THEEXTREMITIES

UPPER
UPPER

EXTREMITIES
Araneta, Myellerva Jayne F. James, Thanapriya T.
Bacon, Mikeman E. Jayaraman, Mouriya
Bartolome, Apple Anne Michelle Mohanty, Ashim Abhilash
B. Kumar
Bumatariya, Divyesh J. Muthusamy, Selva Princy
Fabito, Darielle Vonne G. Patel, Vikalpkumar D.
Hirpara, Naimish R. Savellano, Princess Noreen R.
Hirpara, Sarjeet N. Sibayan, Jilian Rie F.
ANATOMY OF
THE UPPER
EXTREMITIES
Each upper limb (upper extremity) has 30 bones in
three locations:
Humerus in the arm
Ulna and radius in the forearm
8 carpals in the carpus (wrist), the 5 metacarpals in the
metacarpus (palm), and the 14 phalanges (bones of the
digits) in the hand.
HUMERUS (ARM BONE)
Longest and largest bone of the upper limb
It articulates proximally with the scapula and
distally at the elbow with two bones, the ulna and
the radius.
Greater tubercle
- Lateral projection distal to the anatomical neck
Lesser tubercle
- Projects anteriorly
Intertubercular sulcus
Surgical neck
Body (shaft) of the humerus
Roughly cylindrical at its proximal end, but it gradually
becomes triangular until it is flattened and broad at its
distal end.
Deltoid tuberosity
Roughened, V-shaped area at the middle portion of the
shaft
Serves as a point of attachment for the tendons of the
deltoid muscle.
Capitulum
Rounded knob on the lateral aspect of the bone that
articulates with the head of the radius
Radial fossa
Anterior depression above the capitulum that articulates
with the head of the radius when the forearm is flexed
(bent).
Trochlea
Spool-shaped surface that articulates with the ulna which
is located medial to the capitulum
HUMERUS (ARM BONE)
Coronoid fossa
Anterior depression that receives the coronoid process of the ulna when the forearm is flexed.
Olecranon fossa
Large posterior depression that receives the olecranon of the ulna when the forearm is extended
(straightened).
Medial epicondyle and lateral epicondyle
Rough projections on either side of the distal end of the humerus to which the tendons of most muscles of
the forearm are attached.
ULNA
Located on the medial aspect (the little-finger side) of the
forearm and is longer than the radius
Olecranon
Forms the prominence of the elbow at the end of the ulna
Coronoid process
an anterior projection that articulates with the trochlea of the
humerus
Trochlear notch
A large curved area between the olecranon and coronoid
process that forms part of the elbow joint
Radial notch
A depression lateral and inferior to the trochlear notch which
articulates with the head of the radius.
Ulnar tuberosity
Located just inferior to the coronoid
process to which the biceps brachii
muscle attaches.
The distal end of the ulna consists
of a head that is separated from the
wrist by a disc of fibrocartilage.
Styloid process
Located on the posterior side of the
ulna’s distal end.
Provides attachment for the ulnar
collateral ligament to the wrist.
RADIUS
Smaller bone of the forearm and is located on the lateral
aspect (thumb side) of the forearm
Narrow at its proximal end and widens at its distal end.
Inferior to the head is the constricted neck.
Radial tuberosity – point of attachment
The shaft of the radius – widens distally
Styloid process – brachioradialis attachment
Fracture of the distal end of the radius is the most
common fracture in adults older than 50 years.
ULNA AND RADIUS
Ulna and radius articulate
with the humerus at the
elbow joint.
Articulation occurs in two
places:
Where the head of the
radius articulates with the
capitulum of the humerus
Where the trochlear notch
the ulna articulates with the
trochlea of the humerus.
ULNA AND RADIUS
Articulations formed by the
ulna and radius:
Elbow joint
Joint surfaces at proximal
end of the ulna
Joint surfaces at distal
ends of radius and ulna
The ulna and radius are also
attached by a broad, flat,
fibrous connective tissue
which is called interosseous
membrane.
Carpals, Metacarpals, and Phalanges
Carpus
Proximal region of the hand and consists of
eight small bones called carpals that joined to
one another by ligaments.
Intercarpal joints
Articulations among carpal bones
Carpals are arranged in two transverse rows of
four bones each. Their names reflect their
shapes.
Carpals
Carpals in the proximal row (from lateral to medial)
Scaphoid (boatlike)
Lunate (moon-shaped)
Triquetrum (three-cornered)
Pisiform (pea-shaped)
Carpals in the distal row (from lateral to medial)
Trapezium (four-sided figure with no two sides parallel)
Trapezoid (four-sided figure with two sides parallel)
Capitate (head-shaped) – Largest carpal bone
Hamate (hooked)
The proximal row of carpals articulates
with the distal ends of the ulna and
radius to form the wrist joint.
In about 70% of carpal fractures, only
the scaphoid is broken.
Carpal tunnel
The long flexor tendons of the digits and
thumb and the median nerve pass through the
carpal tunnel.
Carpal tunnel syndrome
Narrowing of the carpal tunnel due to such
factors as inflammation
Metacarpus (palm)
Intermediate region of the hand and consists of five bones called metacarpals.
Metacarpal bones are numbered I to V (or 1–5), starting with the thumb, from lateral
to medial.
The bases articulate with the distal row of carpal bones to form the carpometacarpal
joints.
The heads articulate with the proximal phalanges to form the metacarpophalangeal
joints.
The heads of the metacarpals, commonly called “knuckles,” are readily visible in a
clenched fist.
Phalanges
Bones of the digits that make up the distal part of the hand.
Phalanx – single bone of a digit
Each phalanx consists of a proximal base, an intermediate shaft, and a distal head.
The thumb (pollex) has two phalanges, and there are three phalanges in each of the
other four digits.
The first row of phalanges, the proximal row, articulates with the metacarpal bones
and second row of phalanges.
The second row of phalanges, the middle row, articulates with the proximal row and
the third row, called the distal row.
The thumb has no middle phalanx
Interphalangeal joints – joints between phalanges
Muscles of the Upper Limb
Of the four major arm muscles, three flexors are in the anterior (flexor) compartment,
supplied by the musculocutaneous nerve
biceps brachii,
brachialis, and
Coracobrachialis

One extensor (triceps brachii) is in the posterior compartment, supplied by the radial
nerve.
 MUSCLES of
POSTERIOR
COMPARTME
NT of
FOREARM
BLOOD
SUPPLY OF
THE UPPER
EXTREMITIES
Arteries of Upper limb
• Axillary artery
• Ant. and post. circumflex
humeral a.
• Brachial artery
• Radial artery
• Ulnar artery
• Deep palmar arch
• Superficial palmar arch
• Palmar digital arteries
Veins of Upper limb
• Deep veins (named as arteries)
• Superficial veins:
-Basilic vein
-Cephalic vein
SUPERFICIAL VEINS
Cephalic vein
ascends in the superficial fascia on the
lateral side of the biceps and, on reaching
the infraclavicular fossa, drains into the
axillary vein.
Basilic vein
Ascends in the superficial fascia on the
medial side of the biceps
Halfway up the arm, it pierces the deep
fascia and at the lower border of the teres
major joins the venae comitantes of the
brachial artery to form the axillary vein.
Left Ventricle Ascending aorta Aortic arch

Brachocephalic Left common Left Subclavian

carotid

Right Subclavian Right common Common

carotid interosseous

Ulnar
Thyrocervical
Radial
Brachial
Vertebral
Deep brachial
Anterior
circumflex
Internal thoracic
humeral
Posterior
Axillary circumflex
humeral
Subscapular
 Anterior interosseous
Common
interosseous Posterior interosseous

Ulnar Dorsal carpal arch Dorsal metacarpal Dorsal digital

Radial Deep palmar arch Palmar metacarpal

Deep brachial Superficial palmar Common palmar Proper palmar

arch digital digital
Venous Drainage of Upper Limb
SUPERFICIAL VEINS OF UPPER LIMB
Cephalic and basilic veins
Main superficial veins of the upper limb
Originate in the subcutaneous tissue on the dorsum of
the hand from the dorsal venous network
Perforating veins form communications between
the superficial and deep veins
DEEP VEINS OF UPPER LIMB
Venous Drainage of Upper Limb
Cephalic vein
Ascends in the subcutaneous tissue from the lateral aspect of the dorsal venous network, proceeding
along the lateral border of the wrist and the anterolateral surface of the proximal forearm and arm
Often visible through the skin.
Median cubital vein
Anterior to the elbow, it communicates with the cephalic vein, which passes obliquely across the
anterior aspect of the elbow in the cubital fossa (a depression in front of the elbow), and joins the
basilic vein.
Basilic vein
Ascends in the subcutaneous tissue from the medial end of the dorsal venous network along the
medial side of the forearm and the inferior part of the arm
Often visible through the skin.
Median antebrachial vein (median vein of the forearm)
Begins at the base of the dorsum of the thumb, curves around the lateral side of the wrist, and
ascends in the middle of the anterior aspect of the forearm between the cephalic and the basilic veins.
Common pathway:

Even though the superficial veins drain mainly the superficial structures and the deep
veins (lie internal to the deep fascia) drain the deeper structures. The two venous
drainage systems connect via perforating veins. The perforating veins ultimately
drain into the deep veins all along the upper extremity
INNERVATION
OF THE UPPER
EXTREMITIES
 Brachial plexus
 a network of nerves in the shoulder that carries movement and sensory signals
from the spinal cord to the arms and hands.
 passes from the neck to the axilla and supplies the upper limb
Brachial plexus
Formed from the ventral rami of the
5th to 8th cervical nerves and the
ascending part of the ventral ramus
of the 1st thoracic nerve
Divided into several sections:
 Roots
 Trunks
 Divisions
 Cords
 Terminal branches

Mnemonic: The Bear Came Down The River

Brachial plexus
The C5-T1 spinal nerve roots forms three
trunks:
1. C5-C6 = upper trunk
2. C7 nerve root = middle trunk
3. C8-T1 = lower trunk

The three trunks next divide at the

clavicular level into:
1. anterior divisions
2. posterior divisions
Brachial plexus
At the level of the cords, which is distal
to the clavicle, the plexus is termed the
infraclavicular brachial plexus.
The cords are formed as follows :
1. The anterior divisions of the upper
and middle trunks form the lateral cord.
2. The lower trunk’s anterior division
continues as the medial cord;
3. The posterior divisions from the
upper, middle and lower trunks form the
posterior cord.
Brachial plexus
After giving off the axillary nerve, the
posterior cord continues as the radial
nerve.
The medial cord gives a branch to the
medial head of the median nerve and
continues as the ulnar nerve.
While the lateral cord gives a branch to
the lateral head of the median nerve and
continues as the musculocutaneous
nerve.
Innervations
long thoracic nerve from the C5, C6 and C7 nerve roots -> serratus anterior
muscle.
dorsal scapular nerve (branch of the C5 and C6 roots) ->levator scapulae and
rhomboid muscles
A third branch, the nerve to the subclavius from the C5 and C6 nerve roots ->
subclavius muscle (not clinically evaluable)

***Non-function of muscles innervated by these nerves suggests a proximal root

injury and/or avulsion of the plexus from the spinal cord.
suprascapular nerve arises from the upper trunk above the clavicle -> supra- and
infraspinatus muscles.
lateral pectoral nerve (further distal branch of the lateral cord) -> clavicular head
of the pectoralis major
***weakness indicates lateral cord injury.

medial pectoral nerve arises from the medial cord and with the branches from the
lateral pectoral nerve -> sternocostal head of the pectoralis major muscle.
***Examination of the pectoral major muscle is necessary to localize a cord level
injury : - Pectoralis major clavicular head involvement implies lateral pectoral
nerve injury and sternocostal head involvement, injury to both the lateral and medial
pectoralis nerves.Which implies both medial and lateral cord injury.

musculocutaneous nerve (continuation of the lateral cord) -> coracobrachialis and

the biceps and brachialis muscles and continues distally as the lateral
antebrachial cutaneous nerve.
The posterior cord after giving off the axillary nerve also gives off collateral
branches to the muscles of the posterior wall of the axilla.
thoracodorsal nerve -> latissimus dorsi
subscapular nerves -> subscapular and teres major muscle.
Musculocutaneous Nerve (C5/C6/C7)
ORIGIN
• lateral cord of brachial plexus
• formed from anterior divisions of superior and middle trunks
COURSE
• it leaves the axilla by piercing coracobrachialis muscle
• it then passes down the arm beneath biceps muscle 
• it ends as the lateral cutaneous nerve of forearm
SENSORY SUPPLY
• skin of lateral forearm
MOTOR SUPPLY
• anterior compartment of arm (BBC)
• biceps – flexes elbow, supinates forearm
• brachialis – flexes elbow
• coracobrachialis – flexes and adducts the arm at the glenohumeral joint
 Axillary Nerve (C5/C6)
ORIGIN
• posterior cord of brachial plexus
• formed from posterior division of upper trunk 
COURSE
• it passes beneath the shoulder joint through the quadrangular space with the posterior circumflex humeral artery
• it then wraps around the surgical neck of the humerus
SENSORY SUPPLY
• the “sergeant’s patch” of skin over the lower part of deltoid muscle
MOTOR SUPPLY
• shoulder muscles
• deltoid – abducts, flexes and extends shoulder
• teres minor – externally rotates shoulder, forms part of rotator cuff which stabilises shoulder joint
 Radial Nerve (C5/C6/C7/C8/T1)
ORIGIN
• posterior cord 
• formed from posterior divisions of all three trunks
COURSE
• it passes behind the axillary artery and through the triangular interval to enter the posterior compartment of
the arm
• it then winds around the spiral groove of the humerus with the profunda brachii artery, between the heads of
triceps muscle
• it enters the antecubital fossa in front of the lateral epicondyle of the humerus, between the brachialis and
brachioradialis muscles
• it then branches in the proximal forearm into two terminal branches:
-superficial branch (mainly sensory) – descends under brachioradialis muscle to end in the dorsum of
the hand
-deep branch (mainly motor) – pierces supinator muscle and descends along the posterior interosseous
membrane with the posterior interosseous artery
 Radial Nerve (C5/C6/C7/C8/T1)
SENSORY SUPPLY
posterior arm and forearm
lateral ⅔ of dorsum of hand
proximal dorsal aspect of lateral 3½ fingers (thumb, index, middle and half of ring finger)
MOTOR SUPPLY
• posterior compartment of arm
-triceps – extends and adducts shoulder, extends elbow
• posterior compartment of forearm
-brachioradialis – flexes elbow
-anconeus – extends elbow, stabilises elbow joint
-supinator – supinates forearm
-extensor carpi radialis longus and brevis – extend and abduct wrist
-extensor carpi ulnaris – extends and adducts wrist
-extensor digitorum, extensor pollicis longus and brevis, extensor indicis and extensor digiti minimi – extend
thumb and fingers at MCPJs and IPJs
-abductor pollicis longus – abducts thumb
 Median Nerve (C5/C6/C7/C8/T1)
ORIGIN
• lateral and medial cords of the brachial plexus
• lateral root arises from anterior divisions of superior and middle trunks
• medial root arises from anterior division of inferior trunk

COURSE
• the median nerve runs down the arm with the brachial artery: it initially lies lateral to the artery, then crosses over to
lie medial to it about halfway down the arm
• anterior interosseous nerve – descends along the anterior interosseous membrane with anterior interosseous artery
• deep branch – enters hand through the carpal tunnel beneath the flexor retinaculum of the wrist, between flexor carpi
radialis and flexor digitorum superficialis tendons
• superficial/palmar cutaneous branch – arises just before the wrist and pierces the palmar carpal ligament to enter the
palm over the top of the carpal tunnel – this nerve is therefore not affected by carpal tunnel syndrome
 Median Nerve (C5/C6/C7/C8/T1)

SENSORY SUPPLY
•the median nerve does not supply any sensory innervation to the axilla or upper arm
•skin over thenar eminence
•lateral ⅔ palm of hand
•palmar aspect of lateral 3½ fingers
•dorsal fingertips of lateral 3½ fingers (thumb, index, middle and half of ring finger)


MOTOR SUPPLY
•the median nerve does not supply any motor innervation to the axilla or upper arm
•all muscles of anterior compartment of forearm EXCEPT flexor carpi ulnaris and the medial two parts of flexor digitorum profundus
•pronator teres and pronator quadratus – pronate forearm
•flexor carpi radialis – flexes and abducts wrist
•palmaris longus – flexes wrist and tenses palmar aponeurosis
•flexor digitorum superficialis – flexes fingers at PIPJs
 Median Nerve (C5/C6/C7/C8/T1)
• lateral two parts of flexor digitorum profundus – flex index and middle fingers at DIPJs
• flexor pollicis longus – flexes thumb at IPJ
• intrinsic muscles of hand – LOAF muscles
• lateral two lumbricals – flex MCPJs and extend IPJs of index and middle finger
• opponens pollicis – opposes thumb
• abductor pollicis brevis – abducts thumb
• flexor pollicis brevis – flexes thumb at MCPJ
ORIGIN
Ulnar Nerve (C8/T1)
• medial cord of brachial plexus
• formed from anterior division of inferior trunk 
COURSE
• the ulnar nerve runs down the arm on the medial side of the brachial artery
• it passes behind the medial epicondyle of the humerus and enters the forearm between the two heads of flexor carpi
ulnaris
• it travels through the anterior compartment of the forearm beneath flexor carpi ulnaris with the ulnar artery
• it then enters the palm of the hand through Guyon’s canal
SENSORY SUPPLY
• the ulnar nerve does not supply any sensory innervation to the axilla or upper arm
• skin over hypothenar eminence
• medial ⅓ palm of hand
• palmar aspect of the medial 1½ fingers
• medial ⅓ dorsum of hand
• dorsal aspect of medial 1½ fingers (little finger and half of ring finger)
 Ulnar Nerve (C8/T1)
MOTOR SUPPLY
• two muscles of anterior compartment of forearm
• -flexor carpi ulnaris – flexes and adducts wrist
• -medial two parts of flexor digitorum profundus – flex ring and little fingers at DIPJs

• most of the intrinsic muscles of the hand – HILA muscles

• -hypothenar eminence: opponens digiti minimi, flexor digiti minimi brevis and abductor digiti minimi –
oppose, flex and abduct little finger
• -interossei – palmar interossei adduct, dorsal interossei abduct
• -medial two lumbricals – flex MCPJs and extend IPJs of ring and little finger
• -adductor pollicis – adducts thumb

***adductor pollicis is not part of the thenar eminence and actually lies deep beneath it as a separate structure
Physical Examination of the Upper
Extremities
 Physical Examination
Inspection
Palpation –pression
Range of motion examination
Neurological examination
Special tests for the shoulder problems
Examination of the related areas
 Shoulder Inspection
Anterior side
Posterior side
Lateral side
Medial side
Physical Exam
Inspection

Front & back

Height of shoulder and
scapulae
Muscle atrophy, asymmetry
 SHOULDER PALPATION and PRESSION

Bones
Joints
Muscles
Bursae
Nerves
Lymph nodes
 SHOULDER Range Of
Motion
Flexion-180 degree
Extension -45 degree
Abduction -180 degree
Adduction -30 degree
Internal rotation -90 degree
External rotation -90 degree
Physical Exam
Range of Motion

Forward flexion:
0o – 180o
Physical Exam
Range of Motion

Extension
0o – 40 to 60o
Physical Exam
Range of Motion

Internal rotation • External rotation

80-90o – 80-90o
 Speed shoulder tests

External rotation Internal rotation

 Neurological Examination of the Shoulder

Muscle tests :
Flexion
Extension
Abduction
Adduction
Internal rotation
External rotation
 Muscle testing scoring
0 No contraction
1 Flicker or trace contraction
2 Active movement, with gravity eliminated
3 Active movement against gravity
4 Active movement against gravity and resistance
5 Normal power
Shoulder Abduction muscle test
Shoulder flexion and extension muscle test
Shoulder external and internal rotation muscle
test
Shoulder abduction and adduction muscle test
 Neurological Examination of the Shoulder

sensory tests :
C4
C5
C6
C7
C8
T1
T2
 Special Tests for the Shoulder Problems

Yergason test –biceps tendinitis

Neer impingement test-acromioclavicular impingement
Drop arm test –rotator cuff tear
Resisted flexion (Speed)test –biceps tendinitis
Resisted abduction(Supraspinatus) test-supraspinatus lesion
Aprehension test –glenohumeral joint instability
Yergason test
Yergason test for biceps
tendon instability or
tendonitis.
The patient's elbow is
flexed to 90 degrees, and
the examiner resists the
patient's active attempts
to supinate the arm and
flex the elbow.
Drop Arm Test
Passive abduction to 90°
Instruct patient to slowly
lower arm
At 90° abducted arm will
suddenly drop, may need
to add slight pressure
(+) drop = (+) test
SHOULDER PAIN
SPECIAL TESTS

Neer
PASSIVE
Forced forward flexion
of arm with internally
rotated shoulder
Test is positive if pain
occurs at same point as
with active forward
flexion
Speed’s Maneuver
Forward flex the shoulder
against resistance while
maintaining the elbow in
extension and the forearm in
supination. Pain or tenderness
in the bicipital groove in
dicates bicipital tendinitis.
 Rotator Cuff Strength Testing

Weakness on exam
Grade strength on 0→5 scale
Compare to other side

Supraspinatus testing
Apprehension Test/Relocation Test
 ELBOW ANATOMY
Bones
Joints
Ligaments
Muscles
 EVALUATION
INSPECTION
Anterior –posterior side
Medial-lateral side
Carrying angle
Swelling
 PALPATION and PRESSION
Bone palpation :
Lateral epicondyle
Radial head
Medial epicondyle
Olecranon
 SOFT TISSUE PALPATION
Medial aspect
Ulnar nerve
Wrist flexor –pronator group
Medial collateral ligament
Lateral aspect
Wrist extensors (ECRL-ECRB)
Lateral collateral ligament
Annular ligament
 SOFT TISSUE PALPATION
Anterior aspect
Cubital fossa
Brachial artery
Median nerve
Musculo-cutaneus nerve
Posterior aspect
Olecranon bursa
Triceps tendon
 ELBOW ROM
Flexion -135 degree
Extension -0 degree
Pronation -90 degree
Supination -90 degree
 NEUROLOGICAL EXAMINATION

Muscle tests:
Flexion - Extension
Pronation - Supination
Sensation tests
C5-C6-C7-C8-T1
Reflex test:
Biceps reflex –C6
Brachioradial reflex –C6
Triceps reflex-C7
 Elbow Reflex testing
Biceps reflex –C6
Brachioradial reflex –C6
Triceps reflex-C7
 SPECIAL TESTS
Ligament tests (varus-valgus stres test)
Tennis elbow test
Golfers elbow test
Tinels sign for ulnar nerve
Ligament tests (varus-valgus stres test)
Tennis elbow test
Golfers elbow test
Tinels sign for ulnar nerve
 COMMON ELBOW PROBLEMS

Lateral epicondylitis
Medial epicondylitis
Olecranon bursitis
Fractures
Triceps tendinitis
Post immbolization capsular tightness
(contracture)
EXAMINATION of the WRIST and HAND
INSPECTION
Palmar Surface
Creases
Thenar and Hypothenar
Eminence
Arched Framework
Hills and Valleys
Web Spaces
Palpation-Pression
 ROM EXAMINATION
Forearm pronation-90 degree
Forearm supination -90 degree
Wrist flexion (palmar flexion)-90 degree
Wrist extension (dorsal flexion )-90 degree
Wrist radial deviation -30 degree
Wrist ulnar deviation -20 degree
RANGE OF MOTION
Wrist

Flexion
Extension
Radial deviation
Ulnar deviation
Ulnar deviation is
greater than radial
 FINGERS ROM
MCP joint :
Flexion -90 degree
Extension -20 degree
PIP joint :
Flexion -90 degree
Extension -0 degree
DIP joint :
Flexion -80 degree
Extension -0 degree
 THUMB ROM
Flexion
Extension
Abduction
Adduction
Opposition
 NERVES and BLOOD
SUPPLY
Radial nerve
Median nerve
Ulnar nerve

Radial artery
Ulnar artery
 SPECIAL TESTS
Finkelsteins test –De Quervein tenosynovitis
Tinel test –CTS, UTS
Phalens test –CTS
Carpal Tunnel Tests
Neurologic exam
Median nerve sensation
and motor
Phalen’s Test:
both wrists maximally
flexed for 1 minute
Tinel’s Test
 EXAMINATION of the RELATED AREAS

Cervical spine
Shoulder
Elbow
Arteries ,veins ,lymph
gallbladder stone
Heart
 DIAPHYSEAL FRACTURES
OF THE RADIUS AND ULNA
Mechanism of Injury
• Vast majority occur in young males
with good bone stock
• Injuries most frequently occur in
high-energy trauma such as
• motor vehicle accidents
• sports injuries
Signs and Symptoms
 Pain and swelling in the forearm
 Displacement may also complain
of a visible deformity.
 Skin should be inspected to rule
out any open wounds
 Tenderness at the area of the
fracture
The force applied by trauma can be applied either directly or indirectly onto the
diaphysis of the radius and/or ulna;
Direct injury
◦ gunshot injuries
◦ blunt injury to the forearm
◦ Isolated ulnar shaft fractures(night stick fractures)
Indirect trauma
◦ bending - (Monteggia fracture dislocation)
◦ torsional forces - (fall with a hyperpronated forearm and wrist extension
,Galeazzi fractures)
Associated Injuries
⮚ Approximately 1/3 of forearm shaft -isolated injuries, remaining fractures occur in the
presence of at least one additional injury 
⮚Associated injuries can be grouped into:
▪ Those occurring adjacent to the forearm shaft fracture
• minor contusion of the soft tissue sleeve in isolated minimally displaced ulna (nightstick)
fractures to marked soft tissue injury
▪ Those occurring in other sites of the musculoskeletal system
• increasing energy, a greater extent of fracture comminution and displacement is
seen, which in turn increases the risk of injury to the surrounding muscles
⮚ Direct trauma to the forearm causes blunt injury to the soft tissue sleeve, while fracture displacement
will lead to laceration of the soft tissues by the sharp edges of the fracture and may injure the
interosseous membrane, muscles, neurovascular structures, and skin .
Imaging and Other Diagnostic
Studies
⮚ Forearm fractures are routinely diagnosed with posteroanterior (PA) and
lateral radiographs of the forearm. These images should show the forearm
from the elbow to the wrist.
Classification of Diaphyseal Fractures of the Radius and
Ulna
AO/OTA classification
TREATMENT OPTIONS
The main goal of treatment of fractures - recover painless function of
the forearm and upper extremity.

Principles of Treatment -these four key criteria:

1. Obtain adequate reduction
2. Achieve and maintain fracture reduction while
3. Preserving biology and allowing
4. Early range of motion.
Non- operative Treatment
⮚ Mainly limited to isolated fractures affecting the distal two-thirds of the ulna
with less than 50% of displacement and less than 10 degrees of angulation. 
⮚ For stable isolated ulna shaft fractures, below-elbow immobilization is
considered the treatment of choice since it compares favorably to long arm
casting and to ace bandaging.
⮚ Immobilization may be obtained either with a short arm cast or with a below-
elbow brace.
Operative Treatment
⮚ Indications for operative treatment of forearm shaft fractures are
essentially all fractures except undisplaced fractures or isolated
stable ulna shaft fractures.
⮚Open reduction and internal fixation (ORIF) with plates and
screws is the most widely used method of treatment for unstable
forearm fractures.
Monteggia Fracture-Dislocation
 ULNA
• The ulna acts as the axis around which the radius
rotates during pronation–supination.
• Effectively, the axis of rotation of the radius is
located on the line connecting the center of the
radial head and the head of the ulna.
• The proximal ulna comprises the olecranon and
coronoid that form the trochlear notch (greater
sigmoid notch) that articulates with the distal
humerus.
• The radial notch (lesser sigmoid notch) is located on
the lateral aspect of the proximal ulna, just distal to
the trochlear notch.
• This concavity serves as the articulating surface for
the radial head and as the insertion both anteriorly
and posteriorly for the annular ligament.
• Monteggia fracture-dislocations (or
lesions) consist of a proximal radial
dislocation and a fracture of the ulna.

• They are classified according to Bado based

on the direction of the apex of the ulnar
fracture and the direction of the proximal
radial dislocation

• Mechanism of injury: direct blow or fall on

outstretched hand.
 BADO CLASSIFICATION
Type 1 Anterior dislocation of the radial head, fracture of the
ulnar diaphysis at any level with anterior angulation.

Type 2 Posterior or posterolateral dislocation of the radial head,

fracture of the ulnar diaphysis with apex posterior
angulation

Type 3 Lateral or anterolateral dislocation of the radial head,

fracture of the ulnar metaphysis. This occurs almost
exclusively in children, but isolated cases in adults have
been described.

Type 4 Anterior dislocation of radial head with fracture of the

proximal third of ulna and fracture of the radius at same
level. This occurs exclusively in adult patients.
Evaluation:
History:- There may be diffuse swelling around the elbow, but the degree is variable.
It will be painful to move the elbow in any plane.
Physical exam:- Tenderness and deformity. A full neurologic, vascular and
compartment exam should be performed before and after reduction. Dislocations of
the radial head may stretch and injure the posterior interosseous nerve
 An examination should begin with
1. Visual inspection -paying close attention to the skin and soft tissue for visible
bony deformities, muscle contusions, skin lacerations, tendon damage and
neurovascular deficits. It is imperative to identify wounds overlying fracture sites
(i.e., open fracture), which requires immediate surgical intervention.
2. Gentle palpation should be performed identifying deformities and
focal tenderness.
Examination of the proximal and distal joint should be performed to identify
concomitant injuries. Avoid probing open wounds.
• High mechanism crush injuries warrant a detailed neurovascular
exam with repeat serial exams looking for signs of acute
compartment syndrome.
• Inquire about numbness, weakness, paresthesias, and radiating
pain.
• Although nerve injury is less common, examination of the
radial and median nerve distribution is essential in identifying
nerve damage. Ulnar nerve injury is rare.
Radiographic
Any radiographic series for forearm fracture must include quality AP and
lateral views of the elbow, which are necessary and usually sufficient to
identify radiocapitellar incongruity.
Treatment
Ulna:- ORIF ( plate's screw)
Radial head:- closed reduction (open it irreducible or unstable)
PEDs:- closed reduction And cast
Radius:- ORIF
DRJ:- closed reduction, +/- percutaneous pins in supination if unstable,
Cast for 4 to 6 weeks
Complications
• Complications related to adult Monteggia fractures include those
so frequently encountered in elbow trauma.

• Stiffness may result from prolonged immobilization. Fixation

methods should allow early ROM, though loss of reduction may
occur, with resultant instability, non-union or malunion.
Post–operative Rehabilitation
• Adult population- rehabilitation will be predicated upon elbow stability.
• After open reduction and internal fixation (ORIF), the patient should be
placed in a long arm splint at 90 degrees with the forearm supinated.
• Shoulder, hand and wrist mobilization should be encouraged immediately
post-operatively.
• Gentle active-assist elbow range of motion is typically initiated at 7-10
days postoperatively. In the setting of a radial head or coronoid fracture or
collateral ligament tear repair, the patient will be fitted with a hinged
elbow brace, often with an extension block.
• If radial head ORIF or replacement is performed, supination / pronation
should be initiated based on stability of fracture ORIF but within 2-4
weeks
Galeazzi Fracture
Definition
• Galeazzi fractures consist of a fracture of the radial shaft with dislocation
of the distal radioulnar joint.
• Eponyms -“fracture of necessity,” Piedmont fracture, and reverse
Monteggia fracture
• Most often in male
• 25% of isolated radial shaft fractures.
• 7% of all forearm fractures in adults.

• Mechanism of injury
• Torsional forces with axial loading, such as those occurring during a fall
with a hyperpronated forearm and wrist extension.
Classification
Two classification systems have been proposed
when categorizing Galeazzi fractures. 
The first classifications were based on the position of the distal radius:
 Type I: Dorsal displacement
 Type II: Volar displacement
Classification
The second classification system is based on
Rettig ME and Raskin KB who categorized
Galeazzi fractures based on fracture stability:
Type I:
Fracture occurring distally from the 7.5 cm
demarcation (i.e., closer to the wrist)
Associated with significant DRUJ instability
in more than 50% of cases
Classification
Type II:
Fracture occurring proximally from the 7.5
cm demarcation (i.e., further from the wrist)
Associated with significant DRUJ instability
in only around 5% of cases 
 occur within 7.5 cm of
TYPES thearticularsurface of the
distal radius

Type 1

Associated with a
significantly higher rate of
instability of the DRUJ,
frequently requiring open
Galeazzi fractures repair of this joint

Type 2 more proximally.

 Readily reduce
Simple dislocation after radial alignment
has been restored

DRUJ dislocations
associated
with
Interposition of the
Galeazzi fractures extensorcarpiulnaris(ECU)
or
Those in which the DRUJ is
Complex irreducible after extensordigitiminimi
dislocation anatomic reduction of the radial (EDM) between the distal
shaft fracture radius and ulna have been
described
as causes for DRUJ
irreducibility
History
• - fallen onto an outstretched hand.

Symptoms
 pain and swelling in forearm and wrist
 Painful forearm rotation
Physical examination
An examination should begin with a
1. Visual inspection of the skin and soft tissue paying close attention to visible bony
deformities, skin lacerations, muscle contusions, tendon damage and
neurovascular deficits. It is essential to identify wounds overlying fracture sites
(i.e., open fracture), which necessitates immediate surgical intervention. 
2. Gentle palpation should be performed to identify deformities and focal tenderness
A fall on an outstretched hand should raise suspicion for a wrist injury, and
particular attention should be paid to the stability of the DRUJ. 
High mechanism crush injuries merit a detailed neurovascular exam with repeat
serial exams looking for signs of acute compartment syndrome. Inquire about
weakness, numbness, paresthesias, and radiating pain.
Examination of the median and radial nerve distribution is essential in identifying
nerve damage.
Neurovascular examination- Anterior
interosseous nerve palsy
Associated injuries
 ulnar styloid fracture
 Anterior interosseous nerve palsy
 TFCC injury
 DRUJ instability
Plain Radiographs
Radial shaft fracture
 commonly at the junction of the
middle and distal third
 Dorsal or volar angulation
Dislocation of the distal radioulnar
joint
Radial shortening may occur
Management
• In adults, poor results can be
universally expected with
nonoperative treatment of these
injuries because of inadequate
control of deforming forces of the
PQ, brachioradialis, and thumb
abductors and extensors Intraoperative fluoroscopic images showing fracture reduction onto
the plate held by lobster clamps. Fixation is achieved with dynamic plate compression
• Plate and screw fixation is the and a total of six cortices being engaged by screws on each side of the fracture.

preferred mode of fracture

stabilization
• The radial shaft is approached either via a
volar (henry approach) or a dorsal
approach (Thompson approach).
• In most instances the fracture will be
located in the distal half of the radius,
making the volar the most frequently
used approach.
• However, some authors have reported a
higher use of the dorsal Thompson
approach to reduce a theoretical risk of
reduced pronation associated with the
volar approach.
Anterior (Henry) approach to the radius.
The patient is positioned in the supine
position with the forearm supinated on a
hand table
Posterior (Thompson) approach to the radius.
A: The patient is positioned in the supine position with
the forearm pronated either across the chest or on a hand
table.
B: An incision is performed along a line from the lateral
epicondyle of the humerus proximally toward Lister
tubercle distally.
POSTOPERATIVE CARE
• Postoperatively, immobilization for 3 to 6 weeks in a long arm
cast is recommended.
• Galeazzi fractures with dorsal dislocation are immobilized in
supination, whereas those with volar dislocation are
immobilized in pronation.
• Some authors advocate immobilization in neutral after repair.
• Check neurologic and vascular status
• Obtain radiographs to recheck alignment and reduction of the
radius and the DRUJ
 BARTON’S FRACTURE
It is a fracture of the distal radius which extends through the dorsal aspect of the
articular surface with associated dislocation of the of the radiocarpal joint
Since there is no disruption of the radiocarpal ligaments, the articular surface of
fractured distal radius remains in contact with the proximal carpal row
This preserved relationship between the radius and carpus is what distinguishes
the Barton fracture from other types of of distal radius fracture/ dislocation.
 BARTON’S
FRACTURE
 BARTON’S FRACTURE
A. VOLAR SHEARING OR VOLAR LIP (VOLAR
BARTON’S) FRACTURES
More common than dorsal Barton’s fracture
Categorized by the size and comminution of the
volar fragment and whether the sigmoid notch is
involved.
Inherently unstable and nonoperative treatment is
therefore reserved for the elderly, frail patient, or the
rare undisplaced fracture
BARTON’S FRACTURE
B. DORSAL SHEARING OR DORSAL LIP (BARTON’S)
FRACTURES
Rare injuries and usually occur in association with a
variety of other injuries and radiocarpal subluxation
or dislocation
Result of high-energy injury and tend to occur in
younger patients
 BARTON’S FRACTURE
ETIOLOGY
◦ The mechanism of injury vary depending on patient population.
◦ Pediatric and young adult – results from sporting activities and
motor vehicle accidents
◦ Elderly, particularly women – decreased bone density from
osteoporosis which means that less force is needed to cause this
injury
◦ Majority of these fractures are a result of a fall while standing
PATHOPHYSIOLOGY
◦ It is a compression injury with marginal shearing fracture of the distal
radius
◦ The most common cause of this injury is a fall on an outstretched,
pronated wrist.
◦ The compressive force travels from the hand and wrist through the
articular surface of the radius being displaced dorsally along with the
carpus
HISTORY AND PHYSICAL EXAM
◦ Patients with Barton fracture will typically present with acute wrist pain and
deformity following a recent trauma
EVALUATION
◦ Radiographs of the wrist, consisting of at least frontal and lateral views
◦ CT scan can be used to better evaluate anatomic detail or if radiographs are
unclear
◦ MRI to evaluate for associated ligamentous or soft tissue injuries
TREATMENT
◦ The overall goal is to obtain sufficient pain-free motion
◦ Traditionally, the treatment of distal radius fractures is by closed
reduction and immobilization in a splint or cast, this has been and
remains the treatment of choice in non-displaced and stable distal
radial fractures.
 COLLE’S FRACTURE
EPIDEMIOLOGY/ETIOLOGY
 Colles fractures are the most
common type of distal radial
fracture and are seen in all adult age
groups and demographics.
 They are particularly common in
patients with osteoporosis, and as
such, they are most frequently seen
in elderly women.
 Younger patients who sustain Colles
fractures have usually been involved
in high impact trauma or have
fallen, e.g. during contact sports,
skiing, horse riding
MECHANISM
 Most Colles fractures are secondary to a fall on an outstretched hand
(FOOSH) with a pronated forearm in dorsiflexion (the position one
adopts when trying to break a forward fall).
 The proximal row of the carpus (particularly the lunate and scaphoid)
transfer energy to the distal radius, both in the dorsal direction and
along the long axis of the radius. Most fractures are therefore dorsally
angulated and impacted.
CLINICAL PRESENTATIONS/MANIFESTATIONS:
"Dinner Fork" Deformity
History of fall on an outstretched hand
Dorsal wrist pain
Swelling of the wrist
Increased angulation of the distal radius
Inability to grasp object
Signs and Symptoms:
Pain, numbness, tenderness, bruising, deformity of wrist.
DIAGNOSIS
“A careful history including the mechanism of injury establishes
suspicion for a Colles fracture. Diagnosis is most often made upon
interpretation of posteroanterior and lateral views alone.”
The classic Colles fracture has the following characteristics:
 Transverse fracture of the radius
 2.5 cm (0.98 inches) proximal to the radiocarpal joint
 dorsal displacement and dorsal angulation, together with the radial tilt
Other characteristics on plain radiographs may include:
 Radial shortening
 Loss of ulnar inclination
 Radial angulation of the wrist
 Comminution at the fracture site
 Associated fracture of the ulnar styloid process in more than 60% of cases.
EVALUATION
Radiographs are usually the mainstay of evaluation, diagnosis, and initial
management of these injuries. PA and lateral views should be taken at a minimum
to evaluate these injuries. These radiographs help to distinguish the type of injury
among different types of forearm fractures to narrow down and make a diagnosis.
When plain films appear normal, and injury is still suspected, CT may be used to
evaluate for occult fractures.

MRI is not a recommended diagnostic measure as the initial evaluation; however, it

may serve to assess ligamentous or soft tissue extents of these injuries.
FRYKMAN CLASSIFICATION: COLLE’S
FRACTURE
Type I: transverse metaphyseal fracture
-Includes both Colles and Smith fractures as angulation is not a feature
Type II: type I + ulnar styloid fracture
Type III: fracture involves the radiocarpal joint
-Includes both Barton and reverse Barton fractures
-Includes Chauffeur fractures
Type IV: type III + ulnar styloid fracture
Type V: transverse fracture involves distal radioulnar joint
Type VI: type V + ulnar styloid fracture
Type VII: comminuted fracture with the involvement of both the radiocarpal and
radioulnar joints
Type VIII: type VII + ulnar styloid fracture
MANAGEMENTS
The treatment of Colles fractures will depend on the type of Colle's fracture present,
the age and activity level of the patient, the surgeon’s preference, and the patient’s
desires regarding immobilisation and return to activity.
Undisplaced fracture
-May be treated conservatively with a cast alone.
-The cast is applied with the distal fragment in palmar flexion and ulnar
deviation.
Surgical options includes:
 External fixation
 Internal fixation
 Percutaneous pinning
 Bone substitutes.
Closed reduction.
-A fracture with mild angulation and displacement may require
Open reduction and internal fixation or external fixation
-Significant angulation and deformity may require an .
The volar forearm splint
-Best for temporary immobilisation of forearm, wrist and hand fractures,
including Colles fracture.
 SMITH’S FRACTURE
AKA “Extraarticular fracture of
the distal radius” featuring a volar
displacement or angulation of the
distal fragment.
It is also known as a reverse Colles
fracture since the more common
Colles fracture features a dorsal
displacement of the distal fracture
fragment.
ETIOLOGY:
Smith fractures commonly occur either as a fall onto a flexed wrist or as a direct
blow to the dorsal aspect of the wrist.
More common than initially thought, volar displacement of the distal radius can
occur with a fall onto the palm of the hand.
EPIDEMIOLOGY
Smith fractures make up approximately 5% of all radial and ulnar fractures
combined. The highest incidence of Smith's fractures is in young males and elderly
females.
Almost all distal radius fractures arise in children sustaining high-energy falls and
osteoporotic seniors who suffer low-energy falls.
HISTORY AND PHYSICAL EXAM
The physical exam may reveal a deformity of the distal forearm, but the direction of
angulation- dorsal (Colles) or volar (Smith) is difficult to discern on visualization.
Also, present on the exam are swelling, pain, and decreased ROM.
One of Smith’s first diagnostic criteria was a deformed wrist with swelling visible on
the volar side and the prominence of the ulna along the dorsum of the wrist.
NEUROLOGIC CONCERNS IN
SMITH’S FRACTURE
Evaluation of the extremity's neurovascular status is imperative. A compromise
would necessitate immediate attempts at closed reduction. Up to 15% of these
fractures may show symptoms of acute carpal tunnel syndrome (ACTS) from
compression to the median nerve.
Less commonly, but still present neurological concerns include both radial and ulnar
nerve compression.
Another cause of neurovascular compromise seen in Smith fractures and other distal
radius fractures is acute compartment syndrome of the forearm.
EVALUATION
WRIST X-RAY:
-Adequate for the characterization of a distal wrist fracture and can
differentiate between a Colles and Smith fracture.
-Orthogonal views (AP, lateral) are adequate.
CT SCAN:
-May be useful in situations of extensive comminution or intra-articular
fracture patterns.
-Can help define, and best appreciate not only the pattern of injury but also
help the surgeon to plan for operative reduction strategy.
In general, radiographic interpretation should comment on the presence of a distal
radial fracture with volar angulation, the fracture location (extra-, juxta-, or intra-
articular), the degree of angulation, and the degree of displacement. The
radiographic interpretation should also comment on carpal malalignment, carpal
fractures, as well as the articulation of the radio-lunate and radio-scaphoid joints.
MANAGEMENT/TREATMENT:
“The ultimate goal of successful treatment is, of course, to restore alignment.”
A. Conservative Approach
1. Closed reduction followed by Immobilization(Splinting)
-The mainstay of treatment of non displaced and stable distal radius
fractures.
 The closed reduction
-Is performed under procedural sedation, hematoma block, regional nerve
block, intravenous regional/Bier block, or general anesthesia.
2. Closed Reduction with Percutaneous Pinning (CRPP)
-Is another option.
-Kirschner wires are minimally invasive, low-cost, and offer good functional
outcomes for two or three-part fractures. However, this is not a good option for poor
bone quality (i.e., osteoporosis), multiple fragments of comminution.
-Complications include injury to the tendons, nerves or vasculature, pin
migration, fracture settling, and a pin site track infection.
3. External Fixation
-A third option. The principal concept is that external fixation utilizes
ligamentotaxis to maintain appropriate positioning of the fracture fragments.
B. Surgical Approach
1. ORIF (Open Reduction Internal Fixation)
-Has become the most favored method of treatment, especially with the
advancement of locking plates.
-This is the best choice for a fracture that is unstable or not reducible.The
three main categories of internal fixation are dorsal, volar, and fragment specific
fixation.
Smith fractures divide into three
types:
Type I: Most common type, accounting for about 85% of cases, is an extraarticular
fracture through the distal radius
Type II: Less common, accounting for approximately 13%, is an intraarticular
oblique fracture, also referred to as a reverse Barton fracture
Type III: Uncommon, less than 2%, is a juxta-articular oblique fracture
COLLE’s vs. SMITH’s
Fracture
COLLE’s vs. SMITH’s
Fracture
 CHAFFEUR’S FRACTURE
Also known as:
 “Hutchinson fractures” or
“Backfire fractures”
 Are intra-articular fractures of
the radial styloid process. The
radial styloid is within the
fracture fragment
 Often associated with
scaphoid and lunate injuries
ETIOLOGY:
•Radial styloid frxs most commonly occur from tension forces sustained during ulnar
deviation and supination of the wrist.
•Strong radiocarpal ligament, particularly radioscaphocapitate ligament, avulse radial
styloid from metaphysis of the radius.
•Ligamentous attachments maintains alignment radial styloid to carpus, but styloid
may be markedly displaced from the rest of radius.
•Brachioradialis & extrinsic wrist & finger flexors & extensors exert powerful
displacing force on carpus/radial styloid complex.
•Fracture of styloid are frequently accompanied by dislocations of lunate
MECHANISM
These injuries are sustained either from direct trauma typically a blow to the back of the
wrist or from forced dorsiflexion and abduction.

The former accounts for its name; trying to start an old-fashioned car with a hand crank
sometimes resulted in the crank rapidly spinning backward (backfire) out of the driver's
grasp and striking the back of the wrist.

The latter occurs as the scaphoid forcibly impacts upon the radial styloid and can be
considered an avulsion fracture with the radiocarpal ligaments remaining attached to the
radial styloid.
PATHOPHYSIOLOGY
The Chauffeur’s fracture is an intra-articular fracture of the radius that includes the
radial styloid. The fracture fragment can be variable in size. The injury is often the
result of a FOOSH injury with a blow to the back of the wrist causing dorsiflexion and
abduction causing the scaphoid to compress against the radial styloid.
Patients may have small avulsions of the radial styloid that are not clinically
significant, but these injuries are often associated with disruption of the
radioscaphocapitate and other collateral ligaments; this can lead to lunate dislocation
and scapholunate disruption.
These fractures were historically suffered by drivers who would need to start their cars
using a hand crank. Occasionally these cranks would backfire and forcefully strike
drivers on the back of the wrist.
EVALUATION:
The essential elements in the evaluation of distal radial fractures are history and
physical. These will guide a clinician in deciding what further imaging to obtain.
1. X-rays
-Standard imaging modality in the diagnosis of DR fractures. X-rays
examination should look for radial height, radial inclination, radial shift, volar tilt,
ulnar variance, ulnar styloid fracture, and DRUJ widening.

2. Computed tomography (CT) images

-May be necessary if X-rays are equivocal, but the history and physical are
strongly suggestive of a fracture. CT imaging may also be useful in subsequent
surgical planning for fractures that will go to the operating suite for fixation,
especially intra-articular fractures.
3. MRI
-Adds little utility over X-ray and CT in the diagnosis of DR fracture. They may
be useful if ligamentous disruption is highly suspected, but these studies are not
necessary to perform in the Emergency Department. Advanced imaging such as
MRI is more frequently performed in the outpatient setting by orthopedic
specialists.
TREATMENT AND MANAGEMENT
The necessary treatment of all confirmed distal radial fractures involves pain
management, immobilization, and evaluation for open fractures or neurovascular
compromise.
Patients with decreased sensation, motor deficit, neuropathy, or tense forearm
compartments should receive immediate orthopedic consultation.
A pulseless extremity should be seen immediately by an orthopedic surgeon, but may
also warrant an additional evaluation by the vascular surgery service if available.
Open fractures are also an indication for emergent orthopedic
evaluation. Open fractures grading is by the Gustillo-Anderson Scale,
which rates fractures ranging from Grade I through Grade IIIc.
All open fractures graded II or higher will need surgical washout, but
this decision is at the discretion of the surgeon.
All open fractures should receive appropriate tetanus prophylaxis
and antibiotic treatment.
Gustillo Grades I-II may receive a first-generation cephalosporin such
as intravenous cefazolin. Penicillin-allergic patients may receive IV
clindamycin.
Gustillo Grades 3 or greater will require the above plus the addition of
an aminoglycoside such as gentamicin.
GUSTILLO-ANDERSON SCALE
Type I
-Wound ≤1 cm, minimal contamination or muscle damage
Type II
-Wound 1-10 cm, moderate soft tissue injury
Type IIIA
-Wound usually >10 cm, high energy, extensive soft-tissue damage, contaminated
adequate tissue for flap coverage farm injuries are automatically at least Gustillo IIIA
Type IIIB
-Extensive periosteal stripping, wound requires soft tissue coverage (rotational
or free flap)
Type IIIC
-Vascular injury requiring vascular repair, regardless of degree of soft tissue
injury
References:
Vannabouathong C, Hussain N, Guerra-Farfan E, Bhandari M. Interventions for Distal Radius Fractures: A
Network Meta-analysis of Randomized Trials. J Am Acad Orthop Surg. 2019 Jul 01;27(13):e596-e605.
Lawson GM, Hajducka C, McQueen MM. Sports fractures of the distal radius--epidemiology and outcome.
Injury. 1995 Jan;26(1):33-6.
Matsuura Y, Rokkaku T, Kuniyoshi K, Takahashi K, Suzuki T, Kanazuka A, Akasaka T, Hirosawa N, Iwase M,
Yamazaki A, Orita S. Smith's fracture generally occurs after falling on the palm of the hand. Journal of
Orthopaedic Research. 2017 Nov;35(11):2435-41.
Jupiter JB, Kellam JF. Diaphyseal fractures of the forearm. In: Browner BD, Jupiter JB, Levine AM, Trafton
PG, Krettek C, eds. Skeletal Trauma: Basic Science, Management, and Reconstruction. Philadelphia, PA: WB
Saunders; 2008
Dayican A, Unal VS, Ozkurt B, Portakal S, Nuhoglu E, Tumoz MA. Conservative treatment in intra-articular
fractures of the distal radius: a study on the functional and anatomic outcome in elderly patients. Yonsei Med
J. 2003 Oct 30;44(5):836-40
R.J. Medoff.
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