| ID | 247 |
|---|---|
| Name | FRACTURES OF THE RADIUS & ULNA |
| Cause | |
| Signs Symptoms | |
| Diagnosis | Diagnosis: X-ray of the hand (b/v): Both bones are broken either transversely and at the same level or obliquely with the radial fracture usually at a higher level. In children, the fracture is often incomplete (green-stick) and only angulated. In adults, displacement may occur in any direction-shift, overlap, tilt or twist. In low-energy injuries, the fracture tends to be transverse or oblique; in high-enery injuries, comminuted or segmental. |
| Investigations | |
| Management | |
| Introduction | Fractures of the shafts of the radius and ulna are quite common in road accidents. Fractures occur, usually at different levels and different in nature, which defend on the nature of accidents and the force of action. Spiral fracture: A twisting force (usually a fall on the hand) produces a spiral fracture with the bones broken at different levels. Transverse fracture: A direct blow or an angulating force causes a transverse fracture of both bones at the same level. Rotation deformity: Additional rotation deformity may be produced by the pull of muscles attached to the radius, (these 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. |
| History | |
| Etiology | |
| Clinical Features | Clinical features: 1. The fracture is usually quite obvious, 2. The pulse must be felt and the hand examined for circulatory or neural deficit. 3. Repeated examination is necessary in order to detect an impending compartment syndrome. |
| Preventions | |
| Treatment | Treatment: Children: In children, closed treatment is usually successful because the tough periosteum tends to guide and then control the reduction. The fragments are held in a well-moulded full length cast, from axilla to metacarpal shafts (to control rotation). The cast is applied with the elbow at 90°. If the fracture is proximal to pronator teres, the forearm is supinated; if it is distal to pronator teres, then the forearm is held in neutral. The position is checked by x-ray after a week and, if it is satisfactory, splintage is retained until both fractures are united (usually 6-8 weeks). Throughout this period hand and shoulder exercises are encouraged. The child should avoid sports for a few weeks to prevent re-fracture. Occasionally an operation may be required- i. if the fracture cannot be reduced, or ii. if the fragments are very unstable. Fixation with a small plate, Kirschner wires (K-wires) or flexible intramedullary nails is then needed. Adults: In the adults, the fracture fragments are usually not in close apposition, so, reduction is difficult and re-displacement in the cast almost invariable. Therefore, most of the surgeons opt for open reduction and internal fixation from the outset. The fragments are held by interfragmentary compression with plates and screws. Bone grafting is advisable if there is comminution of more than one-third of the circumference. The deep fascia is left open to prevent a build-up of pressure in the muscle compartments, and only the skin and subcutaneous tissues are sutured. With comminuted fractures of unreliable patients, immobilization in plaster is safer. After the operation is completed the arm is kept elevated until the swelling subsides, and during this perioa active exer cises of the hand are encouraged. Additional management for open fractures: 1. An antibiotic of choice should be started. 2. Tetanus prophylaxis should be given as soon as possible. 3. The wounds are excised and extended; the bone ends are exposed and thoroughly cleaned. The nerves and circulation are checked. 4. The fractures are primarily fixed with compression screws and plates; bone graft, if necessary is probably best deferred until the wounds are healed. 5. The wound is best left open but the extensions can be closed. 6. When there is major soft-tissue loss, the bones are better stabilized with an external fixator, and the services of plastic surgeon called in. |
| Complications | Complications: Early complications: 1. Nerve injury: There may be posterior interosseous nerve injury or damage. 2. Vascular injury: There are chances of radial or ulnar artery injury. 3. Compartments 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. A distal pulse does not exclude this, and if there is any sign of circulatory embarrassment, treatment must be prompt. Late complications: 1. Delayed union and non-union: (Most fractures of the radius and ulna heal within 8-12 weeks). In case of delayed union immobilization should be continued beyond the usual time. Non-union may requre bone grafting and internal fixation. 2. Malunion: In case of reduction there is always a risk of malunion, resulting in angulation or rotational deformiry of the forearm, cross-union of the fragments or shortening of one of the bones and disruption of the distal radioulnar jont. If pronation or supination is severely restricted, and there is no cross-union, mobility may be improved by excising the distal end of the ulna. |
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