FRACTURES
OF
E.
MERVYN
Formerly
Fractures
bones
On
of
and
the
the
isolated
other
hand
with
displacement
and
dissatisfaction
difficult
injuries
of the
forearm
treatment
radius
fractures
ulna
shaft
more
the
final
is based
treated
on
by
of greenstick
Complete
the
surgeons
have
immediate
,
.
p
,*._.i
.
open
muscles
and
at
In
ulna.
,.
:
and
ligament
while
the
radial
by the
soft-tissue
of
the
radius
is
produced
forearm-a
between
-
in
the
indiateshata
is
present.
allowed
-
occur
by
the
soft
proximal
while
*
Based
548
in
OB
tissues
attached
radial
fragment
plaster,
and
a
between
the
no
that
Hunterian
Lecture
swings
upper
less
than
results
in
the
the
radius
to set
of
the
peculiar
of
leaving
the
fragments.
radial
fragment
often
as
pivots
the
position
as
do
shortening
and
are
imperfect
if
of
the
forearm
is
broken
equilibrium
lower
and
much
and
fragment
rest
of
degrees,
ignore
the
which
angulation.
we
the
a deformity
the
90
in the
head
of
Thus
the
function
of the
fragments
of the radius
two
of
But
is
pivots
a
it,
ulnar
bones
failures.
bones
distal
to
two
to
shape
beneath
is subcutaneous
two
around
into
adult.
The
deep
which
both
and
the
necessary
ignored.
of
of
many
It
this,
is
the
forearm.
Rotational
can occur
whatever
of the
fracture.
It
is frequently
obvious
on
the
first
from
a discrepancy
in the width
of the two radial
fragments
and
it can be observed
in old fractures
which
have
been
to unite
between
to
is not
that
the
our
element
the
head
rotated
deformity
correction
the
end
attached
with
of
largely
proximal
structures
ulna
are
rotation,
fracture
is
behind
surprising
the
level
radiograph
(Fig.
1)
tworadialfragments
the
fragment
most
important
deformity
between
discrepancy
a
the
there
of
that
in
is
forearm.
radius
lies
some
of
lower
of
rotational
demands
I
the
rate
it
the
; the
that
been
supination
and
bones
reduced
any
although
for
has
at
of
fact
element
yet
between
upper
not
the
moment
continuity
the
in
more
bones
of both
hold
refractory
anatomy
of difficulty
accounts
forearm
these
of both
mechanism
fractures
and
so
and
time
pronation
At
the
lies
in the
annular
)
same
difficult’
importance
.
the
bones
treatment
ULNA
fixation,
The
both
with
of the
AND
are
compartments,
of
during
fractures
especially
internal
to manipulate.
both
discussed.
to reduce
fractures
of the
a cause
fractures
anxiety
aspects
of
in treatment.
concerned
RADIUS
and
and
these
fascial
easy
hold
main
;:
1 he
width
radius,
reduction
why
and
it is not
Certain
as so difficult
consider
some
aspects
the forearm
is of itself
:
FIG.
of the
and
displaced
also
THE
fractures
difficulties
cause
is mainly
are
OF
any
radius
many
consecutive
forearm
regarded
discover
of the
paper
fifty
incomplete
present
and
methods.
shaft
been
Hospital
seldom
This
FRACTURES
of the
To
shaft
of the
WALES
A cczdent
injuries
conservative
hitherto
advise
of the
of
ULNA*
displacement,
ulna
result.
fractures
fractures
forearm,
without
a study
COMPLETE
nghaiiz
of the
difficult
AND
SWANSEA,
Bin;,i
fractures
with
and
of the
and
much
RADIUS
EVANS,
of the
complete
are
THE
the
delivered
an
in
the
them.
two
It
static,
incorrect
rotational
fragments
of the
may
that
determination
at
the
be
argued
further
of
Royal
College
position
ulna;
that
rotation
the
THE
the
may
rotational
occur
rotational
of Surgeons
JOURNAL
Rotation
does
it is presumably
position
during
position
of
England
OF
BONE
AND
of the
reduction
at
on
not
prevented
the
February
JOINT
or
time
28,
of
1950.
SURGERY
FRACTURES
admission
is
radial
fragment
acting
upon
and
of
is
pulled
it,
place
and
the
rotational
rest
to
be
original
and
may
be
easily
but
always
position
of
remainder
returns
forearm
in
one
of the
it
fracture
the
rotation
fragment
is
uncontrollable
be
determined
limb may
the shape
be lined up with it. This
of the bicipital
tuberosity
posterior
radiographs)
normal
side
supination
ulnar
side
to the
back
.
of the
bone
full
pronatlon
on
the
lateral
fine
grades
can
be
for
that
are
the
upper
shape
in
any
one
patient
Technique-To
what
side
as
is made,
forearm
An
and
the
60
degrees
radius
Comparison
of
tuberosity
in cases
the
in known
fragment
of the
In
of the
tuberosity
usually
most
approached
gradual.
2) In
33 B,
NO.
4,
in which
the
of rotation
may
be
supination
NOVEMBER
tuberosity
the
after
of
after
bicipital
of the
ion.
ages,
to demonstrate
radius
side
side
idea
to
be
supination
with
of the
that
of
the
fractures
more
is also
rotation
is
injured
with
In high
seems
full
1945)
taken
supination.
in
(Evans
on the
tuberositv
injured
injured
different
view
normal
60 degrees
the
at
posit
sides.
this
accurate
of the
neutral
and
be employed
the
appearances
a fracture
the
of taking
side
an
side
two
normal
on
gives
tile
and
the
of the
than
taken.
normal
proximal
4 to 7).
(Figs.
normal
the
2)
rotational
practice
for
method
on
of the
In
must
and
rotation
view
of
correctionof
patients
the
views
supination,
3
bones
(Fig.
technique
of the
antero-posterior
of
the
on
; the
“
3)
radius.
different
radiograph
degrees
tuberosity
full
view
(Fig.
pronation
in
is identical
both
before
supination,
the
vary
FIG.
of
forearm
the
full
on
2
fracture
few
of
and
a constant
outline
prominent
the
a
within
found
a further
radius
matching
which
to
antero-posterior
supination,
are
prominence
tuberosity
with
A
there
position
30 degrees
FIG.
.
a projection
positions
tuberosity
“
rotation,
and
of
moved
as a projec-
as
tuberosity
compared
in neutral
of
the
follows.
visible
standardisation
be termed
has
mid-rotation
the
the
achieve
may
briefly
of
the
the
it
is seldom
texture
the
must
of
full
rotational
fragment
and
space
In
and
between
the
it.
on
accurate
the
those
in
appears
shape
guide,
at
patients
radial
of rotation.
these
in
a
determining
matter
radius
but
as
with
.
Between
of difference
used
degrees,
The
side.
position
forty-nine
the
line
.
it
rotational
of
of fifty
an
is prominent
is not
.
in
problem
series
when
proximal
mid-rotation
and
.
; and
tlon
VOL.
tuberosity
; in
the
of the
is done by studying
(as seen in anteroit with
that
of
degrees
radius
the
remaining
outset
rotated
remainder
comparing
varying
bicipital
of the
controlled
into
the
in
solved
one
the
forces
at
a
is
be
position
that
and
in
the
; its
so
position
has
only
upper
position.
that
of the
one
the
soft-tissue
vision
be
reduction
be brought
therefore
the
direct
can
original
cannot
must
fractures
its
this
In
fracture
the
fragment
deformity-It
fragment
part
under
to
of
by
Further
upper
It
rotational
principle
within
treatment.
fractures.
and
2).
In the
to
of the
rotating
open
it,
discrepancy
corrected
stability
of
elementary
the
was
throughout
moment
rotation
Find
(Fig.
of treatment.
.149
ULNA
the
of
with
fracture
deformity
by
so : at
in alignment
particular
AND
throughout.
end
on
not
position
a significant
held
RADIUS
position
there
was
Determination
is
at the
rotational
operations
fairly
this
forearm
was
obtained
during
This
that
and
of the
THE
a certain
retains
described
few degrees
value.
into
in that
rotational
evidence
no
of the
of reduction
In
it
deformity
cases
time
therefore
OF
with
taken
the
into
and
its
becomes
the
1951
injured
account
curve
is
side
(Fig.
short
progressively
cancellous
several
8):
and
characteristics
1) In
of the
tuberosity
in the
supination
pronounced.
less prominent
bone
full
the
As
and
ma
the
its curve
be seen
appearance
tuberosity
is
mid-position
larger
at the
is
and
more
extreme
E.
MERVVN
EVANS
900
FIG.
00
I
4
Frac
to ru of both
bones
in the
forearm.
normal
forearm
in neutral
rotation,
(Belo’)
The
injured
forearm.
Tile
sllape
with
that
of the Ilornlai
Fit;.
Figure
in
4-Initial
60
(iegrees
of the bicipital
side
with
tile
radiograpil.
supination
and
tuiberositv
on
forearm
sui)inated
5
Figure
5in 90 degrees
the iIlj tired
side
60 (legrees.
(-i boe)
The
sllpillatlOil.
correspontis
#{149}1
FIG.
Tile
fracture
the
6
is reduced
after
supinating
forearm
60 degrees.
FIG.
Union
has
taken
7
place
WitllOuit
loss
of
position.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
FRACTURES
ulnar
margin
the
of
the
cancellous
position
it
cortical
bone
of
the
is
on
bone
and
the
and
curve
of
the
In
the
but
rotation
are
of
as
that
correcting
rotation
alignment
essential
has
9 shows
Although
the
variations
occur
at
made
in
full
the
Correction
ends
fit
accurate
are
rotationally
strains
later.
Finally,
on soft
correction
As in many
to
accuracy
since
The
position
this
the
upper
the
next
are
it is impossible
very
to
be
deformity
stability
the
fit
the
more
tissues,
and
deformity
fractures
also
depends
stable
for
stable
these
the
an
range
fracture,
many
fractures
of the
radius
united
11).
a review
bones
of the
over
five
been
allowed
years
pronation
all
as
ROTATIONAL POSITION
FIG.
rotational
position
in fifty
cases,
fracture
Each
a black
OF UPPER RAOIALFRAIIMENT
9
of the
upper
radial
plotted
against
the
case
1S represented
1951
of
the
a
forty-one
Purvis
of from
was
and
cases
(1949)
25
treated
found
to
.
60
reflected
degrees
may
or
was
the
in
The
had
deformity
cases
more,
over
60
degree
of
a clinical
review
seem
may
deformity.
In
loss
showed
excellent
yet
conservatively
residual
rotational
degrees
in
60 per
.
radial
thirteen
error
which
10
fracture
conservatively
of 30
alignment
rotation
(Figs.
of
a pronation
the
of the
inevitably
that
degree.
reduction
length
treated
thirteen
of similar
considerable
proximal
dot.
NOVEMBER
that
cases
patients
deformity
to
supination
with
relationship
lead
of
found
functional
fragment
nineteen
was
will
be shown
the
will
fragment
four
of supination
also
a close
lover
forearm
it
unite
radial
in
in
of
ago,
to
lower
that
bears
limitation
In
ends
is essential.
on
tipper
of
bone
abnormal
as will
bearing
the
the
a corresponding
bone
equilibrium
‘ith
on
of the
means
in plaster,
of movement
view
of
fit
Jagged
be held
pronated
point
the
deformity
important
has
degrees:
4,
cases.
the
case
on
soft-tissue
can
that
of the
No.
higher
the
fracture.
reduction
final
A fracture
from
rotational
has
and
33 B,
tipper
is unreliable.
fragment
largel’
is the
fractures
deformity
elsewhere,
reduction.
important
of both
VOL.
which
perfect
consecutive
the
; in any
upon
Moreover,
and
by
in fifty
considerable
correct
the
immobilise
position
has
be sure
upon
when
should
supination
certain
reduction
displaced.
of rotation
of the
is
of any
to
fragment
level
of
one
neutral
It
.
to
depends
first,
fragment
greater
radius
The
that
the
radial
towards
mentioned.
alignment
in
bicipital
text.)
alignment
position
teaching
normal
(See
in perfect
perfect
remainder
of the
8
of the
been
radius
rotational
accepted
the
already
of the
find
is a tendency
of rotational
result.
but,
rotational
The
more
correction
the
the
the
After
has
fragments
to
and
characteristics
tuberositv.
reduction
the
the
and
case
Tile
is acting.
if they
and
stresses
and
reduction.
and
not
CO(3OO
rotational
of
follow.
there
one
of
maintaining
of
rotational
correcting
rotational
level
teres
the
FIG.
practical
to
between
pronator
in
degrees
of
supination
that
midshaft
than
displacement
be
the
defined
to get
more
it is true
towards
characteristics
varying
part
only
rotary
much
may
Figure
for
one
fractures
supination
the
correction
an
all
how
in
distinct.
need
said
third
in
the
head
characteristic.
straighter
clearly
adequate
deformity-The
been
less
differences
of
deformity
quite
children
551
ULNA
mid-
of
the
curved
and
AND
is pronated
side-between
nevertheless
Importance
line
larger
are
the
in the
The
3)
sharply
young
tuberosity
adult,
until
shaft-is
and
becomes
mid-rotation.
forearm
lateral
is short
RADIUS
the
central.
the
THE
laterally
As
moves
usually
radius
The
bone.
bone
OF
a
leave
a
series
of
Knight
and
deformity
cent,
“the
.
fragment
being
supinated,
with
552
E.
EVANS
MERVYN
resulting
proportional
tion.”
The
rotational
the
fragment
12)-is
and
deformity
may
the
appearance
the
limb.
Technique
in
the
patient’s
against
10
Fit;.
in
10-An
The
neutral
of tile
(Fig.
allowed
deformity
Clinically
fracture
of tile
rotation
normal
11),
corresponds
forearm
in
indicating
to
of both
tuberositv
60
unite
with
a
of the lower
radial
there
was
An
fractures.
radius
max’
during
the
loss
degrees
fracture
60
degrees
fragment
end-to-end
two
with
of
the
weeks
has
the
into
the
predetermined
tion
overlap
may
be
pronation
deformity
the
still
still
under
bone
least
with
the
ten
to
be
the
minutes
around
rotated
palpa-
present
the
in order
then
a
on
forearm
angulating
and
position
to
pull
If on
found
are
and
flexed
should
traction,
ends,
The
elbow
at
by
of
traction
position.
corrected
improve
function
of a sling
and
is
rotational
fractures
by
counter-traction
arm,
cases
to
way
for
upper
the
tipper.
of
shortening
the
of the
the
position
Fractures
the
it
forearm
to
engage
straightening
is checked
manipulation
a
the
radiographicallv
It
and
is
usually
apposition
(76
per
radius
should
be
in
both
the
to
bones
present
deformity
be prevented
watched
has
possible
of
cent
the
if necessary
reduction
of
difficult
to reduce,
especially
ulna,
with
corner-to-corner
must
radial
is repeated
satisfactory
Sometimes
of the
lower
and
until
way
FIG.
A severe
the
the
surgeon
the
end-to-end
been
of 60 degrees.
and
usual
The
obtained.
supination
redtiction
but
that
pronation
on
of supination
be accepted,
first
bones
of the
with
the hand
exactly
that
restore
upper
ii
FIG.
old
shape
and
of
the
recent
of
undertaken
hand
limb.
to
in
be
with
angle.
while
that
correction
manipulation
right
relation
of reduction-The
reduced
supina-
persistent
pronation
in
such
refracture
the
of
from
deformity-usually
lower
(Fig.
Figure
forearm.
limitation
disability
the
been
secure
in
this
series).
radius
in upper-third
reduction
of
by
thumb
traction
carefully.
12
fragment
Joint
on the
upper.
(From
Watson-Jones-
Injuries).
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
is
the
FRACTURES
OF
FRACTURES
As
to
in fractures
of both
be complicated
deformity
must
The
the
be
method
same
of the
to ensure
the
the
arm
If there
there
must
be radio-ulnar
ulna,
THE
of the
Certain
parallel
of which
upper
is precisely
in
and
Cases
radius,
the
forearm,
a corresponding
shortening
dislocation.
the
14).
of the
as
without
likely
and
13 and
shaft
present,
with
are
fragment
of the
be shortened
or
radius
proximal,
(Figs.
radial
are
radius
the
stability
bones
of the
subluxation
on
fractures
cannot
is a fracture
of the
fragment
and
position
two
RADIUS
fractures
distal
reduction
section.
553
ULNA
complete
accurate
rotational
one
other.
OF
of the
\Vhere
of the
AND
SHAFT
forearm,
previous
attention.
a parallelogram,
shortening
THE
of the
in the
special
RADIUS
displacement
corrected
described
merit
form
bones
rotational
of determining
as that
however,
they
by
OF
THE
no
of this
fracture
type
fall
into
I
13
FIG.
Fracture
reduction.
of
shaft
Figure
correction
by
three
groups:
of radius.
14-Normal
of rotational
1)
radio-ulnar
fractures
and
should
fractures
but
without
same
radius
to shorten
thumb
traction
plaster.
Open
Thumb
traction-Thumb
occur,
treated
33 B,
as that
the
through
or
obliquity
NO.
4,
two
types
of the
NOVEMBER
radius.
weeks
resorted
is useful
mentioned
of
the
radial
1951
radial
fracture.
the
In
and
in
the
last
two
types
fractures
in any
above.
to
fracture
Thumb
injury
traction
loop
of the
radius
15
inferior
are
unstable
2)
joint
on
of the
ulna
Similar
the
by
first
running
for
the
continuous
incorporated
in
the
occurs.
radial
the
traction.
is a tendency
a wire
of
16-
with
be treated
in which
Instability
(Figs.
there
should
if shortening
thumb
fixation.
fracture
of
Figure
These
plate
16
comminution
third,
radio-ulnar
oblique
attached
lower
and
inferior
an
ulna
radiograph.
reduction
such
to
the
first
the
with
extension
be
traction
the
reduction
of the
first
should
including
open
of
radius
of
usually
on
primary
of the
strapping
reduction
shaft,
and
with
15-Before
reduction.
radius
prevented
by
Figure
Shortening
the
FIG.
of radius
radius.
subluxation
fracture
during
Fractures
obvious
by
obvious
direction
comminution
end-to-end
VOL.
be
of
subluxation
3) Oblique
in the
to
fractures
or
15
FIG.
Figure
13-Before
alignment
restored
deformity.
Oblique
dislocation
examination.
14
FIG.
shortening
radius
may
and
16);
or
has
been
condemned
inability
is likely
be
due
to
to:
secure
as a cause
354
of joint
stiffness.
in the
The
present
series
traction
thumb
INDICATIONS
The
1)
FOR
indications
Openition
for
is indicated
In
oblique
need
stiffness
a
EVANS
be
continued
for
was
not
only
observed
OPERATION
fixation
a primary
of
MERVYN
OPEN
internal
fractures
E.
may
two
or
three
as
a complication.
AND
INTERNAL
be summarised
weeks,
however,
and
FIXATION
as follows:-
procedure.
the
shaft
of
the
radius
with
inferior
radio-ulnar
dislocation
or
subluxation.
2) In compound
skin
flap
fractures
can
stability
to
provide
the
of both
adequate
limb
while
the
in
alignment
may
In
ulna.
obtained
rotational
Operation
1)
and
skin
In
more
urgent
plastic
loss
such
of such
cases
degree
the
that
radius
procedure
by
only
should
is carried
improvement
correction
Originally
a simple
After
twenty-two
of
deformity.
an
be
immediate
plated
to give
out.
18
FIG.
Note
the
simple
be indicated
unstable
with
cover.
17
FIG.
of radius
Fractures
bones
skin
fracture
operations
still
ununited.
of radius
and
the
fractures
ulna.
are
later.
fractures
of
the
radius
if
radial
length
cannot
be
maintained
by
thumb
traction.
2) For
delayed
union
3) If primary
It
wider
must
than
that
plate
the
certainty
routine,
by
closed
or non-union.
reduction
be
this.
admitted
It
fixation
has
is felt
offers
of correcting
however,
methods
is surely
if all
been
that
prevented
for
that
many
these
a relatively
surgeons
way
of the
associated
the
are
out
deformity
a confession
elements
severe
fractures
safe
rotational
by
of failure.
deformity
injuries.
indications
difficult
of the
under
for
difficulty
direct
These
are
JOURNAL
operation
and
with,
vision.
hold
in the
Such
fractures
reduced
THE
open
to reduce
can
(Fig.
OF
and
are
much
in plaster
recent
a procedure
should
and
fracture,
be
as
treated
17).
BONE
AND
JOINT
SURGERY
a
FRACTURES
Disadvantages
the
half
of
the
; they
time
that
operation.
catastrophies.
tourniquet
Patrick
tissue
In
patients
open
short,
plate
too
young
are
fixation
for
How
order
do
to
the
results
answer
been
studied.
near
the
this
closed
joint
have
period
was
both
bones
nine
compound
approximately
of the
7,500,
forearm
fractures
without
was
approximately
of both
bones
compare
fractures
overlap
OF
UNION
number
that
the
incidence
1 in
150.
eleven
FRACTURES
IN
TREATED
lessened
case
by
of cross-
many
of
of the
been
of the
and
treated
same
shaft
In
have
fractures
during
complete
the
?
forearm
included,
of closed
During
operation
of the
fractures
BOTH
the
fractures
period
of
there
of the
were
radius
alone.
BONES
OF
THE
FOREARM
OPERATION
Avera”e
.
time
.
.
Complications
.
united
cases
a
I
OF
umber
of
at
from
cause
those
bones
of
fractures
\VITHOUT
umber
Age
was
in any
with
have
total
TABLE
RATE
rotation
of both
The
and
by
restored
are occasional
commonest
and
cases
treated
TREATMENT
with
so
of
a series
unknown
contractures
the
risk
been
18).
considered.
consecutive
fractures
in twenty
is not
and
of
of thirteen
not
in
(Fig.
cent
six
had
range
occur
4 per
in
nerve
was
particularly
do
of non-union
final
operation
is not
omitted.
in
paralysis
CONSERVATIVE
complete
been
infection
alignment
treatment
fifty
union
interosseous
to be
conservative
question
Only
wrist
same
of
OF
cases
the
are difficult,
delayed
non-union
rotational
that
treatment
RESULTS
four
that
and
as a routine
such
and
ischaemic
considered
reduction
cent
posterior
paralysis,
(1946)
of an
cases
the
fixation
reported
and
in several
to
and
ULNA
and
9 per
(1949)
fixation,
Injury
and
in
Purvis
without
also
operation,
scar
and
reduction
AND
non-union
non-union
Knight
RADIUS
reduction
Infection,
reported
stated
of
union.
forearm.
cases.
by open
plating
the
the
(1950)
eighty-five
treated
plating
THE
of operation-Operative
upper
Holdsworth
of
OF
of
union
(weks)
Under
29
-
29
7.7
yrs
Over
16
21
Malunion
necessitating
bone
graft
21
I
years
Average
The
treatment
immobilisation
(Table
Union
and
the
1)-All
radius
weeks.
in
all
in plaster.
The
average
the
and
fourteen
a half
weeks.
weeks.
time
bone
Acceptable
VOL.
33 B,
of
reduction
NO.
in the
4,
was
NOVEMBER
50
in
be
In
whole
sixteen
both
one
obtained
1951
under
the
both
series,
more
anaesthesia
radial
fracture
fractures
collapsed
united
and
the
those
over the
patients;
age
patients;
average
to
than
was obtained
in
in all the remainder.
be
that
50
per
above
case,
cent
was
of sixteen
average
of external
thirty-eight
in plaster
within
including
years-twenty-one
is,
general
as follows:
case
week;
is considered
(that
bones
weeks
reduction
into those
under
and
sixteen
years-twenty-nine
of union
case)
cases-iO4
summarised
seventeenth
reduction
fragments)
in
may
united.
Over
(The
union
consisted
the
for union
divided
Under
Reduction-End-to-end
the
at
of
results
fractures
time
If the patients
are
results
are as follows.
seven
cases
The
grafted
was
time
14
(1
end-to-end
patients
thirty-six
104
weeks.
years
the
time
for
union
time
for
union
fixation.)
apposition
(76
per
of
cent).
556
E.
MERVYN
E\ANS
Behaviour
82%
in
patients
(82
held
plaster
per
in
plaster
(14
(Fig.
cent)
until
per
the
In
seven
in
position
in
to
warrant
interference.
19)-In
the
cent)
position
fractures
had
there
plaster
fort\-one
reduced
not
was
a slight
considered
In
was
united.
shift
sufficient
one
patient
(aged
4’
seventy-five
CASES
bones
years)
angulated
was
poor
union
was
in plaster.
(supination
slow
The
60
and
both
functional
degrees,
result
pronation
20
‘4%
ICASESI
STABLE
MALUNION
(ANGULATION)
in
the
of
plaster
COLLAPSE
(GRAFTED)
19
FIG.
Behaviour
boiles
I CASE(2X)
ICASE(2%)
SLIGHTSHIFT
degrees)
radial
of
forearm
treated
fracture
tile
time
of reduction
the
rotational
less
than
1i,ial
linlitatioll
had
fractures
had
been
position
plaster.
bone
grafting
of
the
union
3() degrees.
range
of
In
rotation
had
been
seven,
rotational
20)-Of
; seven
of
more
the
rotational
held
radius
the
displace-
reduction
were
and
undertaken
in thirty-six
fifty
rotational
weeks.
was
In
patients:
estimated
forty
cases
rotational
greater
than
three
15 degrees
radiographicallv
position
a residual
was
deformity-Forty-
examined
in plaster.
there
than
late
were
deformity
the
had
and
Open
secured
patients
whether
In
case
(Fig.
of supination
and
correct.
one
was
mentioned
comminuted
in
_,1ssessment
correct
was
was
already
both
of
to determine
united
case
occurred
eight
after
one
ment
and
fracttires
conservatively.
fifty
In
.
30
had
limitation
per
cent)
deformity
of
degrees.
more
of
at the
(83
than
15
pronation
degrees
; only
four
RANGE
_________NORMAL.
‘‘;T
Jc.
_
-
-:
-
:L’J
-
-45
1c
U)
w
U)
i#{149}
‘i
U
U.
0
H
.
-
-4
-
‘
15
-
I-.
::i
::
:
.
UI
10
:
I
z
i
:
I
60”
50”
40’
7J
30’
20
\
I0
0”.,
10’
SUPINATION
LIMITATION
OF
ROTATION
FIG.
Graph
in
The
fifty
showing
fractures
siladed
limitation
of both
section
20’
30’
40’
50”...
#{176}
PRONATION
of rotation,
(DEGREES)
20
as
compared
with
tile
normal
side,
bones
of the forearm
treated
conservatively.
includes
all cases
with
less than
15 degrees
limitation
of pronation
or supination.
THE
JOURNAL
OF
BONE
AND
JOINT
SURGERY
FRACTURES
had
more
than
function
30 degrees
may
thus
be
Complications-There
conservative
short
time
and
with
peculiar
reduction
and
full
plate
to
a
return
to
open
methods
For
the
It
been
ilas
problem
found
that
23).
new
for
of the
the
It
the
the
deformity
is true
laid
and
disconcerting
These
patients
were
by
of
for
at
the
manipulation
deformity.
by
the
along
the
33 B,
E
NO.
4,
NOVEMBER
1951
AND
for
treated
from
the
routine
open
it is essential
in
find
(16
that
Tile
it
the
is
Figure
Note
22-The
that
supination
the
has
has
normal.
fracture
radial
taken
largely
per
nevertheless
23
was
fracture
place
with
restored
“
forward
reduced
was
made
recurrence
the
bone
was
(Figs.
21
for
a
worrying
has
I
with
it
worth
cent)
deformity
type
presents
1948
temporary,
deformit’
angular
ulna
considered
only
FIG.
of
union
was
is often
22
fracture
and
during
fourteen
to normal:
lines.
radius
treated
deformity
bones
ULNA
deformity
extent
to
be
a reasonably
apart
made
of the
initial
to
architecture
VOL.
the
surgeon
manipulation.
Early
Figure
23-Remodelling
in
however,
fractures
standard
site.
plane.
can
cases
Quite
be
RADIUS
these
the
greenstick
fracture
in a flat
most.
fractures
of
FIG.
typical
in
forearm
all
treatment,
angular
to restore
the
almost
cannot
THE
a significant
an
or near-normal
of cases.
deformity.
in which
to
treated
21-A
complete
349
21
FIG.
angulation
of
children
down
parents
Figure
of the
of
in
claim
OF
fractures
in young
is soon
a
of greenstick
a survey
recurred
that
union
in conservative
element
treatment
in
of
cent
series.
bones
function
FRACTURES
eighty-eight
architecture
plaster.
that
both
Normal
90 per
in the
of
such
success
rotational
; nevertheless
correcting
to
said
normal
557
ULNA
movement.
in over
expectation
to
GREENSTICK
no
regained
fractures
the
fixation.
regard
AND
complications
that
with
RADIUS
of rotational
been
untoward
show
methods
complications
to pay
no
results
THE
limitation
to have
were
Discussion-The
by
total
said
OF
recurred
was
corrected
in
558
b\
E.
manipulation
in a flat
it backwards,
the
as
and
conversion
the
one
of
only
of
sure
the
structures
the
way
of
broken
tile
After
in
element
in
fracture
soft
that
no
for
care
the
in
further
ill
which
reduction
pronation
or
supination
the
ground,
act
equilibrium
until
compression,
and
sonic
of
hand-the
fixed
on
but
lateral
for
the
commonest
the
falling
or
rotatory
The
body
above
main
is to
been
in
advocated
a violation
should
not
of
damage
was
injury-In
great
be
is
to
intact
immobilise
all
fractures
importance.
made
to
or
\\‘henever
retrace
their
path,
so
limb
likely
be
against
the
of the
a
but
part.
a forearm
acting
on
the
to be moving
expected
in
THE
limb
JOURNAL
body
difficulty
few
injuries
falls
will,
will
on
OF
BONE
in
to
the
hand
continue
of course,
be
in a downward
momentum,
need
in general
is sustained-the
the
solely
its
are
one
injury
of
This
for
of particular
there
\Vhen
momentum
grain.”
injury,
it is a subject
which
force
“
involved,
the
will
forwards.
mechanism
played
it
pronating
angulate
mechanism:
in
fact,
procedure
is of
the
not
is hardly
element
to
movements
way
and
is reached.
tend
of the
of this
in
bending
resulted
24
will
have
routine
should
manipulating
many
by
deformity-surely
one
the
forearm
backwards.
a knowledge
is a reversal
because
outstretched
by
calls
forearm
becomes
fracture
is caused
manipulation
simplest
the
injury
supination
has,
causative
tissue,
while
sustained
reduced
frequently
of mid-rotation.
the
angulate
A
of
is obtained
FIG.
A
This
the
reduction
it was
manoeuvre
that
position
or
forwards
this
fracture.
manipulation
bone
bent
that
surgery,
in the
which
structures,
was
correction
fracture
plaster
rotation
noted
complete
of
the
limb
be
a complete
obtaining
manner
EVANS
if the
may
into
reduction.
tile
possible
of
above-elbow
Importance
dislocations
It
principles
the
an
in
thus
versa.
a greenstick
basic
in
limb
plane;
vice
MERVYN
vertical
direction
to
which
AND
JOINT
element
SURGERY
to
FRACTURES
the
forearm
of
will
normal
commonly,
has
vary
while
the
injuries
these
so clear,
it falls,
or
it
is
and
will
the
are
to
some
movement
of the
forced
its
or forced
that,
extent
determine
either
case
and
soft-tissue
injuries
normal
if the
body
more
a rotation
those
injury
sustained
is important.
there
is experimental
may
be
In
pronation
injuries-the
is moving
direction
the
evidence
termed
supination
the
extremes
result-or,
and
range
group-which
suppose
In
fracture
and
go to the
will
rotation
be calculated
pronation
may
injury
reached.
pattern
second
559
ULNA
rotation
within
can
to forced
to
the
supinating
reasonable
rotation
This
a forced
between
In
opposed
AND
extremes
to be expected
as
but
this
limb,
calculations.
injuries
case
these
the
RADIUS
or supination.
differentiation
is pronating
the
support
to
The
THE
which
before
applied
forearm
supination
as
arrested
been
group
is not
be
pronation
beyond-in
accordingly.
former
to
by
or
will
violence
will
respond
anatomy
OF
or
picture
in a rotary
direction
of displacement
and
the
I
FIG.
Figure
26
and
of the
develop
a
there
One
is
in
backward
will,
the
These
Journal
This
angulate,
force
can
follows
distal
that
angulation
the
distal
fragment,
instance,
if the
angulation.
point
we
lower
33 B,
NO.
4,
be
tile
usual
by
the
easily
in
and
illustrated
in
of
Thus
of
angular
NOVEMBER
1951
angle
In
each
the
deformity
mechanically
is likely
angulation
with
the
fracture
related,
case
of
of a broken
(likewise
at
other
to
the
hand;
will
produce
and
supination
vertical
direction
fractures
angulation
(or
a
similarly
decides
forward
both
a
compression
of
the
angulation.
forearm
bone
forward
forwards;
as
with
a whole
bending
or
bow)
is directed
in backward
of the angle
is directed
backwards;
and
so on.
When
speaking
of the direction
of the
prefer
to avoid
ambiguity
by speaking
of deviation
rather
than
angulation.
For
fragment
of a broken
bone
is deviated
backwards,
the bone
as a whole
shows
forward
of
the
25).
is
has
is pronating
forearm
greenstick
describing
allied,
backward
are
(Fig.
element
convention
closely
own
extension
The
angulation
29-The
fracture
by
full pronation.
forearm
presence
rotation
or the
proximal.
(or
convexity)
are
the
one’s
the
forwards
greenstick
with
pronating
29
FIG.
radius.
Figure
reduced
fragment,
which
angulate
but
flexion
while
distal
Supination
most
fragment
the
point
the
force
24).
if they
of tile
implies
VOL.
(Fig.
and
occurring
this
a flexing
fracturing
principles
and
not
bowing)
demonstrate
angulation
fractures
supplies
can
of
been
Pronation
of
28
28-Supination-tvpe
fracture
forwards.
a fracture
deviation
pronation
Figure
Angulation
27-Full
deformity.
injury.
and
forward
fracture.*
*
soft-tissue
developmentally,
FIG.
greenstick
fracture
of radius
and ulna.
is
backwards.
Figure
supination
has reduced
the
nature
27
FIG.
26-Pronation-tvpe
560
E.
which
angulation,
caused
it
(Figs.
different
levels
rotation
force
static
ulna
if
is
method
tissues
on
the
limb
a sapling
and
is rotated
but
easily
it is more
certainty
by
to
greenstick
the
fracture
immobilised
open
full
or
unite
with
reducing
to
those
difficult
redisplacement
recurrence
will
it
in the
of greenstick
method
is fairly
common,
with
the
to
for
those
thus
angulation,
are
restored
to
comparative
or supination
a pronation-type
has
been
the
supinators
angulation
return
after
as
two
reduced
and
cannot
a routine
it
for
just
that
have
it
method
sooner
results,
position
angulation
cases
the
is
immobilisation
the
As
later
of
certain
should
perhaps
above
the
a
fracture
a method
is simple,
required
in
or
for
fragments.
commend
with
the
with
with
disastrous
rotational
fracture
and
to
is used
so treated
overcorrected
is reduction
in
which
fractures
much
to recur,
pronation
because
longer
between
has
be seen
‘ ‘
example,
twist
again.
correcting
be held
fracture
to the
is straight
can
only
the
develop.
takes
deformity
at
; there
the
bent
limb
fragments
recur
greenstick
be
the
in full
pronation
limb
at
can
backwards)
the
has
of the
For
reduction.
full
is complete
Not
plaster
least
intact
or backwards
grasp
and
‘ ‘
position
cannot
to
angulation
of
with.
was
if the
however,
cases
the
flexors
will
rotational
fractures,
the
the
by
manipulation
and
periosteum
dealing
all
; moreover
Immobilisation
atraumatic.
long
shaft
twisted
above-elbow
movement
radial
a gross
these
the
no
been
is repeated.
and
deformity
of treating
reduction
method
reduction,
is
but
the
tissues,
and
type)
has
greater.
: the
hold
(supination
disappears
usual
angulation
the
rotational
the
of
the
to
deformity
a
the
backward
effecti’e,
tend
and
direction
bone
in an
the
supination
fracture
by
one
which
Full
pronation
will
which
method
criticism.
complete
limb
bend
manoeuvre
than
fracture
has
be
supination
One
be,
soft
opposite
intact
supination,
displacement
the
After
the
of
(in
full
a practical
to
the
29).
which
original
alignment.
type
in
the
gently
immobilising
according
As
the
more
to
may
of intact
in the
when
for
rotational
26
sapling
will
at
that
around
naturally
full
angular
is forwards
case
is undone
again
complete,
correct
initiate
and
(Figs.
in
and
with
angulation
or tearing
back
tightened
indicate
If, for example,
most
limb
has
broken
moves
would
simplest,
the
that
often
would
radius
possible.
the
fracture
as the
a green
twist
again
more
their
breaking
if the
to disappear
secured
the
the
force
are
; this
deformity
placing
be
ulna
injuries
then
by
then
easy
is, as it were,
will:
limb
will
or supinate
no
be
of a greenstick
to whether
pronate
force,
The
side
is surprisingly
filly
its
element
bones
supination
to these
rotational
the
the
and
rotating,
approach
the
fractures
than
in pronation
it will
reduction
type),
and
If the
pronation
the
pronation
the
is no undue
as
of
according
(pronation
site.
a new
reversing
these
more
is fractnredwhile
of correcting
In practice
or supination,
for
by
in
angulated
makes
EVANS
corrected
Furthermore,
acting,
it
part
completely
radius
been
conception
damaging
wrist
29).
the
has
angulation
soft
be
to
and
and,
This
can
26
MERVYN
and
be confined
wrist,
in
which
remanipulation
for
of deformity.
CONCLUSIONS
An
which
attempt
is so
and
mechanism
those
injuries
is a complete
be
be
deformity
Soft
of
tissues
the
bone.
upper
end
to
the
obtain
and
the
two
rotational
be used
An
radius
In
of
hold
the
the
with
In
the
upper.
pronation
or
cases
in which
a rotation
to guide
caused
and
hold
by
full
element
a bearing
distinction
extremes
latter
there
lower
radial
In
the
supination
first
has
should
THE
reduction
the
JOURNAL
to
be
OF
BONE
will
be
and
to
may
a rotational
must
have
pattern
injury,
logically
there
movement
shown
in a rotational
pronation
in which
reduction,
been
the
between
those
fragment
shaped
upon
in the
is likely
group
has
violence
hand
of rotational
the
of rotation,
is drawn
and
of the
the
a reduction
forced
the
has
in continuity,
and
and
in which
forearm,
particular,
rotation
radius,
in full
injury
In
remains
fragments,
ways
normal
former,
a reduction.
radial
of the
of the
injuries.
of the
alignment
of those
may
shaft
some
function
forearm
of the
used
types.
of
fracture
immobilisation,
other
to describe
of the
in which
to
treatment
made
a part
between
in accurate
cases
been
treatment
transmitted
safely
the
has
important
a place
of the
just
placed
in certain
in
injury.
as in injuries
be
treated
in
full
AND
JOINT
SURGERY
FRACTURES
supination,
for
to the
advantage.
mechanism
best
In the
compression
only
which
group
of the
body
violence
and
,
the
closely
angulation
the
Injuries
1) Forward
the
elbow
lateral
produce
radius
or
a forward
of the
will
rotational
In
the
and
develop
latter
flexion
are
a backward
angulation.
forearm
remains
injuries
of
: pronation
is pronating
direction
rotation
supinating.
injury
vertical
the
ranges
used
may
be
classified
as follows:
in continuity
and
are
head
be reduced
not
head
of the
radius.
end
of the
lower
ulna.
fracture-dislocation.
and
and
posterior
caused
of the
fractures
of
Reduction
supination.
immobilised
in full
Monteggia
by
radius
the
of
Certain
Siipinatioi.
injuries
rotation
violence.
are
treated
best
supination
to prevent
are probably
In
recurrence
variants
general
it
in full
supination.
bones
of
of dislocation
is considered
that
all
radius,
and
deformity
fractures
is
may
with
of
both
most
easily
advantage
be
the
obtained
forearm,
by
with
backward
manipulating
immobilised
in this
into
full
position.
injuries:
Greenstick
full
fractures
of the
forearm
with
forward
angulation.
Reduction
is best
obtained
pronation.
Injuries
in which
This
group
its
the
shaft
includes
forearm.
and
forearm
that
by
forced
normal
limb
injuries:
angulation.
the
of the
of the
“
be added
into
the
is pronating
injuries
of the
should
The
Greenstick
by
of the
Monteggia
of the
Pronation
will
of the
dislocation
injuries
dislocations
shaft
dislocation
of deformity.
of
injury
considerations
be grouped
limb
the
may
beyond
pattern
side
it is emphasized
force
may
the
while
violence
limb
the
pronation
“
a rotation
561
ULNA
injuries:
2) Backward
3) The anterior
These
while
the
rotation
the
determines
AND
on
injuries
taken
occurring
the
proiiation
tissues
by
Such
occurring
of these
RADIUS
to which
has
a supination
basis
in which
Forced
weight.
a fracture
: so also
On
soft
force,
element
THE
caused
basic
injuries
and
intact
applied
rotational
allied,
the
of injuries
the
the
movement)
are
is usually
of momentum
(in
thus
OF
There
of the
all
is nearly
correction
radius
complete
always
is a dominant
is in two
fractures
of the
a rotational
factor
separate
shaft
deformity
in the
fragments
of the
radius
between
the
and
of both
two
radial
bones
of
fragments
treatment.
REFERENCES
EVANS,
E.
M.
Journal
of
Bone
(1945):
EVANS,
E.
M.
fracture.
Royal
Bone
A.,
Joint
J.
and
of
treatment
the
of
with
forearm
31-B,
Surgery,
Treatment
fractures
of
both
bones
of
the
forearm.
of displacements
Medical
special
reference
to
the
anterior
Monteggia
578.
of the
40,
of Orthopaedics),
British
(1946):
NO.
G. D.
PURVIS,
31-A,
Surgery,
Journal
WATSON-JONES,
33 B,
Joint
(Section
(1950):
tile
Association.
distal
radio-ulnar
joint.
Proceedings
of
the
488.
Proceedings
of the
Annual
Meeting
1949
(Section
201.
R.
fractures.
in
27, 373.
injuries
and
(1947):
F. W.
and
PATRICK,
Bone
of Medicine
Orthopaedics),
KNIGHT,
VOL.
P.
deformity
Surgery,
Pronation
of
F.
Society
HOLDSWORTH,
of
Joint
(1949):
Journal
FITZGERALD,
Rotational
and
A study
of supination
of
and
Bone
R.
(1943):
4,
NOVEMBER
Fractures
(1949):
of
both
bones
of
the
forearm
in
adults.
Journal
of
755.
Joint
Fractures
1951
and
Surgery,
and
Joint
pronation,
28,
with
especial
Third
edition.
reference
to the
treatment
of forearm
737.
Injuries.
Edinburgh:
E. & S.
Livingstone
Ltd.