Fractures of the body of the bones of the forearm: causes, symptoms, diagnosis, treatment

ICD-10 code

• 552.2. Fracture of the body [diaphysis] of the ulna.
• 552.3. Fracture of the body [diaphysis] of the radius.
• 552.4. Combined fracture of the diaphysis of the elbow and radius bones.

Anatomy of the forearm

The forearm consists of two bones: radial and ulnar. Each of them has a body, a proximal and distal ends. The proximal ends of the bones of the forearm are involved in the formation of the elbow joint. The body is divided into upper, middle and lower thirds. The distal end of the ulna ends with the head of the ulna, on which a styloid process is located on the inner side and somewhat posteriorly. The distal end of the radial bone is enlarged and forms an articular surface for articulation with the bones of the wrist. The outer margin of the distal end of the radial bone stands somewhat and is called the styloid process.

The bones of the forearm are covered with muscles, they are divided into three groups: anterior, lateral and posterior.

• The front muscle group has four layers.
• The first layer consists of a round pronator, a radial flexor of the wrist, a long palmar muscle and an ulnar flexor of the wrist.
• The second layer is represented by the superficial flexor of the fingers.
• The third layer includes the deep flexor of the fingers and the long flexor of the thumb.
• The fourth layer is a square pronator.
• The lateral group of muscles consists of the brachial muscle and the long and short extensors of the hand.
• The rear group of mice has two layers.
• The superficial layer consists of the elbow extensor of the wrist, the common extensor of the fingers and the extensor of the little finger.
• The deep layer is represented by a supinator, a long muscle, a finger, the short and long extensors of the thumb and the extensor of the index finger of the hand.

[1]

Classification of forearm fractures

Diaphyseal fractures of the forearm include fractures of both bones or isolated ulnar and radial injuries. In terms of the level of integrity violation, there are fractures in the upper, middle and lower third of the forearm bones.

[2], [3]

Fractures of both forearm bones

ICD-10 code

S52.4. Combined fracture of the diaphysis of the elbow and radius bones.

Causes and symptoms of fracture of both forearm bones

Displacements are along the length, width, at an angle and rotational. The displacement along the width occurs under the influence of the mechanism of trauma, along the length - due to the pull of the entire muscular case of the forearm, at an angle - as a result of the mechanism of injury and reduction of the prevailing flexors and radial muscle groups, which are stronger than their antagonists. The most difficult are the displacements along the axis. The degree of rotation depends on the level of fracture of both bones or radius and the effect of antagonistic muscle groups on the fragments. If a fracture occurred in the upper third of the forearm, below the attachment point of the instep arrestors, but above the attachment of the round pronator, the central fragment will be maximally supinated, and the peripheral fragment will be maximally permeated. The rotational displacement of the fragments exceeds 180 °. Another level of fracture is when the fracture line passes below the attachment of the round pronator. In this case, the central fragment occupies a position intermediate between supination and pronation, since the strength of the muscles that rotate the forearm in the palmar and back sides is balanced. The peripheral fragment is penetrated by a square pronator.

Treatment of fracture of both forearm bones

Indications for hospitalization

Patients with diaphyseal fractures of the forearm bones are hospitalized.

Conservative treatment of fracture of both forearm bones

If there is no displacement of fragments, the treatment consists in anesthesia of the fracture site with a 1% solution of procaine in an amount of 20-30 ml and fixation of the limb with a circular gypsum dressing from the middle third of the shoulder to the heads of metacarpal bones. Limb position: at high fractures the forearm is supine, with fractures at the border of the middle and lower third, the forearm is given the middle position between supination and pronation. Flexion in the elbow joint is 90 °, in the wrist joint - rear extension to the angle of 30 °, fingers in the position of the tennis ball. The duration of permanent immobilization is 8-10 weeks, removable - 1-2 weeks.

In fractures of the bones of the forearm with displacement of fragments, a closed reposition is performed. It can be either manual or hardware. To facilitate the comparison of fragments using apparatus Sokolovsky, Ivanov, Kaplan table, NI. Mileshina.

Under local anesthesia after stretching and rotational setting of the fragments (depending on the level of fracture), the surgeon hand compares the ends of the damaged bones. Without loosening the thrust, a trough-shaped linget is placed from the middle third of the shoulder to the heads of the metacarpal bones in the position achieved by repositioning. Perform a control radiograph. If the reposition is successful, the bandage is turned into a circular dressing. With massive edema, the longevity can be left for 10-12 days before it falls off, and then superimpose a circular gypsum dressing. X-ray control is mandatory! It is always performed after the edema subsides (regardless of whether or not the bandage will be replaced) so as not to miss a secondary displacement of the fragments. The term of permanent immobilization is 10-12 weeks, removable - 24 weeks.

Surgical treatment of fracture of both forearm bones

Operative treatment consists in an open reposition of the bones of the forearm, which is performed from two independent cuts over the fracture site of the radial and ulnar bones. Detach the fragments and fix them in the chosen way. Intraosseous fixation is most often performed with Bogdanov's pins. One rod is driven into the medullary canal of the central fragment of the ulna until it emerges under the skin in the region of the elbow process. The skin is cut. The fragments are compared, the pin is retrograded into the peripheral fragment. On the rear surface of the distal end of the radius after a small additional incision of the skin, a channel is drilled, through which the rod is inserted until it leaves the end of the peripheral fragment. Produce reposition and osteosynthesis, deepening the pin into the central fragment. In case of a cusp fixation, a wide variety of plates are used most often.

After surgical treatment by any of the methods, external immobilization is necessary. Apply gypsum lingetu, after 10-12 days it is converted into a circular gypsum bandage. The term of permanent immobilization is 10-12 weeks, removable - 1-2 weeks.

The presented scheme of surgical treatment until the last decade was considered classical. Not very good results of treatment forced traumatologists to study the biomechanics of implants more deeply, the technique of their implantation, the disadvantages of dependence on immobilization and much more. Science has moved far ahead. However, not everyone has moved away from traditional methods of treatment. Some - due to the poorly equipped peripheral medical institutions, others, apparently, are trying to make a "revaluation of values."

Thus, Holmenschlager F. Et al. (1995) conducted a series of osteosynthesis operations of the forearm bones with beams of spokes, three in each bone (with spokes of different lengths), and received good results.

But nevertheless intramedullary blocked osteosynthesis by pins and (especially) osteosynthesis by LCP and PC-Fix plates become a method of choice in the treatment of diaphyseal fractures of the forearm. Plates with a locked screw and angular stability are fixed with 6 screws (3 above and below the fracture). Osteosynthesis begins with the radius. At the end of the operation, the fascia is not sutured and even cut along to avoid the development of Volkmann's ischemic contracture. Install drainage through the counter-day for 2 days. External immobilization is not needed.

In multi-lobed open fractures of the forearm bones, it is advisable to use spinal and rod apparatuses of external fixation.

Estimated period of incapacity for work

After fractures without displacement to labor, they begin 10-12 weeks after the injury. In other cases, the work capacity is restored in 12-16 weeks.