FRACTURES

E.
MERVYN

OF

THE
EVANS, Bin;,i

RADIUS
SWANSEA, nghaiiz A cczdent

AND
WALES

ULNA*

Formerly

of the

Hospital

Fractures bones On with the and isolated

of

the

radius

and of the more

ulna shaft difficult

without of the of the ulna shaft

displacement, seldom of the and present radius many

incomplete any and cause displaced difficulties fractures anxiety

fractures

of

both

fractures complete are much

in treatment. of during with both these of both bones more bones treatment

other

hand

fractures

displacement

injuries

and
difficult

dissatisfaction
injuries and

with treated

the by

final
on

result.
a study of the of

This
fifty

paper
consecutive

is mainly Certain

concerned
fractures

is based fractures

of the
treatment

forearm

conservative

methods.
forearm OF radius, and are THE

aspects

of the

mechanism

and

of greenstick

also

discussed. AND ULNA of both reduced rate it is in The deep the bones that necessary shape beneath many adult. to of of

COMPLETE Complete the forearm, surgeons ,*._.i advise fractures have hitherto immediate To
, . .

FRACTURES shaft regarded reduction why these of the

RADIUS especially to reduce fixation, are anatomy of difficulty and so of

of the been open discover

and internal

fractures and at refractory the ; the hold any

as so difficult fractures of the a cause

consider some aspects the forearm is of itself muscles and fascial the in the

forearm. radius lies the ulna

compartments,

although

is subcutaneous

it is not
and main hold

easy
at

to manipulate.
same lies in forearm time the

The
accounts element yet has

fact
for of been

that
some

there
of

are
the which

two
failures. is

bones
But of

to set
the peculiar

difficult

rotation, largely

;:

importance

ignored.

In
annular
.

pronation
ligament At the radial behind between rotational correction that

and
while moment between

supination
the of the lower a is the upper less in two than proximal

the
end fracture rotated

head
swings of and into to it,

of
both distal a

the
around

radius
the of is of the Thus and as 90 we the

pivots
head the broken

in the
of forearm and the

ulna. the the of the upper

bones pivots position

continuity soft-tissue radius

fragment structures with the no our element the

equilibrium fragment rest of It this, the the is a deformity

by the
,.

attached two ulnar radial often do are

leaving

lower

fragments. fragment as much if

is

produced

forearm-a demands not surprising

deformity results

degrees, ignore

which

shortening imperfect

and

angulation.

FIG.

I in the

most important deformity between

the function of the fragments of the radius

forearm. Rotational can occur whatever

1 he width

discrepancy
between

tworadialfragments

indiateshata
is present.
-

the level radiograph (Fig. 1) allowed occur attached

of the fracture. It is frequently obvious on the first from a discrepancy in the width of the two radial fragments and it can be observed in old fractures which have been to unite in the them. It

an
two

incorrect
fragments be

rotational
of the argued that rotational ulna;

position
the may rotational occur position
of England

Rotation
position during at
on February

does
prevented

not

between to

it is presumably

by while
*

the

soft in
OB

tissues

may

of the or of
1950.

proximal
Based

radial
plaster,
a

fragment
and that
Lecture

is not
the
delivered

static,

that

further
of

rotation
the

reduction the time

determination
at the Royal

Hunterian

College

of Surgeons

548

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

.149 of fracture the at the the problem upper

admission

is

therefore

of

no

value.

This

is

not

so : at

the

moment

radial
acting

fragment
upon it,

is
and

pulled
it retains

into forearm
there

a certain
this position

position
throughout.

of it, 2).

rotation
Find

by
this

the
position

soft-tissue

forces
outset of at the

and
cases

place
to be

the

rest
described

of the
was

in alignment fracture of treatment.

with (Fig.
discrepancy

and In
in

one only
the

has one

solved of the forty-nine

rotational time
original

deformity and was

in that that held

particular at the
was

series
position

of fifty the

rotational

of reduction
rotational

end

In the
within a

remaining

patients

deformity

corrected

few degrees
evidence may during fairly elementary the In position forearm is be be easily

and
of the obtained

throughout
stability rotating it to

treatment.
of the under It its can upper direct be

Further
fragment vision rotated position. is that an the when

rotational open

operations but

fractures.

returns

original

Determination
principle of

of
one

rotational
in fracture fragment

deformity-It
reduction cannot be controlled

remainder
fragment therefore

of the
fractures

part

must
the

be brought
of the position the ; its so that

into
in remainder

line
space

with
radial must of

it.

rotation

proximal

uncontrollable determined

the

limb may the shape

be lined up with it. This of the bicipital tuberosity

is done by studying (as seen in anteroit with that of

ulnar to the
.

side back
; and the grades be

of the of the
.

radius bone
pronatlon

moved
. .

and
. .

is not
it

visible
as positions

as a projeca projection there within a of are which few the radius. In side patients two must sides. be employed to demonstrate practice the neutral at different appearances
FIG. 2 FIG. 3

tlon

in lateral used for

full side.

appears these and

fracture before
3)

of

both (Fig.

bones 2) and

of

tile after

on fine can

Between in guide, the shape a

forearm
(Fig.

of difference as determining

prominence to position

correctionof

rotational

accurate rotational

degrees,

that
radius The but

matter
the shape in any

are
upper and one

those
texture patient achieve

between
of the the

mid-rotation
is seldom tuberosity tuberosity found

and
on vary in

full
the on

supination,
pronation

for

after
of the and

a fracture

of the
posit ion. ages,

fragment

different the

is identical a constant view antero-posterior supination, the view tuberosity gives injured account is short bone rotation of the on an

Technique-To

standardisation

technique

what
briefly side forearm of 60 the

may
as is made, radius

be termed
follows. and and of of of the the radius the may prominent An

the
compared rotation, in cases outline degrees

tuberosity with in which a further of the of rotation 4 to 7). with taken and its the
1951

; the

method
of the views and on normal the accurate the

of taking
bicipital of the normal

this

view
radius

antero-posterior 30 degrees

radiograph

tuberositv supination. side seems supination with rotation that

(Evans on the
taken In high to be of

1945)
injured with fractures the than taken. normal proximal

is

in neutral

60 degrees injured side injured idea in

more the

degrees

supination,

full side of the

is also of the in the the

Comparison tuberosity fragment In of the usually

in known matching tuberosity most

(Figs. normal be

the into curve cancellous

side (Fig.

several 8): and 1) In

characteristics full supination As

appearance tuberosity is is

pronounced.

the

mid-position

approached
gradual.
VOL.

the
2) In

tuberosity
full 4, supination
NOVEMBER

becomes

progressively

less prominent
of the tuberosity

and
ma

its curve
be seen

larger
at the

and

more

extreme

33 B,

NO.

E.

MERVVN

EVANS

900

00

FIG.

I
Fit;.

Frac to ru of both bones in the forearm. normal forearm in neutral rotation, (Belo) The injured forearm. Tile sllape with that of the Ilornlai

Figure
in

4-Initial
supination

radiograpil.

60 (iegrees of the bicipital

side

with

tile

and tuiberositv on forearm sui)inated

Figure 5in 90 degrees the iIlj tired side 60 (legrees.

(-i boe)
sllpillatlOil.

The

correspontis

#{149}1

FIG. Tile fracture the

6 Union
has taken

FIG.
place

7
WitllOuit loss of

is reduced after supinating forearm 60 degrees.

position.

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

551

ulnar the cortical of The and of adult, rotation the position

margin cancellous it bone radius bone the the curve tuberosity but are
is

of

the bone
usually

bone. moves lateral the and young are less

As central. shaft-is sharply larger

the

forearm
until

is pronated
in the mid-

laterally

3)
side-between quite curved and

The

line
the

of

the
head

on and

the

characteristic. in supination towards than degrees of rotational rotational the but, to The find the of the in the of
Tile
CO(3OO FIG. 8

is short In the of as an one all how may much be in the between

becomes

straighter the defined varying

mid-rotation.

children clearly in distinct. correction for part to get practical to follow. position displacement only

characteristics

differences adequate need essential has rotary more made full that level of the rotational there one and is acting. rotational The accurate rotationally on soft of rotational correction fractures of the reduction. case

nevertheless

Importance deformity-The deformity been of rotation alignment third Figure Although the occur the variations at pronator Correction maintaining ends not
stresses

characteristics tuberositv.

of the (See

normal text.)
.

bicipital

correcting of the fragments

reduction
since the this

has of the rotational teaching in radial greater perfect

already radius alignment position that the fragment supination upon also depends fracture. soft-tissue can be held important one neutral

been in perfect first, should

mentioned. alignment depends when upon the to

It

has

said correcting

that

be sure correct perfect tipper cases. fracture, fractures radius

accepted remainder upper towards next are to is more for stable

immobilise consecutive higher case the many

fractures 9 shows

supination

and is a tendency and the

position in fifty the

is unreliable.

it is true midshaft teres reduction. the if they and correction Finally, As in many accuracy more are strains

very be

considerable

; in any which from largel deformity

it is impossible deformity of any fit the the tissues, of rotation elsewhere,

certain important is the

fragment the on Jagged equilibrium point the fit

of the of bone means as will on the fragment lead cases

view
bone ends abnormal

of will

stability

reduction stable Moreover, reduction has range has pronated 11). five In bones years allowed lower that in
in

of the

and fit

displaced. and deformity these deformity the A fracture

rotational

is essential. be shown functional relationship of the inevitably (Figs. of thirteen deformity or degree more, 60 of loss showed excellent leave series a of a was the in over fracture had 10

After later.

fractures an final that

in plaster, bearing bears the tipper of nineteen treated found of 30 the reflected degree. which The may may cases lover will

result.
to the

of movement united on a review of the ago, to radial four all of unite patients the thirteen was it ith the limitation of forearm was with

a close

radius to and over been of the and degrees: pronation

a corresponding

supination

of both

conservatively that degrees

a pronation error

fragment

deformity of similar a length reduction and rotation cases (1949) treated found that

a clinical review seem yet In

of supination also as
ROTATIONAL POSITION OF UPPER RAOIALFRAIIMENT

to

alignment deformity.

considerable forty-one Purvis of from

FIG.

9
of the upper radial plotted against the case 1S represented

The

rotational

fragment level of

position in fifty cases, fracture Each

25

to
.

60

conservatively residual rotational degrees in 60 per

Knight and deformity cent, the with

by
VOL.

a black
4,

dot. 1951

proximal

radial

fragment

being

supinated,

33 B,

No.

NOVEMBER

552

E.

MERVYN

EVANS

resulting tion. rotational the (Fig. refracture deformity the the lower 12)-is

proportional The disability deformity-usually fragment such and may in correction be and

limitation from

of pronation

supinaof upper cases

persistent

relation that in of

to the to the

the

recent

rotational improve of are and to on minutes around rotated palpait forearm to engage the present the the a

undertaken restore

appearance limb.

function fractures

Technique
reduced manipulation right patients against the
into

of reduction-The
in the The hand the arm, is under ends, position manipulation satisfactory It is cent the usually of in the of apposition usual with for and still by traction, and then is checked reduction possible both the surgeon at with found angulating in order way by elbow should least the to

traction flexed pull ten

angle.

counter-traction

of a sling forearm

upper the be still bone The the a overlap

predetermined
corrected

position.

If on
be

tion may while the

straightening radiographicallv if necessary has to bones present the in radius

10 old shape forearm

limb.
FIG.

ii

Figure forearm.
in neutral

10-An

The normal
11), to

fracture of tile
corresponds

of both tuberositv
exactly

bones of the with the hand

and until

is repeated

been secure this is the series).

rotation

of tile (Fig.
allowed

in
that

60
the

degrees
fracture

of

supination
has

obtained. end-to-end way (76 Sometimes

deformity Clinically

unite with a of the lower radial

60

degrees
on

pronation
the

fragment

per

there

was

loss

of supination

of 60 degrees.

deformity

fractures.

An max the first

end-to-end but weeks two

redtiction shortening and the

of position

the of the

difficult to reduce, especially ulna, with corner-to-corner radius must be should watched be prevented carefully.

in upper-third reduction of by thumb traction

radius during

be accepted,

FIG.

12

A severe

pronation

deformity

of the

lower

radial
and

fragment
Joint

on the
Injuries).

upper.

(From

Watson-Jones-

Fractures

THE

JOURNAL

OF

BONE

AND

JOINT

SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

553

FRACTURES As to deformity The the same in fractures by be must method as that merit form ulna, of the there of both rotational corrected bones

OF of the displacement

THE

SHAFT

OF complete distal

THE

RADIUS of the on radial of the present, without shortening Cases the (Figs. fragment shaft as in and of this radius proximal, 13 and of the the no type are and 14). radius, forearm, fracture fall into is precisely likely the

forearm, of the position section. two of which accurate

fractures fragment and stability upper fractures

be complicated

to ensure the in the previous \Vhere one arm

reduction of the Certain parallel cannot of the or

of determining described special other. must

rotational

however, they of the shortening

attention. the If there be radio-ulnar

bones radius dislocation.

are with

a parallelogram,

be shortened

a corresponding

is a fracture subluxation

I
FIG.

13 of radius. 14-Normal of rotational

FIG.

14 Fractures
radius.

FIG. Figure

15
with 15-Before reduction. radius prevented by

FIG.

16

Fracture reduction.
by

of

shaft Figure correction

Figure 13-Before alignment restored deformity.

of radius of

and

ulna

comminution
Figure 16-

of traction.

Shortening

thumb

three radio-ulnar fractures fractures

groups: and but same traction Open

1)

Oblique or be

fractures subluxation treated obvious fracture by

of

the obvious

shaft, on open of the with In and to the such

usually the first inferior an last reduction

in

the and

lower plate fracture there loop radius radial the 16); been radius

third, These fixation. joint of the

with are 2) on ulna by

inferior unstable Similar the for first the the running

dislocation should without 3) Oblique direction during through reduction

radiograph. radio-ulnar types should a wire of the in which of 15 and has

primary radius

subluxation of the radius. weeks extension be resorted is useful radial fracture. two of the

examination. in the radius thumb plaster. to shorten

oblique two to

as that the

is a tendency incorporated occurs. shortening may be

first strapping

fractures

be treated

continuous in

attached if shortening injury Instability (Figs.

should traction the types of the

Thumb
to occur, comminution end-to-end
VOL.

traction-Thumb
including or reduction
NO.

in any above. fracture Thumb

is likely due to:

mentioned radial
1951

obliquity of the
NOVEMBER

or

inability

to

secure

traction

condemned

as a cause

33 B,

4,

354 of joint in the stiffness. present series The traction thumb need stiffness

E.

MERVYN

EVANS

be was

continued not observed

for

only as

two

or

three

weeks,

however,

and

a complication.

INDICATIONS The Openition 1) In subluxation. 2) In compound skin stability flap can to the fractures provide limb while indications is indicated oblique fractures for a

FOR internal a primary of the of both adequate the

OPEN fixation

OPERATION may

AND

INTERNAL as follows:-

FIXATION

be summarised

procedure. shaft bones skin more cover. urgent of the with In radius skin such plastic loss with inferior degree radius is carried radio-ulnar that should out. only be dislocation an plated immediate to give or

of such the

cases procedure

FIG. Fractures

17 by Note the simple improvement correction of

FIG.

18 of radius and the fractures ulna. are

of radius

and

ulna.

in

alignment

obtained rotational

Originally a simple After twenty-two

deformity.

fracture operations still ununited.

Operation

may

be indicated

later.

1)

In

unstable
delayed

fractures
union reduction be this. admitted It is felt offers is surely if all

of

the

radius

if

radial

length

cannot

be

maintained

by

thumb

traction. 2) For or non-union. has that that a relatively rotational a confession elements of the been for prevented many safe by surgeons fractures way deformity of failure. deformity are out severe the associated indications difficulty direct reduced
THE JOURNAL

3) If primary It wider that the by routine, closed must than plate certainty however,

injuries. for open and Such can (Fig.

operation hold in the and recent a procedure should

are in plaster

much and as treated a

these

difficult of the under These are

to reduce with, vision.

fixation

fracture, be

of correcting methods

fractures

17).
BONE AND JOINT SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

Disadvantages
the of upper eighty-five half of (1950) Holdsworth

of operation-Operative
the forearm. Knight also that Injury and Infection, non-union Purvis in reported

reduction
non-union 9 per (1949) cent

and
and and

fixation
delayed infection non-union

are difficult,
union in in had do 4 per six not

particularly
occur cent of thirteen (Fig. of a series cases

in 18).

cases. stated operation.

reported

treated plating
the time

by open
; they

reduction

without
to

fixation,
cases the

and

four
rotational

cases

of non-union
alignment nerve

in twenty
been unknown was case is not

treated
restored from lessened many

by
at a by of the

in several

of

posterior

interosseous

plating
catastrophies.

operation, tissue
In are short, too

and
Patrick

tourniquet
(1946)

paralysis,
considered

ischaemic
that the

paralysis
final without range

and
of

contractures
rotation

are occasional cause of cross-

the
union.

scar

of an
plate young

open
for

reduction
such treatment

and

that
to be

operation
considered.

was
risk

the
and

commonest
in any

fixation

as a routine

is not

patients

RESULTS How order been near same both nine to the period bones compound studied. wrist was of the do answer the Only joint results this closed have forearm approximately was of both fractures of

OF

CONSERVATIVE treatment consecutive fractures The so and that fractures with total the 1 in eleven
TABLE I
BOTH

TREATMENT compare overlap number incidence 150. fractures During of the have of with been fractures the same shaft of closed those bones of of the included, treated complete period of the operation forearm and during fractures there radius alone. ? fractures the of were In have

conservative fifty complete

question been

of both

omitted. 7,500, approximately bones

RATE

OF

UNION

IN

FRACTURES

OF
\VITHOUT

BONES

OF

THE

FOREARM

TREATED

OPERATION

umber

Age

of
cases

umber

united

Complications

Averae . time union

of

(weks)

Under 29 yrs Over 29

Malunion necessitating bone graft

7.7

16
years

21

21

14

(1

case)

Average

time

of

union

in

50

cases-iO4

weeks

The
immobilisation
Union

treatment
(Table 1)-All
was

in
the grafted time

all

cases The results

consisted may be In whole

in

reduction summarised

under as follows: the radial fractures the

general

anaesthesia

and

in plaster.

fractures at the for union

united. seventeenth in the

one series,

case

fracture united above

collapsed within case, was time time fixation.)

in plaster thirty-six 104 for for weeks.

and weeks.

the

radius The

week;

both including

average

If the patients are results are as follows.

divided Under
Over time

into those under and sixteen years-twenty-nine

those

over the patients;

age

of sixteen

years

the
union union

average average

be 50

of external cent end-to-end

Reduction-End-to-end the bone fragments) of

reduction both

apposition

of

Acceptable
VOL.

reduction
NO.

was

obtained
1951

was obtained in in all the remainder.

thirty-eight

patients

(76

per

cent).

33 B,

4,

NOVEMBER

556
82%

E.

MERVYN

E\ANS

Behaviour patients held in (82

in per plaster

plaster cent) until

(Fig. the the

19)-In reduced fractures had

fort\-one position was united.

In
in

seven
position

(14
in

per

cent)

there
not

was
considered

a slight patient
slow and

shift (aged
both result 20

plaster years)

sufficient

to
4 CASES

warrant
angulated poor
.

interference.
union 60 in plaster.

In
The

one

seventy-five bones was

was degrees,

functional pronation

(supination

ICASESI STABLE SLIGHTSHIFT

ICASE(2%) MALUNION (ANGULATION)

I CASE(2X) COLLAPSE (GRAFTED)

degrees) radial ment bone and

In

one
was in of

case
plaster. the

already
Open radius

mentioned
and reduction were undertaken weeks. displace-

the
and

fracture occurred grafting union was of

comminuted

FIG.

19

secured late were

in thirty-six rotational examined

Behaviour boiles

of

in the

plaster
forearm

of

fifty

treated

fracttires conservatively.

of

_,1ssessment
eight patients

deformity-Fortyradiographicallv

after

tile

fractures

had had position

united been was In one (Fig. ; seven

to determine
correct correct. case and In rotational the more had

whether
been held there deformity fifty than seven,

the
was

rotational
In a residual greater three limitation

position
forty than had 30 more of rotational

estimated
cases degrees. than 15 (83 per deformity

at the
cent) of

time the
less

of reduction rotational than 3() degrees. range of

in plaster. was

1i,ial
linlitatioll

rotation

20)-Of had

patients: 15 degrees

degrees four

of supination

pronation

; only

_________NORMAL. Jc.
-

RANGE
;T _ -:

:LJ

-45

1c

U)

w
U)

i
H

i#{149}

-4

. -

U U.

0
UI

15

I-.

::i
.

::
I

10
z

:
I

i
50 40 30

60

7J

20

I0

0.,

10

20

30

40

50...

#{176}

SUPINATION LIMITATION OF
FIG. Graph

PRONATION ROTATION
20 as compared with tile normal side,

(DEGREES)

in The

fifty

showing fractures

limitation of both

of rotation,

siladed

section

bones of the forearm treated conservatively. includes all cases with less than 15 degrees limitation of pronation or supination.
THE JOURNAL OF BONE AND JOINT SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

557

had
function

more

than
may

30 degrees
thus be said
were

total
to have
no

limitation
been
untoward

of rotational
regained complications in over

movement.
90 per in the cent series. of almost most. be the all

Normal
of cases.

or near-normal

Complications-There Discussion-The by short reduction conservative time and full and plate to

results methods with peculiar regard the a to fixation.

show with return open For rotational

that the to

fractures expectation normal such

of of a

both union claim

bones in in

forearm cases Quite made however, in

can apart for

be

treated the open

a reasonably from routine it is essential

function

complications

methods success element

cannot treatment,

in conservative of the deformity.

to pay

GREENSTICK It no found correcting to new for plaster. 23). the It

FRACTURES the in treatment a survey fractures recurred to children down treated for the

OF of greenstick

THE

RADIUS fractures

AND of the

ULNA radius and during was (16 only

been

said

that

ulna 1948 cent)

presents it (Figs. for

problem that

; nevertheless of the the is true eighty-eight that is soon and patients deformity

of

349

of

these the extent

fractures initial in deformity

treated deformity fourteen is often it the angular

was 21 a in

in which a significant an angular the surgeon standard

considered per temporary, has was recurred

worth

in young laid were disconcerting

architecture parents These

to restore along

bones to lines.

to normal: find that Tile

nevertheless

deformit deformity

corrected

FIG. Figure
angulation

21
typical at the the greenstick site. plane. fracture in a flat

FIG. fracture Figure Note

22
of 22-The that union has has supination the fracture radial taken largely type

FIG. was fracture place with restored

21-A
manipulation by deformity.

I
23
with

forward

by of

reduced was made recurrence the bone

complete

manipulation. Early Figure 23-Remodelling

architecture
VOL.

to

normal.

33 B,
E

NO.

4,

NOVEMBER

1951

558 b\ the as one manipulation and of sure basic in

E.

MERVYN

EVANS

in a flat vice way of

plane; versa. obtaining

thus It into of After may

if the be

limb noted

was that

bent this

forwards manoeuvre This of has,

it was in

reduced fact, not was been

by

bending in of intact

it backwards, conversion the of only the

frequently

resulted advocated a violation damage to immobilise

a greenstick principles reduction.

a complete complete fracture manipulation in the position

fracture. correction surgery, the that

deformity-surely one should procedure

structures the limb

the

routine

an

above-elbow

plaster

of mid-rotation.

Importance
dislocations possible
tile

of
tile broken

the
manner

rotation
in which structures,

element
reduction bone or soft

in

the

causative
is of be should

injury-In
great made importance. to retrace

all

fractures \\henever their path,

or so

is obtained tissue,

FIG.

24 the forearm backwards. is pronating will

fracture

sustained

while

angulate

supination

fracture

will

tend

to

angulate

forwards.

that for the in which

no care the

further
ill

injury reduction because or hand-the on but the the or

is caused calls of supination commonest ground, is reached. falling rotatory body the for is a reversal

by

manipulating of this mechanism: played in it force likely be which the

the of the

limb mechanism

against of the but \Vhen injury of the will, there

the

grain. injury, for few falls will

This

need

manipulation

a knowledge many have way movements not above main is to

in general difficulty injuries on continue be vertical direction element

simplest forearm pronation fixed

it is a subject involved, a part. a forearm momentum

of particular are one body

in the hand to

to

outstretched becomes act and until sonic compression,

is sustained-the of course, to
AND

and The element

equilibrium lateral

acting expected
THE

on in

the its

limb solely

is hardly

to be moving

in a downward which
JOINT

momentum,
OF BONE

JOURNAL

FRACTURES

OF

THE

RADIUS

AND

ULNA

559 may injury In will either and and go to the result-or, case soft-tissue those extremes more a rotation injury sustained In evidence pronation picture direction and the or the

the of

forearm normal has the support so clear,

will anatomy will been accordingly. forearm the these injuries

respond or be applied The

by

pronation

or supination. which case and the between supinating can the second pronation that, determine within be calculated a forced

This

movement rotation reached. of the rotation normal and there may supination is moving direction body fracture

beyond-in before to the or In

commonly, violence will while former to vary

arrested

these limb,

extremes pattern

are forced its

differentiation to be expected

injuries range be

is pronating injuries calculations. as it

is important. is experimental termed injuries-the in a rotary of displacement

group

group-which or forced if the the

supination is not as it falls,

opposed
reasonable

to forced
to suppose

but

this

rotation

will

to

some

extent

I
FIG. Figure 26 FIG.

27
greenstick
Figure

FIG.

28

FIG.

29
greenstick

26-Pronation-tvpe

28-Supination-tvpe

fracture of radius and ulna. is backwards. Figure supination has reduced the

Angulation 27-Full deformity.

fracture forwards. been

of

radius. Figure reduced

The angulation 29-The fracture by full pronation.

is has

nature and develop fracture.* there backward fractures supplies These

of the a is in will, the principles

soft-tissue and

injury. deviation of

Pronation occurring the this force Supination angulate but the easily
convention

and distal

flexion while fragment, ones the extension (Fig. element in

are the with own are 25). presence

closely forearm forearm of similarly In each the a

allied,

both

mechanically is likely at other produce supination compression of angulation. forearm

developmentally, forward One angulation if they fracturing can

a fracture

is pronating angulation with fracture related, case vertical of

to the a

backward

can

demonstrate a flexing (Fig. angulate, force be

by

pronating in and forwards

the will and

hand;

pronation

which

24).

rotation illustrated
of describing
Thus of

decides

direction the

most
usual

greenstick
angular
forward

fractures
deformity
angulation

with
a whole
or

This

and not bowing)

angulation the distal fragment, instance, if the angulation.

point we lower

bow) is directed in backward of the angle is directed backwards; and so on. When speaking of the direction of the prefer to avoid ambiguity by speaking of deviation rather than angulation. For fragment of a broken bone is deviated backwards, the bone as a whole shows forward

fragment the point

or the proximal. (or convexity)

the

angle

(or

forward forwards;

bending

33 B,

NO.

4,

NOVEMBER

1951

560
angulation,

E.

MERVYN

EVANS

which it (Figs. levels force ulna This and, conception is on part the the method has if 26 and

can to the been it of

be 29).

completely Furthermore, radius angulated for

corrected in these more rotating, approach element to these

by than and its then

reversing fractures the supination deformity injuries the the with the ulna

the

rotational bones are would radius naturally effectie, supination to hold by

force often indicate moves

that broken that around be greater. backward and : the

has at a the

caused different rotation static angulation damaging soft

; this the would most in full tend

acting, a new

in pronation

is fractnredwhile makes the pronation it will side will of a greenstick

possible. simplest, limb and will angular One has the no twisted and the angulation

If, for example,

least intact

of correcting pronation reduction is surprisingly pronate or supinate breaking twist again the gently the the of supination, which method Full or supination
of

be then

by be

placing tightened fracture

tissues In practice

the full the at

reduction. pronation limb the at fracture twist again. to recur, thus to the

deformity

or supination,
(pronation wrist site. as and secured but their certainty according greenstick immobilised initiate As open full will complete unite reducing
atraumatic.

according
type), filly force, limb will: is rotated again easily rotational by to immobilising the in full type (in and complete,

to whether
easy

the

angulation
(Figs. 26 case of intact which the opposite manoeuvre by bone the and usual bend to may

is forwards
29). be, has direction method the with. backwards) recur develop. fractures longer with the commend angulation cases that have to is used two cannot will takes method between position plaster For soft and been

(supination
but to reduction manipulation and the Not of

type)
grasp

or backwards
; there

and The a sapling limb

as the sapling

is complete has limb can only bent to the

is no undue

no

or tearing a green is undone in the original than After limb the the the of treating in an one intact

tissues,

is, as it were, if the back when more for

disappears is repeated. periosteum

is straight be seen is reduction

If the

to disappear more it is more correct

correcting fragments be held pronation in has the angulation after a routine results, for it should above required

the are

angulation, restored comparative

of the can in full

alignment. fracture

reduction, above-elbow is dealing was flexors all greenstick

with

or supination a pronation-type been supinators the sooner for As the reduced and cannot method or later fracture of and which for is in a

example, which because with return as

fracture the to displacement

which

angulation deformity long movement if the will it has fracture and for those be deformity much overcorrected

a practical criticism.

rotational radial rotational however, in the of greenstick common, shaft

immobilisation

pronation
fracture

; moreover

the

so treated to with

disastrous it position just

with these difficult

a gross fractures,

fragments.

a method certain be confined

is simple, perhaps the wrist,

Immobilisation cases is fairly of deformity.

rotational

to

those

in

redisplacement recurrence

remanipulation

CONCLUSIONS An which
mechanism

attempt is so and

has

been

made of

to describe of the forearm of the In of the end hold bone. function

some injuries. radius the radius, former,

of the In

ways

in which forearm, distinction

the has and hand is likely fragment

element a bearing is drawn those in the to

of rotation, upon between there will may be placed in the

important treatment in which fracture to the obtain the

a part the upper and two alignment in full cases injury shaft

of the remains and In and upper. full

normal particular,

those be safely deformity

injuries transmitted be used

in continuity, rotation extremes latter lower the first has has the the In of the there radial group been shaped

in which reduction movement be must and

is a complete

of the

of rotational

to

a reduction. fragments, with the or hold by

a rotational in certain a place injury. in full as in injuries

between rotational immobilisation,

radial pronation in which

in accurate cases the Soft of treatment tissues other

reduction, shown the logically

supination violence pronation

to pattern

have just

of those may types. be used An

a rotation forced

of the treated
JOINT

to guide caused

and

a reduction

in a rotational should
JOURNAL

injury,

be
AND

SURGERY

FRACTURES

OF

THE

RADIUS

AND

ULNA

561 side

supination,

for

only

thus

are

the

intact

soft

tissues

on

the

pronation

of the

limb

used

to the

best In the

advantage. mechanism
is usually

of injuries
the basic

caused
force, has

by injuries
the the the

rotation
a rotation

violence
force

it is emphasized
may the injury be added by

that
the of In and

vertical
direction

compression

to which

of momentum
(in group closely angulation On the which the the
,

of the
violence and and : so also basis

body

weight.
occurring

Such
taken while

may
limb limb

be grouped
beyond or

into
normal

forced
ranges

rotation
the

injuries
rotational latter are flexion

applied element

movement) allied,

injuries a fracture

is pronating of the a forward of the forearm is pronating

supinating. : pronation will develop classified

rotational

determines occurring injury considerations while

pattern the forearm produce

a backward as follows:

a supination of these

will

angulation. may be

injuries

Injuries
Forced

in which
proiiation

the
injuries: dislocation

shaft

of the
of the of the head

radius
of the end

remains
radius. of the

in continuity

1) Forward

2) Backward 3) The anterior

dislocation Monteggia should

lower

ulna.

fracture-dislocation. and by radius immobilised violence. treated in full supination general supination. it to prevent recurrence

be reduced

of deformity.
of the elbow dislocations Pronation angulation. supination. Siipinatioi. Greenstick by full pronation.

The
and of the injuries:

lateral
are head not

and
of the

posterior

Monteggia
rotation are best

injuries

are probably
In in full

variants

of dislocation
that all

caused

is considered

Greenstick

fractures Reduction Certain injuries: fractures

of of fractures

the may

radius, is with

and most

of

both easily be

bones obtained

of

the by

forearm, manipulating in this

with position.

backward into full

deformity

advantage

immobilised

of the

forearm

with

forward

angulation.

Reduction

is best

obtained

Injuries
This

in which
group correction

the

shaft
all

of the
complete

radius
fractures

is in two
of the treatment.

separate
shaft of the

fragments
radius and of both bones of

includes

the
and

forearm.
its

There

is nearly
is a dominant

always
factor

a rotational
in the

deformity

between

the

two

radial

fragments

REFERENCES
EVANS, Journal
EVANS,

E.
of

M.
Bone

(1945):
and

Rotational Joint Surgery,

deformity

in

tile

treatment

of

fractures

of

both to

bones

of

the

forearm.

27, 373.
injuries of Surgery, the forearm

E.

M.
Journal

(1949):
of

Pronation Bone and

with 578. of the

special distal

reference radio-ulnar of the

the

anterior Proceedings

Monteggia of
(Section

fracture.
FITZGERALD,

Joint

31-B,

F.

P. F. W.

(1947): (1950):
PURVIS,

Treatment (Section British G. D. 755. of supination

of displacements of Orthopaedics), Medical

joint. Annual
forearm

the

Royal
of

Society

of Medicine
201.

40,

488.

HOLDSWORTH, Orthopaedics), R. and Joint A.,

Association.
Fractures of

Proceedings both with Third

Meeting
in adults.

1949

KNIGHT, Bone
PATRICK, fractures. WATSON-JONES,

and

Journal

of

Surgery, A study
of Bone

31-A,

J.

(1946): Journal R.

and Surgery, and Joint

pronation, 28, 737. Injuries.

especial edition.

reference Edinburgh:

to the

treatment

of forearm Ltd.

(1943):

Fractures

E. & S.

Livingstone

VOL.

33 B,

NO.

4,

NOVEMBER

1951