Fractures of the bones of the diaphysis of the forearm. Fractures of the bones of the forearm Fracture of the diaphysis of the radius and ulna

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Causes: direct impact, sharp angular deformation.

Signs. Deformation, swelling, impaired movement, pain on palpation of the fracture area, pain on loading along the axis of the forearm, pathological mobility and crepitus at the level of the fracture are detected. It is imperative to check the mobility and sensitivity of your fingers!

When one of the bones of the forearm is fractured, the deformation and swelling are not so pronounced, and local pain is determined only in the area of the damaged bone. The presence of dislocation of the head of the radial bone during a fracture of the ulna prevents flexion in elbow joint. To clarify the diagnosis, it is very important to take x-rays of the forearm bones along the entire length (after anesthesia).

Treatment. First aid is immobilization with a transport splint along the posterior surface from the heads of the metacarpal bones to the upper third of the shoulder, the limb is in a position of flexion at the elbow joint up to 90° (Fig. 1, a).

Rice. 1. Transport immobilization of the forearm (a) and therapeutic immobilization of the forearm for fractures in the proximal (b) and distal (c) sections

For fractures without displacement of fragments apply a two-split plaster cast from the metacarpophalangeal joints to the upper third of the shoulder for 8-10 weeks.

Rehabilitation - 2-4 weeks.

Working capacity is restored after 2 1/2 -3 months.

For fractures with displacement of fragments Reposition is performed with the patient lying down. After anesthetizing the fracture sites, the arm is placed on a side table, the shoulder is abducted and the limb is bent at the elbow joint to 90°. Two assistants gradually (!) perform traction along the axis of the forearm (traction by the fingers and hand, counter-traction by a towel or a wide band of gauze thrown over the distal shoulder). The traumatologist eliminates the lateral displacement of fragments by squeezing the interosseous space from the anterior and back surfaces forearms. After reposition, a posterior plaster splint is applied from the metacarpophalangeal joints to the upper third of the shoulder and an additional plaster splint is applied to the palmar surface of the forearm and shoulder. The area of the interosseous space is carefully modeled (it is permissible to insert longitudinal ridges). The splints are fixed with a bandage (Fig. 2) and a control radiograph is taken (after 2 weeks, repeat the X-ray control!).

Rice. 2.

If the fracture is localized in the upper third of the forearm, then reduction and immobilization are performed in the position of supination of the forearm. For fractures in the middle and lower thirds, the forearm is held in an intermediate position between pronation and supination (Fig. 3). To reposition fractures of the forearm bones, the devices of Sokolovsky, Demyanov, etc. (Fig. 4) with the application of plaster casts are successfully used. The period of immobilization is 12-16 weeks. It is important 7-10 days after repositioning of the fragments to check their position x-ray and exclude secondary displacement.

Rice. 3. Displacement of fragments in fractures of the radius: a - in the proximal part; b - c distal section

Rice. 4. Devices for repositioning fragments of forearm bones: a - Sokolovsky; b - Demyanova

Rehabilitation - 4-6 weeks. Working capacity is restored after 4-5 months.

Surgical treatment indicated for unsuccessful reposition, secondary displacement of fragments. For osteosynthesis, metal rods and compression plates with screws are used (Fig. 5).

Rice. 5. Internal osteosynthesis of both forearm bones: a — state of fragments before fixation; b — bone osteosynthesis; c — intraosseous osteosynthesis

Immobilization with a plaster cast for 10-12 weeks.

Rehabilitation - 4-6 weeks.

Working capacity is restored after 3-4 months.

The use of external fixation devices (Fig. 6) reduces the time of rehabilitation and disability by 1-1 1/2 months.

Rice. 6.

In case of Monteggia injuries, osteosynthesis of ulnar bone fragments is performed and the dislocation of the radial head is reduced (Fig. 7).

Rice. 7. Monteggia's fracture. Reposition and immobilization with a plaster cast (arrows indicate the direction of traction)

Immobilization (10-12 weeks) is carried out in the position of flexion and supination of the forearm.

Rehabilitation - 6-8 weeks.

The period of incapacity for work is 3-4 months.

In case of Galeazzi fractures, fixation with a compression plate is performed to hold fragments of the radial bone, and in the distal part the reduced head of the ulna is fixed with a knitting needle (Fig. 8).

Rice. 8.

Immobilization - 3-4 weeks.

Rehabilitation - up to 6 weeks.

Periods of incapacity for work - up to 3 months.

Complications: rotational contracture, neuritis, false joints.

Traumatology and orthopedics. N. V. Kornilov

Moisov Adonis Alexandrovich

Orthopedic surgeon, doctor highest category

Moscow, st. Dmitry Ulyanov 6, bldg. 1, metro station "Akademicheskaya"

Moscow, st. Artsimovicha, 9 bldg. 1, metro station "Konkovo"

Moscow, st. Berzarina 17 bldg. 2, metro station "Oktyabrskoye Pole"

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Education and professional activity

Education:

In 2009 he graduated from Yaroslavl State Medical Academy specializing in general medicine.

From 2009 to 2011, he completed clinical residency in traumatology and orthopedics at the base clinical hospital ambulance medical care them. N.V. Solovyov in Yaroslavl.

Professional activity:

From 2011 to 2012, he worked as an orthopedic traumatologist at Emergency Hospital No. 2 in Rostov-on-Don.

Currently working in a clinic in Moscow.

Internships:

May 27 - 28, 2011 - Moscow- III International Conference “Foot and Ankle Surgery” .

2012 - training course on Foot Surgery, Paris (France). Correction of forefoot deformities, minimally invasive surgeries for plantar fasciitis (heel spurs).

February 13 -14, 2014 Moscow - II Congress of Traumatologists and Orthopedists. “Traumatology and orthopedics of the capital. Present and future."

June 26-27, 2014 - took part in V All-Russian Congress of the Society of Hand Surgeons, Kazan .

November 2014 - Advanced training "Application of arthroscopy in traumatology and orthopedics"

May 14-15, 2015 Moscow - Scientific and practical conference with international participation. "Modern traumatology, orthopedics and disaster surgeons."

2015 Moscow - Annual international conference.

May 23-24, 2016 Moscow - All-Russian Congress with international participation. .

Also at this congress he was a speaker on the topic "Minimally invasive treatment of plantar fasciitis (heel spurs)" .

June 2-3, 2016 Nizhny Novgorod - VI All-Russian Congress of the Society of Hand Surgeons .

In June 2016 Assigned. Moscow city.

Scientific and practical interests: foot surgery And hand surgery.

Damage to the bones in the forearm area is one of the most common. This skeletal lesion is recorded in 12-30% of cases.

The main method for diagnosing pathology is radiography. After a fracture, the patient notes acute pain, swelling in the affected area, as well as a violation of the normal shape of the limb.

Anatomy of the forearm

The radius and ulna form the girdle of the forearm. Throughout the entire length of the bones, they are connected by an interosseous membrane.

The distal part of the bones of the forearm takes part in the formation of the wrist joint.

The proximal (upper) part of the ulna has a lunate notch that allows it to form a connection with the radius. And both bones form an articulation with humerus- elbow joint.

Causes of fracture of both bones of the forearm

The main risk factors that lead to serious forearm fractures include:

lack of skills to correctly group when falling;
making sudden careless movements;
elderly age patient;
the presence of malignant bone lesions.

Fractures usually occur after direct damaging impact. Common causes of fractures include: strong blows on the forearm, traffic accidents and falling on the arm.

Medical statistics show that a fracture of both bones occurs less frequently than damage to one of the bones of the forearm.

Symptoms of a forearm fracture

A diagnosis of a fracture of the forearm bones can be made after detecting characteristic symptoms in the form of:

sharp local pain;
hemorrhages;
swelling of soft tissues;
shortening of the forearm;
crepitation (crunching) of bone fragments when moving the hand;
limited mobility upper limb, difficulties in flexing and extending fingers;
forearm deformities;
pathological mobility upon palpation.

First aid for fractured forearm bones

The algorithm of actions when a fracture of the forearm bones is detected involves:

Immobilization (immobilization) of a limb using a splint. You can make a retainer from scrap materials if you have a solid piece of box, a board or stick, a bandage or a long piece of cloth. Help consists of applying a splint to the shoulder, elbow and wrist joints. The splint will immobilize the arm and relieve additional stress from the injured limb;
Taking painkillers. It is forbidden to take alcohol to relieve pain syndrome, since its impact may aggravate the victim’s condition;
Application of a hemostatic bandage for an open fracture. If a person is bleeding, it should be stopped using a pressure bandage. The wound must be bandaged tightly. If arterial bleeding is observed, a tourniquet is applied to the shoulder.

Types of forearm fractures

Everyone knows open and closed fractures of the forearm bones. Depending on the nature of the fracture, damage can be:

helical;
oblique;
splintered;
transverse

There are cases when bone fragments during fractures are displaced at an angle, in width or in length. Depending on the location of the injury, fractures can occur in the lower, middle, or upper third of the forearm.

Treatment methods for forearm fractures

Almost always, when both bones of the forearm are fractured, the fragments are displaced with simultaneous rotation. This often happens at the time of injury and is aggravated by the traction of the forearm muscles. This injury itself is unstable and there is a high risk of re-displacement. If there was a fracture of only one bone, this would be a completely different matter and treatment tactics.

But for complete anatomical restoration and speedy rehabilitation of a fracture of both bones, surgery - osteosynthesis - is necessary. Fixation of bones during surgery can be performed using various metal structures: plates and screws, rods, wires, Ilizarov devices, rod devices.

Conservatively (i.e. without surgery), such fractures are difficult to treat. Displacement in length and width in a closed position can be eliminated, but rotation (rotation) of the bone around its axis is almost impossible. In addition, after repositioning (reduction) during the entire period of stay in the cast, secondary displacement may occur due to traction of the forearm muscles.

Artificial bone fixators in the form of plates and rods can be removed 6-18 months after surgery. Restoration of the ability to work of a victim of a fracture of both bones of the forearm can be achieved 1.5-3 months after the operation.

Rehabilitation after a fracture

For effective recovery, patients with forearm fractures should attend:

physiotherapeutic treatment (paraffin baths, electrophoresis, UHF, mud baths);
massotherapy;
Exercise therapy. Start off physical exercise for development of the joint it is possible 4 days after surgery. For the first 10 days, the patient is allowed to voluntarily strain the limb under a plaster cast.

When the plaster is removed, the patient begins active movements in the elbow and wrist joints. It is also recommended to make rotational movements in the forearm area.

After 2-3 weeks, you can begin exercises with light dumbbells. Training is performed at least 3 times a day, the patient performs 10-15 repetitions. The weight of dumbbells should not exceed 3 kg, otherwise the patient will experience overexertion and severe pain.

Don't self-medicate!

Determine the diagnosis and prescribe correct treatment Only a doctor can. If you have any questions, you can call or ask a question at.

Diaphyseal fractures of the forearm bones, according to our data, account for 72.7% of other injuries in this segment. Depending on the location, they are usually divided into fractures of the upper, middle and lower third. This traditional division is completely justified, since each localization has its own anatomical, physiological, biomechanical and clinical characteristics.

In addition, there are some age-related differences in forearm fractures at different levels. In older and middle-aged children school age, for example, fractures are more common middle third, fractures of the lower third are somewhat less common and fractures of the upper third of the diaphysis are less common. In preschool and primary school age, most fractures are localized in the distal forearm; fractures of the middle third occur relatively less frequently.

Causes

Fractures of the upper third of the forearm in children of any age are the least common location of injury. The incidence of fractures of one or both bones of the forearm and their levels in outpatients and inpatients are also different. With rare exceptions, the literature usually presents data without distinguishing between outpatient and inpatient. In total, the number of fractures of the radius is significantly greater than the number of fractures of both bones of the forearm and isolated fractures of the ulna combined.

Our separate analysis of outpatient and inpatient patients showed that this pattern applies more to the outpatient population of patients childhood. Among inpatients, fractures of both forearm bones are in first place in terms of frequency, followed by fractures of the radius, and isolated fractures of the ulna are the least common. Among outpatients, injuries in the distal forearm, according to various authors, are observed on average from 60 to 80%, the middle third is in second place, and fractures of the upper third of the forearm are the least common. In inpatients, fractures of the middle third predominate, followed by injuries to the lower third and, least often,
fractures of the upper third of the forearm are observed.

Our experience is based on an analysis of 134,000 injuries to the forearm bones in children, of which 94.7% were treated in an outpatient setting and 5.3% used inpatient treatment methods. Among outpatients with forearm fractures, there were 3.1% fractures in the upper third, 21.3% in the middle third, and 75.6% in the lower third.

7120 children were treated in inpatient conditions, of which fractures were localized in the upper third of cases in 12.9% of cases, in the middle third - 59.2%, in the lower third - 27.9%. In 78.6% of patients, fractures of both bones were observed at various levels, in 19.3% - isolated fractures of the radius and in 2.1% - isolated fractures of the ulna. This pattern is determined age characteristics growing children's bones and biomechanical conditions for the occurrence of injury.

The most common indirect mechanism of injury in the proximal forearm is counteracted by a thickened ulna, stably articulating in the trochlear glenohumeral joint, lacking rotational movements. Thinned, articulating in two joints - the brachioradial and radioulnar joints, the radius, on the contrary, in the proximal part of the forearm is quite mobile and pliable. At this level in childhood, more conditions are created for subluxations, dislocations and fracture-dislocations of the head of the radial bone, as well as Monteggia-type fracture-dislocations that usually arise from direct trauma. As for fractures, which mostly arise from indirect trauma emanating from the counter-impact force when a child falls with emphasis on the hand, they are predominantly found near the application of this force - in the distal forearm with an extensive fragile osteochondral structure germinal zone.

The pattern in the prevalence of fractures in the distal forearm is explained by the fact that in children of primary and secondary school age, the growing bones in this area, having lost the elastic properties of cartilaginous tissue, have not yet acquired the strength of mature bone. As you move upward from the wrist joint, the force of the injury weakens, and the strength of the bones of the forearm, especially the elbow, on the contrary, increases and the frequency of fractures decreases more and more. For clinical practice Of primary importance are the age of the patient, the mechanism of injury, the level and plane of the fracture, the types and degree of displacement of fragments, revealed by clinical and radiological methods of examination, which determine treatment tactics and the final outcome of the injury.

The influence of a traumatic factor in combination with action in the forearm area large number muscles causes a wide variety of displacement of bone fragments: from minor angular displacements with preservation of the periosteal continuity of the segment and the integrity of the cortical plate on the concave side of the bone (fractures of the “green stick”, “rubber tube” type) to complete separation of fragments with their displacement in width and length . In case of fractures of both bones of the forearm with complete separation of the fragments, the nature of the displacement is determined by a violation of the relationships between the fragments of the radial bone, followed by fragments of the ulna, intimately connected to each other by the interosseous membrane.

The levels of fracture of the radius, depending on the place of attachment of the supinators and pronators to it, set the proximal and distal pairs of fragments to a greater or lesser degree of pronation of the forearm and hand below the level of the fracture.

Types of offsets

Converging and diverging types of displacements are quite rare in pediatric practice, although among our observations they were noted in 5.1% of cases. Different thicknesses of the radius and ulna bones throughout
the forearms and the unequal levels of transition of the diaphyseal to metaphyseal sections contribute to another observed pattern: in case of fractures of two bones of the forearm, the level of the radial bone fracture is located proximal to the level of the ulna fracture.

Displacement of radial bone fragments, regardless of the level of the fracture, is usually more pronounced than that of the ulna. Thanks to the attachment more muscles, fragments of the radial bone are more mobile and less stable after comparison, especially in the proximal part, if the fracture occurs between the attachment of the supinator and pronator teres.

The cause of instability of even well-reduced fragments is an unrecognized rotational displacement, which usually occurs due to the oppositely directed action of the supinator on the central fragment and the pronator teres on the peripheral. Its radiological sign is a violation of the relative position of the fracture planes of both fragments and adduction of the upper edge of the distal fragment towards the interosseous space, revealed on an anteroposterior radiograph.

A similar phenomenon is observed in the distal forearm, when the level of the radial bone fracture is located in the area of attachment of the pronator quadratus to it. The action of the predominant part of the muscles on the central or peripheral fragment helps to bring it towards the interosseous space with its simultaneous internal rotation. For fractures of the radius in the lower third under the influence of the abductor longus, pronator quadratus and extensor brevis muscles thumb the peripheral fragment is sharply rotated inward and pressed against the ulna. Therefore, during reposition, supination of the hand, vigorous pulling of the thumb and subsequent immobilization of the forearm and hand in a supinated position are necessary. Thus, in pediatric traumatological practice, both in the area of the upper third and in the distal part of the forearm, there are specific features of the displacement of bone fragments, there is a specificity in their comparison, and the same need arises to give the forearm and hand a supination position during immobilization.

Diagnostics

Diaphyseal fractures of the forearm bones are accompanied by the usual well-known clinical signs, inherent in a certain location of the fracture and the severity of the injury. In contrast to epimetaphyseal injuries, with diaphyseal localization of fractures, difficulties in diagnosis are relatively rare. Fractures without separation of fragments are usually accompanied only by a violation of the axis of the forearm.
If the fragments become separated and lateral, longitudinal and rotational displacements occur, acute pain, swelling, corresponding deformation of the forearm and dysfunction of the limb appear. X-ray data clarify the level of the fracture, establish the fact of violation of the integrity of one of both bones of the forearm, indicate the nature of the fracture plane, the type, direction and degree of displacement of the fragments.
Due to the fact that it is not always possible to have radiographs capturing one, and even more so both adjacent joints, the presence or absence of rotational displacement of fragments must be judged based on the data clinical trial patient and carefully study the relative positions of the fracture planes of displaced bone fragments on radiographs.
The diagnostic stage ends with a study of the condition of the distal parts of the limb to determine whether their innervation and blood circulation are intact or impaired.

Treatment of diaphyseal fracture of the forearm bones

IN therapeutic tactics for diaphyseal fractures of the forearm bones in children, conservative methods should always be the desired rule, operative methods should always be a forced exception (Fernander D. L., 1981). The success of treatment of diaphyseal fractures of the forearm bones in children is entirely determined by the skill of closed comparison of fragments in compliance with the basic rule of traumatology that reposition should be early, gentle, complete and one-time. The words of N.G. Damier are very appropriate here that “an indispensable condition for the successful implementation of conservative treatment of fractures in children is mastery of the techniques of manual reduction, traction and fixation of fragments.”

If for other diaphyseal locations of fractures in children, such as the humerus, femur and tibia bones, we
we still have such excellent conservative method treatment, as a system of constant skeletal traction, then in the forearm area, as is known, its use according to for obvious reasons extremely difficult. The desire to achieve closed manual comparison of forearm bone fragments is always justified, since reduced bone fragments in children are usually held more stably in contrast to adult patients, in whom, due to the predominant bevel of the fracture plane in such fractures, the fragments are difficult to compare, are often displaced a second time and often require surgical reposition and primary metal osteosynthesis.

Failures of conservative tactics mainly occur in early childhood, when the small diameter of the bone, unstable fracture planes and a mobile central fragment of the radius, surrounded by muscles and hematoma, make it difficult to compare the fragments.

The plan for closed reduction should always be carefully considered based on the level of the fracture, the nature of the fracture and the type of displacement of the fragments, and whether one or both bones are damaged. In children, diaphyseal fractures of the forearm bones without displacement of the fragments are rare. There are purely angular displacements of greater or lesser magnitude, usually with preservation of periosteal continuity (like a “green stick”). Any angular displacement of fragments of one or both bones of the forearm requires mandatory elimination and restoration of the correct anatomical shape inherent in each bone. Acceptable are angular deviations of the axis, the curvature directed towards its natural physiological shape of no more than 10°. For the radius these are the dorsal and radial directions, for the ulna - the dorsal.

In our practice, there have been cases when, during the elimination of purely angular displacements or in the process of applying a plaster cast or splint, complete lateral and longitudinal displacements of fragments occurred, which were detected on control radiographs. In this regard, some careful authors recommend eliminating primary or remaining angular deformities of the forearm after applying a plaster cast, but before it hardens (G. Heinzl, 1963). Such techniques are quite justified, especially with beveled or obliquely transverse fracture planes.

For fractures with complete primary separation of fragments, closed manual reduction is performed. In order to prevent additional trauma to damaged tissues associated with their possible overstretching during traction along the axis of the forearm, and to technically facilitate the comparison of fragments during reposition, we widely use the angular bending technique. The direction of the bend angle is usually determined by the level of the fracture, the nature of the fracture plane and the direction of the lateral displacement of the distal fragments. Particular care is taken to prevent possible trauma to the neurovascular bundle by the sharp edges of bone fragments in the area of the apex of the corner bend.

Usually, when distal fragments are displaced posteriorly, the angle of artificial bending of the forearm bones is created open in the dorsal direction. When the distal fragments are displaced anteriorly, the angle of inflection is created facing anteriorly.

Most often, several types of displacement of fragments are observed, and the sequence of their elimination is always important. Initially, rotational and lateral displacements are eliminated. For final stage reposition - elimination of displacements along the length - the most applicable technique is angular bending. Stretching of the distal limb is carried out gradually, slowly, until stable contact between the ends of the bone fragments. Then, continuing traction at the same angle, the axis of the forearm is aligned, giving it a certain position between supination and pronation, depending on the level of the fracture. It is extremely important to take into account the nature of the fracture plane of one and the other bone.

This moment is taken into account more from the side of the radius, as the main support for the distal limb. A transverse or transversely serrated fracture surface is more favorable for the stability of juxtaposed fragments. With an oblique plane of fracture of both bones it is also possible for the most part achieve sufficient contact between fragments. The end parts of fragments in children are often rough, helping to retain the fragments until the primary bone adhesion that forms between them.

The created contact between bone fragments is controlled by radiography 7-8 days after reposition. If the achieved comparison is maintained and the axis of the forearm remains correct, immobilization of the limb continues for at least 5-6 weeks. If secondary displacement occurs, the bandage is cut circularly and the reposition is repeated. If control radiography does not confirm sufficient comparison of fragments, indications for intraosseous osteosynthesis are given. Using an economical approach, if possible intermuscular, bone fragments of both bones are exposed without skeletonizing them. Reduction of fragments is carried out using single-tooth hooks.

Initially, a rod or thick wire is inserted into the ulna, then through a burr hole in the distal metaphysis, the rod is inserted into the radius. Regardless of the level of the fracture, the forearm bent at a right angle after suturing the surgical wounds is given a supination position, which ensures fusion of the fragments with full straightening of the interosseous membrane during the period of immobilization, which is important for the early subsequent restoration of pro- and supination movements of the forearm.

Both after closed and open reduction of fragments, circular bandages and plaster splints are used for immobilization. In children under 10 years of age, when the fragments are stable, deep, well-modeled splints are applied from the upper third of the shoulder to the level of the heads of the metacarpal bones.

The splint covers two-thirds of the circumference of the limb in the average physiological position of the forearm bent at a right angle for a period of about 3-4 weeks. In older children, after elimination of significant displacements, in cases of stale fractures, after additional corrections and elimination of secondary displacements, immobilization is carried out with a circular plaster cast for up to 1.5-2 months. During the same time, the limb is fixed with a circular plaster cast in the supination position of the forearm after metal osteosynthesis.

Features of damage to the distal forearm.

The distal forearm is one of the most common locations of various bone injuries in children. In this area, there are three types of fractures: metaphyseal, epimetaphyseal and epiphyseal, as well as three types of epiphysiolysis: osteoepiphysiolysis with damage to the metaphysis, osteoepiphysiolysis with damage to the epiphysis and the so-called “pure” epiphysiolysis. Metaphyseal fractures and osteoepiphysiolysis with damage to the metaphysis account, according to our data, for 85.5%.

The most serious prognostically are epiphyseal fractures and osteoepiphysiolysis with damage to the epiphysis. With metaphyseal fractures, in most cases both bones are broken, the plane of the fracture is often transverse. The higher the level of the radius fracture, the more often the ulna fracture occurs. Metaphyseal fractures near the epiphyseal zone and osteoepiphysiolysis of the radius are often accompanied by epiphysiolysis of the ulnar head or avulsion of the styloid process, and in some cases, dislocation of the head of the ulna according to the Galeazzi type of injury. “Pure” epiphysiolysis of the radius, osteoepiphysiolysis with puncture of part of the epiphysis and epiphyseal fractures at this level occur quite rarely.

Probably, not without reason, many authors argue that the germ cartilage cannot be considered the place of least resistance to injury (S. A. Reinberg, 1964). The cartilaginous tissue of the epiphyseal zone, together with the layers of perichondrium and periosteum woven into it, firmly connects the epiphysis with the metaphysis. In order for epiphysiolysis to occur, a large force of injury is needed. The predominant types of fragment displacement at this level are dorsal radial with a tendency for the central fragment of the radius to become wedged between both distal fragments.

Purely dorsal displacements occur much less frequently, as well as displacements of distal fragments in the palmar direction in the form of so-called flexion fractures. Ulnar displacement of distal fragments is very rare. Careful examination of radiographs in two conventional projections contributes to the acceptance the right decision both in diagnostic and therapeutic-tactical terms. Damage without displacement of fragments in this area is not common and with “pure” epiphysiolysis they often remain undiagnosed. The muscles running from the shoulder to the forearm and hand contribute to certain displacements of the fragments.

Practical experience convinces us of the advisability of following a certain sequence in eliminating the existing displacement components even in the case of these damages.
First of all, radial and ulnar lateral displacements are eliminated, and then anteroposterior ones. It is necessary to strictly adhere to this rule.
To hold the reduced fragments, it is advisable to resort to the so-called fixing position of the hand after reposition.
For the most common extension osteoepiphysiolysis with a beveled fracture plane and a tendency to dorsal displacement, the classic position of the hand in a plaster cast in the position of palmar flexion and moderate ulnar deviation is practiced.
After 10-12 days, the hand is transferred to the average physiological position and fixed for about the same time. Taking into account the nature of the damage, the type and degree of displacement of fragments, the completeness and timeliness of reposition, the immobilization period ranges from 4 to 6 weeks, with mandatory control radiography in a plaster cast 7-8 days after reposition.

It should be emphasized that after the edema subsides, bone fragments in this area, even being well compared, are prone to secondary displacement. Under the influence of the muscles attached to the area of the hand and fingers, especially those starting in the distal forearm - the long flexor and short extensor of the pollicis, the quadratus pronator and the long abductor muscle, the distal fragments, despite plaster immobilization, can be displaced a second time both at an angle and by type of lateral shift.

Immobilization of the limb in case of these injuries is carried out with a circular plaster cast, which is more reliable than a plaster splint. For all types of damage in the area of the growth zones, timely, gentle and complete elimination of all components of the displacement is required. After comparison of long-displaced fragments, with remaining unresolved displacements after multiple traumatic reductions, as well as after open reduction with intervention on the epiphyseal growth cartilage and epiphysis, the subsequent normal process of growth and development of the forearm may be disrupted.

Premature closure of the growth zone may occur, lateral deformity may occur, and growth retardation of the forearm may occur with clubhand phenomena, as, for example, with Madelung’s deformity. Such developmental disorders are all the more possible the younger the injured child is. In children over 13-14 years of age, such a danger is unlikely. In conclusion, it should be noted that with correct and timely recognition of the nature of the damage, as well as early, gentle, complete and one-time reposition of fragments, the prognosis for all these injuries is usually favorable.

1) FRACTURE OF THE FOREARM - CORONIOD PROCESS. The mechanism of injury is usually indirect (a fall on an outstretched arm or the dorsum of a maximally bent forearm).

Recognition. Pain, swelling in the elbow area, diffuse tenderness on palpation, dysfunction of the elbow joint (especially flexion).

Treatment. For fractures without clinically significant displacement, the elbow and wrist joints are immobilized with a plaster cast in a flexion position at a right angle for 2 weeks. Then a removable splint is applied for 1-2 weeks. To eliminate a slight displacement, bend the forearm at the elbow joint at an acute angle. If closed reduction is impossible, or if a bone fragment is pinched between the articular surfaces, surgical treatment is indicated.

2) FRACTURE OF THE FOREARM - HEAD AND NECK OF THE RADIAL BONE occurs when falling on an abducted arm and the forearm deviates outward; it can be combined with fractures of the head of the humeral condyle.

Recognition. pain, swelling of the elbow joint, hemarthrosis, local tenderness that increases with palpation. Movement in the elbow joint is limited and painful, especially pronation and supination of the forearm.

Treatment. For cracks of the head, neck and fractures without clinically significant displacement (no more than 2-3 mm), epiphysis-olysis without displacement, immobilization is carried out with plaster loiget from the upper third of the shoulder to the bases of the fingers of the upper limb bent at the elbow joint at a right angle; The position of the forearm is average between pronation and supination. The duration of immobilization is 2-3 weeks, in children - 1-1 VI weeks. Marginal fractures with displacement into the joint cavity (comminuted fractures), as well as secondary and chronic disorders are subject to surgical treatment.

3) FRACTURE OF THE FOREARM - ULNA DHAPHYSUS more often associated with direct trauma. Usually the fracture is localized in the lower third, less often - in the middle and upper thirds of the diaphysis.

Recognition. Pain, swelling, hemorrhage, deformation depending on the nature of the displacement, local tenderness on palpation, moderate dysfunction.

Treatment. For non-displaced fractures, immobilize the forearm bent at a right angle with a circular plaster cast from the base of the fingers to the upper third of the shoulder.

Working capacity is restored after 10-12 weeks. Displacements are eliminated under local anesthesia, in children - under general anesthesia. Immobilization for 10-12 weeks, in children - 4-6 weeks. Exercise therapy, massage, and mechanical physiotherapy are prescribed in a timely manner. Working capacity is restored after 12-14 weeks.

4) Fracture of the forearm - radial diaphysis

more often associated with direct trauma, localized mainly in the middle third. All types of displacement of fragments are possible, except for significant displacement along the length, since this is prevented by the intact ulna bone.

Recognition. Pain, swelling, the forearm is always in a pronated position. Local pain is determined by palpation. There is dysfunction, especially active pronation and supination.

Treatment. For non-displaced fractures, a circular plaster cast is applied from the base of the fingers to the middle third of the shoulder in the position of bending the forearm at a right angle (in children, a plaster splint). The immobilization period is 7-8 weeks, for children - 3-5 weeks. Exercise therapy, massage, and mechanical physiotherapy are prescribed. Working capacity is restored after 9-10 weeks.

Closed reduction is performed under local, conduction anesthesia, less often under general anesthesia. The period of immobilization is 10 weeks, in children 4-6 weeks. During immobilization, rhythmic muscle contractions and movements in free joints are performed, and UHF is prescribed through a cast from the 4-5th day. After removing the bandage, exercise therapy, massage, and mechanical physiotherapy are indicated. Working capacity is restored after 10-12 weeks.

The bones of the forearm (radius and ulna) are connected to each other by an interosseous membrane, the proximal and distal radioulnar joint.

The radius is curved and rotates around the ulna along an axis running from the head of the radius to the styloid process of the ulna. Incorrect immobilization with partial preservation of the rotational movements of the forearm leads to the fact that both fragments of the radius bone are displaced together, and the fragments of the ulna bone rotate on one another (like millstones). This results in nonunion of the ulna. In the 20–30s of the last century, nonunion of the ulna in diaphyseal fractures of the forearm bones was so common that it was regarded as a typical result of treatment.

Angular deformations of bones, violation of their length, dislocations in the radioulnar joints and the formation of interosseous synostoses lead to limitation or loss of supination and pronation. Accurate congruence of both radioulnar joints is important, so restoring the normal length of both forearm bones is of great importance.

Rotational movements of the forearm (pronation, supination) are carried out by two supinators: the biceps brachii muscle and the supinator muscle, which are attached to the third part of the radius, and two pronators: the round pronator, which is attached to the middle third of the radius and the square pronator in the distal part of the radius.

Pronators (a) and supinators (b) of the forearm:
1-m. pronator teres, 2-m. pronator quadratus, 3-m.biceps brachii,
4-m.supinator

In case of fractures in the third forearm, the proximal fragments will be in the supination position, and the distal fragments will be in the pronation position.

For fractures of the forearm in the middle third, below the attachment of the pronator teres. The proximal fragments occupy a position intermediate between supination and pronation.

In case of fractures of the forearm bones in the lower third, the proximal fragments will be slightly pronated.

Therefore, reposition of fractures of the forearm bones in V/3 is carried out in the supination position, in S/3 in a position average between supination and pronation, and in N/3 in the pronation position, and therapeutic immobilization (from V/3 of the shoulder to the heads of the metacarpal bones) in the position , close to the physiological average.

The muscle sheaths of the forearm are covered with common fascia. Therefore, with the formation of subfascial hematomas, compartment syndrome can quickly develop.

Mechanism of injury in fractures of the forearm bones

Fractures of the bones of the forearm occur mainly under the influence of direct trauma: an accident, a fall from a height, a parrying blow during an attack.

Fractures and dislocations of the forearm occur with direct impact on the pronated (Monteggia) or supinated (Galeacia) forearm.

Classification of forearm bone fractures

Fractures are divided into closed and open. By localization in the upper, middle and lower third of the forearm. There are isolated fractures of the radius, ulna and both bones of the forearm without displacement and with displacement of fragments. Displacements can be at an angle, in width, in length and rotational. The latter depend on the place of muscle attachment - supinators and pronators.

By nature, the fracture sites are transverse, oblique, splintered, and multi-fragmented (segmental). Children are characterized by subperiosteal fractures, greenstick fractures, epiphysiolysis, and osteoepiphysiolysis.

There are fracture-dislocations of the forearm:

1. Monteggia - a combination of a fracture of the proximal third of the ulna with a dislocation of the head of the radius.

2. Galeations - a combination of a fracture of the distal third of the radius with a dislocation of the head of the ulna.

3. Divergent radioulnar dislocation. This is a rupture of the distal radioulnar joint, with proximal displacement of the carpal bones and distal dislocation of the radius and ulna.

Clinic and diagnosis of fractures of the diaphysis of the forearm bones

Clinical diagnosis of forearm fractures is based on the presence of pain, swelling, deformation, pathological mobility and crepitus of fragments. It is necessary to specifically look for signs of fracture-dislocations - swelling, deformation and limitation of movements in the elbow or wrist joints.

X-ray of the forearm bones performed in two projections with the obligatory capture of adjacent joints (elbow and wrist).

Treatment of fractures of the diaphysis of the forearm bones

Conservative treatment. First aid: if there is a wound, apply an aseptic bandage. The arm bends at a right angle at the elbow joint. Immobilization Cramer's ladder splint from the fingertips to the upper third of the shoulder.

The main goal of treatment is early anatomical reposition and strong fixation of fragments.

For non-displaced fractures, a circular plaster cast is applied from the metacarpophalangeal joints to the upper third of the shoulder for a period of 10 weeks. After 2 weeks, X-ray control is required to exclude the presence of secondary displacement of fragments.

For transverse fractures with displacement, where the end stop of the fragments is possible, closed reduction is performed.

Reposition technique. The patient lies on his back. An arm bent at a right angle on a side table. General anesthesia. One assistant grabs the shoulder with both hands or a towel, the other - the patient’s fingers and hand. For fractures of the proximal third, the forearm is supinated, for fractures of the middle third - in a neutral position, for fractures of the distal third - in a pronated position. Length traction is performed for 2–4 minutes until the fragments are stretched. If the patient's fingers are wet and slippery, they can be covered with adhesive tape to make the grip on the fingers stronger. The surgeon uses his fingers to perform the final reduction. Without removing the traction, a circular plaster cast is applied from the metacarpophalangeal joints to the upper third of the shoulder. After reposition, X-ray control is performed in two projections. The patient must be hospitalized in a hospital under 24-hour medical supervision. If swelling of the limb increases, the plaster cast must be cut longitudinally. After the swelling has subsided, an x-ray control is taken to exclude displacement of the fragments. Further treatment of the patient is outpatient. The immobilization period is 10 weeks from the moment of reposition.

In children under 10 years of age with angular displacement of fragments, closed reduction of the fracture is performed with fixation with a circular plaster cast for a period of 4–6 weeks, depending on age. In children over 14 years of age, fractures of the diaphysis of the forearm bones are treated as in adults.

Surgical treatment.

Indications for surgery:

fractures in which it was not possible to eliminate the displacement of fragments by closed reduction, as well as their secondary displacement that developed after applying a plaster cast;
comminuted and multi-fragmented fractures;
often fracture-dislocations of Galeazzi and Monteggia;
open fractures.

Main methods of surgical treatment:

Open bone metal osteosynthesis using plates, intramedullary osteosynthesis using rods with locking.
Extrafocal compression-distraction osteosynthesis using the Ilizarov apparatus or rod devices.

The radius is curved, so intramedullary osteosynthesis should be avoided. When performing external osteosynthesis, screws must not be passed in the direction of the interosseous membrane (threat of synostosis formation).

For osteosynthesis of the radius, a dorsal approach is used, going from the external epicondyle of the humerus to the distal articular surface radius bone. During osteosynthesis of the ulna, longitudinal access is made along the bone crest.

Surgical approaches to the ulna and radial bones of the forearm: a) access to the ulna, b) access to the radius

The purpose of metal osteosynthesis is anatomical reposition, restoration of the correct relationship between the radius and ulna along the length, and strong fixation. For this purpose, compression plates with limited contact, plates with lateral screw stability, plates with monocortical fixation and point contact are used. For comminuted fractures (type C), bridge plates are used without exposing the fracture zone. For osteosynthesis with plates, a minimum of 6 screws are used, 3 above and below the fracture site.

During osteosynthesis of comminuted and especially open fractures VKDO is indicated by the Ilizarov apparatus or rod devices.

Fracture of the ulna with dislocation of the head of the radius (Montagia fracture-dislocation)

There are extension and flexion types of fractures. More often, the extensor type occurs - a fracture of the ulna in the upper or middle third, the fragments form an angle open posteriorly, the head of the radial bone moves anteriorly and to the radial side. Possible damage to the radial nerve. With the flexion type of fracture, the ulnar bone fragments are displaced at an angle open anteriorly, and the head of the radial bone is dislocated posteriorly.

A) Extensor; B) Flexion type

Clinic. The forearm is shortened. Upper third the forearms and elbow joint are swollen. Movement in the elbow joint is limited, especially flexion. With palpation, you can determine the head of the radial bone that has shifted anteriorly. The final diagnosis is made after studying radiographs.

Treatment. Emergency closed reduction under general or regional anesthesia is indicated.

Reposition technique: the forearm is supinated, traction is applied along the axis with the creation of counter-traction on the shoulder. The dislocated head of the radial bone is adjusted with the fingers and the fragments of the ulna are reduced, the forearm is bent at an angle of 80°. If the head of the radius is not kept in the reduced position, then it is fixed percutaneously with a Kirschner wire, the end of which is left under the skin. With continued traction, a plaster cast is applied from the heads of the metacarpal bones to the middle third of the shoulder for a period of 8–10 weeks. The pin is removed after 3 weeks. A control radiograph is taken after reposition and 5–7 days after the edema has subsided.

Surgical treatment indicated for unsuccessful attempts at closed reduction, secondary displacement in a plaster cast, damage to the radial nerve, chronic dislocations of the radial head and nonunion of the ulna.

The operation consists of open anatomical reposition of the ulna with external osteosynthesis with a plate and percutaneous fixation of the radial head with a wire. In old cases, resection of the head of the radial bone is performed.

Fracture of the radius in the lower third and dislocation of the head of the ulna (Galeazzi fracture-dislocation)

With fractures in the lower and middle third of the radius and displacement of the fragments at an angle, dislocation of the head of the ulna occurs in the dorsal or palmar side, opposite to the angular displacement of the fragments of the radius.

Clinic. There are signs that characterize any diaphyseal fracture. Contracture of the wrist joint is characteristic. Palpation reveals displacement of the head of the ulna. When you press on it, it is easily set and just as easily returns to its original place.

The diagnosis is clarified on an x-ray in two projections.

Treatment. The Galeazzi fracture-dislocation is easily reduced, but it is usually not possible to fix it with a plaster cast. Secondary displacement occurs in the plaster cast. The main method of treatment is closed, simultaneous manual reduction of displaced fragments of the radius, reduction of the head of the ulna with percutaneous fixation with Kirschner wires and application of a circular plaster cast. After closed reduction, percutaneous fixation is performed with Kirschner wires: one wire is passed perpendicular to the axis of the forearm through the head of the ulna into the radius, the second wire is passed through both bones of the forearm below the fracture of the radius, and the third wire is above the fracture site. The ends of the needles are left under the skin. A circular plaster cast is applied from the head of the metacarpal bones to the middle third of the shoulder. The forearm is in a mid-position between supination and pronation, bent at a right angle at the elbow joint.

Surgical treatment indicated in case of ineffectiveness of closed reduction with fixation with pins, in stale cases, in case of non-union of the radial bone. An open reduction of the radius is performed with metal osteosynthesis with a plate and fixation of the head of the ulna.

Literature: Traumatology and orthopedics: / ed. V.V. Lashkovsky. - 2014.