FOREARM AND WRIST

FRACTURES
DR HILLAH
OUTLINE
• Introduction
• Epidemiology
• Relevant Anatomy
• Mechanism of injury
• Clinical Assessment
• Radiological Assessment
• Types of forearm fractures
• Management
• Complications
• Prognosis
 INTRODUCTION
• The forearm : radius and ulna.
Ulna is medial and radius lateral.
• The wrist joint : distal end
radius/ulna and the carpal bones.
• Fractures of the forearm :
- near the wrist (distal)

- in the middle of the

forearm
- near the elbow
(proximal) .
 EPIDEMIOLOGY
• Common in the pediatric population
- Incidence of 1 in 100 children each year, and the
- peak age 5 to 14 years : 34% of the cases.
- Both radius /ulna fractures constitute a 5.4% of all fractures in
children under 16 years of age.
• Adults, a higher incidence between 25 to 34 years of age group.
• In the forearm fractures, the most common site is at the distal radius
or ulna (32.9%).
• Open fractures, most commonly involve the diaphyseal region
Relevant Anatomy
• Two bones
- Radius
- Ulna
• Proximal radioulnar joint (PRUJ)
articulating radial head with
proximal ulna
• Distal radioulnar joint •
Articulation of ulnar head with
distal radius
• Interosseous membrane
MUSCLES OF THE FORERARM

The muscles in the anterior compartment of the

forearm are organized into three layers:

• Superficial: flexor carpi ulnaris, palmaris longus,

flexor carpi radialis, pronator teres.

• Intermediate: flexor digitorum superficialis.

• Deep: flexor pollicis longus, flexor digitorum

profundus and pronator quadratus.

This muscle group is associated with pronation of the

forearm, flexion of the wrist and flexion of the
fingers.
Muscle of the Forearm
The muscles in the posterior
compartment of the forearm
the extensor muscles.
They are divided into two
layers:
• superficial
• deep
The general function of
these muscles is to produce
extension at the wrist and
fingers.
Muscles of The Forearm
• Posterior compartment
Deep layers
 Blood and Nerve
innervation
• All the muscles of the anterior
compartment are supplied by
the median nerve except the
flexor carpi ulnaris and the
medial half of flexor
digitorum profundus(Ulna
nerve )
• Posterior compartment is
supply by the radial nerve
.
• The blood suppy is by
radial and ulna artery
 Mechanism of injury
Forearm fractures may result from
both low energy and high energy
trauma.
• Fall onto an outstretched hand.
• Motor vehicle accidents.
• Athletic injuries .
• Falls from height.
• Child abuse
 CLINICAL ASSESSMENT
ATLS protocol, including
primary and secondary surveys.

• Primary survey

• The secondary survey includes e

proper history, complete head-to-
toe examination, and local
examination of the affected parts
once the patient is stabilized
 CLINICAL ASSESSMENT
• PRESENTING COMPLAINS
• HISTORY OF PC
• PHYSICAL EXAMINATION
• RADIOLOGICAL INVESTIGATION ( x- ray of the entire forearm showing
the wrist and the elbow joints)
• SPECIAL INVESTIGATION (MRI , CT SCAN)
 CLINICAL ASSESSMENT
• Presenting complains
- Acute pain,
- swelling,
- local tenderness,
- visible deformity on forearm.
-wound with bone sticking out
of the skin
 CLINICAL ASSESSMENT
• History of presenting complains
- what happened ?
- when did it happen ?
- where did it happen?
- How did it happen?
-Any associated injury?
- Past medical history ?
-Smoking ? Alchohol?
 CLINICAL ASSESSMENT

• A systematic examination from head

to toe
• Neurological examination the affected
forearm .
• Vascular examination should be well
documented
• Early identification of the signs and
symptoms of compartment syndrome is
necessary to avoid the complications
of tissue necrosis and ischemia
 RADIOLOGICAL
ASSESSMENT
• Plain Radiography
Anteroposterior and lateral views of the
forearm. Showing wrist and elbow joint
-A standard anteroposterior view with
elbow extended and the forearm in full
supination.
- A lateral view can result in overlapping
of the radius and ulna; therefore, an
oblique view of the forearm can be
useful to determine the fracture pattern,
whether it’s a simple fracture or
comminuted fracture.
 RADIOLOGICAL
ASSESSMENT
• Computed tomography (CT) is
only indicated if there is a
suspicion of intraarticular distal
end radius fracture pattern.

• However, routinely CT and MRI

are not frequently done for the
assessment of acute forearm
fractures.
 TYPES OF FOREARM AND WRIST
FRACTURES
• Forearm fractures • Wrist fractures
- Monteggia fractures - Colles fractures
- Galleazi fractures - smith s fractures
- Essex Lopresti fractures - Radial styloid fracture
- Isolated radius or ulna fractures
 Monteggia fracture
• Ulna fracture associated with
dislocation of the proximal radio
ulna joint
• Common in children peak age 4
to 10
• In adult high energy injury
Galleazy fracture
• Fracture of the radius(distal 1/3)
associated with dislocation of
the distal radio ulna joint
• 3 to 7 % of forearm fracture
• Usually fall on outstretched hand
Essex Lopresti fracture
• Fracture of the radial head
associated with dislocation of
the distal radio ulna joint and
rupture of the interosseous
membrane .
• This usually occurs from a
fall or high energy trauma
with the elbow extended
Isolated Raduis or ulna fractures
• Mostly caused by direct blow to
the forearm
• Always rule out Monteggia and
galleazy fractures .
Colles᾽ Fracture
• Most commonly women 60-70
years
• 90% of all distal radial fractures
• Dorsally displaced fracture distal
radial fracture about 2 to 3cm
proximal to the radiocarpal joint.
• FOOSH main cause .
• Dinner fork deformity
Smith᾽s fracture
• Fracture of the distal radius with
volar displacement or angulation.
• It typically results from a fall on
the dorsum of the hand with a
flexed wrist.
Radial styloid fracture
• Chauffeur fracture
• Isolated intraarticular fracture of
the radial styloid
• Can be associated with carpal
bone fractures
Management of forearm fractures
• Goal of treatment • Resuscitation
- obtain acceptable reduction,
- stable fixation and bony
healing,
- early return to activities of daily • Definitive treatment
living,
-preservation of function, and
minimizing complications
Definitive treatment
• Conservative management
- indicated for unicortical
fracture and
- undisplaced or
- minimally displaced fracture
(<50% displacement, <10 degrees
of angulation).
Using Cast (pop or fiber glass)
Functional brace . X ray follow up
Definitive
treatment
• Operative management
• - unstable fracture
• Galleazi , Monteggia ,
intraarticular
fractures ,Radial styloid
fractures ….
• Open of closed reduction
and internal fixation
• External fixation
Complications
• Early
-Soft tissue
- Neuro vascular
-Infection
-Bleeeding
-Compartment syndrome
-Radio ulna synostosis
• Late
-Mal union , Non union, Osteomyelitis .
CRPS
 PROGNOSIS
• Overall, forearm fractures have a good prognosis with union rates of
approximately 95% to 98%.
• The plate osteosynthesis shows a slightly better outcome as compared
to the third-generation intramedullary nail.
• The outcome of an open fracture depends on the severity and grade of
the injury.
• Open fractures are associated with a high incidence of complications
like infection and non-union, which results in a significant increase in
morbidity and overall health care cost.