Howard Charles

D. Goldberg, MD #{149}Jeremy W. R. Young, MD S. Resnik, MD #{149}Thomas E. Gillespie, MD

Double Injuries ofthe A Common Occurrence’ To evaluate the frequency of different types of forearm fractures and, in particular, determine the frequency of double injury to the forearm, the authors prospectively examined 119 consecutive forearm fractures and found double injuries to the forearm in all but five cases. In 79 of the 119 patients (66%), ligamentous injury was seen in addition to the obvious fracture. Nine patients with apparent isolated fractures on initial radiographs underwent examination by means of radionuclide bone scanning, which revealed a second injury in eight of them. Four patients with apparent single fractures did not undergo bone scanning because of their critical conditions. In four patients, a single fracture was initially diagnosed, but after reduction and casting, dislocation of the radioulnar joint was seen. These findings indicate that injury to the forearm almost invariably occurs at two or more sites and involves either both bones or bone and ligament. Because the distal radioulnarjoint was affected in 71 patients (60%), scrutiny of the wrist is imperative whenever injuries to the bones of the forearm are discovered. Index terms: Radiography #{149} Radius, 42.4199, 42.42, 431.4199 #{149} Trauma, 42.4199,42.42, 431.4199, 432.42 #{149} Ulna, 42.4199, 432.4199 Radiology

1992

185:223-227

I

A prospective

0

reprint requests RSNA, 1992

tOJ.W.R.Y.

MD

Forearm:

that ring strucpelvis and mandible are prone to injury at two sites (1,2). Gertzbein and Chenoweth (1) have elegantly demonstrated that the pelvic ring is invariably injured at two sites, even if injury at only one site is seen on initial radiographs. The jaw, specifically the mandible and ternporomandibular joints, has been reported to have multiple fractures in 50%-60% of cases; most published studies report a frequency of 1.5-1.8 jaw fractures per patient (2). Traditionally, the lower leg and forearm have not been included in the list of ring structures, although, practically, they consist of two separate bones united by ligaments and joints. Although Monteggia (3-7) and Galeazzi (6,8-li) fracture-dislocations are well recognized, forearm fractures with double dislocations, double fractures with dislocation, fracture and dislocation of the same bone, and more obvious fractures of both bones have received little attention in the musculoskeletal literature. Several authors have described isolated fractures of one bone without either fraclure or dislocation of the other bone (3,12-17). Because our experience has shown that this type of forearm injury is rare, we designed a study to evaluate the frequency of different types of forearm fractures and, in particular, to determine the frequency of double injury to the forearm. AND

METHODS

study was performed in forearm fractures initially examined in the emergency department or shock trauma center of our institution during a 6-month period. Fractures of only the distal radial epiphysis and distal radioulnar articulation (ie, Colles, Smith, and Barton fractures) were exduded from the study. All radiographs were first exammed by two radiologists (J.W.R.Y., C.S.R.) who specialize in orthopedic and trauma 119 consecutive

dress

I. Reiner,

T is well established hires such as the

MATERIALS

I From the Departments of Radiology (H.D.C., J.W.R.Y., B.I.R., C.S.R.) and Orthopaedic Surgery (T.E.C.), University of Maryland Medical System, 22 S Greene St, Baltimore, MD 21201. Received March 20, 1992; revision requested April 27; revision received May 11; accepted June 3. Ad-

#{149}Bruce

radiology

and

subsequently

by

a medical

student to evaluate (a) the number of frachires, (b) the number of bones involved, (c) any obvious dislocations at either end of the bones, and (d) any additional abnormalities after casting or pinning. Any differences in interpretation were resolved by consensus. Nine patients with one fracture only and no obvious second fracture or dislocation also underwent examination by means of radionuclide bone scanning. In four cases in which only a single fracture was found on radiographs, bone scans could not be obtained because the patient’s critical condition prevented transport from the shock trauma center.

RESULTS One patients

hundred fourteen of the 119 (96%) had a combination of fractures of both bones or of fractures and dislocations. In five patients, a second site of injury was not identifled (see next paragraph). Thirtyseven patients (31%) had unequivocal Galeazzi fractures, defined as fracture of the radius with dislocation of the distal radioulnar joint. Thirty-four patients (28%) had fractures of both the radius and the ulna. Thirteen additional patients (11%) had fractures of both the radius and the ulna with a dislocation at either the proximal or distal radioulnar joint (Figs 1, 2). Eight patients (7%) had a fracture and dislocation of the same bone (Fig 3). Six patients (5%) had unequivocal Monteggia fractures, which are defined as fracture of the ulna with dislocation of the proximal radioulnarjoint. Two patients (2%) had a fracture of either the radius or the ulna with dislocalions of both proximal and distal radioulnar joints, and one patient (1%) had a fracture of the distal radius, disruption of the distal radioulnar joint, and total dislocation of the elbow (Fig 4). One patient (1%) had fractures of both bones and dislocations of both distal and proximal radioulnar joints.

223

t

..

__ Figure tures

1.

Double

have

occurred

and ulna, with ulnar joint.

Lfracture-dislocation. through

dislocation

the

Fracdistal

radius

at the distal

radio-

I Figure

In 17 patients (14%), only an isobated fracture of one bone was seen on initial radiographs. In 12 of these patients, subsequently

17 patients, radionuclide bone were obtained, and in eight of nine patients, a second injury identified by means of increased dioisotope activity at the distal ulnar

joint

(Figs

tient, no definite uptake was seen, was

Figure

a second site of injury was shown. In nine of these

heavily

casted

5, 6). In the

increase although and

scans the was raradio-

ninth

the

scan

was

not obtained until 17 days after trauma. In four of the 17 patients, mitial radiographic and clinical interpretation suggested a single forearm fracture, but after reduction and casting, there was clear evidence of distal radioulnar dissociation (Fig 7). In the other four patients with only one site of injury seen initially, a radionuclide bone scan could not be performed because of the critical condition of the patient. 224

Radiology

#{149}

Double

fracture-dislocation.

This

DISCUSSION

pa-

in tracer the patient

2.

radiograph shows fractures of the distal ulna and proximal radius with dislocation of the radial head.

Much

has

been

written

about

fore-

arm fractures and dislocations, but the frequency of different types of fracture has received little attention in the muscuboskebetal literature. A Monteggia fracture-dislocation is a fracture of the ulnar shaft with associated dislocation

of the

proximal

radioulnar

joint (3-5,7,17). Although it was originally described by Monteggia, Bado (3) refined the description and classifled this type of injury, including injuries

composed

bones with Monteggia nosed,

because

of fractures

radial lesions the

of both

head dislocation. are often misdiagdislocation

of the

There

3. Same-bone is an oblique

which dorsal

is foreshortened, with overriding angulation of the distal fragment.

proximal

radius

fracture-dislocation. fracture of the distal

ulna,

and

may

be overlooked is cornpounded whenever the fracture of the ulna is in the middle or distal third, because the elbow is less likely to be included in the radiograph (4,16,18). A Galeazzi fracture-dislocation is a fracture of the distal radius with dislocation of the distal radioulnar joint (6,11). Again, the dislocation is often overlooked. Mikic (8) reported that only 80% of patients with Galeazzi lesions had dislocation of the radioulnar joint that was evident during dinicab examination and on radiographs at initial evaluation. In the other patients (20%), the pattern and type of the injury became evident only after complete dislocation of the joint occurred later. This is in agreement with our findings of four patients with apparent isolated ulnar fractures at initiab presentation who developed un-

(4,5,7,18). This oversight

October

1992

with

the

work

noweth

(1),

of Gertzbein

would

and

account

Che-

for

the

high frequency of double injuries of the forearm. In addition to a total of 49 Galeazzi and six Monteggia fracture-disbocations,

we

found

fractures

of both bones with distal radioubnar joint disruption, dislocation of the radial head, or both in 14 patients, as well as fracture of a single bone with one or two dislocations in 10 patients. Thus,

ited

79 of 119

patients

ligamentous

(66%)

injury

exhib-

in addition

to

fracture.

The actual frequency types of injury is poorly confused in the skeletal Rogers

(16), who cites states that injury

(13),

of the various reported and literature. Smith to the

and Sage forearm

usually results in a fracture of both bones-or, less commonly, a fracture of one bone and dislocation of the other-and that a direct blow may cause an isolated fracture of one bone. However, our findings support those

that

of other

single

14,15).

that rare

authors

bone

who

injury

Stansberry

et al (15)

isolated ulnar fractures that they would indicate

tional

injury.

believe

is rare

Furthermore,

(8,

believed

were so addiMikic

(8)

concluded

that radial fractures are almost invariably associated with dislocation of the distal radioulnar joint, and in a detailed examination of the distal

radioulnar

Vesseby fractures

bated

joint

(14) found of the

in 172

only

radial

nine head,

patients,

isolated 13 iso-

ulnar

fractures, and five isolated of the proximal radioulnar joint. However, cases of apparent single fractures or dislocations continue to be cited or reported (12-14). Isolated radial fractures have been reported by some authors to occur more commonly (15,16), while isobated ulnar fractures have been reported more frequently by others (13). In 1957, Smith and Sage (13) reported a study of 338 patients with 555 forearni fractures. They found 53 patients (16%) with single radial fractures, 85 patients (25%) with single ubnar fractures, and 200 patients (60%) with fractures of both bones. No mention was made of any disbocations. The distribution of forearm fractures in our study shows great variation from these results, because we found single fractures in only 4% of our patients. This may reflect a changing patient population. Even in the relatively short period of 35 years since the study by Smith and Sage, more injuries occur at high speeds and the survival rate is greater. Rapid dislocations

a.

b.

Figure 4. demonstrate

the distal

Fracture and double a grossly displacing

radioulnar

equivocal radioulnar and eight scans

joint

and

dislocation. fracture

total

dislocation of the joint after casting patients in whom

indicated

increased

the

distal radioubnar sence of dislocation

(a) Anteroposterior of the distal radius,

elbow

distal (Fig bone

uptake

account

Volume

radius

and

(6,8,9).

treatment 185

Number

#{149}

Mistakes

of this 1

high

frequency

of

morbidity Fractures

in Galeazzi fractures (9). of the shafts of both fore-

in

arm

are relatively

which fraccom-

in diag-

instability

for the

7)

mon pattern of injury in our study (49 patients [41%]). Instability of the distab radioulnar joint is caused by disruption of the triangular fibrocartibage complex due to displacement of the distal nosis

of

dislocation.

joint despite abon plain radio-

graphs (Figs 5, 6). This pattern, included the 37 overt Galeazzi ture-disbocations, was the most

and (b) lateral radiographs with complete dissociation

they

bones occurred

in only

common,

(28%) in our study. Stansberry (15) studied 137 patients with fractures concomitant

and

found radial

but

34 patients

et at ulnar

only two without fractures. One of

the reasons for this type of injury is that both bones are considered to function actuality,

as a single

anatomic

unit.

In

the forearm functions, bike the pelvis, as a ring structure held together by strong ligaments. Such an arrangement,

which

is in agreement

transport

a better

to trauma

outcome

centers

for patients

has

bed to

involved

Radiology

225

#{149}

.,

b. Figure

5.

Fracture

(a) The plain mite

of the

radiograph

abnormality.

proximal

shows

(b) However,

ulna.

no other this

def-

radionu-

clide bone scan reveals increased activity, both at the fracture site and at the distal radioulnar joint. Incidental injury to the upper arm

is seen.

in high-speed accidents. Thus, a larger number of severely injured multitrauma victims are seen. In our study, 75% of the patients were admitted to the shock trauma center, and most of these demonstrated injury to the forearms in association with other marked skeletal and softtissue injury. Fractures and dislocations of the same bone are reported much less frequently. However, eight of our patients (7%) had a fracture of the ulna with dislocation of the distal radioulnar joint (Fig 3). In addition, one patient in our study had a fracture of the ulna with dislocations of both proximal and distal radioulnar joints, another patient had dislocation of the distal radioulnar joint and thiftif elbow dislocation associated fracture of the 4), and still LhiI fractures iiiI dislocations at the elbow and distal radioulnar joint. In our literature search, we could find no documented cases of forearm fractures associated with double dislocations. Our study suggests that Gabeazzi fracture-dislocations are more cornmon than other studies have mdicated, with a 41 % frequency of such injuries compared with a previously reported frequency of 6%-7% (9). It is noteworthy that only a single bone fracture was diagnosed with plain radiography in 17 of 119 patients (14%). Twelve of these 17 patients 226

Radiology

#{149}

,

.

.

.

..

‘

were

subsequently shown to have of the distal radioulnar joint; such injury manifested as either displacement after manipulation or increased radioactivity on bone scans. Furthermore, because tests were incomplete, it could not be determined whether a second injury was actually present in the five other patients. While our results may be influenced injury

by association

with

I

b. Figure

6.

(a) Plain

radiograph

shows

frac-

ture of the distal increased rowhead), tivity

over

ulna. (b) Bone scan shows activity over the fracture site (aras well as markedly increased acthe

dental scaphoid the scan.

distal

radioulnar

fracture

joint.

was identified

An

mci-

on

a shock-trauma

center (with proportionately severe injuries), the findings cate that isolated fractures of bone may be extremely rare, they occur at all, and that the

more still mdione if indeed distal

radioulnar joint is a likely location of undiagnosed injury in forearm fractures. In our study, the distal radioulnar joint was injured in 71 of 119 paOctober1992

tients (60%). In view of the potential for long-term morbidity associated with overlooked injury in patients with an apparent single forearm fracture, a second site of injury should be considered present until disproved. U References 1.

2.

Gertzbein SD, Chenoweth DR. Occult injuries of the pelvic ring. Clin Orthop 1977; 128: 202-207. Rogers LF. Radiology ofskeletal trauma. New York: Churchill Livingstone, 1982; 264.

3. Badoj. 1967;

4.

5.

6.

7. 8.

9.

10.

11.

12.

13.

14. 15.

16.

17.

The Monteggia

DormansJP, Rang M. The problem of Monteggia fracture-dislocations in children. Orthop Clin North Am 1990; 21:251-256. Kalamchi A. Montegia fracture-dislocations in children. J Bonejoint Surg [AmI 1986; 68: 615-619. Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bonejoint Surg [AmJ 1982; 64:857863. Wiley JJ, Galey JP. Monteggia injuries in children. J Bonejoint Surg [Bri 1985; 67:728-731. Mikic ZDJ. Galeazzi fracture-dislocations. Bone Joint Sur IAml 1975; 57:1071-1080. Moore TM, Klein JP, Patzakis MJ, HarveyJP. Results of compression-plating of closed Galeazzi fractures. J Bone Joint Surg [Am] 1985; 67:1015-1021. Moore TM, Lester DK, Sarmiento A. The stabiizing effect of soft tissue constraints in artifiaal Galeazzi fractures. Clin Orthop 1985; 194: 189-194. Reckling FW, Peltier LF. Ricardo Galeazzi and Gafeazzi’s fracture. Surgery 1965; 58:453459. Roy DR. Completely displaced distal radius fractures with intact ulnas in children. Orthopedics 1989; 12:1089-1092. Smith H, Sage FP. Medullary fixation of forearm fractures. J Bone Joint Surg [Ami 1957; 39:91-98. Vessely DC. The distal radio-ulnar joint. Clin Orthop 1967; 51:75-91. Stansberry SD, Swischuk LE, SwischukJL, Midgett TA. Significance of ulnar styloid fractures in childhood. Pediatr Emerg Care 1990; 6:99-103. Rogers LF. Radiology of skeletal trauma. New York: Churchillhivingstone, 1982; 485497. Papavasiliou VA, Nenopoulos SP. Monteg-

gia-type

a.

b.

Figure 7. “Delayed” instability. (a) Immediate ture of the distal ulna, with normal alignment open fixation, dorsal angulation of the distal

projected

dorsal

Volume

185

radiograph demonstrates a comminuted of the distal fragment. (b) After reduction fragment is obvious; the longitudinal axis

18. fracand is now

lesion. Clin Orthop

50:71-86.

elbow fractures

in children.

Orthop 1988; 233:230-233. Giustra PE, Killoran PJ, Furman The missed Monteggia fracture. 1974; 110:45-47.

Clin

RS, RootJA. Radiology

to the carpus.

Number

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Radiology

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