Fracture dislocations of forearm bones: causes, symptoms, diagnosis, treatment

ICD-10 code

• S52.0. Fracture of upper end of ulna.
• S53.0. Dislocation of the head of the radius.
• S52.5. Fracture of the lower end of the radius.

Classification of fracture dislocation of the forearm bones

There are two types of fracture-dislocations of the forearm bones: Monteggia and Galeazzi. In the first case, there is a fracture of the ulna in the upper third with a dislocation of the head of the radius. In the second case, there is a fracture of the radius in the lower third with a dislocation of the head of the ulna.

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Monteggia fracture dislocation

ICD-10 code

• S52.0. Fracture of upper end of ulna.
• S53.0. Dislocation of the head of the radius.

Classification

A distinction is made between flexion and extension types of injury.

Reasons

The extension type occurs when a fall occurs and the upper third of the forearm hits a hard object or is hit in this area. The ulna is fractured, and continued violence leads to a rupture of the annular ligament and dislocation of the head of the radius.

The flexion type of injury occurs when the load is applied mainly to the distal part of the forearm and directed from the back to the palmar side and along the longitudinal axis of the forearm. There is a fracture of the ulna in the middle third with displacement of the fragments at an angle open to the palmar side and dislocation of the head of the radius to the back side.

Symptoms and diagnosis

Extension type. Pain at the fracture site and severe dysfunction of the elbow joint. The forearm is slightly shortened, edematous in the upper third and in the elbow joint area. Movements in the elbow joint are sharply limited, when attempting to move - pain and a feeling of an obstacle along the anterolateral surface of the joint. Palpation reveals a protrusion in this area. Palpation of the ulnar crest at the site of injury reveals pain, deformation, possible pathological mobility and crepitus. The radiograph reveals anterior dislocation of the head of the radius, a fracture of the ulna at the border of the upper and middle thirds with an angular displacement. The angle is open to the back.

Flexion type. The disruption of the bone relationships determines the clinical picture of the injury: pain in the area of the fracture and the elbow joint, which is deformed due to swelling and the head of the radius protruding backwards, moderate limitation of function due to pain, shortening of the forearm. The X-ray picture confirms the diagnosis.

Treatment

Conservative treatment

Conservative treatment consists of repositioning the fragments and eliminating the dislocation. The manipulation is performed under local or general anesthesia manually or with the help of devices for repositioning the bones of the forearm.

• In the extension type, traction is applied to the wrist of the forearm bent at a right angle and supinated, and the fragments of the ulna are aligned. If the reposition is successful, the radius is often repositioned on its own. If this does not happen, the dislocation is eliminated by applying pressure to the head of the radius and shifting it backwards.
• In the flexion type, traction is also applied to the wrist of the supinated but extended forearm. By pressing the fingers from the back to the palmar surface of the forearm, the surgeon aligns the fragments. Further manipulations are the same as in the extension type of injury.

Upon completion of the intervention, a circular plaster cast is applied from the upper third of the shoulder to the heads of the metacarpal bones with flexion at the elbow joint at an angle of 90°, supination of the forearm and a functionally advantageous position of the hand for 6-8 weeks. Then, rehabilitation treatment begins, keeping the removable splint for another 4-6 weeks.

Surgical treatment

Surgical treatment is used in case of failure of closed manipulations. The most common reason for unsuccessful attempts at reposition and elimination of dislocation is interposition - the introduction of soft tissues between fragments or between articulating surfaces.

The operation involves removing the interponate, reducing the radial head, and retrograde intraosseous metal osteosynthesis of the ulna. To prevent repeated dislocations, the annular ligament is sutured or plasticized with a strip of autofascia. Sometimes, to prevent reluxation, a Kirschner wire is passed through the radial humerohumeral joint and removed after 2-3 weeks. Another way to hold the head is to pin it to the coronoid process with a short wire.

After the operation, the limb is fixed with a plaster cast from the upper third of the shoulder to the metacarpophalangeal joints for 6 weeks, then it is converted into a removable cast and preserved for another 4-6 weeks.

In chronic cases of Monteggia fracture dislocation, osteosynthesis of the ulna and resection of the head of the radial bone are performed.

Approximate period of incapacity

After conservative treatment, work is possible after 12-16 weeks. After surgical treatment, restoration of work capacity occurs after 12-14 weeks.

Galeazzi fracture-dislocation

ICD-10 code

S52.5. Fracture of the lower end of the radius.

Classification

Based on the mechanism of injury and displacement of fragments, extension and flexion types of damage are distinguished.

• In the extension type, the fragments of the radius are displaced at an angle open to the back, and the dislocation of the head of the ulna occurs to the palmar side.
• The flexion type of injury is characterized by the displacement of the fragments of the radius at an angle open to the palmar side, and the head of the ulna is displaced to the dorsal side.

Reasons

Galeazzi fracture-dislocation is possible from direct and indirect mechanisms of injury, resulting in a fracture of the radius in the lower third and dislocation of the head of the ulna.

Symptoms and diagnosis

The diagnosis is based on the mechanism of injury, pain and dysfunction of the wrist joint, angular deformation of the radius, and pain on palpation. The head of the ulna protrudes outward and to the back or palmar side, and is mobile. Its movement is painful. An X-ray confirms the diagnosis and helps determine the type of injury.

Treatment

Treatment can be conservative and surgical.

Conservative treatment

Conservative treatment begins with sufficient pain relief using one of the methods. Then manual or hardware repositioning of the radius fracture is performed by traction on the hand in the middle position between supination and pronation of the forearm. The surgeon eliminates displacements in width and at an angle manually. It is also not difficult to reduce the head of the ulna. The difficulty lies in the fact that it is not always possible to hold the ulna in the reduced position. If this is still possible, then a pad is placed in the area of the head of the ulna, and the limb is fixed with a plaster cast from the upper third of the shoulder to the base of the fingers for 6-8 weeks, and then for active physiotherapy treatment the immobilization is converted into a removable one and retained for another 4-6 weeks.

Surgical treatment

If conservative measures are unsuccessful, they proceed to surgical treatment. They start with stable osteosynthesis of the radius with an intramedullary pin or plate. To hold the head of the ulna, various methods are used: plastic surgery of the radioulnar ligament, fixation with a Kirschner wire, fixation of the radius and ulna at the same time with their convergence in the Ilizarov apparatus. Some authors advise resecting the head in difficult cases.

The volume and duration of immobilization are the same as for conservative treatment.

It should be remembered that the treatment of fracture-dislocations always begins with the elimination of the dislocation, and then the reposition of the fragments is performed. This is the rule. The treatment of Monteggia and Galeazzi injuries is an exception, when the reposition is performed first and only then the dislocation is eliminated.

There are two more types of fracture-dislocations described in the literature, but we have never encountered them. These are the Malgen fracture-dislocation (fracture of the ulnar and coronoid processes and anterior dislocation of the forearm) and the Essex-Lopresti fracture-dislocation - dislocation of the head of the radius (sometimes with a fracture), dislocation of the head of the ulna, rupture of the interosseous membrane and proximal displacement of the radius. Both fracture-dislocations are treated surgically.

Approximate period of incapacity

Working capacity is restored within 11-13 weeks.