CLOSED FRACTURE LEFT DISTAL RADIUS

CLOSED FRACTURE LEFT DISTAL ULNA

PRESENTED BY:

ADVISORS:

SUPERVISOR:

ORTHOPAEDIC AND TRAUMATOLOGY DEPARTMENT

MEDICAL FACULTY
HASANUDDIN UNIVERSITY
2015
IDENTITY
Name : GEM

Age : 7 years old / Boy

Admission : August 29th, 2015 at 19.15

Registration : 724033
AUTOANAMNESIS

Chief Complain : Pain at the left wrist

Suffered since 1 day before admitted to Wahidin
General Hospital.
Patient was jumping from monkey bar and fell
with the left hand contact with the ground first.
History of unconscious (-), history of vomitting (-).
Prior treatment at Siloam Hospital.
GENERAL STATUS
Concious wellnourished
Vital sign
Respiratory rate : 20 x/min
Pulse : 92 x/min
Temperature : 36.7oC
NRS 4
 LOCAL STATUS

Left Forearm Region

Look : Deformity (+), Swelling (+), Hematome (+), Wound (-)
Feel : Tenderness (+)
Move : Active and passive motions of elbow joint can not be
evaluated due to pain
Active and passive motions of wrist joint can not be
evaluated due to pain

NVD : Sensibility is good, pulsation of radial and ulnar artery

is palpable, CRT <2
CLINICAL FINDINGS
RADIOLOGICAL FINDINGS
LABORATORY FINDINGS
WBC : 10.500/ ul
RBC : 4.690.000/ ul
HBG : 10.3 g/dl
HCT : 31.3 %
PLT : 321.000/mm3
CT : 800
BT : 300
HBsAg : Non reactive
 DIAGNOSIS
Closed Fracture Left Distal Radius

Closed Fracture Left Distal Ulna

MANAGEMENT
IVFD
Analgesic
Closed reduction under narcosis
Apply Long Arm Cast
Post closed reduction
Post closed reduction
DISTAL RADIUS AND ULNA
FRACTURES IN CHILDREN
 EPIDEMIOLOGY
The incidence of pediatric fractures is
increasing
Approximately 50% of all children will fracture
at least one bone during childhood, 80%
occur in children >5 years of age.
Forearm fracture are very common. They
make up 40% of all pediatric fractures
Pediatric forearm fractures
o 60% occur in the distal metaphyses of the
radius or ulna
o 20% in the shaft
o 14% in the distal physis
o
 ANATOMY
Embriologi
The radial and ulnar shafts ossify during
the eighth week of gestation.
The distal radial epiphysis appears at age 1
year (often from two centers); the distal
ulnar epiphysis appears at age 5 years;
The radial head appears at ages 5 to 7
years; the olecranon appears at ages 9 to
10 years.
These all close between the ages of 16 and
18 years.
ANATOMY
ANATOMY
 MECHANISM OF INJURY
Indirect:
The mechanism is a fall onto an
outstretched hand. Forearm rotation
determines the direction of angulation:
o Pronation: Flexion injury (dorsal angulation)
o Supination: Extension injury (volar
angulation)

Direct: Direct trauma to the radial or ulnar

shaft.
 TYPE OF FRACTURES
Physeal fractures
o Salter-Harris I
o Salter-Harris II
o Salter-Harris III
o Salter-Harris IV
o Salter-Harris V

Metaphyseal fractures
o Buckle fractures
o Greenstick fractures
o Complete fractures
Physeal Fractures
Metaphyseal Fractures
 CLINICAL EVALUATION
A history of a fall.
Presents with pain, swelling, variable gross
deformity, and a refusal to use the injured
upper extremity.
A careful neurovascular examination is
essential. Injuries to the wrist may be
accompanied by symptoms of carpal tunnel
compression and more proximal fractures
may be associated with anterior
interosseous nerve (AIN) or posterior
interosseous nerve (PIN) injuries.
 CLINICAL EVALUATION
In cases of dramatic swelling of the forearm,
compartment syndrome should be ruled out.
The classic signs of compartment
syndrome
pain out of proportion to injury,
pallor
paresthesias
paralysis
Pulselessness
Forearm fasciotomy.
 RADIOGRAPHIC EVALUATION
Anteroposterior and lateral views of forearm,
wrist, and elbow should be obtained.
o Physeal fractures are almost invariably Salter
Harris type I or II, with the epiphysis shifted and
tilted backwards and radially. Type V injuries are
unusual
o Metaphyseal injuries may appear as mere buckling
of the cortex (easily missed unless appropriate
views are obtained), as angulated greenstick
fractures or as complete fractures with
displacement and shortening. If only the radius is
fractured, the ulna may be bent though not
fractured.
 Treatment
Complete fractures
Closed reduction
o Reduced under anaesthesia
o Reduction technique :
The hand is grasped and traction is applied in the length of the
bone (sometimes with extension of the wrist to disimpact the
fragments); the distal fragment is then pushed into place by
pressing on the dorsum while manipulating the wrist into exion,
ulnar deviation and pronation.
o The position is then checked by x-ray
A full-length cast is applied with the wrist neutral and the
forearm supinated.
After 2 weeks, a check x-ray is obtained; the cast is kept on
for 6 weeks. If the fracture slips, especially if the ulna is
intact, it should be stabilized with a percutaneous K-wire.
 Treatment
Greenstick fractures
Greenstick fractures are usually easy to reduce but apt
to re-displace in the cast! Some degree of angulation
can be accepted: in children under 10, up to 30 degrees
and in children over 10, up 15 degrees.
Closed reduction
o Reduction technique : reduced by thumb pressure
The arm is immobilized with three-point xation in a full-
length cast with the wrist and forearm in neutral and the
elbow exed 90 degrees.
After 2 weeks the cast is changed and the fracture re-x-
rayed. If it has re-displaced a further manipulation can
be carried out.
The cast is nally discarded after 6 weeks.
 Treatment
Physeal fractures
Closed reduction :
Reduced under anaesthesia
Reduction technique : pressure on the distal
fragment.
The arm is immobilized in a full-length cast with
the wrist slightly exed and ulnar deviated, and
the elbow at 90 degrees. The cast is retained for
4 weeks.
 Treatment
Buckle fractures
Buckle fractures require no more than 2
weeks in plaster, followed by another 2
weeks of restricted activity.
 Complications
EARLY
Forearm swelling and threatened
compartment syndrome This dire
combination can be prevented by avoiding
over-forceful or repeated manipulations,
splitting the plaster, elevating the arm for
the rst 2448 hours and encouraging
exercises.
 Complications
LATE
Malunion This late sequel is uncommon in children
under 10 years of age. Deformity of as much as 30
degrees will straighten out with further growth and
remodelling over the next 5 years. This should be
carefully explained to the worried parents.
Radio-ulnar discrepancy Premature fusion of the
radial epiphysis may result in bone length disparity
and sub-luxation of the radio-ulnar joint. If this is
troublesome, the radius can be lengthened and, if
the child is near to skeletal maturity, the ulnar
physis fused surgically.