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Fractures of the bones of the forearm
FRACTURES
OF THE BONES OF THE FOREARM
A DISCUSSION OF NON,OPERATIVE CONSECUTIVE VOIGT
MOONEY,
TREATMENT AND REPORT RECENT CASES
OF 150
M.D., F.A.C.S.
PITTSBURGH, PA.
T
HE non-operative treatment of fractures of the bones of the forearm is better understood when one recaIIs the skeIeta1 anatomy and the intricate muscIe mechanisms invoIved in fractures of the radius and uIna. I shaI1 confine my discussion of the treatment and principIes invoIved to the cases of my series in which the patient was under sixteen years of age. ANATOMICAL
COtiSIIljERATION
undergoes the dispIacement and it carries with it the carpus and the hand. The trianguIar disc, fixed by the apex to the joint at the base of the styIoid process of the uIna and by its base to the dista1 ridge of the uInar notch of the radius, is the most important Iigament in the activities concerned with rotation at the radio-uInar joint. This joint is at its weakest from the point of view of muscIe contro1. The superior radio-uInar joint pIays a part in fractures, with dispIacement, of the upper haIf of the uIna. If the dispIacement is marked, there must resuIt a fracture of the head of the radius or a dispIacement of the upper end. The muscIes of the forearm divide themseIves into three groups (Davis): I. Those which extend the fingers. 2. Those which ffex and extend the wrist. 3. Those which pronate and supinate the radius and the hand. Radius is pronated by (I) M. pronator quadratus. (2) M. pronator radii teres. Radius is supinated by i$ g. supiyator brevis. . supmator Iongus (brachioradiaIis). (5) M. biceps. MuscIe action pIays an important part in dispIacement of the fractures of the radius and uIna. There are four types: I. There may be simpIe over-Iapping.
The uIna is directIy continuous with the humerus. It is a fixed hinged joint and is concerned onIy with flexion and extension. The uIna does not take part in inward rotation (pronation) and outward rotation (supination) of the forearm. The radius is continuous with the hand. At the upper end and the Iower end, the radius rests in the uIna. The radius aIone moves, revoIving about with the uIna as an axis, thus aIIowing pronation and supination. The radius is concerned with the motion of the hand, the uIna with that of the arm. The interosseous space is at its maximum in supination, whiIe in fuI1 pronation the radius nearIy contacts the uIna. The head of the radius rotates in the orbicuIar Iigament; the Iower end of the radius revoIves around the head of the uIna and rests in the interarticuIar triangular cartiIage. The range of motion is I 40’=‘-I 60”. The anatomy of the inferior radiouInar articuIation is important when one considers the intricate mechanism of the (Fig. 3.) 2. There may be obIiteration of the forearm. The term, “disIocation of the interosseous space because the pronator is a misnomer. The head of the uIna” quadratus and teres both pass from the uIna is fixed. It does not disIocate. It is uIna to the radius, the one at the Iower end, the Iower extremity of the radius which 268
NEW
SERIES VOL. XXIX,
No. 2
Mooney-Fracture
the other at the upper portion of the forearm. When they contract they tend to
draw
the bones
together.
(Fig.
IO.) The
I. EpiphyseaI separation of dista1 end of radius dorsally. Before reduction.
contracts and tends to tiIt bra chioradiahs the upper end of the Iower fragment toward the uInar side.
of Forearm
American
JOU~~I
of
surgery 269
the biceps and supinator brevis. There are no muscIes to oppose them. When the bones are broken beIow the middIe of the
FIG. 4. Case 149 iIIustrated
in Figure 3. After reduction.
forearm, the pronator radii teres remains attached to the upper fragment. Considering the supinating action of the biceps and
FIG. 5. Method used to hoId reduced epiphysea1 separation of dista1 end of radius dorsaIIy and fracture of bones within 1% inches of joint. Note application of adhesive plaster.
the FIG. 2. FIG. 3. FIG. 2. EpiphyseaI separation of dista1 end of radius dorsaIIy. After reduction. Note hand is dressed in patmar Bexion. FIG. 3. Fracture of radius and ulna with overIapping.
3. Fragments may be rotated on one another in the direktion of pronation and supination. When the fractures occur above the insertion of the pronator radii teres the upper fragment is rotated outwardIy by
supinator ture is treated and pronation
brevis, therefore, the fracmidway between supination (thumb up).
4. AnguIar deformity or simple at the site of fracture. (Fig. 14.)
bending
MATERIAL
I have divided this non-operative series of 150 fractures of the forearm, which have been treated by me during the Iast seventeen months, into aduIts and those sixteen
270
American Journal of Surgery
Mooney-Fracture
of Forearm
AUGUST, 193~
years or younger. There were 49 ad&s and IOI chiIdren (67 per cent). CompIete fractures of the distaI ends of
I. EpiphyseaI separation of the dista1 end of the radius dorsaIIy and fractures of the bones within r$g inches of the joint
Le radius and uIna in chiIdren and T r . :. -1 ~_. _L ,’ : aaorescence are a arstmct entrty ana must not be confused with the so-caIIed CoIIes’ fractures.
FIG. 7. Traction cast in use, not new, but serviceable in nonoperative treatment of fractures of bones of forearm. FIG. 8. PIaster-of-Paris cast, with forearm in fuI1 supination.
TABLE
I
Site of Fracture Ad&s .. . . . 25 CoIIes’ fracture. Epiphyseal separation of distal end of 2 radius dorsally.. . ... .. .... Radius betow pronator radii teres.. . . 5 Ulna beIow pronator radii teres. . . . 3 Radius and uIna below pronator radii 0 teres........................... Radius above pronator radii teres. 0 Ulna above pronator radii teres.. 3 Radius and uIna above pronator radii teres........................... 3 7 Head of radius. UIna with dislocation of head of 1 radius.......................... -
Total.........................
49
Children 0 IO 30 5 28 ; I5 0 0 IO1
The oIdest patient with epiphysea1 separation was twenty years, the youngest ten years. Ten of the patients were under sixteen years. In the tota number of chiIdren 73.7 per cent of the fractures were in the Iower third. The Ieft forearm was fractured twice as often as the right. The radius usuaIIy fractured higher than the uIna. TREATMENT
The treatment of fractures of the bones of the forearm, in chiIdren and adoIescents, may be cIassified according to the reIationship of the, fractures to the insertion of the pronator radii teres and the treatment of greenstick fractures:
Iine are best dressed, after reduction, in paImar flexion (compIete pronation). (Figs. 1-6.) No splint or pIaster-of-Paris is needed, just adhesive and a musIin bandage. The reduction of the separated epiphysis is not diffrcuIt if the case is recent, but if it is two weeks after injury, one must operate. CompIete fractures of the radius and uIna at the Iower end are best reduced under the fluoroscope and then are dressed in paImar IIexion as described. After two weeks of this treatment, the forearm is dressed in a straight position with a muslin bandage and the patient continues to carry the forearm in a sIing. II. CompIete fractures of the radius and uIna beIow the pronator radii teres and above the pronator quadratus. A. The transverse fractures are reduced under the fIuoroscope and heId with a weIIpadded right angIe spIint or a pIaster-ofParis cast, the joint above and beIow the fracture being fixed. The forearm is heId in the semi-pronated position (thumb up) because of the mechanics of muscle puI1 as aIready described. B. The obIique fractures are held in reduction by the traction cast. (Fig. 7.) The traction and counter-traction wiII overcome the muscIe puI1 on the fragments and the semi-pronated position wiII accom-
New SERIES VOL.XXIX, No. z
Mooney-Fracture
pIish the reduction. After two or three weeks of traction the union is suffIcientIy soIid to aIIow the moIding of the fragments
of Forearm
American ~~~~~~~of
surgery 27 I
by means of feIt pads. Any forearm or a wedge cast may be used. B. Fractures beIow the pronator
spIint radii
FIG. IO. FIG. II. FIG. g. FIG. g. Case No. 24. Compke oblique fractures of radius and uIna above pronator radii teres. FIG. IO. Case No. 24. After a&cation of traction cast. FIG. I I. Case No. 24. Six wee& her.
and the appIication of a snugIy fitting cast. III. CompIete fractures of the radius and uIna above the pronator radii teres. It is noted that the proxima1 fragment of the radius is aIways in supination. A. Transverse fractures are reduced under the Ruoroscope and heId by means of a cast with the forearm in fuII supination and the eIbow at 80”. (Fig. 8.) However, if placing the forearm in supination causes a great increase in bony dispIacement, then that position which ~111 assist in maintaining the reduction shouId be used. I do not recommend the use of the wooden, interna right angIe splint, as I have seen severa cases of ischemic paraIysis foIIow their use. B. The obIique fractures are heId reduced by means of the traction cast (Fig. 7), the forearm being fuIIy supinated. (AIso see Figs. 9-1 I .) or greenstick fractures of Iv. Incomplete the radius and &a. A. Fractures within 135 inches of the wrist joint are moIded and heId in position
teres and above the pronator quadratus are treated by means of a weII-padded wedge cast. The forearm is heId in the semi-pronated position (thumb up). c. Fractures above the pronator radii teres are heId in good aIignment by means of a weII-padded wedge cast with the forearm fuIIy supinated. The eIbow is heId at 80”. v. Fracture of the uIna. The position of the fracture depends on direct vioIence. The dista1 fragment is most often dispIaced to the radia1 side because of the puI1 of the pronator quadratus muscle. The upper fragment, articulating with the humerus by a pure hinged joint, cannot be dispIaced itseIf, but the radius and hand can move bodiJy toward the ulna. Fractures of the uIna are treated with the forearm in fuI1 supination. After-treatment: Start at once to move the fingers and shouIder. AI1 casts are to be spIit. (Figs. 7 and 8.)
272
American
Journal
of Surgery
Mooney-Fracture
Board sphnts shouId be wider than the forearm, thus avoiding squeezing together of the bony fragments and constriction of
of Forearm
Aucusr, 1938
mu&e 2. The knowIedge of the intricate mechanism in fractures of the radius and uIna wiI1 assist in the non-operative treat-
FIG. 12. Wedge cast. Felt pads are applied after first covering arm with sheet cotton.
the circuIation. Bowing of the fractured fragments is best avoided by having a snugIy fitting arm cast about the elbow joint. If the board spIint is used, muItipIe strips of zinc oxide adhesive are fastened to the arm above and beIow the elbow. The ends of the adhesive strips shouId not overlap. Sings shouId be adjusted so as to lift high the forearm and shoulder girdIe. Those patients wearing the traction cast are observed frequentIy for earIy signs of ischemic paraIysis. Comment: None of the IOI children was operated on. However, there were 3 cases in which the radius was compounded, but there was no interna fixation used when the bone was repIaced. None of the cases was treated by suspension traction. Ten per cent of the patients were hospitaIized. There were two refractures. There were no permanent nerve injuries or ischemic paralysis. SUMMARY
AND
CONCLUSIONS
manipuIative meI. Non-operative, chanical treatment of fractures of the radius and uIna in chiIdren and adoIescents ends in a good functiona result.
FIG. 13. FIG. 14. FIG. 13. Wedge cast used to straighten out a greenstick fracture. Fro. 14. AnguIar deformity or simpIe bending at site of fractures.
ment of these fractures. 3. EpiphyseaI separation of the dista1 end of the radius dorsaIIy and fractures of the bones within 135 inches of the joint Iine are best dressed, after reduction, in palmar flexion. RoughIy, fractures of the upper third of the forearm are dressed in supination whiIe fractures of the Iower two-thirds are dressed in semi-pronation. 4. A perfect anatomica resuIt, aIthough desired, is not essentia1 for a good functiona1 resuIt. 5. The rea1 vaIue of the study of these that operative cases is, we concIude, interference is rareIy justified in patients under sixteen years. REFERENCES I. PIERSOL, G. A. Human Anatomy. Ed. 9, PhiIa., Lippincott, 1930. 2. DAVIS, G. G. Applied Anatomy. Ed. 8, PhiIa., Lippincott, 1929. 3. SCUDDER,C. L. The Treatment of Fractures. 4. MOONEY, V. Fractures of the bones in chiIdren and adolescents. Non-operative treatment. Pennsylvania M. J. (May) 1931.
OF THE BONES OF THE FOREARM
A DISCUSSION OF NON,OPERATIVE CONSECUTIVE VOIGT
MOONEY,
TREATMENT AND REPORT RECENT CASES
OF 150
M.D., F.A.C.S.
PITTSBURGH, PA.
T
HE non-operative treatment of fractures of the bones of the forearm is better understood when one recaIIs the skeIeta1 anatomy and the intricate muscIe mechanisms invoIved in fractures of the radius and uIna. I shaI1 confine my discussion of the treatment and principIes invoIved to the cases of my series in which the patient was under sixteen years of age. ANATOMICAL
COtiSIIljERATION
undergoes the dispIacement and it carries with it the carpus and the hand. The trianguIar disc, fixed by the apex to the joint at the base of the styIoid process of the uIna and by its base to the dista1 ridge of the uInar notch of the radius, is the most important Iigament in the activities concerned with rotation at the radio-uInar joint. This joint is at its weakest from the point of view of muscIe contro1. The superior radio-uInar joint pIays a part in fractures, with dispIacement, of the upper haIf of the uIna. If the dispIacement is marked, there must resuIt a fracture of the head of the radius or a dispIacement of the upper end. The muscIes of the forearm divide themseIves into three groups (Davis): I. Those which extend the fingers. 2. Those which ffex and extend the wrist. 3. Those which pronate and supinate the radius and the hand. Radius is pronated by (I) M. pronator quadratus. (2) M. pronator radii teres. Radius is supinated by i$ g. supiyator brevis. . supmator Iongus (brachioradiaIis). (5) M. biceps. MuscIe action pIays an important part in dispIacement of the fractures of the radius and uIna. There are four types: I. There may be simpIe over-Iapping.
The uIna is directIy continuous with the humerus. It is a fixed hinged joint and is concerned onIy with flexion and extension. The uIna does not take part in inward rotation (pronation) and outward rotation (supination) of the forearm. The radius is continuous with the hand. At the upper end and the Iower end, the radius rests in the uIna. The radius aIone moves, revoIving about with the uIna as an axis, thus aIIowing pronation and supination. The radius is concerned with the motion of the hand, the uIna with that of the arm. The interosseous space is at its maximum in supination, whiIe in fuI1 pronation the radius nearIy contacts the uIna. The head of the radius rotates in the orbicuIar Iigament; the Iower end of the radius revoIves around the head of the uIna and rests in the interarticuIar triangular cartiIage. The range of motion is I 40’=‘-I 60”. The anatomy of the inferior radiouInar articuIation is important when one considers the intricate mechanism of the (Fig. 3.) 2. There may be obIiteration of the forearm. The term, “disIocation of the interosseous space because the pronator is a misnomer. The head of the uIna” quadratus and teres both pass from the uIna is fixed. It does not disIocate. It is uIna to the radius, the one at the Iower end, the Iower extremity of the radius which 268
NEW
SERIES VOL. XXIX,
No. 2
Mooney-Fracture
the other at the upper portion of the forearm. When they contract they tend to
draw
the bones
together.
(Fig.
IO.) The
I. EpiphyseaI separation of dista1 end of radius dorsally. Before reduction.
contracts and tends to tiIt bra chioradiahs the upper end of the Iower fragment toward the uInar side.
of Forearm
American
JOU~~I
of
surgery 269
the biceps and supinator brevis. There are no muscIes to oppose them. When the bones are broken beIow the middIe of the
FIG. 4. Case 149 iIIustrated
in Figure 3. After reduction.
forearm, the pronator radii teres remains attached to the upper fragment. Considering the supinating action of the biceps and
FIG. 5. Method used to hoId reduced epiphysea1 separation of dista1 end of radius dorsaIIy and fracture of bones within 1% inches of joint. Note application of adhesive plaster.
the FIG. 2. FIG. 3. FIG. 2. EpiphyseaI separation of dista1 end of radius dorsaIIy. After reduction. Note hand is dressed in patmar Bexion. FIG. 3. Fracture of radius and ulna with overIapping.
3. Fragments may be rotated on one another in the direktion of pronation and supination. When the fractures occur above the insertion of the pronator radii teres the upper fragment is rotated outwardIy by
supinator ture is treated and pronation
brevis, therefore, the fracmidway between supination (thumb up).
4. AnguIar deformity or simple at the site of fracture. (Fig. 14.)
bending
MATERIAL
I have divided this non-operative series of 150 fractures of the forearm, which have been treated by me during the Iast seventeen months, into aduIts and those sixteen
270
American Journal of Surgery
Mooney-Fracture
of Forearm
AUGUST, 193~
years or younger. There were 49 ad&s and IOI chiIdren (67 per cent). CompIete fractures of the distaI ends of
I. EpiphyseaI separation of the dista1 end of the radius dorsaIIy and fractures of the bones within r$g inches of the joint
Le radius and uIna in chiIdren and T r . :. -1 ~_. _L ,’ : aaorescence are a arstmct entrty ana must not be confused with the so-caIIed CoIIes’ fractures.
FIG. 7. Traction cast in use, not new, but serviceable in nonoperative treatment of fractures of bones of forearm. FIG. 8. PIaster-of-Paris cast, with forearm in fuI1 supination.
TABLE
I
Site of Fracture Ad&s .. . . . 25 CoIIes’ fracture. Epiphyseal separation of distal end of 2 radius dorsally.. . ... .. .... Radius betow pronator radii teres.. . . 5 Ulna beIow pronator radii teres. . . . 3 Radius and uIna below pronator radii 0 teres........................... Radius above pronator radii teres. 0 Ulna above pronator radii teres.. 3 Radius and uIna above pronator radii teres........................... 3 7 Head of radius. UIna with dislocation of head of 1 radius.......................... -
Total.........................
49
Children 0 IO 30 5 28 ; I5 0 0 IO1
The oIdest patient with epiphysea1 separation was twenty years, the youngest ten years. Ten of the patients were under sixteen years. In the tota number of chiIdren 73.7 per cent of the fractures were in the Iower third. The Ieft forearm was fractured twice as often as the right. The radius usuaIIy fractured higher than the uIna. TREATMENT
The treatment of fractures of the bones of the forearm, in chiIdren and adoIescents, may be cIassified according to the reIationship of the, fractures to the insertion of the pronator radii teres and the treatment of greenstick fractures:
Iine are best dressed, after reduction, in paImar flexion (compIete pronation). (Figs. 1-6.) No splint or pIaster-of-Paris is needed, just adhesive and a musIin bandage. The reduction of the separated epiphysis is not diffrcuIt if the case is recent, but if it is two weeks after injury, one must operate. CompIete fractures of the radius and uIna at the Iower end are best reduced under the fluoroscope and then are dressed in paImar IIexion as described. After two weeks of this treatment, the forearm is dressed in a straight position with a muslin bandage and the patient continues to carry the forearm in a sIing. II. CompIete fractures of the radius and uIna beIow the pronator radii teres and above the pronator quadratus. A. The transverse fractures are reduced under the fIuoroscope and heId with a weIIpadded right angIe spIint or a pIaster-ofParis cast, the joint above and beIow the fracture being fixed. The forearm is heId in the semi-pronated position (thumb up) because of the mechanics of muscle puI1 as aIready described. B. The obIique fractures are held in reduction by the traction cast. (Fig. 7.) The traction and counter-traction wiII overcome the muscIe puI1 on the fragments and the semi-pronated position wiII accom-
New SERIES VOL.XXIX, No. z
Mooney-Fracture
pIish the reduction. After two or three weeks of traction the union is suffIcientIy soIid to aIIow the moIding of the fragments
of Forearm
American ~~~~~~~of
surgery 27 I
by means of feIt pads. Any forearm or a wedge cast may be used. B. Fractures beIow the pronator
spIint radii
FIG. IO. FIG. II. FIG. g. FIG. g. Case No. 24. Compke oblique fractures of radius and uIna above pronator radii teres. FIG. IO. Case No. 24. After a&cation of traction cast. FIG. I I. Case No. 24. Six wee& her.
and the appIication of a snugIy fitting cast. III. CompIete fractures of the radius and uIna above the pronator radii teres. It is noted that the proxima1 fragment of the radius is aIways in supination. A. Transverse fractures are reduced under the Ruoroscope and heId by means of a cast with the forearm in fuII supination and the eIbow at 80”. (Fig. 8.) However, if placing the forearm in supination causes a great increase in bony dispIacement, then that position which ~111 assist in maintaining the reduction shouId be used. I do not recommend the use of the wooden, interna right angIe splint, as I have seen severa cases of ischemic paraIysis foIIow their use. B. The obIique fractures are heId reduced by means of the traction cast (Fig. 7), the forearm being fuIIy supinated. (AIso see Figs. 9-1 I .) or greenstick fractures of Iv. Incomplete the radius and &a. A. Fractures within 135 inches of the wrist joint are moIded and heId in position
teres and above the pronator quadratus are treated by means of a weII-padded wedge cast. The forearm is heId in the semi-pronated position (thumb up). c. Fractures above the pronator radii teres are heId in good aIignment by means of a weII-padded wedge cast with the forearm fuIIy supinated. The eIbow is heId at 80”. v. Fracture of the uIna. The position of the fracture depends on direct vioIence. The dista1 fragment is most often dispIaced to the radia1 side because of the puI1 of the pronator quadratus muscle. The upper fragment, articulating with the humerus by a pure hinged joint, cannot be dispIaced itseIf, but the radius and hand can move bodiJy toward the ulna. Fractures of the uIna are treated with the forearm in fuI1 supination. After-treatment: Start at once to move the fingers and shouIder. AI1 casts are to be spIit. (Figs. 7 and 8.)
272
American
Journal
of Surgery
Mooney-Fracture
Board sphnts shouId be wider than the forearm, thus avoiding squeezing together of the bony fragments and constriction of
of Forearm
Aucusr, 1938
mu&e 2. The knowIedge of the intricate mechanism in fractures of the radius and uIna wiI1 assist in the non-operative treat-
FIG. 12. Wedge cast. Felt pads are applied after first covering arm with sheet cotton.
the circuIation. Bowing of the fractured fragments is best avoided by having a snugIy fitting arm cast about the elbow joint. If the board spIint is used, muItipIe strips of zinc oxide adhesive are fastened to the arm above and beIow the elbow. The ends of the adhesive strips shouId not overlap. Sings shouId be adjusted so as to lift high the forearm and shoulder girdIe. Those patients wearing the traction cast are observed frequentIy for earIy signs of ischemic paraIysis. Comment: None of the IOI children was operated on. However, there were 3 cases in which the radius was compounded, but there was no interna fixation used when the bone was repIaced. None of the cases was treated by suspension traction. Ten per cent of the patients were hospitaIized. There were two refractures. There were no permanent nerve injuries or ischemic paralysis. SUMMARY
AND
CONCLUSIONS
manipuIative meI. Non-operative, chanical treatment of fractures of the radius and uIna in chiIdren and adoIescents ends in a good functiona result.
FIG. 13. FIG. 14. FIG. 13. Wedge cast used to straighten out a greenstick fracture. Fro. 14. AnguIar deformity or simpIe bending at site of fractures.
ment of these fractures. 3. EpiphyseaI separation of the dista1 end of the radius dorsaIIy and fractures of the bones within 135 inches of the joint Iine are best dressed, after reduction, in palmar flexion. RoughIy, fractures of the upper third of the forearm are dressed in supination whiIe fractures of the Iower two-thirds are dressed in semi-pronation. 4. A perfect anatomica resuIt, aIthough desired, is not essentia1 for a good functiona1 resuIt. 5. The rea1 vaIue of the study of these that operative cases is, we concIude, interference is rareIy justified in patients under sixteen years. REFERENCES I. PIERSOL, G. A. Human Anatomy. Ed. 9, PhiIa., Lippincott, 1930. 2. DAVIS, G. G. Applied Anatomy. Ed. 8, PhiIa., Lippincott, 1929. 3. SCUDDER,C. L. The Treatment of Fractures. 4. MOONEY, V. Fractures of the bones in chiIdren and adolescents. Non-operative treatment. Pennsylvania M. J. (May) 1931.