Fractures of The Radius and Ulna

dr. Muh. Sakti SpOT

ORTHOPEDY AND TRAUMATOLOGY DEPARTEMENT

WAHIDIN SUDIROHUSODO HOSPITAL
HASANUDDIN UNIVERSITY

Axiom :
A fracture of one of the paired bones,
especially when angulated or displaced, is
usually accompanied by a fracture or
dislocation of its "partner."

The shafts of the radius and the ulna are surrounded by four primary
muscle groups whose pull frequently results in fracture displacement or
nullification of an adequate reduction
1.Proximal: The biceps brachii and the supinator insert on the proximal
radius and exert a supinating force.
2.Midshaft: The pronator teres inserts on the radial shaft and exerts a
pronating force.
3.Distal: Two groups of muscles insert on the distal radius.
A.
The pronator quadratus exerts a pronating force, which may cause
displacement.
B.
The brachioradialis and abductor pollicis longus and brevis
produce deforming forces. Of these, the brachioradialis exerts the
predominant displacing force.

Fractures at Shaft of Radius and Ulna are divided into

three groups:
(1) Radius fractures,
(2) Ulna fractures
(3) Fractures of both the radius and ulna

Radius fractures
Can be divided into three groups on the basis of muscular
attachments and consequent fragment displacement after a
fracture :
1.The proximal one-third of the radial shaft just distal to
the insertion of the supinator and the biceps brachii. Both of
these muscles exert a supinating force and will result in
displacement of the proximal radius if a fracture occurs
2.The middle one-third of the radial shaft where the
pronator teres exerts a pronating force
3.The distal one-third of the radius. In this area the
pronator quadratus exerts a pronating force on the fracture
fragment

Examination
Tenderness over the distal radioulnar joint
may be secondary to subluxation or
dislocation and should alert the physician
to the possibility of a Galeazzi fracture.

Imaging
Routine anteroposterior (AP) and lateral
views of the forearm are usually
adequate
Axiom: Isolated fracture of the radial
shaft without an ulnar fracture is an
unusual injury and the physician must
suspect injury to the distal radioulnar joint
when treating these

Galeazzi fracture

Associated Injuries
A distal radial shaft fracture associated with
a distal radioulnar dislocation (Galeazzi
fracture)

Treatment
Nondisplaced Proximal One-Third
Application of splints
The elbow should be in 90 of flexion with the forearm in supination.
Supination of the forearm is required with this fracture because of the
supinating forces of the supinator and biceps muscles that insert on the
proximal portion of the radius
Displaced Proximal One-Third
Treatment of choice is open reduction and internal
fixation

Nondisplaced Midshaft One-Third

The elbow should be in 90 of flexion and the
forearm in moderate supination
Displaced Midshaft One-Third
The treatment of choice is open reduction and
internal fixation

Nondisplaced Midshaft Distal One-Third

The elbow should be in 90 of flexion and the
forearm in pronation.
Application of splints
Displaced Midshaft Distal One-Third
Open reduction with internal fixation is the treatment
of choice

Complications
1. Malunion or non-union may be secondary to inadequate reduction
or immobilization.
2. Rotational deformities must be detected and treated early in the
management of these fractures.
3. Distal radioulnar joint subluxation or dislocation
4. Neurovascular injuries

Ulnar Shaft Fractures

Ulnar shaft fractures can be classified into
three groups:
(1) Nondisplaced,
(2) Displaced (>5 mm),
(3) Monteggia fractures

 Monteggia fractures are displaced fractures of

the proximal one-third of the ulnar shaft combined
with a radial head dislocation.
Radial head dislocations can only occur if
there is complete rupture of the annular
ligament.

Monteggia fractures are classified into four types:

1. Ulnar shaft fracture with an anterior dislocation of the radial
head. There is usually anterior angulation of the distal
fragment.
2. Ulnar shaft fractures with a posterior or posterior-lateral
dislocation of the radial head
3. Ulnar metaphyseal fractures with lateral or anterolateral
dislocation of the radial head.
4. Ulnar and radial shaft fracture (proximal one-third) and
anterior dislocation of the radial head.

Two mechanisms of injury frequently result in

fractures of the ulna :
1.A direct blow (nightstick fracture)
2.Excessive pronation or supination
Examination
Swelling and tenderness
Pronation and supination will be mildly
painful
Monteggia fractures often will reveal
shortening of the forearm due to
angulation
Radial head may be palpable in the
antecubital fossa following anterior
dislocations

Imaging
AP and lateral views of the forearm
elbow and wrist views should be added to
exclude articular injury, subluxation, or
dislocation

Any fracture of the ulna, especially proximal

fractures, evaluate the radiocapitellar line on
the lateral radiograph.
A line drawn down the center of the shaft
and head of the radius should intersect the
middle of the capitellum.
If this intersection does not occur, the
proximal radioulnar joint is disrupted

Associated Injuries
Axiom: Displaced ulnar fractures are
frequently associated with radial fractures or
dislocations of the radial head
Paralysis of the deep branch of the radial
nerve can occur
Acute compartment syndrome

Treatment
Nondisplaced / minimally Displaced (<5
mm) Ulnar shaft fractures
Can be treated with a long-arm cast with the elbow in 90
of flexion and the forearm neutral was recommended
After 1 week the splint or cast be replaced by a
prefabricated functional brace

Treatment
Displaced (>5 mm) Ulnar shaft fractures
Open reduction with internal fixation
Monteggia Fracture In adults, Surgical correction is
indicated
Monteggia Fracture In children, Closed reduction of the
ulnar fracture is then typically carried out under general
anesthesia, followed by relocation of the radial head by
direct pressure during supination of the forearm

Complications
Monteggia fractures require emergent referral because
of a high incidence of complications, including :
1.Paralysis of the deep branch of the radial nerve is
usually secondary to a contusion and typically heals
without treatment.
3.Non-union may be due to an inadequate reduction
or may be secondary to inadequate immobilization.
3.
Recurrent dislocation or subluxation of the
radial head due to an unrepaired tear in the annular
ligament is common after closed reductions

Combined
Radius and Ulna Fractures

Two mechanisms result in fractures of

the forearm shaft
A direct blow
Fall on an outstretched arm (the most
common mechanism )

Examination
Pain, swelling, deformity
Examination of the elbow and wrist is important to
detect possible injury to the proximal or distal
ligamentous structures
Deficits of the radial, median, and ulnar nerves are
uncommonly seen, but must be excluded by careful
physical examination and documentation

Imaging
Plain foto of the forearm AP and lateral views
Wrist and elbow views should also be obtained and
evaluated for fracture, dislocation, or subluxation

AP and lateral radiographs demonstrating

greenstick fractures of the distal radius and
ulna in a child.

Associated Injury
Injury to the proximal and distal radioulnar
joints
Acute compartment syndrome

Treatment
Nondisplaced Radius and Ulna Fractures
This is an uncommon injury
If neither bone is displaced or angulated, the patient can
be treated with anteroposterior splints, with the elbow in
90 of flexion and the forearm neutral
Definitive management includes a well-molded long-arm
cast
Caution: Repeat radiographs are required as delayed
displacement is common

Treatment
Displaced Radius and Ulna Fractures
Attempts at closed reductions in adults
generally fail in achieving and maintaining
proper alignment and rotational corrections
The treatment of choice is open reduction
with internal fixation

Complications
1. Infection is commonly seen with open fractures.
2. Nerve damage is uncommon in closed injuries, but is frequently
seen with open fractures.
3. Vascular compromise is an uncommon complication because of
the presence of arterial collaterals.
4. Non-union or malunion may be secondary to inadequate
reduction or inadequate immobilization.
5. Compartment syndromes
6. Synostosis (bone fusion) of the radius and ulna may complicate
the management of combined shaft fractures.
7. Pronation and supination may be impaired if fractures are
poorly managed