevis, extensor digitorum, extensor carpi ulnaris and extensor digiti
minimi share a common tendinous origin at the lateral epicondyle.

Brachioradialis

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The brachioradialis is a paradoxical muscle. Its origin and innervation are characteristic
of an extensor muscle, but it is actually a flexor at the elbow.
The muscle is most visible when the forearm is half pronated and flexing at the elbow
against resistance.
In the distal forearm, the radial artery and nerve are sandwiched between the
brachioradialis and the deep flexor muscles.
 Attachment: Originates from the proximal aspect of the lateral supracondylar ridge of
humerus, and attaches to the distal end of the radius, just before the radial styloid
process.
 Action: Flexes at the elbow
 Innervation: radial nerve

Extensor Carpi Radialis Longus and Brevis

The extensor carpi radialis muscles are situated on the lateral aspect of the posterior forearm.
Due to their position, they are able to produce abduction as well as extension at the wrist.

 Attachment: The ECRL originates from the supracondylar ridge, while the ECRB
originates from the lateral epicondyle. Their tendons attach to metacarpal bones II
and III.
 Action: Extends and abduct the wrist
 Innervation: radial nerve

Extensor Digitorum

The extensor digitorum is the main extensor of the fingers. To test the function of the muscle,
the forearm is pronated, and the fingers extended against resistance.

 Attachment: Originates from the lateral epicondyle. The tendon continues into in the
distal part of the forearm, where it splits into four, and inserts into the extensor hood
of each finger.
 Action: Extends medial four fingers at the Metacarpal phalangs and interphalang
joints
 Innervation: radial nerve (deep branch)

Extensor Digiti Minimi

the extensor digiti minimi lies medially to the extensor digitorum.

 Attachment : Originates from the lateral epicondyle of the humerus. It attaches, with
the extensor digitorum tendon, into the extensor hood of the little finger.
 Action : Extends the little finger, and contributes to extension at the wrist.
 Innervation: Radial nerve (deep branch).

Extensor Carpi Ulnaris

The extensor carpi ulnaris is located on the medial aspect of the posterior forearm. Due to its
position, it is able to produce adduction as well as extension at the wrist.
 Attachment: Originates from the lateral epicondyle, and attaches to the posterior and
lateral part of the olecranon.
 Action: Extends and stablises the elbow joint. Abducts the ulna during pronation of
the forearm.
 Innervation: radial nerve

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 Figure 6. cross sectional posterior forearm muscle
B. DEEP MUSCLES

There are five muscles in the deep compartment of the posterior forearm – the
supinator, abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus and
extensor indicis.
With the exception of the supinator, these muscles act on the thumb and the index finger.

Supinator
The supinator lies in the floor of the cubital fossa. It has two heads, which the deep
branch of the radial nerve passes between.
 Attachments: It has two heads of origin. One originates from the lateral
epicondyle of the humerus, the other from the posterior surface of the ulna. They
insert together into the posterior surface of the radius.
 Actions: Supinates the forearm.
 Innervation: Radial nerve (deep branch).

Abductor Pollicis Longus

The abductor pollicis longus is situated immediately distal to the supinator muscle. In the
hand, its tendon contributes to the lateral border of the anatomical snuffbox.

 Attachments: Originates from the interosseous membrane and the adjacent posterior
surfaces of the radius and ulna. It attaches to the lateral side of the base of metacarpal
I.
 Actions: Abducts the thumb.
 Innervation: Radial nerve (posterior interosseous branch).

Extensor Pollicis Brevis

The extensor pollicis brevis can be found medially and deep to the abductor pollicis longus. In
the hand, its tendon contributes to the lateral border of the anatomical snuffbox.

 Attachments: Originates from the posterior surface of the radius and interosseous
membrane. It attaches to the base of the proximal phalanx of the thumb.
 Actions: Extends at the metacarpophalangeal and carpometacarpal joints of the
thumb.
 Innervation: Radial nerve (posterior interosseous branch).

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Extensor Pollicis Longus
The extensor pollicis longus muscle has a larger muscle belly than the EPB. Its tendon travels
medially to the dorsal tubercle at the wrist, using the tubercle as a ‘pulley’ to increase the
force exerted.
The tendon of the extensor pollicis longus forms the medial border of the anatomical snuffbox
in the hand.
 Attachments: Originates from the posterior surface of the ulna and interosseous
membrane. It attaches to the distal phalanx of the thumb.
 Actions: Extends all joints of the thumb: carpometacarpal, metacarpophalangeal and
interphalangeal.
 Innervation: Radial nerve (posterior interosseous branch).

Extensor Indicis Proprius

This muscle allows the index finger to be independent of the other fingers during extension.
 Attachments: Originates from the posterior surface of the ulna and interosseous
membrane, distal to the extensor pollicis longus. Attaches to the extensor hood of the
index finger.
 Actions: Extends the index finger.
 Innervation: Radial nerve (posterior interosseous branch).

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 Figure 7. artery of forearm

The radial and ulnar arteries are formed by the bifurcation of the brachial artery within the
cubital fossa:
Radial artery – supplies the posterolateral aspect of the forearm. It contributes to anastomotic
networks surrounding the elbow joint and carpal bones.
 The radial pulse can be palpated in the distal forearm, immediately lateral to the
prominent tendon of the flexor carpi radialis muscle.
Ulnar artery – supplies the anteromedial aspect of the forearm. It contributes to an anastomotic
network surrounding the elbow joint.
 Also gives rise to the anterior and posterior interosseous arteries, which supply deeper
structures in the forearm.
These two arteries anastomose in the hand by forming two arches – the superficial palmar arch,
and the deep palmar arch.
The anterior interosseous artery runs on the anterior surface of the interosseous membrane
with the anterior interosseous branch of the median nerve. It gives off muscular branches and
the nutrient arteries supplying the radius and ulna. The posterior interosseous artery traverses
the interosseous membrane proximally to reach the extensor compartment, where it runs
between the superficial and deep groups of muscles, giving off numerous muscular branches

FRACTURE OF FOREARM

EPIDEMIOLOGY

Forearm fracture are more common in men than in woman, secondary to the higher incidence
in men of motor vehicle collisions (MVC) and motorcycle accidents (MCA), contact athletic
participation, altercation, and falls from a height.
The incidence of distal radius fracture in the elderly correlates with osteopenia and rises in
incidence with increasing age, nearly in parallel with the increased incidence of hip fractures. It was
found that before the age of forty the incidence of fracture in the distal end of the forearm was about
equal in males and females. Above the age of sixty these fractures in women outnumbered those in
men by a factor of more than seven. This dramatic rise in the incidence of fracture in the female was
associated with progressively less severe trauma and more displacement of the fractures. In males, on
the other hand, relatively more severe trauma was found to cause relatively less displacement of the

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fractures. In females the ratio of metaphyseal to shaft fractures rose from three in children to seventy-
two in the aged, whereas in males this ratio changed relatively little.

MECANISM OF INJURY

Mechanism of injury and pathology Fractures of the shafts of both forearm bones occur quite
commonly. A twisting force (usually a fall on the hand) produces a spiral fracture with the bones
broken at different levels. An angulating force causes a transverse fracture of both bones at the same
level. A direct blow causes a transverse fracture of just one bone, usually the ulna. Additional rotation
deformity may be produced by the pull of muscles attached to the radius: they are the biceps and
supinator muscles to the upper third, the pronator teres to the middle third, and the pronator quadratus
to the lower third. Bleeding and swelling of the muscle compartments of the forearm may cause
circulatory impairment and compartment syndrome. Injuries to the bones of the forearm should be
considered intra-articular fractures, because the forearm is a quadrilateral joint – with the proximal
distal radioulnar joint at one end and the distal radioulnar joint at the other. Disruption of any one part
– the radioulnar joints or the shafts of the long bones – will usually disrupt another part of the
quadrilateral ring Malalignment is likely to affect forearm rotation especially in the skeletally mature.
The fracture mechanism is often high-energy trauma, resulting in: Axial compression, Bending,
Rotation, Direct trauma.

TYPES OF FRACTURE
Fractures are variable in appearance but for practical reasons they are divided into
a few well-defined group.
COMPLETE FRACTURES
The bone is
(1) In a transverse fracture the fragments usually remain in place after
reduction;
(2) In an oblique or spiral, they tend to shorten and redisplace even if the
bone is splinted.
(3) In an impacted fracture the fragments are jammed tightly together and
the fracture line is indistinct.
(4) A comminuted fracture is one with more than two fragments with
interlocking of the fracture surfaces; it is often unstable.
INCOMPLETE FRACTURES
The bone is incompletely divided and the periosteum remains in continuity. In a greenstick
fracture the bone is buckled or bent (like snapping a green twig); this is seen in children, whose bones
are less brittle than those of adults. Children can also sustain injuries where the bone is plastically
deformed (misshapen) without any crack visible on the X-ray. In contrast, compression fractures
occur when cancellous bone is crumpled, typically in adults where this type of bone structure is
present, such as in vertebral bodies, calcaneum and the tibial plateau

Opened or compound fracture

 The skin may be pierced by the bone or by a blow that breaks the skin at the time of
the fracture
 The bone may or may not be visible in the wound.

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Figure 8. types of fracture

Figure 9. Types of fracture

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CLASSIFICATION

A. Simple Injury
are fractures without associated ligamentous disruption. Included in this group are isolated
fractur of radius and ulna (the "nightstick" fracture)
Fracture of the radius alone is very rare, and fracture of the ulna alone is uncommon. These
injuries are usually caused by a direct blow – the ‘nightstick fracture’. They are important for
two reasons:
• An associated dislocation may be undiagnosed; if only one forearm bone is broken along its
shaft and there is displacement, then either the proximal or the distal radioulnar joint must be
dislocated. The entire forearm, elbow and wrist should always be X-rayed.
• Non-union is liable to occur unless it is realized that one bone takes just as long to
consolidate as two.

Fracture of both the radius and the ulna (the”both-bone” fracture).

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 Clinical presentation:
 Patients typically present with gross deformity of the involved forearm pain,
swelling, and loss of hand and forearm function. Pain and deformity are the most
obvious clinical signs; the pulse must be felt and the hand examined for circulatory
or neural deficit. Repeated examination is necessary in order to detect an impending
compartment syndrome. Pain out of proportion to the injury is the cardinal sign.
 Ulnar fractures are easily missed – even on X-ray. If there is local tenderness, a
further X-ray a week or two later is wise. The fracture may be anywhere in the radius
or ulna. The fracture line is transverse, and displacement is slight. In children, the
intact bone sometimes bends without actually breaking (‘plastic deformation’). To
assess an X-ray for this it is important to remember that the ulna is usually straight on
a lateral radiograph.
B. Montegia fracture
a fracture of the shaft of the ulna associated with anterior dislocation of the proximal
radioulnar joint; the radiocapitellar joint is inevitably dislocated or subluxated as well. More
recently the definition has been extended to embrace almost any fracture of the ulna
associated with dislocation of the radiocapitellar joint, including transolecranon fractures in
which the proximal radioulnar joint remains intact.
Bado Classification of Montegia Fracture:
- Type I: Anterior dislocation of the radial head with fracture of ulnar diaphysis at any
level with anterior angulation (Mechanism: forced pronation of the forarm)
- Type II: Posterior/posterolateral dislocation of the radial head with fracture of ulnar
diaphysis with posterior angulation (mechanism: axial loading of he forearm with a
flexed elbow)
- Type III: Lateral/anterolateral dislocation of the radial head with fracture of ulnar
metaphysis. (mechanism: forced abduction of elbow)
- Type IV: Anterior dislocation of the radial head with fracture of both raidus and ulna
with in proximal third at the same level. (type 1 mechanism in which the radial shaft
additionally fails)

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 Figure 10. Bado Classification of Montegia Fracture

 Mechanism of injury: Usually the cause is a fall on the hand; if at the moment of impact the
body is twisting, its momentum may forcibly pronate the forearm. The radial head usually
dislocates forwards and the upper third of the ulna fractures and bows forwards. Sometimes
the causal force is hyperextension
 Clinical feature: The ulnar deformity is usually obvious but the dislocated head of radius is
masked by swelling. A useful clue is pain and tenderness on the lateral side of the elbow. The
wrist and hand should be examined for signs of injury to the radial nerve.
C. Galleazi Fracture/piedmont fracture / fracture of necessity
A fracture of radial diaphysis at the junction of the middle and distal thirds with associated
disruption of the distal radioulnar joint.

 Mechanism of injury
This injury was first described in 1934 by Galeazzi. The usual cause is a fall on the hand,
probably with a superimposed rotation force. The radius fractures in its lower third and the
inferior radioulnar joint subluxates or dislocates.
 Clinical features
The Galeazzi fracture is much more common than the Montegia. Prominence or tenderness
over the lower end of the ulna is the striking feature. It may be possible to demonstrate the
instability of the radioulnar joint by ‘ballotting’ the distal end of the ulna (the ‘piano-
key sign’) or by rotating the wrist. It is important also to test for an ulnar nerve lesion,
which may occur.
 Piano Key sign Examination:
- Patient arm is pronated and supported by examiner
- Stabilize the radius with on hand and grip the ulna with the other.
- Push up and down on the ulna., examiner push down on distal ulna like a “piano key”
- Definition of positive result: if the patient experiences pain when the ulna is depresses,
or if there is ulnar laxity. Difference in mobility and pain compared to uninvolved side
- The test is negative if the patient does not experience pain when the ulna is depressed,
and if there is no ulnar laxity.

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D. Colles Fracture
 is a transverse fracture of the radius just above the wrist, with dorsal displacement of the
distal fragment. It is the most common of all fractures in older people, the high incidence
being related to the onset of postmenopausal osteoporosis. Thus, the patient is usually an
older woman who gives a history of falling on her outstretched hand.
 Original colles fracture usually in elderly, osteoporosis, postmenopause, woman and
extraarticular
 MOI: Force is applied in the length of the forearm with the wrist in extension. The bone
fractures at the corticocancellous junction and the distal fragment collapses into extension,
dorsal displacement, radial tilt and shortening
 Clinical features: We can recognize the most common fracture pattern (as Colles did long
before radiography was invented) by the ‘dinner-fork’ deformity, with prominence on the
back of the wrist and a depression in front. In patients with less deformity there may only be
local tenderness and pain on wrist movements.
 Frykman classification of colles fracture

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 Figure 11. Radiology of colles fracture

E. Smith Fracture
 described a fracture about 20 years later in which the distal fragment is angulated or displaced
volarward (‘Smith’s fracture’ ). It is caused by a fall on the back of the hand and is an unstable
injury due to the force generated by the long flexors crossing the wrist. There is a similar
fracture with volar displacement which involves just the anterior half of the distal radius with
an intact dorsal surface. The carpus slips forward with the anterior block of bone. Alternatively,
the volar half of the distal radius surface can shear off; the fragment moves forwards, carrying
the carpus with it. This is sometimes known as a ‘Barton’s fracture
 Clinical feature: The patient presents with a wrist injury, but there is no dinner-fork deformity.
Instead, there is a ‘garden-spade’ deformity.

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 Figure 12. Radiology of smith fracture

F. Essex- Lopresti Injury (radioulnal dissociation)

Is a fracture or dislocation of the radial head with disruption of the distal radioulnal
articulation and tearing of the entire interosseous membrane. Attention may be focused on the
injury at the lateral elbow or a galeazi -type fracture- dislocation in the distal forearm, but the
major component of the injury, radioulnar dissociation, is frequently overlooked. Early
diagnosis and appropriate treatment (maintaining a radial capitelar articulation to prevent
proximal migration of the radius) is important to obtaining a satisfactory result.

G. Chauffeur Fracture (Hutchinson fractures or backfire fractures)

 An isolated fracture of the radial styloid process is also called a Hutchinson's or
chauffeur's fracture. Displacement of the fragment is uncommon. There can be associated
injury to the scapholunate ligament. In most cases a fracture of the radial styloid process is
part of a comminutive intraarticular fracture.
 Mechanism of injury: Direct trauma: Typically, a direct blow to the back of the wrist.
Forced dorsiflexion and abduction, (usually via a fall on outstretched hand).

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COMPLICATION

EARLY

A. Nerve Injury
Exposure of the radius in its proximal third risks damage to the posterior interosseous
nerve where it is covered by the superficial part of the supinator muscle. The proximal
fragment of radius may have rotated so the nerve may not be where it is expected
B. Compartemen syndrome
Fractures (and operations) of the forearm bones are always associated with swelling of
the soft tissues, with the attendant risk of a compartment syndrome
It is very important, in performing open reduction and internal fixation, to deflate the
tourniquet and provide adequate hemostasis prior to wound closure. The forearm fascia
must nor be closed.
C. Infection
Is manage by returning the patient to the operating room. Where the wound can be
adequately opened and cleaned. Culture are obtained. Delayed wound closure is
performed after 5 days if the infection under control. In some instantces, the wound will
be left opened and allowed to heal secondarily.

LATE
A. Delayed union and non-union
Most fractures of the radius and ulna heal within 8–12 weeks; high-energy fractures and
open fractures are less likely to unite. Delayed union of one or other bone (usually the
ulna) is not uncommon; immobilization may have to be continued beyond the usual time.
Non-union will require bone grafting and internal fixation.
B. Malunion
With closed reduction there is always a risk of malunion, resulting in angulation or
rotational deformity of the forearm, cross-union of the fragments, or shortening of one of
the bones and disruption of the distal radioulnar joint

DIAGOSIS

HISTORY

There is a history of trauma with pain and swelling in the forearm. There may be deformity. The
skin is examined for wounds that may communicate with the fracture. The elbow and distal radioulnar
articulation are examined to determine whether they have been injured. Neurologic deficit is
infrequent except with penetrating injuries and high-energy open fractures.
Patient Typically present with gross deformity of the involved forearm, swelling and loss of hand
and forearm function

PHYSICAL EXAMINATION

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 The physical examination must include a thorough inspection of the overlying soft tissues (with
documentation). If the fracture is open, a clinical photograph may be taken for documentation
purposes and to avoid multiple clinicians having to take down dressings to observe the wound. Distal
neurologic and vascular status must be assessed and documented for all fractures.
It is necessary to classify the soft tissues overlying the fracture and to grade any open wounds
according to the well-known Gustilo-Anderson system. Compartment syndromes in areas of the body
prone to this malady (erg, the forearm and lower leg) must be ruled out by careful examination and
documentation and serial assessment.
Palpate the entire limb—including the joints above and below the injury—for areas of pain,
effusions, and crepitus. Often, accompanying or associated injuries may be present (eg, injuries to the
spine with a jumping mechanism of injury). Assessment of range of motion (ROM) may not be
possible due to pain, but this should be documented. Assessments for ligamentous injury and tendon
rupture, as well as other noteworthy tests that surround a special examination of the joints, should be
completed and documented.

Multiple traumatic injuries

Initial assessment of a patient with polytrauma follows the Advanced Trauma Life Support
(ATLS) protocols and includes the identification and treatment of life-threatening injuries. The first
step is evaluation of the individual's airway, breathing, and circulation (the ABCs). Immediate
endotracheal intubation and rapid administration of intravenous fluids may be necessary. Full spinal
precautions must be maintained until injury to the complete spine can be excluded clinically and
through diagnostic imaging (with radiography or computed tomography [CT]).

At the initial examination of the patient, it should be noted that:

• Shock, anemia or bleeding
• Damage to other organs, such as the brain, spinal cord or internal organs of the thoracic cavity,
pelvis and abdomen
• Predisposing factors, for example in pathological fractures (Paget's disease)
On physical examination:
a) Look (Inspection)
- Deformity: angulation (medial, lateral, posterior or anterior), discrepancy (rotation, shortening or
extension)
- Swollen or bluish
- Function of village (loss of movement function)
- Swelling, bruising and deformity may be obvious, but the important thing is whether the skin is
intact. If the skin is torn and the wound has a relationship with the fracture, the injury is open
(compound)
b) Feel (Palpation)
Palpation is done carefully because sufferers usually complain of pain. Things that need to be
considered:
- Local temperature increases
- Tenderness; superficial tenderness is usually caused by damage to deep soft tissue due to a
fracture in the bone
- Crepitation; can be known by touching and must be done carefully
- Vascular examination in the distal area of trauma in the form of palpation of the radial artery,
dorsalis pedis artery, posterior tibial artery in accordance with the affected limb. Refilling of the
arteries in the nails
- Vascular injury is an emergency that requires surgery
c) Move (movement)
- Pain when moved, both active and passive movements
- Movement that is not normal is the movement that occurs not on the joint

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 - In patients with fractures, each movement will cause severe pain so that the movement test should
not be done roughly, besides it can also cause damage to soft tissues such as blood vessels and
nerves, document median, radial, and ulnar nerve function
- pain with passive stretch of digits ,alert to impending or present compartment syndrome

RADIOGRAPHIC EXAMINATION

Radiographs in the anteroposterior and lateral projections of the forearm, wrist, and elbow are
adequate to evaluate most injuries of the forearm. Occasionally, comparison views of the opposite
wrist or computed tomography (CT) imaging are helpful in evaluating the relative positions of the
distal radius and ulna. additional views: oblique forearm views for further fracture definition and
ipsilateral wrist and elbow to evaluate for associated fractures or dislocation. radial head must be
aligned with the capitellum on all views
Magnetic resonance imaging (MRI) to obtain axial T2-weighted images with fat suppression as
well as ultrasound can be used to determine the integrity of the interosseous membrane when an
Essex-Lopresti injury is a consideration.

Colles Fracture Smith Fracture

Chauffeur Fracture Montegia Fracture

Galeazzi fracture Nightstick Fracture

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Essex- Lopresti fracture dislocation Bothbone Fracture

FRACTURE MANAGEMENT
The principle of handling fractures generally includes recognition, traction, reduction of
immobilization and restoration of normal function and strength with rehabilitation. 12,13
1) Recognition
Relative movement after injury can interfere with the supply of neurovascular extremities
involved. Therefore, once known the possibility of a long bone fracture, the injured limb must be
attached to protect it from more severe damage.
Significant soft tissue damage can also be used as an indication of possible fracture, and immediate
installation of splints and further examination is needed. This should especially be done in cervical
spinal cord injuries, where contusions and laserasi on the face and scalp indicate the need for
radiographic evaluation, which can show a cervical spine fracture and / or dislocation, and the
possibility of surgery to stabilize it (Smeltzer C and B. G Bare, 2001).
2) Traction
The traction tool is given with the pulling force on the fractured member to straighten the shape
of the bone. There are 2 types, namely:
i. Skin Traction
Skin traction is to pull the fractured part of the bone by attaching tape directly to the
skin to maintain its shape, helping to cause muscle spasm in the injured part, and is usually
used for short periods (48-72 hours). Maximum load of 4-5 kg because if the excess skin will
loose
ii. Skeletal traction
It is traction that is used to straighten injured bones in long joints to maintain the shape by
inserting pins / wires into the bone. This traction is placed at the distal tibia tuberosity (trauma to
the koksea joint, femur, knee), to the tibia or calcaneus (cruris fracture). The complications that
can occur in the installation of traction are disorders of blood circulation at a load of> 12kg,
trauma to the peroneus nerve (cruris), compartment syndrome, infection where the pin enters

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3) Reduction
In the management of fractures with reduction can be divided into 2, namely:
i. Closed Reduction / ORIF (Open Reduction Internal Fixation)
Fracture reduction (bone setting) means returning bone fragments to their alignment and
anatomic rotation. Closed reduction, traction, can be done to reduce fracture. The particular
method chosen depends on the nature of the fracture, but the underlying principle remains the
same.
Before reduction and fracture immobilization, the patient must be prepared to undergo the
procedure and permission must be obtained to perform the procedure, and analgesics are given
according to the provisions. Anesthetic may be needed. The extremities to be manipulated must be
handled gently to prevent further damage. Closed reduction in many cases, closed reduction is
done by returning bone fragments to their position (the edges are interconnected) with manual
manipulation and traction.
Indication of ORIF installation
Absolute
1. It cannot be repositioned except through surgery
2. Fractures are unstable and tend to be displaced after repositioning
3. Fractures that have a long unification time and are difficult to fuse
4. Fractures that are opposite to the position with muscle motion
Relative
1. Multiple fractures where immediate fixation can reduce the risk of general complications and
multi organ failure
2. Fracture in patients with difficult nursing care

ii. Open Reduction / OREF (Open Reduction External Fixation)

In certain fractures can be done by external reduction or commonly known as OREF,
usually performed on fractures that occur in the long bones and fragmented fractures. Externally
with fixation, the pin is inserted through the skin into the bone and connected with fixation on the
outside. The usual indication of management with external fixation is an open fracture of the shin
that requires treatment for dressings. But it can also be done in a fracture closed ulna radius.
External fixation that is most often successful is the bone superficial eg tibial stem
4.) Rehabilitation
Avoid atrophy and contractures with physiotherapy. All efforts are directed at bone and soft
tissue healing. Reduction and immobilization must be maintained as needed. Neurovascular
status (eg assessment of blood circulation, pain, touch, movement) is monitored, and orthopedic
surgeons are notified immediately if there are signs of neurovascular disorders. Anxiety, anxiety
and discomfort are controlled by various approaches (eg convincing, changes in position,
strategies for pain relief, including analgesics). Isometric exercises and muscle settings are
sought to minimize disuse atrophy and increase blood circulation. Participation in daily living
activities is sought to improve self-function and self-esteem. A gradual return to the original
activity is attempted according to the therapeutic limits. Usually, internal fixation allows for early
mobilization. Surgeons who estimate the stability of fracture fixation, determine the extent of
movement and stress on permissible extremities, and determine the level of activity and weight
of the body.

Non-operative
1. Indications:
 Fractures without displacement and without associated dislocation
 Patients in poor general condition with high surgical risks
2. Treatment
 Cast for minimum 4 weeks— including adjacent joints
 Fractures in proximal forearm, cast in supination. A cast in supination position will
reduce the displacing forces of supinator and biceps brachii muscles.

26
  Fractures in middle or distal part, cast in neutral rotation
 X-ray controls—frequently, ideally weekly to show fracture position.
3. Risks
 Chance of delayed or nonunion is up to 30%.
 Limited range of motion (ROM) after immobilization
o Pronation, supination
o Contracture of interosseous membrane

Operative

1. Indications
 Displaced fractures of both radius and ulna
 Displaced, isolated fracture of either bone
o Rotated or angulated > 10° (displaced 50%)
 Fractures combined with radioulnar dislocations
o Monteggia injury (ulnar fracture and dislocation of radiocapitellar joint)
o Galeazzi injury (distal radius and dislocation of distal radioulnar joint)
 Open fractures

1. Goals of operative treatment

 Anatomical reduction
 Restoration of length (ulna and radius)
 Restoration of axial and rotational alignment
 Restoration and stabilization of joints
 Repair of soft-tissue injuries
A stable fixation allows immediate postoperative movement

2. Technique

Type A (simple) and B (wedge) fracture

o Technique with absolute stability
1. Interfragmentary lag screw (if possible)
2. Compression plate

27
 Type C (complex) fracture
o Technique with relative stability
1. Absolute stability technique not often achievable
2. Relative stability by bridge plating common
Check pronation and supination intraoperatively after reduction
and fixation.

3. Choice of implants
 3.5 mm plate
o Gold standard
o 7–8 holes
o DCP, LC-DCP, or LCP

 Elastic stable intramedullary nails (ESIN)

o Remains controversial in adults—no reliable rotation control
o Excellent results in pediatric forearm diaphyseal fractures

 External fixator
o Open fractures
o Careful pin insertion

o Fracture consolidation
1. Cannot be achieved by external fixation alone
2. Rates of nonunion and malrotation are considerable
4. Strategy

28
 Order of fixation:
 Normally, the simpler of the two fractures will be approached first and
preliminary fixation is undertaken.
 If both bones have similar fractures, then the ulna will normally be addressed first

5. Approach
 Ulna
o Arm is positioned in pronation.
o Skin incision:
1. The standard ulnar approach offers good exposure along the whole ulnar shaft. The length
of the incision depends on the exposure needed.
2. The skin incision follows the subcutaneous border of the ulna, along a line drawn
between the tip of the olecranon process and the ulnar styloid process.
3. If the forearm is markedly swollen, it may not be possible to close the skin of the ulnar
approach. In these circumstances, it is better to plan the skin incision over the adjacent
extensor muscle compartment, so an open incision will have a muscular bed rather than
exposing the implant.

29
 Radius
o Arm is positioned in supination.
o Skin incision:
1. The anterior (Henry) approach offers good exposure of the whole length of the radius.
The length of the incision depends on the extent of exposure needed. The Henry approach in
the proximal forearm might result in a more obvious scar.

2. The landmarks for the skin incision are:

 Styloid process of the radius
 Groove between the brachioradialis muscle and the insertion of the biceps brachii tendon

3.Thompson Approach (posterior approach of the radius)

Landmarks
 Proximal:lateral epicondyle of the humerus
 Distal: dorsoradial tubercle (Lister's tubercle)

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6. Postoperative treatment
 Temporary immobilization with a well-padded, bulky splint for 10–14 days is
advised to allow adequate soft-tissue healing. This can be longer for
unreliable patients. During this period, elevation, gentle finger motion, active
and passive, together with elbow flexion/extension and shoulder motion, can
be started.
 Functional treatment starts as soon as possible: 6–8 weeks postoperative.
There is a high risk of stiffeness if this is delayed.
 X-ray control at 1, 6, and 12 weeks postoperatively
 Removal of implants is rarely indicated as there is a high risk of neurovascular
injury and refracture.

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 BIBLIOGRAPHY

1. Blom A, Warwick D, Whitehouse MR, editors. Apley & Solomon‘s System of

Orthopaedics and Trauma (10th edition). New York: CRC Press, 2018
2. American College of Surgeons. Advanced Trauma Life Support for Doctors (ATLS):
Student Course Manual. 7th ed. Chicago: American College of Surgeons; 2004
3. Elstrom A, John, Virkus, Walter et al. Handbook Of Fracture Third Edition. Mc
Graw Hill Professional;2006
4. Braunstein, Volker. Forearm fracture.Ao Trauma
5. Reto Babst MD, Prof. of Surg. Forearm Fracture. Clinic for Orthopedics and
Trauma Luzerner Kantonsspital 6002 Luzern Switzerland.
6. Richard Buckley, MD, FRCSC Clinical Professor, Department of Surgery, General
Principles of Fracture Care Treatment & Management Head of Orthopedic
Traumatology, University of Calgary Faculty of Medicine, Canada
7. Paulsen F. & J. Waschke. 2013. Sobotta Atlas Human Anatomy ;Brahm U.
Penerbit. Jakarta : EGC.
8. A, Kenneth, Zuckerman D, Joseph et al.Handbook of fracture fifth edition. Wolters
Kluwer Health .2015

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