به نام خدای بخشنده و مهربان

1. به نام خدای بخشنده و مهربان دکتر اکبری اقدم استادیار دانشکده پزشکی اصفهان

2. Forearm,Monteggia&GalleazziFracture Dislocations

3. Forearm Both Bone Fracture • Common 12 to 16y • Most common site for refracture • Fx suspected >>child has not returned all normal arm function within 1 to 2 days of injury

4. Classification • Practical classification 2 bones 3 levels 4fracture patterns (Bow,Greenstick,Compelet&Comminuted)

6. Treatment • Closed Reduction still remains the gold standard for closed isolated pediatric forearm fractures

7. Non or minimally displace Long arm cast(except above 4 y with stable distal third fx) 1 and 2 week visit 6-8 week cast After that splint until union compelet

8. Displaced fractures Manipolation with sedation Contorol with fluroscopy Sugar tong splint(7-10 layers 3inch plaster) Next week x-ray and change splint to cast 2 next weeks follow up 4 weeks after reduction can chang short cast Except under 4 y Return to sport now if…

9. Acceptable limits of angulation • Distal third< 20 degree • Middle third< 15 degree • Upper third <10 degree • 100% translation with <1cm shortening • Rotation< 45 degree.difficult to measure Bicipitaltuberisity and radial styloid

10. Surgery • Open fracture • Fracture with unacceptibale reduction • Fx in assosiatedsupracodylarfx(to avoid risk of compartementsyn)

11. Interamedullary fixation is preferred If one bone fixation Fix ulna If both bone should be fix,radius first 2-2.5 mm nail brace or cast 6-12 mo nail removal

13. Complications • Redisplacement • Forearm stiffness • Refracture • Malunion • Nonunion • Cross union(synostosis) • Infection • …

14. Monteggia Fracture Dislocation InChildren

15. Classification(Bado) • Type 1 • Ant dis radial head associated with ulnardiaphysealfx at any level(most common)

17. Type 1 Equivalents • Ant radial head dislocasion (include pulled elbow) No plastic deformity of ulna • Ant dis radial head with radial neck fx • Ant dis radial head with fx of radial diaphysealfx proximal to ulnarfx • ….

18. Mechanism of injury • direct blow theory • Hyperpronation theory • Hyperextention theory

19. clinic • Fusiform swelling elbow • Pain &limit ROM elbow

20. Treatment • Three steps: • Correcting the ulnar deformity • Stable reduction of radial head • Maintaining ulnar length and fx stability

21. Postoperative care • A bivalved long arm cast 4-6 w slight supination and elbow 90 to 110 flex • Radiography every 1 to 2 w • Hardware remove

22. Traumatic versus Congenital dislocation • Congenital Posterior Bilateral Can be associated with various syndromes • Traumatic Isolated ant. Or ant lateral dislocation Unless congenital or systemic difference

23. Type 2 • Posterior monteggiafxdx • Rare in children usully older patient • Mechanism Direct force,sudden rotation and supination Suddenly loaded in longitodinal direction elbow at 60 flex

24. treatment • Incomplete fx ulna>>close reduction casting in extension • If doubt>>interamedullary fixation • Comminuted or very proximal ulnarfx>>open reduction plate screw

25. Monteggia type 3 • Lat swelling,varus,significant limitation of ROM • Mechanism>>hyperextesion of elbow combined with pronation

27. treatment • Incomplete or plastic deformation of ulna Close reduction >> Elbow in extension longitudinal traction valgussterss test Long arm cast elbow 70 to 80 flex

28. Type 4 • Ant dis with fx both radius and ulna Radial fx level same or distal too ulnarfx • Fx unstable fixation

30. Compelications Chronic Monteggia Injury Under 12 years old MRI Determine congruency radial head and capitellum

31. Surgery Radial nerve identify Anconeous-extansorcarpiulnaris interval Repair or reconsteraction of annular lig Radius head unreduceable >>ulnarosteotomy After radial head redauction>>anullarligrepi

32. Pediatric Galeazzi Fractures • Fracture of the distal radius with DRUJ disruption • Mechanism >>axial load ,forearm rotation • Signs &symptoms>>pain,limitation of forearm rotation,wrist flex ext

33. Classification • Type 1 dorsal (apex volar)displacment • Type 2 volar(apex dorsal)displacment • Galeazzi equivalent Distal radius fx with distal ulnarphysis disruption

35. Treatment • Volar apex Radius fx greenstick or incomplete Close reduction and long arm cast in supination Complete fx Open reduction and fix with plate

36. Dorsal apex • Incompelet radius fx Close reduction • Compeletfx Open reduction