Please rate topic.
Average 4.3 of 62 Ratings
Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
Longitudinal radioulnar dissociation, including Essex Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT?
Central band ligament
Accessory band ligament
Dorsal oblique accessory cord ligament
Distal oblique bundle ligament
Select Answer to see Preferred Response
The IOM includes 5 types of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The annular ligament is not a part of the IOM.
The IOM bridges the radius and ulna and acts as a hinge for rotation of radius about ulna. The central portion is thickened, and forms the central band which is the most important ligament for IOM load distribution characteristics.
Noda et al, in a cadaver study, identified the precise anatomical insertions and attachment points of each of the 5 IOM components. They found the most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head.
Pfaeffle et al also performed a cadaveric biomechanical study applying compressive loads to specimens with IOMs that are intact, cut, or cut/reconstructed with flexor carpi radialis allografts. They found that reconstruction of the IOM can restore the normal load transfer chararcteristics and that the central band of the IOM is the most important portion of the IOM to be reconstructed.
Illustration A shows the ligaments of IOM membrane: CB = central band, AB = accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord
The annular ligament is a strong band of fibers, which encircles the head of the radius and keeps the radius in contact with the radial notch of the ulna, but is not a part of the IOM.
Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H
J Hand Surg Am. 2009 Mar;34(3):415-22. PMID: 19211201 (Link to Abstract)
Noda, JHS 2009
Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM
J Hand Surg Am. 2005 Mar;30(2):319-25. PMID: 15781355 (Link to Abstract)
Pfaeffle, JHS 2005
Please rate question.
Average 2.0 of 30 Ratings
A 25-year-old female sustains the isolated fracture seen in Figure A. The patient elects to have nonoperative management. When compared to operative treatment, which of the following is true of the clinical outcome following nonoperative management?
Long arm cast immobilization is necessary with nonoperative management
Twenty degree loss of forearm rotation is expected with nonoperative management
Loss of wrist motion is expected with nonoperative management
Loss of elbow motion is expected with nonoperative management
Equivalent clinical outcomes
The clinical presentation is consistent for an isolated ulnar fracture, or "night stick" fracture. For minimally displaced and angulated fractures, nonoperative management has equivalent clinical outcomes to surgical treatment.
Isolated ulnar shaft fractures with greater than 10 degrees of angulation or 50% displacement can result in loss of forearm rotation if treated nonoperatively. For minimally displaced fracture, nonoperative treatment results in union with good function. Time to union has been found to be greater in nonoperative groups, but clinical outcomes equivalent.
Pollock et al. compared two patient groups treated with short term immobilization or long term cast treatment and found no significant difference between wrist and elbow motion between the two groups. The short term immobilization group in their study had a shorter time to union and lower non union rate as well.
Pollock FH, Pankovich AM, Prieto JJ, Lorenz M.
J Bone Joint Surg Am. 1983 Mar;65(3):339-42. PMID: 6826596 (Link to Abstract)
Pollock, JBJS 1983
HPI - History of trauma 14 days ago. Placed in cast at outside institution.
How would you treat this fracture?
Average 3.0 of 31 Ratings
Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury?
Once ankylosis of the forearm or elbow occurs
Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occuring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT).
The referenced study by McAuliffe et al is a retrospective review of heterotopic ossification (HO) about the elbow followed by 1000 cGY (5 fractions over 1 week) of XRT as early as 3 months post-injury. They were able to achieve an average arc of motion > 100 degrees.
The other referenced study by Beingessner et al is a review of HO excision of the forearm. They found that excision and XRT, followed by 6 weeks of indomethacin, led to an increase of forearm motion from an average of 17 degrees to 136 degrees when the excision was done at 4 months post-injury.
Beingessner DM, Patterson SD, King GJ.
J Hand Surg Am. 2000 May;25(3):483-8. PMID: 10811753 (Link to Abstract)
Beingessner, JHS 2000
McAuliffe JA, Wolfson AH.
J Bone Joint Surg Am. 1997 May;79(5):749-55. PMID: 9160948 (Link to Abstract)
McAuliffe, JBJS 1997
Average 2.0 of 44 Ratings
A 22-year-old male sustains the closed injury seen in figure A. The injury is best treated with which of the following methods?
Flexible intramedullary nailing
Open reduction and internal fixation with acute bone grafting
Open reduction and internal fixation
Closed reduction and functional bracing
The xray shows a comminuted, high energy both bone forearm fracture. Open reduction and internal fixation without bone grafting is the most appropriate treatment. Acute bone grafting is only indicated if a large bony void, such as segmental bone loss of the radius, is present to allow the displaced bone ends to heal together despite their diastasis.
In Moed et al's review, primary internal fixation in open forearm fractures led to nearly a 90% union rate (44/50) and good/excellent results in 85%. Autogenous cancellous grafting was recommended if interfragmental compression could not be obtained.
In Wright et al's review, there was no significant difference between union rates in comminuted both bone forearm fractures whether or not autograft was used (97% v. 98%). However, these did not have bone loss per se, and only evaluated whether or not comminution was present.
Wright RR, Schmeling GJ, Schwab JP
J Orthop Trauma. 1997 May;11(4):288-94. PMID: 9258828 (Link to Abstract)
Wright, JOT 1997
Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr.
J Bone Joint Surg Am. 1986 Sep;68(7):1008-17. PMID: 3745238 (Link to Abstract)
Moed, JBJS 1986
Average 3.0 of 27 Ratings
A 27-year-old male sustains a type I open both bone forearm fracture as seen in Figure A. During irrigation and debridement a 1 cm of cortex is removed leaving a segmental gap. Which of the following adjuvants is recommended to supplement your internal fixation?
Bone grafting in the primary fixation of fractures is typically limited to those with segmental defects. While the increased surface area of a comminuted fracture may aid in the healing potential, the segmental defect is a limiting factor to fracture healing. Calcium sulphate, tricalcium phosphate, BMP-3, and calcium phosphate are not indicated in this clinical picture. BMP-2,4,6, and 7 all have osteoinductive activity but BMP-3 does not demonstrate osteoinductive activity.
In their retrospective review of 198 fracture, Wright et. al found BG was not indicated for comminuted open fracture, and only recommend BG when there is a segmental bone defect.
Wei et. al also performed a retrospective review of 64 fractures in 49 patients and found BG was not indicated for comminuted open fracture, and only recommend BG when there is a segmental defect.
Finally, Schemitsch and Richards determined that optimal outcome post forearm fracture depends on restoration of the radial bow.
Wei SY, Born CT, Abene A, Ong A, Hayda R, DeLong WG Jr.
J Trauma. 1999 Jun;46(6):1045-8. PMID: 10372622 (Link to Abstract)
Wei, JTACS 1999
Schemitsch EH, Richards RR.
J Bone Joint Surg Am. 1992 Aug;74(7):1068-78. PMID: 1522093 (Link to Abstract)
Schemitsch, JBJS 1992
Average 3.0 of 24 Ratings
What is the primary advantage of two incisions compared to one for open reduction internal fixation of a both bones forearm fracture?
lower risk of synostosis
lower risk of wound complications
lower rate of radial neuritis
less pronator teres denervation
lower malunion rate
Post-osteosynthetic synostosis is a known complication in both bone forearm fractures. The risk is increased in fractures of the proximal 1/3 of the ulna and radius. Other risk factors include severity of injury, head trauma, polytrauma. Vince et al found synostosis was often associated with bone fragments or hardware in the interosseous space. Bauer et al found 1/65 cases treated utilizing the two-incision approach developed synostosis, while 5/12 cases in which the fractures were stabilized using a single incision developed synostoses. They recommended a two incision approach to both bones ORIF.
Vince KG, Miller JE.
J Bone Joint Surg Am. 1987 Jun;69(5):640-53. PMID: 3110165 (Link to Abstract)
Vince, JBJS 1987
Bauer G, Arand M, Mutschler W.
Arch Orthop Trauma Surg. 1991;110(3):142-5. PMID: 2059537 (Link to Abstract)
Bauer, AOTS 1991
Average 3.0 of 28 Ratings
Treatment of an atrophic nonunion of the radial diaphysis should include which of the following?
Ultrasound bone stimulator
Plate exchange with autogenous cancellous grafting
Plate exchange with ulnar shortening osteotomy
Atrophic nonunions of the radius and ulna are fairly rare with modern techniques of fixation; the few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions.
The referenced study by Ring et al noted a 100% healing rate and improved patient reported outcomes with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting for atrophic forearm nonunions. They recommend compression plating when possible to obtain optimal healing.
Illustration A shows an example of an atrophic nonunion of the radius.
1: Ilizarov fixation is not indicated for radial diaphyseal nonunions.
2 and 3: Electrical stimulation and ultrasound stimulation have not been shown to have increased radiographic or functional outcomes as compared to revision fixation and bone grafting.
5: Shortening osteotomy would create alterations in muscle length and lead to decreased hand/digital function.
Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB
J Bone Joint Surg Am. 2004 Nov;86-A(11):2440-5. PMID: 15523016 (Link to Abstract)
Ring, JBJS 2004
Average 4.0 of 17 Ratings
All of the following have been shown to increase the risk of refracture following removal of forearm plates used for internal fixation EXCEPT:
initial fracture comminution
initial fracture displacement
use of 3.5 mm dynamic compression plate
plate removal before 12 months
immediate activity as tolerated following removal
The Rumball et al article reviewed factors which influenced refracture after removal of the forearm plates. The factors that appeared to influence the refracture rate were degree of initial displacement and comminution, physical characteristics of the plate, early removal and lack of postremoval protection. Plates removed under 15 months showed an increased risk of refracture. There were no fractures in this series using the 3.5 DCP plate.
Deluca et al concluded that, in retrospect, radiolucency at the site of the original fracture was seen in most patients (with refracture) when the plate was removed.
Chapman et al found that all the refractures in their group had been intially treated with a 4.5 DCP plate, and that none of the patients with a 3.5 DCP had a refracture.
Rumball K, Finnegan M.
J Orthop Trauma. 1990;4(2):124-9. PMID: 2358925 (Link to Abstract)
Rumball, JOT 1990
Deluca PA, Lindsey RW, Ruwe PA.
J Bone Joint Surg Am. 1988 Oct;70(9):1372-6. PMID: 3182889 (Link to Abstract)
Deluca, JBJS 1988
Chapman MW, Gordon JE, Zissimos AG.
J Bone Joint Surg Am. 1989 Feb;71(2):159-69. PMID: 2918001 (Link to Abstract)
Chapman, JBJS 1989
Average 2.0 of 40 Ratings
An otherwise healthy 30-year-old male sustains a left forearm injury as a result of a fall from a ladder. Initial examination in the emergency room reveals a clean 2 centimeter laceration over the volar forearm associated with the radiographs shown in Figures A and B. Treatment should consist of irrigation and debridement of the wound followed by which of the following?
Closed reduction and casting of left radius and ulna
Temporary external fixation of the left radius and ulna
Definitive external fixation of the left radius and ulna
Open reduction and internal fixation of the left radius and ulna with delayed skin closure
Open reduction and internal fixation of the left radius and ulna with immediate skin closure
The clinical scenario is consistent with an open fractures of the distal radial and ulnar shafts. Literature shows that definitive plating of an open forearm fracture followed by primary closure of the wound is acceptable treatment at the time of injury.
Chapman et al performed a retrospective review of 50 patients with immediate internal plate fixation of an open diaphyseal fracture of the forearm. The functional results were excellent or good in 85%.
The review by Levin is a comprehensive review of the literature on early versus delayed closure of open fractures, and covers the change in thought from previous literature, including change in technology, surgical techniques, and a more critical review of previous literature.
Injury. 2007 Aug;38(8):896-9. Epub 2007 Jun 21. PMID: 17585912 (Link to Abstract)
Levin, INJURY 2007
Average 3.0 of 23 Ratings
During open reduction and internal fixation of a both bone forearm fracture, restoration of the radial bow has been most associated with which of the following?
Improvement in wrist extension strength
Improvement in wrist flexion strength
Restoration of forearm rotation
Restoration of elbow range of motion
Decreased incidence of synostosis
Restoration of the anatomy of the radial bow directly correlates with the range of motion postoperatively (pronation-supination).
The referenced study by Schemitsch et al found that restoration of the normal radial bow was related to the functional outcome. A good functional result (more than 80 percent of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow. Similarly, the recovery of grip strength was associated with restoration of the location of the radial bow toward normal.
A 42-year-old male sustains a closed, isolated ulna shaft fracture with 2mm displacement and 3 degrees valgus angulation. He is treated conservatively with early range of motion but presents at one year with a painful atrophic nonunion. What treatment is indicated at this time?
Open autogenous cancellous bone grafting
Open reduction internal fixation with autogenous bone grafting
Closed reduction and percutaneous pinning
Use of an implantable ultrasound device
Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique.
Clin Orthop Relat Res. 1986 Nov;(212):219-30. PMID: 3769288 (Link to Abstract)
Street, CORR 1986
Average 3.0 of 33 Ratings
Title: Forearm Fractures - What Approaches? Presenter: Robert J. Strauch, MDColu...
HPI - Machine twist and injury right forearm
How would you manage this patient at this point?
HPI - Patient underwent surgery 2 years ago after falling while playing soccer. He suffered a comminuted diaphyseal radial shaft fracture, treated with open reduction and internal fixation with 2 K-wires.
How would you manage this patient?
HPI - Pain and swelling in LEFT wrist - patient cannot remember any history of trauma
What is the best treatment of this injury?
HPI - 16 year old patient presents following open forearm fracture of the ulna, fixed with ulnar ORIF and skin graft, 10 months ago.
The fixation has become infected and appears that the union is not complete. Wound discharge has been present for 3 weeks.
No pain, good function of hand.
Extension at wrist causes flexion of the finger at PIP and DIP joints.
HPI - Pain left forearm for 5 months
No fever or discharge
Do you think this is infected?
HPI - Patient with Parkinson disease, many falls. Fell 2 years ago with a diaphyseal radius fracture operated with a volar plate and healed. Fell again and new fracture on the proximal side of the plate. Non dominant extremity. Xrays show old distal radius fracture with malunion on ipsilateral side of undeterminate age
How would you treat this patient at this time (fx adjacent to hardware)?
HPI - The pt was apparently well 1 week prior to admission, he was climbing a coconut trees on the evening and fell to the ground from a height of approximately equal to 2 story house and sustained broken both-bone fx of right forearm.
The patient had loss of consciousness and only woke up when he already in hospital with his right forearm covered with bandages. and he probably brought to hospital by passerby.
The patient is unable to recall the positioning of the limbs, head and chest when he fell. He currently complains of continued pain and inability to move right forearm. Since he regained consciousness from the accident he also complains of mild headache and double vision on his left eye .
He also complains of chest pain on breathing especially on left chest. However, the pain score is lesser compared the first day he regained consciousness.
Looking at the PIP dislocation in the ulnar gutter (post splinting radiograph), do you think it is reduced?
HPI - - First intervention. Trauma July 2008: fracture of both bones (we do not have x-ray control of the fracture and intervention), compression plates with BioTek.
- Second intervention: 8 months after: radius nonunion, compression plate with autoplastic iliac crest graft. Healed
- Third intervention. Trauma Jan 2014: refracture of both bones, plates without grafting.
- Now comes by us with rx control: nonunion both bones.
The radius in all three cases as always been operated through Thompson approach
How would you treat this patient?
HPI - 51 year old male (electrician) presented at the ER after a direct blow from a stick to the forearm (not dominant hand).From the radiological control we found a Ulnar diaphysis fracture (closed) type B1.1. We performed a closed reduction under local anesthesia and we applied a long arm cast.
treatment options (conservative or not)
HPI - Young football player fall on his forearm during a match
How would you treat this injury?
HPI - there is h/o RTA 6months ago.Initially treated by pop.Now c/o pain and inability to perform routine activities
HPI - h/o fall at play injury to the left foream.pain at wrist motion
HPI - Patient sustained a closed Fx R/U after road traffic accident 1 year back
How could this be treated?
HPI - This patient had ORIF fracture ulna radius 3 years ago which united uneventfully. 2 days ago he was playing foootball game, involved in tackle and recieved other player kick on his forearm.His xrays show fracture ulna around distal screw of plate.
How will u manage this case?
HPI - h/o fall from a height of 3 ft. sustained a closed fracture both bones forearm. no signs of any neurovasculardefecit
HPI - *Conveyor belt injury
How will you manage this case?
HPI - He had a gunshot injury 8 months back. Compound fracture of both radius & ulna. Managed conservatively.
What is the management?