Elbow and Forearm Injuries

Ovid: Manual of Orthopaedics

Editors: Swiontkowski, Marc F.; Stovitz, Steven D.
Title: Manual of Orthopaedics, 6th Edition
> Table of Contents > 18 – Elbow and Forearm Injuries

Elbow and Forearm Injuries
I. Ruptures of The Distal Biceps Brachii
  • Location.
    Rupture of the distal biceps may occur at the muscle tendon junction or
    more commonly at its tendinous insertion into the radial tuberosity.
  • Mechanism of injury.
    Often a chronic case of distal biceps tendinitis has been present,
    making the tendon susceptible to failure with forceful supination of
    the hand or elbow flexion.
  • Examination.
    A palpable defect is present at the elbow and the bulk of the biceps
    muscle is retracted proximally. Often, this shortened muscle is prone
    to spasm for several weeks after the injury occurs. The patient has
    minimal weakness to elbow flexion but does have weakness to hand
  • Treatment. If
    the rupture occurs at the muscle tendon junction, nonoperative care
    with early range-of-motion (ROM) exercises are indicated (1).
    Treatment of distal tendon tears is controversial. The biceps functions
    as a weak elbow flexor, but it is a strong supinator of the hand.
    Individuals who do not like the cosmetic deformity or are involved in
    activities that require supination strength should undergo operative
    repair. A single curvilinear incision is made that allows exposure to
    locate the retracted tendon proximally, and the original biceps tunnel
    to the radial tuberosity is used. A repair of the tendon to the
    tuberosity with suture anchors is completed. A sling is used for 4
    weeks postoperatively with an active assisted ROM program initiated
    immediately postoperatively.
II. Dislocation of The Elbow Joint
accounts for 20% of all dislocations, second only to glenohumeral and interphalangeal joints.
  • The mechanism of injury is usually a fall on an hyperextended arm.
  • The history
    of an elbow injury must document, if possible, the mechanism of injury;
    type and location of pain; amount of immediate sensory, motor, and
    circulatory dysfunction; treatment before examination; time when
    swelling began; and any history of elbow injuries.
  • The examination
    of an injured elbow must document, if possible, the degree of effusion,
    location of any ecchymosis, ROM, and stability of the joint when
    compared with that of the opposite side. In the examination of an
    injured elbow, there may be confusion about whether the deformity
    arises from a dislocation of the elbow or from a supracondylar
    fracture, but this can be resolved clinically by comparing the relative
    positions of the two epicondyles and the tip of the olecranon by
    palpation. These three bony points form an
    isosceles triangle. The two sides remain equal in length in a
    supracondylar fracture. If the elbow is dislocated, however, the two
    sides become unequal (Fig. 18-1).
    The position of the proximal radius should also be palpated on the
    lateral surface of the elbow to rule out a radial head dislocation. The
    function of the peripheral nerves and the state of the circulation to
    the hand, including capillary refill and presence of radial pulse,
    should be carefully noted. The anterior interosseous branch of the
    median nerve and the radial nerve are most frequently involved.
  • Roentgenograms
    demonstrate whether the displacement is directly posterior (most
    common), posterolateral, or posteromedial. Roentgenograms should
    include a lateral view of the elbow, an anteroposterior view of the
    humerus, and an anteroposterior view of the forearm. Fractures of the
    coranoid process have been identified in 10% to 15% of elbow
    Figure 18-1.
    The two epicondyles and the tip of the olecranon form an isosceles
    triangle. This triangle is maintained with a supracondylar humeral
    fracture, but with an elbow dislocation, the two sides of the triangle
    become unequal or distorted.
  • P.252

  • Treatment
    consists of immediate closed reduction, which is essential, and may
    require anesthesia for proper muscle relaxation. Reduction can usually
    be achieved by gentle traction on the slightly flexed elbow, applying
    countertraction to the humeral shaft. After reduction, motion should be
    nearly full, and medial and lateral stability should be assessed. With
    a simple posterior elbow dislocation, a portion of the collateral
    ligaments are generally intact so the joint is fairly stable and early
    motion may be instituted after 3 to 5 days of splinting (2).
    With other dislocations, the collateral ligaments may be completely
    disrupted, creating an unstable joint and necessitating longer
    immobilization before active exercises are started. Postreduction
    roentgenograms are mandatory because they, too, help determine
    postreduction treatment. If the joint space is not congruent, generally
    cartilage fragments, bony debris, or ligament is in the joint, and open
    reduction and collateral ligament repair are indicated. If significant
    articular fragments are displaced, they should be internally fixed with
    recessed small or “minifragment” implants at the same time. Coranoid
    fractures, unless involving more than 50% of the length, do not require
    internal fixation (3). If the elbow is stable
    after collateral ligament repair, motion should be initiated as with
    stable reductions treated in a closed manner. For an unstable elbow,
    following operative repair external fixators, which allow active ROM,
    are useful (4).
  • Postreduction treatment
    • If the medial and lateral ligaments are intact and are providing a stable elbow joint,
      the elbow is placed in a padded posterior splint in 90 degrees of
      flexion that extends far enough to support the wrist. The elbow is kept
      elevated above the heart until the swelling recedes. Active flexion is
      begun in 3 to 5 days to achieve as much ROM as possible. Passive ROM is
      contraindicated. Repeat radiographs should be obtained within 3 to 5
      days to make certain the


      remains congruent. The elbow is kept in the posterior splint when not
      being exercised. As soon as the patient can achieve near full
      extension, use of the splint may be discontinued.

    • If the elbow is unstable
      and the joint is congruent on roentgenograms, it is splinted in 90
      degrees of flexion for 2 to 3 weeks with initial elevation to help
      control swelling. Radiographs must be obtained in the splint initially
      and at 3 to 5 days to ensure that the elbow is congruous. An active
      exercise program is then begun to regain ROM. Open reduction is
      generally not necessary; there is no documented advantage to open
      reduction over closed reduction (2,5,6).
  • Complications
    • Up to 15 degrees limitation of full extension as well as some limitation of flexion is common unless an intensive rehabilitation program is instituted.
    • Traumatic peripheral nerve injuries may occur: Ulnar, median, combined ulnar and median, and brachial plexus injury have all been reported.
    • Compromise of circulation can occur as a result of posttraumatic swelling or injury to the brachial artery. See Chap. 2, III, for a discussion of compartmental syndromes.
    • Myositis ossificans can develop, and its treatment should follow the guidelines in Chap. 2, V. Posttraumatic elbow stiffness can be successfully treated by open release (7).
      If associated with postresection instability, a hinged external fixator
      distractor can be used with good results in motivated patients (8).
    • Chronic instability can be difficult to diagnose; when recognized, surgical reconstruction is generally successful (6).
III. Fractures of The Olecranon
  • Fractures of the olecranon may be divided into four groups:
    • Transverse and undisplaced
    • Transverse and displaced
    • Comminuted and minimally displaced with clinical findings suggesting an intact triceps aponeurosis
    • Comminuted and displaced, indicating a disrupted extensor mechanism
  • Treatment
    • Undisplaced fractures should be treated
      in a posterior splint with the elbow flexed 90 degrees. Pronation and
      supination movements are started in 2 to 3 days, and flexion-extension
      movements are started at 2 weeks. Protective splinting or a sling is
      used until there is evidence of union (usually approximately 6 weeks).
      Closed clinical and roentgenographic follow-up is essential to ensure
      full ROM and to identify any displacement.
    • Displaced fractures should be reduced
      anatomically and fixed internally with tension band wiring technique or
      by tension band plating via a posterior approach. An olecranon lag
      screw should not be used without tension band wire. If used alone, the
      screw does not provide maximum stabilization when the elbow flexes
      because half of the fracture is placed in compression and the other
      half is placed in tension, as shown in Fig. 10-9. Regardless of the type of internal fixation used, motion should be started within the first few days postoperatively.
      • The tension band wiring technique for a transverse displaced fracture
        of the olecranon begins with reduction without devitalization of the
        fragments. Stabilization of the fragments is accomplished by two
        Kirschner wires introduced parallel to each other and to the anterior
        cortex of the ulna. Place the drill hole just distal to the fracture,
        transversely through the posterior cortex of the ulna. Thread the
        1.2-mm (or 16 to 18 gauge) wire through the drill hole, cross the ends
        in a figure-8 style, pass the wire around the protruding ends of the
        Kirschner wires, and tie the wire under tension, providing two twists,
        one on each side of the ulna. This makes the tension even across the
        fracture site. The result should be a figure-8 tension band wire with
        the crossover point lying over the fracture. Finally, shorten the
        projecting ends of the Kirschner wires and bend them to form U-shaped
        hooks that are then impacted gently into the bone over the tension wire
        (Fig. 18-2) and


        reconstruct the triceps incision over the bent wires. Similar results
        can be obtained by inserting a 6.5-mm cancellous screw (with or without
        a large washer) across the fracture and using the same figure-8

        Figure 18-2.
        The tension band wiring technique. Two parallel Kirschner wires cross
        an olecranon fracture at right angles. One strand of 18-gauge wire has
        been inserted within the triceps tendon anterior to the Kirschner
        wires. The second wire is inserted through the dorsal ulnar cortex of
        the ulna (A). The fixation is secured (B). (JB Lippincott From Hansen ST, Swiontkowski MF. Orthopaedic trauma protocols. New York: Raven Press, 1993:112, with permission).
      • The tension-band wiring technique for comminuted displaced fractures
        of the olecranon is much the same except that an anatomic reduction is
        more difficult to achieve and small Kirschner wires may be required for
        stabilization of minor fracture fragments.
IV. Epiphyseal Fractures of The Proximal Radius
  • Mechanism of injury. These pediatric injuries occur from a fall on the outstretched hand.
  • Examination.
    Pain, occasionally swelling, and tenderness are usually present over
    the upper end of the radius. There is also limitation of motion.
  • Treatment
    • Fractures with less than 15 degrees of angulation are immobilized in a long-arm splint for 2 weeks. Active exercise is then initiated while the arm is protected in a sling.
    • P.255

    • Angulation of greater then 15 degrees
      calls for manipulation under anesthesia. If this fails, operative
      reduction is required. After reduction, the fracture is usually stable.
      If not, internal fixation is used with a fine, smooth Kirschner wire
      introduced from distal to proximal, stopping short of the articular
      surface of the radial head. The pin can be removed at 3 weeks and
      active motion initiated. The radial head should never be removed in
V. Fractures of The Head And Neck Of The Radius
  • Mechanism of injury.
    This injury should be suspected following a fall on the outstretched
    hand whenever there is swelling of the elbow joint, tenderness over the
    head of the radius, and limitation of elbow function (especially
    painful pronation and supination).
  • Roentgenograms.
    If the fracture is not apparent on the anteroposterior and lateral
    roentgenograms, films obtained with the head of the radius in varying
    degrees of rotation are helpful. An anterior fat pad sign, indicative
    of an elbow effusion, should alert the treating physician to order
    these special roentgenograms.
  • Treatment
    • Minimally displaced (less than 1 mm) fractures of the head (Mason 1) or impacted fractures of the radial neck
      are treated with a posterior splint with active motion exercises
      beginning in the first 3 to 5 days. This treatment is followed by the
      wearing of a sling and active movement of the elbow. Acutely, it is
      helpful to aspirate the elbow effusion and inject 5 mL of 1% lidocaine
      to be sure that elbow motion is full and unimpeded.
    • Displaced fractures involving less than
      one third of the articular surface (Mason 2) are treated by early
      motion if the postaspiration and lidocaine injection examination
      reveals a full ROM. If motion is blocked or if there is an associated
      elbow fracture or dislocation, the fracture is treated by open
      reduction with minimal fragment screws and early motion (9,10). The radial head should not be excised.
    • Comminuted or displaced fractures of the
      head that involve more than one third of the articular surface and
      displaced or unstable fractures of the neck are treated by early
      excision of the radial head with or without placement of a metal
      prosthesis if it is anticipated that after 4 to 5 days pain will
      restrict active exercises (5,11).
      If adequate movement can be achieved before the fifth day after injury,
      excision may be avoided. The end result of excision of the radial head
      is good, but a normal elbow motion is generally not achieved. Fifty
      percent of the patients have a late complication of subluxation and
      pain at the distal radioulnar joint (12,13).
      Insertion of a Silastic prosthesis to prevent late complication appears
      warranted, but complications from the prosthesis itself are not
      uncommon (synovitis, prosthesis fracture); therefore, the authors
      recommend a metal prosthesis when indicated (11).
VI. Monteggia Fracture-Dislocation of The Elbow
  • This is a dislocation of the radial head and a fracture of the proximal ulna. There are four types, as described by Bado (see Selected Historical Readings), depending on the direction of radial head dislocation and associated radial fracture.
  • The mechanism of injury
    may be a “failed” posterior dislocation of the elbow, that is, the ulna
    fractures instead of dislocating because of an axial loading force.
    Alternatively, the injury may occur as a result of an anteriorly or
    posteriorly directed blow.
  • Treatment
    • Children.
      Closed reduction of the ulna is carried out. If the radial head has not
      been indirectly reduced by realigning the ulna, reduction of the radial
      head is attempted by supination of the forearm and direct pressure on
      the radial head, which usually is successful. When the radial head
      cannot be anatomically reduced, removal of the interposing joint
      capsule with repair of the anular ligament is advisable.
    • Adults. Operative treatment is recommended (14,15,16).
      Open reduction with compression plate fixation of the ulna is generally
      followed by indirect reduction of the radius. If reduction of the
      radius is not obtained, an open reduction


      be done. If the radial head is unstable, cast for approximately 6 weeks
      in supination, then start active exercises. If the radial head is
      stable after closed reduction or open repair, start early active motion
      with a hinged elbow orthosis, maintaining the forearm in supination.
      Protect the arm until the fracture is healed. With anterior dislocation
      and an unstable closed reduction, the arm may be immobilized in 100
      degrees to 110 degrees of elbow flexion, which relaxes the biceps and
      helps maintain reduction of the radial head. If the radial head remains
      subluxed after ulnar fixation, the forearm should be supinated while
      applying pressure over the radial head.

VII. Diaphyseal Fractures of The Radius and Ulna (3, 10, 15, 16, 17, 18, 19, 20, 21, 22, 23)
  • Roentgenograms.
    Of all fractures, this type best exemplifies the need for visualizing
    the joint above and below fractures of long bones (elbow and wrist).
  • Treatment
    • Children. The
      fractures are usually of the greenstick type, and even with
      considerable displacement, a dense periosteal sleeve ordinarily
      remains. This sleeve is usually sufficient to make satisfactory closed
      reduction possible. Greenstick fractures tend to redisplace unless the
      fracture is overreduced, that is, unless the opposite cortex has been
      fractured with the reduction. For the closed reduction in which
      angulation is the only deformity to be corrected, conscious sedation
      and hematoma block may be adequate. Where there is total displacement
      with shortening of either of both bones, a brief general anesthetic
      enhances a traumatic reduction. In the child, operative treatment is
      generally unnecessary because remodeling with growth is excellent and
      there is an increased likelihood that cross-union will develop after
      operative treatment. In the mature adolescent, failure to obtain a
      satisfactory closed reduction is an indication for open reduction and
      treatment as for the adult. Bone grafting of operatively reduced
      fractures in the adolescent is not necessary.
    • Adults. (16,17,20,21,22)
      • Principles.
        It is difficult to achieve a satisfactory closed reduction of displaced
        fractures of the forearm bones, and, if achieved, it is hard to
        maintain. Unsatisfactory results of closed treatment have been reported
        to range from 38% to 74% (19). For this reason, open reduction with internal fixation is routine except in cases of undisplaced fractures.
      • Undisplaced single bone fractures should be treated in a long-arm cast until there is roentgenographic evidence of union or definitive evidence or delayed union.
      • Fractures of both bones or a displaced isolated fracture
        of the radius or ulna should be treated by open reduction, plate
        fixation, and cancellous bone grafting whenever there is bone loss.
        Bone grafting should not be performed routinely (21,22).
        This treatment is carried out as a semielective procedure as soon as
        the patient’s condition warrants; reduction is easiest when the
        fracture is treated within the first 48 hours. At a minimum, there must
        be screws engaging six cortices above and below the fracture site.
        Great care must be exercised to restore the length and curvature of the
        radius relative to the ulna to prevent loss of pronation and supination
        (19,20). The use of a 3.5-mm plate system has nearly eliminated the problem of refracture after plate removal (16,24).
        Previously, this problem was thought to be related to
        “stress-protection” of the underlying cortical bone but is now
        understood to be related to cortical bone ischemia (16).
        Plates should not be routinely removed from healed adult diaphyseal
        forearm fractures. Eight-hole plates are used most often. If bone
        grafting is indicated because of significant bone loss, the graft
        should be taken without disturbing either table of iliac bone or its
        muscle attachments, as described in Chap. 10, II.K;
        postoperatively, morbidity from the graft site is minimized. Reliable
        patients may be placed in a removable splint and early motion started
        as soon as wound healing is complete.


VIII. Galeazzi Fracture of The Radius (25)
  • Description.
    This fracture is at the junction of the middle and distal third of the
    radius and is combined with a subluxation of the distal radioulnar
    joint (said to represent approximately 5% of forearm fractures).
  • Treatment.
    The treatment of choice is the same as for an isolated displaced
    fracture of the radius with forearm immobilization in supination for 6
    weeks. The radius is fixed anatomically with a volar approach and plate
    fixation as for bone forearm fractures. If the distal radioulnar joint
    remains stable in supination as documented radiographically, a long-arm
    splint is applied to this position. In a reliable patient, elbow motion
    can be started with the forearm in supination using a hinged orthoses
    or Munster cast as soon as wound healing is confirmed. Occasionally, an
    open reduction of the distal radioulnar joint is necessary because of
    inability to reduce the joint. If the reduction is unstable, fixation
    with two Kirschner wires from the ulna to the radius is advisable; the
    wires are removed in 4 weeks. The Kirschner wire should be a minimum
    size of .062 in. or larger to avoid breaking. The distal radioulnar
    joint must be confirmed to be reduced by roentgenograms during the
    immobilization period.
IX. Isolated Ulna Fractures
  • Mechanism.
    This fracture frequently occurs as the result of a blow across the
    subcutaneous surface of the bone, thus the term “nightstick fracture.”
  • Treatment. If
    the fracture is displaced and not associated with radial head
    subluxation, it can be well treated conservatively. Functional bracing
    or treatment with casting yields 95% to 98% union rates with good
    fixation (26,27,28).
X. Colles’ Fracture (29)
  • This extraarticular fracture of the
    distal radius was first described by Abraham Colles in 1814. In this
    important paper, he differentiated this injury from the rare
    dislocation of the wrist on clinical grounds without the aid of
  • Examination. The wrist and hand are displaced dorsally in relation to the shaft of the radius (Fig. 18-3) to form the classic silver-fork deformity. Tenderness is found over the distal radius and over the ulnar styloid.
  • Roentgenograms. Anteroposterior and lateral films are essential and often show the following:
    • Comminution of the dorsal cortex
    • The following displacements, in varying degrees, of the distal fragments:
      • Dorsal displacement
      • Dorsal angulation
        Figure 18-3. A: Colles’ fracture. B: Smith fracture (reversed Colles’ fracture). C: Barton fracture (causes displacement of the anterior portion of the articular surface).
      • P.258

      • Proximal displacement
      • Radial displacement
      • Articular extension. If the articular fractures are displaced, treatment is different.
  • Treatment
    must be directed as vigorously toward maintaining hand, elbow, and
    shoulder function as toward obtaining an acceptable cosmetic result.
    • The radiocarpal joint normally faces palmarward
      anywhere from 0 degrees to 18 degrees, so any amount of dorsal
      angulation is usually unacceptable, and better alignment should be
      attempted. Reduction of extraarticular fractures that are angulated
      palmarward between 1 degrees and 15 degrees depends on the age of the
      patient and the activity level desired; ordinarily, no reduction is
      necessary. If the palmar tilt is between 10 degrees and 20 degrees, the
      fracture should be immobilized with no attempt at reduction. The normal
      radial deviation of the radiocarpal joint ranges from 16 degrees to 28
    • Reduction of
      this fracture usually is easy to achieve but difficult to maintain. It
      may be performed under a hematoma block, a Bier block (intravenous
      regional anesthetic), or an axillary block. Reducing the deformities
      that have been described previously involves the following steps:
      • Fingertrap traction with a 10-lb weight
        hung from a strap across the arm is used, and the elbow is flexed 90
        degrees in the line of the forearm to disimpact the fracture. Manual traction is an equally effective alternative.
      • While traction is maintained, pressure is
        applied to the dorsal aspect of the distal fragment and to the palmar
        aspect of the proximal fragment to correct dorsal displacement and rotation.
      • Pressure is applied on the radial aspect of the distal fragment to correct radial deviation.
    • The following are useful clinical tests of reduction:
      • Palpation of
        the normal wrist shows that the radial styloid lies 1 cm distal to the
        ulnar styloid, and this relationship should be restored on the injured
      • There should be no tendency toward recurrence of the deformity;
        that is, when one holds the elbow with the forearm parallel to the
        ground, the wrist contour appears normal. This may be difficult to
        assess with severe swelling.
    • Methods of immobilization
      • The wrist usually is immobilized
        with the hand in ulnar deviation, the wrist neutral to no more than 15
        degrees of volar flexion, and the anterior splints or single posterior
        splint extending over the first and second metacarpals to maintain the
        full ulnar deviation. Splints should be placed over a single layer of
        Webril applied with an adherent. Splints are wrapped in place by
        bias-cut stockinet or by an elastic bandage. Because of the potential
        for swelling, a circular cast is not advisable as initial treatment.
        The splints may be incorporated into a circular cast after all
        adjustments for swelling have been made. It is essential to allow full
        (90-degree) flexion of all metacarpophalangeal joints.
      • Short-arm versus long-arm casting.
        If the surgeon wishes to maintain an accurate reduction, the elbow
        joint should be immobilized. A forearm splint-cast is appropriate,
        however, in the following situations:
        • When the individual is debilitated or elderly
        • When an incomplete reduction is to be accepted
        • When no reduction is attempted, and the impacted position of the fragments is accepted
      • In the younger individual with a severely comminuted and displaced extraarticular fracture, consider external skeletal fixation through the radius and the second metacarpal to maintain proper position and length (21).
        Immobilization in the fixator for at least 6 weeks is usually
        necessary, followed by mobilization of the wrist. In the older patient
        with badly comminuted fractures, early excision of the distal ulna and
        acceptance of radial


        shortening may also be considered (29). See Chap. 10, II.J, for a discussion of external skeletal fixation.

      • The presence of intraarticular extension
        changes the treatment paradigm in all but the most debilitated
        patients. A displacement of more than 3 to 4 mm mandates an attempt at
        closed reduction. Displacement of more than 2 mm warrants reduction in
        an adult because of the association of residual displacement with
        degenerative joint disease of the radiocarpal joint (30).
        Closed reduction of articular displacement is rarely successful.
        Therefore, an open reduction through a dorsal approach; Kirschner wire
        fixation; bone graft for the dorsal defect; and pins, external
        fixation, or small fragment plates for neutralization are generally
        recommended. There has been increased interest in open reduction in the
        internal fixation over the last decade to improve functional outcomes
        of these fractures in adults younger than 65 to 70 years of age where
        functional decrease is high (18,31).
  • Aftercare
    • Frequent active movements of the fingers and elevation of the hand are both essential to reduce swelling and relieve pain. Full movement of the shoulder joint also must be maintained.
    • Within 1 week of treatment, the following criteria should be met:
      • There is full, active movement of the fingers and the shoulder.
      • Pain is minimal and readily controlled with minimal analgesics.
      • The immobilization is satisfactory and comfortable.
    • Follow-up roentgenograms obtained through the splint should be obtained:
      • After reduction
      • On the third day or when the swelling subsides
      • After 10 to 14 days
      • At 6 and 12 weeks after injury
    • Duration of immobilization.
      If the fracture is unreduced, it should be immobilized for 4 to 6
      weeks. If the fracture is reduced, it should be immobilized for 6 to 8
      weeks. Diminishing of tenderness over the site of fracture is evidence
      of progressive union. The wearing of a removable dorsal splint for
      several weeks after cast removal can improve patient comfort while
      allowing mobilization of the extremity.
  • Complications
    • The most frequent complication is stiffness of the finger joints and shoulder.
    • Pain with finger movement or numbness in the radial three digits often can signify a carpal tunnel syndrome.
      The pain usually is associated with complaints or abnormal neurologic
      findings in the median nerve distribution. If the abnormal findings
      persist for 3 days or increase in severity over 4 to 12 weeks, the
      carpal tunnel should be surgically released. If the patient has severe
      median nerve deficit, carpal tunnel release should be part of the
      initial management, which generally involves percutaneous pinning,
      external fixation, or open reduction.
    • Pain over the distal radioulnar joint
      on supination of the forearm is a common complaint when immobilization
      is discontinued. The symptoms usually disappear within 6 months. Warn
      the patient of this problem in advance; if symptoms persist after full
      mobilization of the hand, excision of the distal ulna should be
    • Some recurrence of deformity
      is common. It is rare for the fractured wrist to have the same
      appearance as a normal wrist. Give the patient advance warning about
      this discrepancy and stress the desirability of good function rather
      than cosmesis.
    • If rupture by attrition of the extensor pollicis longus
      is diagnosed, early repair is indicated. This may occur even with
      nondisplaced fractures. This is thought to be due to damage to the
      blood supply to the paratenon.
XI. Distal Radial and Ulnar Fractures in Children
  • Description. These fractures are often referred to incorrectly as Colles’ fractures because the deformity of the wrist is similar.
  • P.260

  • Roentgenograms.
    Roentgenographic examination is diagnostic. Be certain that the
    fracture is not one of the types of epiphyseal slips described below in
  • Treatment.
    When completely displaced, these fractures can be difficult to reduce.
    Manipulation should be done with the patient anesthetized or under
    conscious sedation, and the rule “one doctor, one manipulation”
    applies. Direct traction alone is rarely successful and should not be
    attempted, especially without complete patient relaxation under an
    • Manipulative reduction consists of either
      • Traction in line with the deformity until the bone ends can be “locked on,” followed by correction of the deformity.
      • Increasing the angulation of the distal fragments by manipulation (re-creating the deformity)
        until the bone ends can be “locked on,” followed by alignment of the
        distal fragment to the proximal fragment to correct the deformity.
    • If reduction can be achieved,
      it is usually stable, and treatment then consists of immobilization as
      for a Colles’ fracture in a long-arm splint with the elbow at 90
    • The fracture infrequently requires open reduction.
XII. Smith and Barton Fractures of The Distal Radius
  • Smith fracture
    is a fracture of the distal radius with the distal fragment and
    accompanying carpal row displaced volarly (reversed Colles’ fracture; Fig. 18-3B).
    The articular surface of the radius is not involved. This injury is
    usually secondary to a blow on the dorsum of the wrist or distal radius
    with the forearm in pronation.
    • Treatment may
      initially consist of a closed reduction under anesthesia. Longitudinal
      treatment is applied in a line with the deformity (pronation and
      flexion) until the fragments are distracted. Supination and pushing
      dorsally on the distal fragment reduce the fracture. The fracture
      should be immobilized with the forearm positioned in supination and the
      wrist in extension. These fractures are highly unstable and the patient
      should be informed that this may occur and that open reduction with
      pins or small fragment plates is generally necessary.
    • Postmanipulative care is the same as for a Colles’ fracture.
  • Barton fracture is a fracture-dislocation in that the triangular fragment of the volar surface of the distal radius is sheared off (Fig. 18-3C). This fragment along with the carpus is displaced volarly and proximally.
    • The mechanism of injury is usually forced pronation under the axial load.
    • Treatment of
      this fracture by closed methods is difficult. Unless there is
      significant comminution, open reduction and fixation with a volar
      buttress plate is recommended.
XIII. Distal Radial Epiphyseal Separation
  • The usual mechanism of injury
    is a fall on the outstretched hand with a forced rotation of the wrist
    into dorsiflexion, resulting in dorsal displacement of the distal
    radius through the epiphyseal plate.
  • This fracture follows the rule of epiphyseal injuries (see Chap. 1, VIII.B). It is usually a Salter class 1 or 2 fracture of the epiphysis; hence, growth arrests may occur. The parents of an injured child must be gently acquainted with this fact.
  • Good-quality roentgenograms are essential in determining the type of epiphyseal separation.
  • Treatment.
    The younger the child, the more angulation and displacement can be
    accepted with assurance of normal subsequent function and cosmesis. In
    a child of any age, angulation exceeding 25 degrees or displacement exceeding 25% of the radial height should be reduced.
    A less-than-automatic reduction is preferable to repeated
    manipulations. The reduction is accomplished after adequate anesthesia
    to ensure complete muscle relaxation. Traction is applied in the line
    of deformity. The manipulation and postreduction treatment are the same
    as for a Colles’ fracture. The patient should be immobilized in a
    long-arm cast for 3 to 4 weeks, followed by a short-arm cast for 2 to 4
    weeks. Parents should be reassured that remodeling of the plate and
    joint motion will occur.



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2. Melhoff TL, Noble PC, Bennett LB, et al. Simple dislocation of the elbow in the adult. J Bone Joint Surg (Am) 1988;70:244–249.
3. Regan W, Morrey BF. Fractures of the coronoid process of the ulna. J Bone Joint Surg (Am) 1989;71:1348–1354.
4. Pugh
DM, Wild LM, Schemitsch EH, et al. Standard surgical protocol to treat
elbow dislocations with radial head and coronoid fractures. J Bone Joint Surg (Am) 2004;86:1122–1130.
5. Josefsson
PO, Gentz CF, Johnell O, et al. Surgical versus nonsurgical treatment
of ligamentous injuries following dislocations of the elbow. J Bone Joint Surg (Am) 1987;69:605–608.
6. O’Driscoll SW, Morrey BF, Korinek S, et al. Elbow subluxation and dislocation: a spectrum of instability. Clin Orthop 1992;280:17–28.
7. Husband JB, Hastings H II. The lateral approach for operative release of posttraumatic contracture of the elbow. J Bone Joint Surg (Am) 1990;72:1353–1358.
8. Morrey BF. Treatment of the contracted elbow: distraction arthroplasty. J Bone Joint Surg (Am) 1990;72:601–618.
9. King GJ, Evans DC, Kellom JF. Open reduction and internal fixation of radial head fractures. J Orthop Trauma 1991;5:21–28.
10. Ring D, Quintero J, Jupiter JB. Open reduction and internal fixation of fractures of the radial head. J Bone Joint Surg (Am) 2002;84:1811–1815.
11. Moro
JP, Werier J, MacDermid JC, et al. Arthroplasty with a metal radial
head for unreconstructible fractures of the radial head. J Bone Joint Surg (Am) 2001;83:1201–1211.
12. Broberg MA, Morrey BF. Results of delayed excision of the radial head after fracture. J Bone Joint Surg (Am) 1986;68:669–674.
13. Mikic ZD, Vukadinovic SM. Late results in fracture of the redial head treated by excision. Clin Orthop 1983;181:220–228.
14. Mih AD, Cooney WP, Idlers RS, et al. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop 1994;199:156–158.
15. Ring D, Jupiter J, Simpson HS. Montegoia fractures in adults. J Bone Joint Surg (Am) 1998;80:1733–1744.
16. Unthoff HK, Boiscert D, Finnegan M. Cortical porosis under plates, reaction to unloading of necrosis? J Bone Joint Surg (Am) 1994;76:1502–1512.
17. Chapman MW, Gordon JE, Zissimos AG. Compression plate fixation of acute fractures of the diaphysis of the radius and ulna. J Bone Joint Surg (Am) 1989;71:159–169.


18. Ring
D, Prommersberger K, Jupiter JB. Combined dorsal and volar plate
fixation of complex fractures of the distal part of the radius. J Bone Joint Surg (Am) 2004;86:1616–1652.
19. Sarmiento A, Ebramzaden R, Brys D, et al. Angular deformities and forearm function. J Orthop Res 1992;10:121–133.
20. Schemitsch
EH, Richards RR. The effect of malunion on functional outcome after
plate fixation of both bones of the forearm in adults. J Bone Joint Surg (Am) 1992;74:1068–1078.
21. Vaughan PA, Lui SM, Harrington IJ, et al. Treatment of unstable fractures of the distal radius by external fixation. J Bone Joint Surg (Br) 1985;67:385–389.
22. Wei SY, Born CT, Abene A, et al. Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46:1045–1048.
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25. Moore TM, Klein JP, Patzakis MJ, et al. Results of compression plating of closed Galeazzi fractures. J Bone Joint Surg (Am) 1985;67:1015–1021.
26. Atkin DM, Bohay DR, Slabangh P, et al. Treatment of ulnar shaft fractures: a prospective, randomized study. Orthopedics 1995;18:543–547.
27. Gebuhr
P, Holmich P, Orsnes T, et al. Isolated ulnar shaft fractures:
comparison of treatment by a functional brace and long-arm cast. J Bone Joint Surg (Br) 1992;74:757–759.
28. Sarmiento A, Lotta LL, Zych G, et al. Isolated ulnar shaft fractures treated with functional braces. J Orthop Trauma 1998;12:420–424.
29. Altissimi M, Antencci R, Fiacca Mancini GB. Long-term results of conservative treatment of fracture of the distal radius. Clin Orthop 1986;206:202.
30. Knirk JL, Jupiter JB. Intraarticular fractures of the distal end of the radius in young adults. J Bone Joint Surg (Am) 1986;68:647–659.
31. Simic PM, Weiland AJ. Fractures of the distal aspect of the radius: changes in treatment over the past two decades. J Bone Joint Surg (Am) 2003;85:552–564.
Selected Historical Readings
Bado JL. The Monteggia lesion. Clin Orthop 1967;50:71–86.
Burwell HN, Charnley AD. Treatment of forearm fractures in adults with reference to plate fixation. J Bone Joint Surg (Br) 1964;46:404–425.
Fowles JV, Sliman N, Kassab MT. The Monteggia lesion in children: fracture of the ulna and dislocation of the radial head. J Bone Joint Surg (Am) 1983;65:1276–1282.
Fuller DJ, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg (Br) 1982;64:364–367.
Linscheid RL, Wheeler DK. Elbow dislocations. JAMA 1965;194:1171–1176.
Mason M. Some observations on fractures of the head of the radius with a review of 100 cases. J Bone Joint Surg (Br) 1954;42:123–132.
Monteggia GB. Instituzione chirugiche, 2nd. Milan: G. Maspero, 1814.
Morrey BF, Chao EY, Hui FC. Biomechanical study of the elbow following excision of the radial head. J Bone Joint Surg (Am) 1979;61:63–68.
Taylor TK, O’Connor BT. The effect upon the inferior radioulnar joint of excision of the end of the radius in adults. J Bone Joint Surg (Br) 1964;46:83–88.

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