Forearm Fractures


86
Forearm Fractures


Habeeb Khan CCPA1 and Rudolf W. Poolman MD PhD2


1St. Joseph’s Healthcare, Hamilton, ON, Canada


2Leiden University Medical Center, Amsterdam, The Netherlands


Clinical scenarios


Case 1



  • Patient A, a 42‐year‐old male carpenter, fell from a ladder and landed on his dominant right forearm.
  • He was taken to the local Emergency Department, where radiographs showed a displaced fracture of the distal radial shaft.
  • Physical examination showed a step deformity in the distal third of the forearm. No neurological or vascular deficits were found.
  • He was treated with an open reduction and internal fixation (ORIF).

Case 2



  • Patient B, a 38‐year‐old male construction worker, was struck on the ulnar aspect of his left forearm by a falling metal rod at a construction site.
  • He was taken to the local Emergency Department, where radiographs showed an isolated minimally displaced midulnar shaft fracture.
  • On examination, he was neurovascularly intact.
  • Treatment recommendation was immobilization with a short arm cast for six weeks.

Top four questions



  1. In patients with radial shaft fractures/Galeazzi‐type fracture‐dislocations, does radiological radial shortening more accurately predict distal radioulnar joint (DRUJ) injury compared with radial shaft fracture location?
  2. In patients with isolated ulnar fractures, does surgical treatment lead to better functional outcomes compared with nonsurgical treatment?
  3. In patients with Galeazzi‐type fractures, does surgical reconstruction or temporary transfixion of the DRUJ prevent decrease in range of motion (ROM) of the forearm compared to nonsurgical treatment?
  4. In patients with forearm fractures treated with plate fixation, does plate removal after bony union lead to higher refracture/complication rates compared with patients who retain their hardware?

Question 1: In patients with radial shaft fractures/Galeazzi‐type fracture‐dislocations, does radiological radial shortening more accurately predict distal radioulnar joint (DRUJ) injury compared with radial shaft fracture location?


Rationale


One of the most common causes for residual wrist disability after distal radial fractures is DRUJ instability.1 As they are not always obvious on radiographs, DRUJ injuries may be missed during the initial assessment and treatment of a radial fracture; potentially delaying a patient’s return to full function. Thus, defining radiographic parameters to identify DRUJ involvement in radial shaft fractures would be beneficial to form an optimal treatment plan for the patient.


Clinical comment


In the rehabilitation period, patient A continued to experience pain in his right wrist, as well as weakness during pronosupination. He also complained of decreased grip strength. This was affecting his ability to continue his work as a carpenter. Detailed repeat examination revealed an unstable DRUJ.


Available literature and quality of the evidence



  • Level III: 2 retrospective cohort studies.

Findings


Tsismenakis and Tornetta assessed the predictive value of various radiographic parameters of DRUJ injuries (Table 86.1).2 These included: (i) >5 mm radius shortening on standard PA radiographs, (ii) radial fracture within 7.5 cm from the lunate facet, and (iii) ulnar styloid fracture. Sixty‐six patients were assessed. Radiographs of 21 patients showed radial shortening >5 mm; six of these patients had DRUJ instability. Twenty‐six of the radial fractures were within 7.5 cm of the lunate facet; five of these had DRUJ instability. Ulnar styloid fractures were seen in 13 patients; DRUJ instability was present in four of these patients. Thus, they concluded that radiographs alone are insufficient to diagnose DRUJ instability preoperatively. However, due to the high negative predictive value (NPV) of the parameters, it is unlikely for DRUJ instability to occur in patients with <5 mm shortening or fractures >7.5 cm from the lunar facet.


Additionally, Ding et al. assessed radial shaft fracture obliquity, in addition to the previously mentioned radiographic parameters (Table 86.1).3 A total of 102 patients were assessed. Radiographs of 59 patients showed fracture obliquity >30°; 35 of these had DRUJ instability. Forty‐four fractures were <7.5 cm from the midarticular surface of the radius; 25 of these were associated with DRUJ instability. Radial shortening of >5 mm was seen in 35 patients; 29 of these had DRUJ instability. Twenty‐nine ulnar styloid fractures were seen; 19 were associated with DRUJ instability. They concluded that the most sensitive radiographic parameter to predict DRUJ instability was radial shaft fracture obliquity >30°, while radial shortening <5 mm was the most specific parameter to exclude DRUJ instability.


Resolution of clinical scenario



  • Due to the low sensitivity of radiographic parameters (fracture obliquity >30°, fracture distance >7.5 cm from lunate facet, radial shortening >5 mm, and ulnar styloid fracture) in predicting DRUJ instability, radiographs alone are insufficient to diagnose DRUJ injuries.
  • Along with careful physical examination, the above‐mentioned parameters may be helpful in ruling out DRUJ injuries.
  • Fractures of the middle and proximal thirds of the radial shaft (>7.5 cm from lunate facet) are less likely to be associated with clinically significant DRUJ injuries.
  • In both cases, given that the injuries are distal, DRUJ injury should be considered. All radiographic parameters should be considered and assessed, though given their poor diagnostic performance further imaging may be needed .

Question 2: In patients with isolated ulnar fractures, does surgical treatment lead to better functional outcomes compared with nonsurgical treatment?


Rationale


There is currently no consensus as to the best treatment plan for isolated ulnar shaft fractures, which may lead to complications such as nonunion, radioulnar synostosis, and decreased forearm ROM.4


Clinical comment


The recommended treatment plan for patient B was immobilization with a short arm cast for six weeks. However, the patient was interested in surgical treatment options as he believed he could return to work sooner, and have better stability and functional outcomes with a surgical fixation.


Table 86.1 Radial shaft fracture obliquity and radiographic parameters.

































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Nov 28, 2021 | Posted by in ORTHOPEDIC | Comments Off on Forearm Fractures

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Tsismenakis and Tornetta Ding et al.
Sensitivity Specificity PPV NPV Sensitivity Specificity PPV NPV
Fracture distance
<7.5 cm		 71% 64% 19% 95% 54.3% 66.1% 56.8% 63.8%
Radial shortening >5 mm 86% 69% 29%