Definition: Fracture of the ulnar radial styloid is one of the common upper extremity injuries, including double fracture of the ulnar radius, simple ulnar styloid fracture or simple radial styloid fracture with normal upper and lower ulnar radial joints.
Delayed healing and nonunion are rare in pediatric patients, and closed reduction external fixation is usually successful, so conservative treatment is the standard of care for this fracture. However, significant angular deformity of the forearm can lead to permanent loss of anterior or posterior rotation with residual forearm flexion deformity, so early and proper treatment should not be neglected. Fascial septal syndrome occurs less frequently in the upper extremity, and once it occurs the consequences are severe. In severe fractures of the ulnar radial diaphysis one should be alert for its occurrence and early detection and treatment .
Etiology and pathogenesis.
I. Direct violence.
Mostly seen in heavy blows or machine injuries, knife cuts, the fracture is transverse or comminuted type, and the fracture line is in the same plane. Due to the direct action of violence, it is mostly accompanied by soft tissue injuries of different degrees, including muscle and tendon rupture, neurovascular injury, etc.
II. Indirect violence.
When the palm of the hand lands during a fall, the violence is transmitted upward through the wrist joint resulting in the fracture of the middle or upper 1/3 of the radius, and the residual violence is transmitted obliquely downward through the interosseous membrane to the ulna, resulting in the ulnar fracture, so the ulnar fracture line is lower than the radial fracture line. Radial fractures are mostly transverse or serrated, and ulna is mostly short oblique type.
Third, torsional violence.
When the body is tilted to one side during a fall, the forearm is subjected to both longitudinal conduction and rotational torsion, and a spiral-type double fracture of the ulnar radius occurs. The fracture lines are in the same direction, mostly high ulnar fractures and low radial fractures.
Clinical manifestations.
Local swelling, deformity and pressure pain after trauma to the forearm, there may be bone rubbing sounds and abnormal activity, and forearm movement is limited. In children, the fracture is often a green branch fracture with an angular deformity without displacement of the bone end. Sometimes combined with median nerve or ulnar nerve or radial nerve injury, attention should be paid to the examination.
Treatment principles.
1, fractures without displacement or fractures with mild displacement of the single ulna and radius, functional exercises such as external fixation in plaster are feasible.
2.The fractures with more obvious displacement are administered with manual repositioning. External fixation in plaster for at least 4-6 weeks for stable fixation.
3. Unstable fractures and open fractures that have been manually rehabilitated. Surgical treatment of internal fixation (e.g. plate, elastic nail) for vascular nerve injury.
Double fractures of the ulnar radial trunk
① Green branch fracture.
② Double fractures of the ulnar radial trunk at the same level and transverse fractures of the ulnar radial trunk at different levels.
③ Double transverse fractures of the ulnar radial trunk at the same level and in the same direction of displacement.
Treatment methods.
1. Conservative treatment: the forearm is fixed in a cast under continuous traction by an assistant. The length of the palmar side is from the transverse elbow to the transverse wrist, the dorsal side from the ulnar hawk to the wrist joint, the radial side from the radial head to the radial tuberosity, and the ulnar side from the medial epicondyle of the humerus to the base of the fifth metacarpal. If the fracture is originally displaced angularly or laterally, a pressure pad is placed with a three-point or two-point compression method according to the direction of displacement. For middle and upper 1/3 fractures, a flat pad is placed on the palmar side of the forearm where the fracture is angulated, and a flat pad is placed on the distal and proximal sides of the dorsal forearm, and another flat pad can be placed on the radial side of the fracture because the fracture end is easily angulated to the palmar and radial sides; for upper 1/3 fractures, the proximal radius is easily displaced to the radial side, and another flat pad can be placed on the radial side of the proximal radius. The use of a split bone pad is not recommended because it has been observed that it is difficult to prevent the ulnar radius from coming together, but it is likely to cause skin compression necrosis. After resetting the ulnar-radial stem double fracture, the forearm is fixed in plaster, and the forearm is kept in neutral position to prevent rotation. For the lower 1/3 ulnar fracture, the ulnar cast should exceed the wrist joint, fixing the wrist in the radial deviated position and the forearm in the rotated anterior position. The lower 1/3 fracture is slow to heal, so the fixation time can be extended. For superior 1/3 and middle 1/3 ulnar fractures, the forearm is fixed in a neutral position. Children are immobilized for 4-5 weeks. For superior 1/3 radius fractures, the forearm is fixed in neutral or rotated posterior position, and for middle 1/3 and lower 1/3 fractures, the forearm is fixed in neutral position with the elbow flexed at 90 degrees and the triangular scarf suspended over the chest. Plaster fixation for 4-6 weeks.
2.Surgical treatment.
Closed reduction elastic nail internal fixation: At present, the most widely used internal fixation method for ulnar radial diaphyseal fracture in children is elastic intramedullary pin. If the ulnar radius is fixed internally, external fixation is usually not needed, and in some cases, the bone position of the other bone is relatively stable after single bone fixation, so it is supplemented by forearm U-shaped cast braking. The internal fixation can be removed in 3 months after surgery.
Internal fixation with an incisional plate: Of course, for comminuted fractures, old fractures with closed medullary cavity and unstable fractures in older children close to growth arrest, and patients with high requirements for bone position, internal fixation with an incisional plate can achieve good repositioning and stabilization results.
Open fractures: The fracture should be debrided in the operating room to make it a closed wound. The treatment plan is then determined by the degree of fracture angulation. In children of all ages, an ulnar radius fracture with an angle of 0° to 10° is allowed. Children under 5 years of age can tolerate such an angle and have the ability to reshape the fracture, so they can be maintained in a cast, while children over 5 years of age have a decreased ability to reshape and may have residual forearm rotation dysfunction, so closed reduction should be performed to keep the angle below 10°. For cases with angulation greater than 20°, it is unacceptable regardless of age, so closed reduction should be chosen to correct the angulation deformity. If manual reduction fails or if the fracture is unstable and prone to redisplacement, closed reduction elastic intramedullary pin internal fixation should be considered. For severe comminuted fractures, old fractures, etc., internal fixation with plates should be considered.
Postoperative rehabilitation
1. Whether it is external fixation by manipulation or internal fixation by incision, the affected limb should be elevated after surgery, and the degree of swelling, sensation, movement and blood circulation of the limb should be strictly observed to be alert to the occurrence of osteo-fascial compartment syndrome.
2.Practice finger flexion and extension activities on the first day after surgery. 4-6 weeks after the film to confirm that the fracture has healed, only then can the forearm rotation activities.