Foreign pathology fractured two bones of the forearm

2021-01-30 12:00 AM

Pull along the forearm shaft with continuous and increasing pull, until the stack deviation stops, then straighten the deviations to the side, bend the remaining angle

Outline

Fractures of the two forearm bones account for 15-20% of all fractures in the forearm area. Meet at all ages. This type of fracture has relatively complicated displacement, especially the upper third fracture, difficult orthopedic manipulation.

Causes and mechanisms

Often due to falls, fights, and traffic accidents.

Direct mechanism: Falling forearm down hard soil tissue, raising arm to block the blow ... bones often break across both bones in the same position.

Indirect mechanism: The fall against the elbow stretches and bends 2 bones, causing cross fracture, twisting, and stair fracture. The two bones often fracture in two different locations. The cylindrical bone is low, the rotating bone is high.

Mixed mechanism: Both direct and indirect, causing complex types of fractures: 2-story fracture, 3rd fragment fracture ...

Classify

According to the fracture position on the rotating bone divided:

Fracture of the upper third: Fracture on the round stomach.

Fracture of the middle 1/3 and lower 1/3: Fracture below the abdominal muscles of the round and the square belly.

The meaning of this classification is to evaluate the possibility of more or less deviation.

Broken top 1/3

The proximal segment is in the full supine position because the supine muscles are short and the biceps are pulled, the distal segment is due to the round and square abs.

Broken 2/3 below

The proximal segment slightly because in addition to the two supine muscles, there is also the opposite involvement of the round abdominal muscles, the distant prone because of the square abs.

Clinical forms

By location: As above.

Age: Fractures in adults.

Fractures in children: Shape fracture, the rotational bone is bent and not visible fracture line and fresh stem fracture, the bone is only broken on one side of bone shell, the other shell is bent.

Closed or open fracture.

Diagnose

Medical history

Causes and mechanisms.

Clinical symptoms

Include signs of certainty and uncertainty

Certain signs

Deformation: Angled, short, ladder deformation.

Crunching noises: Detects when looking for sharp pain or unusual movement.

Unusual movements.

Signs of uncertainty:

Throbbing Point: If there is a fracture, it indicates where the fracture is.

Swelling, loss of muscle function: These are warning signs, pointers, need to examine more other signs.

Painful remote percussion: Difficult to do, only if there is no definite sign of a fracture.

Subclinical

X-ray: Take 2 faces of face and side. Both of them put the forearms in the supine position and grab all the joints at the ends. X-ray film shows the exact location of fracture, fracture line and displacement. On that basis, we have the direction of treatment.

The principles of treatment

First aid

Fracture anesthesia: Use Novocain 1-2% 10ml per side.

Fixing brace: Wooden brace, Cramer brace. It is recommended to keep your forearms on your back when placing the brace (so that you do not have to remove the brace during x-rays).

Real treatment

General principles: Manipulation - motionless - exercise.

There are two main methods: conservative treatment and surgical treatment:

Conservative treatment: manipulation and cast - hands

Anesthesia: Fracture or tangle numb or general anesthesia (children should give anesthesia).

Osteopathy: Follow 2 principles:

Maneuver the far fracture with the near fracture.

Manipulation of the short-stack deviation first, the remaining deviations are rectified later. So, need to pay attention when manipulating:

Must be placed in the appropriate forearm position depending on the fracture location: If the fracture of the upper third of the forearm is fully supine, while the 2/3 fracture under the forearm let it lightly tilt.

Pulling along the forearm axis with continuous and increasing pull, until the stack deviation stops (= due to the length), then straighten the deviations to the side, fold the remaining angle. Rotation deviation has been corrected when posing.

While manipulating attention squeeze the middle forearm to separate the membrane to avoid the tension touches the head between the head and the pillar.

Motionless: Arm-forearm cast-arm cast elbow 90 0. Traction must still be maintained during the cast.

There are two ways to manipulate:

Manual manipulation: Requires 3 people: 1 person to hold the arm, 1 person to pull the forearm and 1 person to manipulate.

Adjustment by frame: Only 1 person is needed. Patient is lying on his back, arm 90 0, elbow 90 0. The fingers are hung with sewing baskets towards the ceiling as a counterbalance. Traction is applied to the arms by weights with increasing weight depending on the patient's body (sometimes up to 7-10kg). Forearms fully supine when fractured at upper 1/3 and slightly tilted for lower 2/3 fracture.

Measure the length of 2 bones, compare with the healthy side, when the remaining deviations are gone and the membrane is separated by X-ray film.

Hold the arm-for-hand cast and wait for the dough to dry before pulling the weight. Make a vertical incision if the limb is very swollen and cut away the excess cast, especially on the palm of the hand (see more on cast) X-ray check after cast. If the manipulation is good (the deviation has been completely rectified or the deviations are acceptable), the patient can be returned, instructing the patient to practice the movement of fingers, shoulders, high limbs and re-examination of powder over time. regulations. If the manipulation is not good, the rectification can be opened a second time. After two manipulations but still do not meet the requirements, we should change to another method (combined bone surgery (KHX).

Conservative treatment usually has good results in fractures that are different, fractures of the lower 2/3, fractures in children.

Surgical treatment

Surgery aims to correct the fracture and uses a KHX device (such as a nail, splint, vis) to fix a broken bone.

Advantages:

Osteopathy is correct, restoring the original anatomical shape.

It is possible to firmly fix the fractured bone (using AO implantation) to avoid immobilization of the joints, to help the patient practice movement, early and quickly restore function.

Weakness:

 There may be an infection, osteitis.

Further anatomical damage and scarring of the hand may occur.

There may be complications of anesthesia, anesthesia ...

Need many good equipment: Aseptic operating room, tools that combine strong bones and do not cause allergies, skilled surgeons.

The most commonly used KHX surgery is:

Screw braces for rotating and cylindrical bones.

Fasteners for rotating bones, Rush nails for pillars.

Dinh Rush or both bone marrow nail.

The nails are usually unstable, so a 1-month reinforcement is required.

In open fractures, surgical focus is to filter the wound, fix the broken bone often using a cast, external fixation or only minimal bone combination to keep the bone axis and strengthen the cast. Limit use of complex bone combinations inside.

Symptoms

Early complications

Injury shock and fatty vascular occlusion are rare unless multiple other lesions are combined. Common complications are:

Compaction of the cavity: Forearm has 3 compartments, often with compression in the anterior chamber (Volkmann syndrome).

Pinched blood vessels, nerves.

Puncture of the skin leads to open fractures.

Late complications

Deflection: Common due to manipulation not all deviations or a secondary deviation in the dough without detecting, the deflection can be: short stack, angled, rotated, or 2 bones that have heads together (interlocking, with X, K ...) this deflection can lose function of the face.

Joints: Less common, usually due to:

Squeeze soft tissue into two ends of broken bone.

Broken many pieces, the fragments deviate far.

Loss of bone segment (open fracture).

 Incorporating bone is not strong but for early exercise.

Poor source of nutrition eg 1/3 fracture below pillar.

Volkmann syndrome: Due to poor treatment chamber compression.

Nutritional disorder syndrome: Due to long-term immobility and lack of exercise, it leads to muscle atrophy, osteoporosis, limiting joint movement.

Monitoring, rehabilitation after treatment

If well manipulated, immobilized, the bones will heal in two months. Exercise regularly during immobilization, helping to restore function well. Pay attention to correct forearms prone.

Powder immobilization time: 8-12 weeks, children: 4-6 weeks.

If after this time the bones are not yet firmly solidified, they can be immobile for another 2-4 weeks. If it still does not heal, there may be delayed healing of the bone or joint prosthesis.

In the type of fresh stem fracture in children, it is necessary to straighten the remaining shell and then cast it like other 2 forearm fractures.

Clinical manifestations of the forearm fracture

Single fracture of a rotating bone or cylinder

Single fracture of a rotating or cylindrical bone is less common than fracture of both bones. Maybe it's because the force is not strong enough to break the other bone. However, it is necessary to carefully examine the two upper and lower rotating joints to avoid missing damage in these two places.

Usually, a third fracture between the rotator bone or the lower 1/3 of the pillar bone.

Clinically, the patient has incomplete loss of muscle function, rarely sees visual distortion (distortion may be seen on the touch (such as stairs), has swelling, a sharp pain in the fracture area, and sometimes a scratching sound. Pain-free longitudinal joint and joint: X-ray of the entire forearm is required, can show horizontal or diagonal fracture, usually less displacement. (If fracture has deviation, sometimes it is difficult to manipulate).

Treatment: Conserved by manipulating the arm-for-hand cast. If that fails, a combined bone surgery, Rush nail or splint is required.

Backing up is usually good if it is well manipulated.

Broken 1/3 below the pillar bone risk of prosthetic joint or slow bone healing due to poor nutrition.

Time immobilized like a fracture of 2 forearm bones.

Monteggia derailment

Characteristics

A third fracture in the abutment with an upper pivotal dislocation (due to a rupture of the ligament) was first introduced by Monteggia in Milan in 1814. In treatment, it is often difficult to come in late. Long-term cast often have stiff elbow joint, if fixed not firmly, for early training joints easily dislocate and more risk of osteopathic prostheses.

Causes and mechanisms

The Monteggian derailment has a mechanism that is both direct and indirect. Pillar fracture due to direct impact, rotational bone due to indirect force. The most common cause is the patient being hit directly on the forearm and supported by the arm. The same can be attributed to falling and hitting the forearm against the hard ground in the bent position.

Classify

Bado's resolution includes 4 types:

The cusp rotates to the front, the broken pillar is bent forward, accounting for 60% of cases.

The cusp rotates to the back or the outside, the broken pillar is bent forward, accounting for 15%.

Rotating apical outward or anteriorly, fracture of the parietal region at the upper end of the cylindrical bone accounts for 20%.

The cusp is dislodged anteriorly, with the body fracture in both rotating and cylindrical bones.

Or can split Monteggia into 2 bodies:

Ergonomics: Bone crest tilted forward; broken pillar bent backwards. (often met).

Fold: Head of bone is dislodged backward. Pillar fracture is folded open first. (less common).

Diagnose

The mechanism of injury.

Clinical symptoms:

Look for symptoms to indicate a cylindrical fracture and upper abutment dislocation.

Signs of cylindrical fracture:

1/3 pain swelling in the base of the column.

The deformation is bent backwards (stretched) or opened anteriorly (foldable), sometimes only visible deformation when touching 1/3 on the cylindrical bone.

Signs of upper pivot-rotational dislocation: manifested through arm-spun dislocation or rotational derailment: the cot is no longer in its normal position (in front of the overhang when the elbow flexes and below it when the elbow is stretched). Restricted patient prone to forearms.

X-ray

X-ray film confirms that there is a fracture of the upper 1/3 pillar and a rotating skeletal dislocation (loss of arm joint - rotation, the dot of the i (spherical convex) is not located at the apex of the i (rotating cap).

Treatment

Possible conservative or surgical treatment:

Conserve

Arm-for-hand cast:

Used in new fractures.

Manipulating like a fracture of two forearm bones. Special attention should be paid to manipulating all the overlap of the cylindrical bone so that the rotating cap can enter. When manipulating and measuring the length of the pillar bone until the deflection stops, the husband will straighten and push the crown to turn in. After manipulation, allow the elbows to bend as much as possible, re-check the position of the crank bone, then cast the wing cast - elbow hand bend 90 0 forearm to lie, hold dough for 3 weeks, if the crown is not rotated keep dough another 3-5 weeks of neutral arm tension.

Surgery

If manipulation is not in place, surgery should be done early to re-position the joint and combine the pillar. Broken pillar will be fixed with Rush nail (if broken horizontally) or with viscera (if fractured cross or multiple pieces).

If the cusp is rotated easily, it is necessary to regenerate the ligament.

In case of late arrival, the cap is difficult to manipulate (if manipulated, it can also cause stiffness later), the cap should be removed.

If the rotating cap is not easily dislocated, then after surgery, patients should practice movement early to avoid limiting prone.

Prospective and complications

If well manipulated, the patient will regain motor function. However, there are also many early complications:

Cal deviated, cylindrical prosthesis.

The rotating cap is still displaced, the patient has lost the function of tiptoeing forearm and is unable to reach maximum elbow.

Elbow joint stiffness; There are many reasons for the reinforcement around joints such as rough manipulation, drug treatment ...

Broken Galeazzi

Is the type of fracture below 1/3 of the rotator bones with the dislocation of the lower pillar.

Causes and mechanisms

Often due to falls against stretched wrists.

Anatomical injury

Include:

Fracture of the lower third of the rotational bone, tearing the connective membrane, dislocation of the lower column, triangular ligament fracture or fracture of the abutment of the abutment.

Diagnose

Based on clinical symptoms and X-ray.

Clinical symptoms: swelling, pain and deformation of the lower one third of the spine. Very typical deformation: forearms are angled outward, wrists tilted toward the rotating bone. The crown of the pin is turned up higher than the pinnacle.

X-ray: confirm the diagnosis of the above lesions.

Treatment

First aid

Fracture anesthesia: Use Novocain 1-2% 10ml per side.

Fixing brace: Wooden brace, Cramer brace. It is recommended to keep your forearms on your back when placing the brace (so that you do not have to remove the brace during x-rays).

Real treatment

General principle: manipulation, motionlessness, movement practice.

There are two main methods:

Conservative treatment:

Arm-forearm-hand sealing and cast are indicated for non-deviated fractures.

Anesthesia: Fracture or tangle numb or general anesthesia (children should give anesthesia).

Osteopathy: Follow 2 principles:

Maneuver the far fracture with the near fracture.

Manipulation of the short-stack deviation first, the remaining deviations are rectified later. So need to pay attention when manipulating:

Must be placed in the appropriate forearm position depending on the fracture location:

Break the upper third of the forearm so that it is fully supine.

Break 2/3 under the forearm to slightly tilt.

Pulling along the forearm axis with continuous and increasing pulling force, until the stack deviation stops (= due to the length), then straighten the deviations to the side, fold the remaining angle. Rotation deviation has been corrected when posing.

While manipulating attention squeeze the middle forearm to separate the membrane to avoid the tension touches the head between the head and the pillar.

Motionless: Arm-forearm cast-arm cast elbow 90 0 . Traction must still be maintained during the cast.

There are two ways to manipulate:

Manual manipulation: It takes 3 people: 1 woman to hold the arm, 1 person to pull the forearm and 1 person to manipulate.

Adjustment by frame: Only 1 person is needed. Patient is lying on his back, arm 90 0 , elbow 90 0 . The fingers are hung with sewing baskets towards the ceiling as a counterbalance. Traction is applied to the arms by weights with increasing weight depending on the patient's body (sometimes up to 7-10kg). Forearms fully supine when fractured at upper 1/3 and slightly tilted for lower 2/3 fracture. Measure the length of 2 bones, compare with the healthy side, when the remaining deviations are gone, and separate the membrane based on X-ray film. Wait for the cast to dry before removing the weight. Should make a vertical incision if the limb is very swollen and cut off the excess cast especially on the palm of the hand (see more article on cast).

X-ray check after cast. If the manipulation is good (the deviation has been completely rectified or the deviations are acceptable), the patient can be returned, instructing the patient to practice the movement of fingers, shoulders, high limbs and re-examination of powder over time. regulations. If the manipulation is not good, the rectification can be opened a second time. After two manipulation but still not satisfactory, so change to another method (bone combination surgery).

Conservative treatment usually has good results in fractures that are different, fractures of the lower 2/3, fractures in children.

Surgical treatment: Surgery aims to correct the broken bone and uses KHX tools (such as nails, splints, screws) to fix broken bones. Indicated in cases of displacement fractures.

Advantages:

Osteopathy is correct, restoring the original anatomical shape.

It is possible to firmly fix the fractured bone (using AO implants) to avoid immobilization of the joints, to help the patient to exercise, to quickly restore function.

Weakness:

There may be an infection, osteitis.

Further anatomical damage and scarring of the hand may occur.

There may be anesthesia or anesthesia complications.

Need many good equipment: sterile operating room, solid and hypoallergenic KHX tools, skilled surgeons.

The most commonly used bone combination surgery is the vis brace for the rotating bone.

In open fractures, surgical focus is to filter the wound, fix the broken bone often using a cast, external fixation or only minimal bone combination to keep the bone axis and strengthen the cast. Limit use of complex bone combinations inside.

Preventive

Propaganda and education in the community about traffic and labour laws.

It is necessary to educate students in elementary schools about the causes of fractures in order to limit accidents occurring in daily life and in schools.

It is necessary to educate the community of good local first aid in fracture cases to limit complications in fractures.

For grassroots health facilities that need an early diagnosis, correct handling and referral to specialized medical care for early treatment to minimize complications caused by fractures of 2 forearm bones such as Volkmann's syndrome, limited movement arm.

Educate patients on rehabilitation exercises after treatment