CHAPTER XV. FRACTURES OF THE UPPER END OF THE RADIUS. (Part 1)

CHAPTER XV. FRACTURES OF THE UPPER END OF THE RADIUS. Surgical Anatomy. — The sections on "Surgical Anatomy" under the headings of ''Fractures of the Lower End of the Humerus," ''Dislocations of the Elbow" and "Dislocations of the Head of the Radius" apply in a large measure in fractures of the upper end of the radius. The head of the bone is surrounded by the orbicu- lar ligament, except where the latter comes in contact with the lesser sigmoid cavity of the ulna. The supinator brevis is attached Fig. 262. Fig. 261. — Fracture of head and neck of radius. Fig. 262. — Comminuted fracture of head of radius. to the shaft and extends upward onto and almost completely sur- rounds the neck of the bone. The biceps is attached to the pos- terior half of the tuberosity and acts as a supinator of the forearm as well as producing flexion. A bursa is interposed between the tendon of this muscle and the anterior half of the tuberosity. The interior of the head of the radius is composed of a fine meshed cancellous tissue which is covered by a layer of compact bone. The surface compact tissue is heaviest on the top of the head. The circumference of the head, coming in contact with the orbicular 197 198 FRACTURES AND DISLOCATIONS ligament, is covered by only a very thin layer of compact bone. That found on the surface of the neck is a little heavier. The tuberosity is not a heavy, solid prominence of compact tissue but is composed only of a thick crust of compact bone, the interior being made up of a wide meshed cancellous tissue. The upper epiphysis of the radius consists of a scale of bone corresponding to the superior articular surface. When viewed laterally under the X-ray it appears as a line, throwing much the same shadow as would a coin seen on edge. This epiphysis begins Fig. 263. — Fracture of head and neck of radius. to ossify in the fifth year, and joins the shaft during the seven- teenth or eighteenth year. Fracture of the upper end of the radius is rare. The head may be broken as a complication of luxations, by violence transmitted in the long axis of the shaft (such as sustained in falls on the hand) and by direct trauma. The fracture may consist of a small fragment detached from the articular surface or the entire head may be extensively comminuted. Impaction of the neck into the head is not an uncommon type of injury. When this occurs im- paction is usually greater on one side of the bone than on the other, so the head is no longer ''true" when the shaft is rotated. FRACTURES OF UPPER END OF RADIUS 199 Fractures of the neck are iisiially transverse or nearly so. A verti- cal fracture may exist passing throngli both head and neck. Fractures of the upper end of the radius are, as a rule, accom- panied by only slight deformity, if any, and almost invariably Fig. 264. — Fracture of head of radius. Fig. 26.5. — Fracture of head uf i-; Head "off center." •ted into head. exist as complications of dislocations of the elbow or radial head alone, or of fracture of the lower end of the humerus or of the ulna. As an isolated injury they are unusual though by no means as rare as supposed prior to the advent of the X-ray. Symptoms. — Fracture of the head of the radius alone is often productive of very few symptoms, and if not thoroughly examined the condition may be overlooked and treated as a sprain. Local pain and swelling are present over the head of the bone. The swelling may extend halfway down the outer aspect of the forearm 200 FRACTURES AND DISLOCATIONS and local spasm of the muscles in this region is almost invariably present. Supination and pronation are usually possible but this rotary action of the forearm may be restricted through spasm and pain, or by the head of the bone being "off center." If a frag- ment becomes displaced into the joint it may block either flexion or extension of the elbow. It may be possible to detect crepitus by direct manipulation and in some cases a fragment may be felt and moved. Crepitus is most commonly elicited by supinating and pronating the forearm while the fingers of the opposite hand palpate the head. The head of the bone may or may not rotate with the shaft during this manipu- lation, depending on whether or not the fractured surfaces are firmly engaged. It is impossible to detect crepitus in impacted cases. Failure of the head to rotate with the shaft is conclusive when present, but it is not at all uncommon to find the head ro- tating with the shaft in the presence of fracture of the head or neck. When the fractured surfaces are not engaged the biceps may pull the upper end of the lower fragment forward and the resulting change in the axis of the radial side of the forearm may be apparent. This forward displacement by the biceps usually hin- ders flexion until the deformity is corrected. Diagnosis. — The diagnosis of fracture of the upper end of the radius may be very easy or quite difficult, depending on the symp- toms. If the parts are carefully examined it will usually be pos- sible to determine the nature of the injury by the symptoms just described, but in some cases (especially well muscled persons and instances in which the swelling is pronounced) a Rontgenogram may be necessary to arrive at a diagnosis. Behind the external condyle of the humerus and head of the radius, and internal to the extensor tendons arising from the epicondyle, is a depression or dimple which affords ready access in palpating these bony parts. A slight transverse depression between the capitellum and radial head may be felt and the radius should be distinguished from the humerus. The surgeon should not make the mistake of palpating the external condyle to determine rotation of the radial head. Such a mistake w^ould not seem probable yet the author has seen it made more than once. The X-ray should be used if there is the least doubt as to the nature of the condition. Treatment. — The management of these cases depends on the nature of the fracture, the displacement of the fragments and the FRACTURES OF UPPER END OF RADIUS 201 association of other lesions. When the fracture is confined to the head, the orbicular ligament, if not ruptured, will usually pre- vent displacement of the main fragments, though a portion of the head may escape into the joint and require removal. As a rule, however, fracture of the upper end of the radius calls for little aside from immobilization of the forearm, which is well accom- plished by an internal right angle splint. If the head is badly comminuted it may be advisable to remove the fragments, round up the end of the shaft and secure it in place by suturing the Figs. 266 and 267. — Loss of carrying angle and gun-stock deformity the result of fracture of both bones helow the elbow. Palpation in this case shows the liumeral condyles and olecranon to be in normal relation. Loss of carrying angle and gun- stock deformity are usually the result of fracture of the lower end of the humerus. orbicular ligament and other adjacent fibrous tissue over it. When obstruction to flexion or extension is caused by a detached frag- ment of the head it should be. removed. When the fracture is below the head, and the shaft is displaced forward by the action of the biceps, the splint should be so padded that pressure will be made in a backward direction on the upper end of the lower frag- ment. The use of pads and the acutely flexed position should never be employed at the same time. The use of padding in the bend of the elbow with the forearm in acute flexion, may give rise to 202 FRACTURES AND DISLOCATIONS serious disturbances of the circulation and in the function of the median nerve. When the fracture is below the orbicular ligament acute flexion will sometimes afford better reduction than the use of direct pressure and the right angle splint. Operative Treatment. — Operation may be indicated for the removal of a loose fragment in the joint or to apply internal fixa- tion to a fracture of the neck when other means fail to maintain reduction. The open method, however, is seldom called for in recent cases. When a loose fragment requires removal the incision will be made according to the position of the fragment. For other conditions of the upper end of the radius, requiring operation the posterior longitudinal incision will be found as satisfactory as any. The posterior aspect of the external condyle is a landmark from which the incision is begun and carried directly downward from two to three inches; after the skin incision is made the muscles are separated and the upper end of the radius exposed. In the presence of much comminution the head is to be excised, the end of the shaft rounded up and sutured in place. If the fracture is somewhat below the head it may be possible to so place a loop of wire that the lower fragment will be bound to the upper, thus preventing the forward displacement due to the pull of the biceps. The action of the biceps may be somewhat further relaxed by put- ting the arm up in greater flexion than the right angle. There is little that can be done with fracture of the head aside from exci- sion, but unless the comminution is great it is best to wait and determine how much restriction of motion wall be present when recovery is complete. If the loss of function is then pronounced a secondary operation may be performed and the head removed. It is surprising what good results often follow complete excision of the head. Fractures above the lower border of the orbicular liga- ment seldom unite, regardless of the treatment employed, so there is little use in attempting anything in the "way of operative pro- cedure aside from excision in fractures confined to the head. After-Treatment.— The afte-r-treatment of fractures of the upper end of the radius, like other fractures about the elbow, requires close attention to avoid constriction when swelling sets in, and as the arm decreases in size during the subsidence of this swelling the dressings should be tightened daily to secure proper support and immobilization. In children union will be present at the end of two and a half weeks, but is not firm enough at this time to FRACTURES OF UPPER END OF RADIUS 203 permit of removal of all dressings; the member should be pro- tected and supported for another ten to fifteen days before all splints are removed, especially if the child is active and not easily controlled. In adults the parts should be immobilized for a period varying- from three to five weeks according to the age of the patient. If the fracture is confined to the head union cannot be expected, regardless of the period of immobilization, and the most important element in the after-treatment is then the early insti- tution of passive motion to preserve the rotary action of the fore- arm. Passive supination and pronation should be begun as early as the end of the first week or ten days unless the traumatic reaction persists. When the fracture is of the neck passive motion should be delayed until union is firm enough to withstand manipulation. Prognosis. — The outlook depends on the nature of the fracture and the treatment followed. In extensive comminution of the head there is likely to be pronounced loss of supination and pro- nation of the forearm although the rotary action of the forearm is usually restored with operation and excision. Perfect function shonUl follow fracture of the neck if the fragments unite in ap- proximation ; if there is deformity following recovery the rotary action of the forearm may be seriously impaired. CHAPTEE XYI. FRACTURES OF THE RADIAL AND ULNAR SHAFTS. Surgical Anatomy.— The shafts of the bones of the forearm may be broken together, or either bone may be broken separately. It is more common to see both bones broken than to find a fracture of either bone as an isolated injury. Fracture of the radius alone is often the result of indirect violence ; the lower end of the radius Fig. 268. — Section of radius showing disposition of compact and cancellous tissue. Fig. 269. — Section of ulna showi'ng disposition of compact and cancellous tissue. O., Olecranon; C, Coronoid. supports the carpus and violence sustained by the hand is trans- mitted to this bone rather than the ulna. Fracture of the shaft of the ulna is usually the result of direct violence ; the posterior border is subcutaneous throughout and is particularly exposed to injury in falls on the back of the forearm and in warding blows 204 FRACTURES OF RADIAL AND ULNAR SHAFTS 205 from the head. When both bones are broken the cause may be either direct or indirect violence. Fracture of the bones of the forearm is a particularly common accident in childhood. When the shaft of either bone is broken alone the deformity is, as a rule, not pronounced since the opposite shaft acts as a splint in prevent- ing displacement. The various deformities accompanying fractures of the radial and ulnar shafts depend on the nature and direction of the causa- tive trauma and the different muscles attached to the bones. In speaking of the deformities due to muscular action in different regions of the forearm it will be understood that they obtain only when the serrated fractured surfaces are not so engaged as to pre- vent displacement. Fracture of the radial shaft, below the tuber- osity and above the insertion of the pronator radii teres, is likely to be accompanied by supination of the upper fragment and pro- nation of the lower. The biceps and supinator brevis produce supination of the upper fragment, and the first named muscle will also tend to displace the lower end forward. The lower fragment will occupy a position of pronation due to the action of the pro- nator radii teres and the pronator quadratus, and the upper end of the lower fragment will usually be displaced toward the ulnar shaft through the action of these two muscles. When the fracture is below the insertion of the pronator radii teres both fractured ends will be displaced toward the radius by the pull of these two pronators. In fractures of the shaft of the ulna the upper end of the lower fragment may be displaced toward the radius by the action of the pronator quadratus; the nearer the fracture is situ- ated to the upper border of this muscle the more pronounced the action. The relation of the bones during supination and pronation is of importance in treating fractures of the forearm. In supination the interosseous membrane is taut and the two bones in the same plane. As the forearm is carried into pronation the lower end of the radius describes an arc about the lower end of the ulna, and when pronation is complete the radial shaft crosses the shaft of the ulna obliquely. In complete pronation the shafts of the two bones are nearer than in any other position. The obliquity of the fibres of the interosseous membrane is such that with upward longitudinal stress on the radius a portion of the strain is imparted to the ulna. The oblique ligament is composed of fibres passing 206 FRACTURES AND DISLOCATIONS in the opposite direction and tends to prevent the radius being: pulled away from the humerus. The shafts of both bones are composed of heav}" tubes of compact tissue, and the fractures seen in this region are those common to the shafts of other long bones. They may be transverse, oblique, spiral, comminuted, multiple, green-stick, subperiosteal, etc. Divergence of either the upper or lower pair of fragments occurs only with rupture of the inter- osseous membrane and is rare. In unusual cases the ends of all four fragments may be close together and embraced by one callus. In other instances angular deformity of the fragments of one bone toward the opposite shaft may be accompanied by a large callus which interferes with the rotary action of the' forearm. When both bones are fractured the break in the ulna is usuallv at a sli^htlv Fig. 270. — Fracture of both bones of the forearm the result of direct violence. Hand displaced dorsally and slightly to the radial side. Fracture of ulua transverse and de- formity pui-ely angular. Fracture of radius is slightly oblique so that there is an ele- ment of overriding as well as angularity in the displacement of this bone. The slight overriding of the radial fragments causes the hand to be displaced a little to the radial side as well as backward. Arrow points to wound produced by lower end of upper fragment of radius penetrating the skin. Angular deformity corrected at once. Radius could not be perfectly reduced and persisted in slipping out of place. Operation about one week following injury ; radius secured in reduction by circular Avire, which is bad practice in compound cases before the wound has healed. (See "Operative Treatment of Compound Fractures and Luxations.") Ultimate recovery perfect. higher level. In rare instances the fractures may be situated at opposite ends of the shafts. Muscular action is known to have pro- duced fracture of the bones of the forearm, but is extremely rare. Symptoms. — The symptoms accompanying fractures of the bones of the forearm vary with the region of the fractures, the age of the patient, and whether or not both