Common forearm fractures/dislocations Galeazzi fracture-dislocation A Galeazzi fracture-dislocation involves a fracture of the distal third of the radial shaft with dislocation of the distal radioulnar joint. The mechanism of injury is axial loading of an outstretched hand with wrist extension and forearm pronation (Panagopoulos et al., 2021). In children, the peak incidence for this fracture is age 9 to 12 years. Participation in sports, especially football and wrestling, is a risk factor. Another risk factor is osteoporosis. Patients with a Galeazzi fracture-dislocation will typically complain of pain at the injury site. Evaluation includes inspection of the skin and soft tissue, with attention to visible bony deformities as well as concomitant conditions such as skin lacerations and muscle contusions. Gentle palpation can be done to determine if deformity and/or tenderness are present. Inquiry regarding the presence of weakness, numbness, paresthesias, and radiating pain is important. Nerve damage is uncommon, but if indicated, examination of median and radial nerve function may be necessary. Treatment for this condition is surgical intervention for adults and conservative management for children (Johnson and Smolensky, 2023). Monteggia fracture A Monteggia fracture is a fracture to the proximal ulna with dislocation of the radial head. The mechanism of injury is a direct blow to the forearm with the elbow extended and the forearm pronated. The ulnar fracture energy is transmitted along the interosseous membrane. This causes a rupture of the proximal quadrate and annular ligaments with consequential disruption of the radiocapitellar joint. In younger males, this type of fracture is usually due to high- energy trauma such as falls from height, sports injuries, or motor vehicle crashes. In older adults, the mechanism is low-energy trauma, such as a ground-level fall (Johnson and Silberman, 2023). Monteggia fractures are classified as follows: ● Type I : Fracture of the proximal ulna and radial head dislocation anteriorly. This type is more common in children due to the mechanism of injury. The mechanism of injury for type 1 fractures is direct blow to the posterior elbow, a hyperpronated force on an outstretched arm, or contracted biceps resistance to forearm extension causing dislocation followed by impact leading to ulnar fracture (Johnson and Silberman, 2023). Type 1 fractures are most commonly seen as in contact sports athletes. ● Type II : Both the ulnar shaft fracture and radial head dislocation are directed posteriorly. This is the most common type in adults. The mechanism of injury is axial loading of the forearm with a slightly flexed elbow, such as a fall onto an arm that is not fully outstretched. This type is associated with instability of the ulnohumeral joint with high rates of radial head fracture and posterior interosseous nerve injury (Johnson and Silberman, 2023).
● Type III : Ulnar fracture with the radial head dislocated laterally. The mechanism of injury is a varus force on an extended elbow with greenstick fracture of the ulna. It is most common in children after a fall, as they often put out their arm as a protective reaction (Johnson and Silberman, 2023). ● Type IV: Fractures of both the ulnar and radial shafts with anterior dislocation of the radial head. This fracture type is rare (Johnson and Silberman, 2023). Clinical Presentation Symptoms will include pain at the injury site. Examination should include inspection for soft tissue and bony deformities and muscle contusions and gentle palpation for deformity and tenderness. A neurovascular exam is warranted for high-mechanism crush injuries to look for signs of acute compartment syndrome. Clinicians should inquire about the presence of numbness, weakness, paresthesias, and radiating pain. Nerve injuries are less common, but examination of radial and median nerve function should be completed if indicated. All Monteggia fractures are unstable, requiring surgery (Johnson and Silberman, 2023). Essex-Lopresti fracture Essex-Lopresti fracture is also known as longitudinal radioulnar dissociation. It occurs when a high-energy axial load is applied to the forearm, usually a fall on an outstretched hand. This injury consists of a fracture to the radial head, a disruption of the distal radioulnar joint, and rupture of the interosseous membrane. This injury is often either missed or poorly treated, which can lead to instability Patients often complain of pain in the wrist and elbow secondary to a significant injurious event. Forearm rotation increases pain. Grip strength is weak. Wrist tenderness is common, especially on the ulnar side. The interosseous space may also be tender (Singh, 2019). Healthcare Consideration: For many fractures of the hand, wrist, and forearm, a fall on an outstretched hand (FOOSH) is a common mechanism of injury. This includes fractures to the distal radius (Smith fracture, Colles fracture, Barton fracture, Chauffeur fracture), carpal fractures (scaphoid fracture, triquetrum fracture, hamate fracture), and forearm fractures (Galeazzi fracture- dislocation, Monteggia fracture-dislocation, Essex Lopresti fracture-dislocation, radial head fracture; Fahrenhorst- Jones & Jones 2010). (Masouros et al., 2019). Clinical Presentation
FOREARM OVERUSE INJURIES
Chronic exertional compartment syndrome of the forearm Chronic exertional compartment syndrome is characterized by a reversible increase in pressure within the elastic fascial compartment of the forearm, which leads to compromised circulation, pain, and neurological symptoms. This condition is rare, most commonly occurring in rowers and motorcyclists (Buerba et al., 2019), but has also been reported in baseball players, bodybuilders, cyclists, kayakers, rock climbers, swimmers, water skiers, wheelchair athletes, and wind surfers (O’Dowd et al., 2021).
Differential diagnosis includes stress fracture, deep vein thrombosis, radiculopathy, tendinitis, and peripheral nerve entrapment. Definitive diagnosis involves needle measurements of compartmental pressure (Buerba et al., 2019).
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