Forearm, Wrist, and Hand Reduction

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Chapter 10 Forearm, Wrist, and Hand Reduction

Forearm fractures

Overview

1. Fractures of both bones of the forearm (Figure 10-1) should be reduced anatomically (except in children younger than 12 years) to preserve forearm rotation.

a. Only accept as much deformity as can remodel in 1 year.
b. In children younger than 8 years, bayonet apposition and 20 degrees of angulation is acceptable.
c. In children older than approximately 8 years, length should be restored and angulation of 10 degrees is acceptable.
2. A Monteggia fracture is a combination of a radial head dislocation and a fracture of the ulna. The vast majority of Monteggia fractures should be treated surgically.

a. Anatomic reduction of the ulnar fracture often results in spontaneous reduction of the radiocapitellar dislocation.
b. In children, a greenstick fracture of the ulna may occur or the ulna may plastically deform, and the radial head dislocation is often missed (Figure 10-2).
c. The direction of radial head displacement and ulnar fracture angulation varies and dictates the reduction maneuvers.

3. A Galeazzi fracture is a combination of a radial fracture and a distal radioulnar joint dislocation.

a. The vast majority of Galeazzi fractures should be treated surgically.
b. Anatomic reduction of the radial fracture often results in spontaneous reduction of the distal radioulnar joint dislocation.

4. Nightstick fractures of the diaphyseal ulna can accommodate 10 degrees of angulation and 50% translation.
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Figure 10-1

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Figure 10-2

Indications for Use

1. Ulnar shaft fractures with or without radial head dislocation
2. Radial shaft fractures with or without distal radioulnar joint dislocation
3. Fractures of both bones of the forearm

Precautions

1. Even if an anatomic reduction is achieved, follow-up should occur within a week of the injury.
2. Do not use an intravenous (IV) stand that is attached to the ceiling unless it is specifically designed to handle large weights.
3. Ensure that the finger trap is secure! Sudden and unanticipated release of traction can result in injury to both the patient and the physician.

Pearls

1. Patient positioning is key to obtaining appropriate traction. Strict positioning of the shoulder to 90 degrees and flexion of the elbow to 90 degrees allows perfectly longitudinal traction to be applied through the fracture site.
2. Be patient! Allow 5 to 10 minutes for traction to result in disimpaction of the fracture.
3. Forewarn patients that their index and long fingers may hurt more than their forearms by virtue of the finger trap.

a. Also inform patients that their fingers will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the finger traps are removed.
b. Performing a digital block of the index and long fingers before traction may be considered in certain patients.

4. To “release traction” while performing the reduction maneuver, it is often easier to simply grasp the hand and allow slack in the fingertrap or traction loop.

Improvisation

1. Reduction of a forearm fracture requires tailoring the technique to each fracture type.
2. If supplies are limited, taping the forearm to a stiff board will suffice until definitive management can be arranged.
3. Alternative reduction methods can be attempted if no traction is available.

a. Grasp the proximal forearm and the distal forearm with the thumb of the proximal hand just proximal to the fracture site (Figure 10-3).
b. Pull traction while using your thumb to key in the fracture by pushing on the proximal fragment at the fracture apex (Figure 10-4).

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Figure 10-3

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Figure 10-4

Equipment

1. Stockinette: 3 inches wide, 4 feet long
2. Rolled gauze: 2 inches wide
3. IV pole
4. Weights: 10 to 15 lb
5. ABD pad (optional)

Basic Technique

1. Patient positioning:

a. Supine on stretcher
b. Shoulder to 90 degrees and flexion of elbow to 90 degrees

2. Landmarks:

a. Ulnar head
b. Radial head
c. Radial styloid
d. Subcutaneous border of ulna

3. Steps:

a. Position the patient.
b. Prepare finger traps.
c. Set traction, if necessary.
d. Obtain traction views, if desired.
e. If a long arm cast will be applied afterward, place cast padding on the elbow and proximal surface before applying traction.
f. Perform a reduction maneuver.
g. Apply a cast or splint.
h. Remove traction.
i. Obtain elbow, forearm, and wrist films.

Detailed Technique

1. Position the patient:

a. The patient should be supine on the stretcher with his or her shoulder girdle entirely off the side.
b. If a long arm cast will be applied afterward, place a stockinette (see Chapter 13).

2. Begin sedation.
3. Prepare finger traps:

a. Attach a rolled gauze finger trap (Chapter 8) to the index and long fingers using a double-ring construct (Figure 10-5).
b. Abduct the shoulder to 90 degrees and flex the elbow to 90 degrees to create a 90-90 position.
c. Secure the other end of the traction to the IV pole.

4. Set traction, if necessary (Figure 10-6).

a. Cut a 2-foot length of stockinette.
b. Place an ABD inside the stockinette for padding (optional).
c. Cut small holes in each end of the stockinette.
d. Drape the stockinette around the forearm.
e. Hang the traction weights.
f. Allow traction to hang for at least 5 minutes (less than 1 hour is recommended).
5. Obtain traction views (optional). Portable anteroposterior (AP) and lateral radiographs of the forearm, wrist, and elbow can be obtained in traction to evaluate the reduction.
6. Perform a reduction maneuver (Figures 10-7 and 10-8).

a. The direction in which forces are applied depends on the type of fracture.
b. Bring the distal fragment to the proximal fragment.
c. Correct forearm rotation to match proximal fragments, generally as described below:

(1) Proximal fractures of both bones of the forearm: mild supination
(2) Midshaft fractures of both bones of the forearm: neutral
(3) Distal fractures of both bones of the forearm: slight pronation

7. Apply a splint (see Chapter 13) or a cast (see Chapter 13) while maintaining traction.

a. Prepare an interosseous mold (Figure 10-9).
b. Flatten the ulnar border of the cast/splint with your shin (Figure 10-10) or a flat surface (Figure 10-11).
8. Obtain postreduction AP and lateral films of the elbow, forearm, and wrist.
image

Figure 10-5

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Figure 10-6

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Figure 10-7

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Figure 10-8

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Figure 10-9

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Figure 10-10

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Figure 10-11

Distal radius fracture reduction

Overview

1. Many distal radius fractures, particularly in children, can be treated with closed reduction and casting (Figure 10-12).
2. The principle of the distal radius fracture reduction method is to:

a. Disimpact the fracture by using hanging traction
b. Manually reduce the distal fragment

3. This procedure can be performed by a single individual when an IV pole and traction weights are used.
image

Figure 10-12

Indications for Use

1. Displaced distal radius fractures
2. Carpal fractures

Precautions

1. Do not use an IV stand attached to the ceiling unless it is specifically designed to handle large weights.
2. Ensure that the finger trap is secure! A sudden and unanticipated release of traction can result in injury to both the patient and the physician.

Pearls

1. Patient positioning is key to obtaining appropriate traction. Strict positioning of the shoulder to 90 degrees and flexion of the elbow to 90 degrees allows perfectly longitudinal traction to be applied through the fracture site.
2. Be patient! Allow 5 to 10 minutes for traction to result in disimpaction of the fracture.
3. Forewarn patients that their thumb may hurt more than their wrist by virtue of the finger trap.

a. Also inform patients that their thumb will likely turn blue but that this symptom is normal, expected, and will resolve shortly after the finger traps are removed.
b. Performing a digital block of the thumb before traction may be considered in certain patients.

4. To “release traction” while performing the reduction maneuver, it is often easiest to simply grasp the forearm and allow slack on the finger trap or traction loop.

Improvisation

1. Alternative reduction methods can be attempted if traction is not available or is ineffective.

a. Alternative 1: Use your thenar eminences to “contour” the forearm and apply traction if minimal displacement is present (Figure 10-13).
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