After elimination of the dislocation of the bones of the forearm, the limb is fixed. Traumatic dislocations of the forearm. Mechanism. Classification, diagnosis, treatment. Isolated dislocations and subluxations in children

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Traumatic dislocations and subluxations of the forearm are second in frequency after dislocations of the shoulder and account for 18-27%. They are observed more often in men aged 10-30 years and in women aged 50-70 years.

Flattening of the semilunar notch of the ulna, flattening of the leaf surface of the shoulder, hypervalgus or varus position of the forearm, weakness of the ligamentous apparatus of the elbow joint are anatomical prerequisites for dislocations in the elbow joint.

Dislocations and subluxations of the forearm occur as a result of direct and indirect trauma. The variety of occurring dislocations in the elbow joint is explained by the complexity of its anatomical structure. There are dislocations of the bones of the forearm backwards, anteriorly, outward, inward; dislocations and subluxations of the head of the radius anteriorly, posteriorly and outwards; divergent dislocation of the forearm. Subluxations are cases where there is partial contact between the articular surfaces. The course and outcome of dislocation or subluxation of the forearm depend not only on the magnitude in the form of displacement, but also on the nature of the damage to the soft tissues surrounding it. Usually, dislocation of the forearm is accompanied by a hematoma, damage to the capsular-ligamentous apparatus, muscles, periosteum, and in some cases compression of blood vessels and nerves. Soft tissue injuries are directly dependent on the magnitude and direction of the acting force. This can explain the fact why the same type of dislocation in different patients proceeds and ends far from the same.

Diagnosis of dislocation of the forearm is usually not difficult. Patients are concerned about the forced position of the limb, the impossibility of movements in the elbow joint, severe pain in it. In all cases, there is a deformity of the elbow joint, depending on the type of dislocation, swelling of this area is pronounced. When trying to make passive movements, a symptom of "springy mobility" is revealed.

The most common (90%) are posterior dislocations of the forearm. According to experimental data, they occur when falling on the arm, slightly bent at the elbow joint. With increased abduction of the forearm, the lateral ligaments are significantly damaged. Possible separations of the medial ligament with a fragment of the medial epicondyle or coronoid process, in children - epiphysiolysis of the medial epicondyle. Shearing compression forces in the glenohumeral joint result in fractures of the head of the radius, the capitate eminence, or the lateral epicondyle of the shoulder. With posterior dislocation, more often than with other types, damage to the radial, median and ulnar nerves, the brachial artery occurs, and the shoulder muscle is significantly injured.

When the forearm is dislocated posteriorly, due to its displacement in the proximal direction, the impression of shortening of the forearm and lengthening of the shoulder is created. The axis of the forearm is deflected (often outwards) in relation to the axis of the shoulder. The olecranon will stand posteriorly, its apex is displaced upwards and is located above the level of the condyles of the shoulder. This distinguishes a dislocation from a supracondylar fracture of the shoulder, in which Gueter's triangle, formed by the tip of the olecranon and both epicondyles of the humerus, is not broken.

Anterior dislocations of the forearm are less common (about 4.5%). They occur when you fall on the most bent elbow joint. With an anterior dislocation, a retraction is noted at the site of the olecranon, the forearm seems elongated compared to the forearm of a healthy arm. This type of dislocation is characterized by damage to a greater or lesser extent to both lateral ligaments of the anterior and posterior sections of the joint capsule. Damage to the tendon of the triceps muscle of the shoulder, tearing of the muscles attached to the condyles of the shoulder are possible.

Lateral and medial dislocations of the forearm "are very rare. The elbow joint is expanded in the transverse direction. The axis of the forearm is shifted outwards or inwards, respectively. These types of dislocations of the forearm are often combined with a fracture of the medial or lateral epicondyle of the humerus, head of the radius.

Divergent dislocation occurs extremely rarely. It occurs when the ulna and radius bones diverge back, forward, inward or outward, and is the result of a brute acting force. Not only the capsular-ligamentous apparatus of the elbow joint is damaged, but also the interosseous membrane.

X-ray examination of patients with dislocations of the forearm is mandatory before reduction and after it. Elbow radiographs show associated fractures of the coronoid process, radial head, capitate eminence, or medial epicondyle.

Dislocations of the forearm, as noted, are accompanied by damage to the capsular-ligamentous apparatus of the elbow joint. In this case, the lateral ligaments are damaged along or with the separation of the bone fragment. The main stabilizer of the elbow joint is the medial ligament. With its integrity, dislocation in the elbow joint does not occur. After elimination of the dislocation of the forearm, it is imperative to determine the latent instability of the elbow joint to prevent chronic instability.

A great help in the early diagnosis of damage to the capsular-ligamentous apparatus of the elbow joint is provided by an X-ray contrast study, in which a contrast agent (verografin, urographin) is injected into the joint cavity. In the presence of a defect in the capsular-ligamentous apparatus, the contrast agent is determined in the para-articular tissues.

Elimination of dislocation of the forearm in fresh cases is performed either under local anesthesia with the introduction of 20-25 ml of a 2% solution of novocaine into the joint cavity or under anesthesia. The reduction of the dislocation under general anesthesia is preferable due to the better relaxation of the surrounding muscles to prevent additional injury to the capsular-ligamentous apparatus and articular cartilage. Reduction of the posterior dislocation of the forearm. The patient is laid on his back, the diseased arm is taken away from the body to a right angle. The surgeon stands outward from the abducted shoulder and with both hands grabs the lower part of the shoulder above the elbow joint, puts his thumbs on the olecranon and head of the radius. The assistant becomes on the same side to the right of the surgeon and takes the patient's hand with one hand, and the lower part of the forearm with the other. The surgeon and assistant produce a smooth extension of the arm while simultaneously bending it at the elbow joint. The surgeon, pressing on the olecranon and the head of the radius, moves the forearm anteriorly and the shoulder backwards. Reduction usually occurs without much effort, with a clicking sound.

In case of posterior external dislocation of the forearm, the surgeon uses his thumb to press on the olecranon and head of the radius not only anteriorly, but also medially.

Reduction of the anterior dislocation of the forearm. The patient is placed on the dressing table, the arm is taken to a right angle. The assistant fixes and counter-extends the shoulder, and the surgeon, pulling the forearm with one hand and pressing on the proximal part of the forearm downwards, outwards and backwards with the other hand, flexes the forearm at the elbow joint.

Reduction of dislocation of the forearm inwards. The patient is laid on the table, the shoulder is taken to a right angle. One assistant fixes and holds the shoulder, the other stretches the forearm along the axis. The surgeon with one hand presses on the proximal part of the forearm from the inside to the outside, and with the other hand simultaneously presses on the external condyle of the shoulder from the outside to the inside.

Reduction of external dislocation. The assistant fixes the abducted shoulder, and the surgeon with one hand stretches the forearm, the other presses the upper part of the forearm inwards and backwards, bending the elbow joint.

After eliminating the dislocation of the forearm, it is necessary to check the pulse on the radial artery, movements in the joint to exclude infringement of the capsule, and lateral stability of the joint. X-ray examination is mandatory: standard radiographs, contrast arthrograms and radiographs with forearm valgus.

If the joint is stable or grade I instability is established, conservative treatment is indicated. Immobilization is carried out with a plaster splint applied from the shoulder to the metacarpophalangeal joints with the elbow joint flexed at an angle of 90°, on average between pronation and supination, for a period of 2–3 weeks, depending on the data of radiopaque examination. From the very first days, the patient is recommended to carry out active movements with the fingers of the hand, which contributes to the resorption of edema and hemorrhage in the area of the elbow joint. From the 2-3rd day, isometric tensions of the muscles surrounding the elbow joint begin.

After removing the gypsum splint, restorative treatment is carried out.

The indication for surgical treatment is lateral instability of the elbow joint II-III degree. At the same time, the lateral capsular-ligamentous apparatus is carefully sutured, rare sutures are applied to the capsule of the anterior and posterior sections. The period of immobilization is determined depending on the extent of damage to the capsular-ligamentous apparatus, the age and profession of the victim. Treatment of dislocation of the forearm with detachment of the medial epicondyle of the shoulder. In the absence of displacement of the epicondyle after elimination of the dislocation of the forearm, the treatment is conservative. Displacement of the epicondyle greater than 2 mm and its possible infringement in the joint cavity are indications for surgical intervention. In this case, the epicondyle or its fragment is removed from the joint cavity and, depending on the size, fixed with a screw, knitting needles or transosseous lavsan sutures. Sutured interligamentary gaps. Treatment of dislocation of the forearm with a fracture of the coronoid process. The size of the torn fragment and the stability of the joint are taken into account. If the joint is stable, after elimination of the dislocation of the forearm, conservative treatment is carried out. In the presence of lateral looseness, surgical treatment is indicated to avoid the development of chronic instability. The intervention is carried out through the anteromedial access. With a large fragment of the coronoid process, it, together with the medial ligament attached to it, is fixed to the base with two to three transosseous lavsan sutures or a screw. Small fragments are removed, the ligament is sutured with transosseous sutures.

Treatment of dislocation of the forearm with a fracture of the head of the radius. In case of fractures of the head and neck of the radius without displacement, after elimination of the dislocation of the forearm, conservative treatment is carried out. If there is a displacement of the head or its fragment, resection of the broken head or removal of the fragment is indicated within the next 1-3 days after the injury. In this case, careful suturing of the damaged capsular-ligamentous apparatus is very important.

Habitual dislocation of the elbow

If the dislocation in the elbow joint was repeated more than 3 times without adequate trauma, we can talk about habitual dislocation of the forearm. This pathology is very rare: only 1.9% of dislocations in the elbow joint become habitual.

Constitutional features (weakness of the ligamentous apparatus, anomalies in the development of the semilunar notch of the ulna) and post-traumatic changes in the elbow joint predispose to habitual dislocation of the forearm.

Of great importance in stabilizing the elbow joint is the sufficient depth of the semilunar notch of the ulna. Normally, it averages an arc of 178.9° (160-190°). When the arc is less than 160°, the depth of the notch decreases and sufficient adhesion of the shoulder block and the notch of the ulna is not provided. In children, the coronoid process is still cartilaginous, small in size, as a result of which flattening of the notch is also observed. In addition, in early childhood, a fracture of the cartilaginous coronoid process, invisible on radiographs, is often not recognized. Vicious union

It, as well as the lack of complete consolidation, soon leads to habitual dislocation. In adults, habitual dislocation of the forearm is often observed after severe posterior dislocations of the forearm with extensive damage to the anterior and posterior parts of the joint capsule, fracture of the coronoid process, and avulsion of the shoulder muscle. Habitual dislocation of the forearm is accompanied by weakness of the capsular-ligamentous apparatus of the elbow joint, which leads to repeated dislocations from a slight effort. When the elbow joint is extended, an abnormal varus or valgus position of the forearm occurs. Despite the lateral instability of the elbow joint, there may be a limitation of flexion-extension movements in the joint. This is due to the fact that as a result of the high reactivity of the tissues of the elbow joint, coarse scar tissue develops in the area of the former injury, ossifications appear. X-ray examination of the elbow joint reveals multiple ossifications along the lateral ligaments, flattening of the semilunar notch of a congenital nature or as a result of an improperly fused comminuted fracture in the elbow joint.

Restoring the stability of the elbow joint in such situations is possible only by surgery. Many methods of surgical treatment have been proposed, which can be divided into three groups:
1) operations aimed at deepening the semilunar notch by bone grafts in the region of the coronoid or olecranon process;
2) various methods of tenodesis (by moving the places of attachment of the tendons of the biceps muscle, shoulder muscle);
3) suture or plasty of the capsular-ligamentous apparatus. After operations of the first type with the use of bone grafts, there is a significant limitation of movements in the elbow joint. Various types of tenodesis lead to discoordination of the muscles of the elbow joint. More preferable are various ways to strengthen the capsular-ligamentous apparatus of the elbow joint (Fig. 5.2).

Dislocations and subluxations of the head of the radius

Isolated dislocations and subluxations of the radial head are rare. Most often, the head of the radius is displaced anteriorly, less often - outwards and backwards. Dislocation of the head of the radius anteriorly may be accompanied by a fracture of the ulna in the upper third, damage to the deep branch of the radial nerve. Dislocation occurs when falling on an extended and supinated arm, when the arm gets into the rotating mechanisms of machines.

Diagnosis is based on the clinical picture. With dislocation of the head, lateral flexion in the elbow joint is slightly limited. With other dislocations, flexion is difficult and limited. Dislocation of the head outwards is determined by palpation. X-ray confirms the diagnosis.

Eliminate dislocation under anesthesia. The assistant fixes the shoulder in the supinated position, the surgeon stretches the pronated and unbent forearm at the elbow joint, fixes the elbow joint with the other hand and presses with his thumb on the head of the radius at the moment of supination of the forearm. After the control radiography, it is necessary to immobilize the limb with a posterior plaster splint in the position of extreme supination of the forearm for a period of 3 weeks. In case of an unstable position of the head after reduction, it must be fixed transarticularly with knitting needles. With an irreducible dislocation of the radial head, an open reduction or resection of the head is performed, the results of which are much better if it is performed early after the injury. Pronation subluxation of the radial head is a common injury in children aged 1 to 4 years. Typically, such a subluxation occurs when the child is sharply pulled by the hand and forearm. Predisposing factors for such dislocation are relative weakness of the annular ligament and underdevelopment of the neck of the radius. In addition, the articular bag between the head of the radius and the humerus in young children is wider, the synovial membrane forms a fold that is infringed between the articular surfaces. Diagnosis is based on a typical history and clinical presentation. Usually the forearm is pronated, bent at the elbow joint, pressed against the body. Forearm movements cause sharp pain. Children often point to pain in the lower third of the forearm and wrist joint. X-ray examination, as a rule, does not reveal a defect.

The reduction of the head occurs easily, usually without anesthesia. The surgeon produces traction for the patient's hand in the position in which the arm is, achieving full extension in the elbow joint, then performs rotational movements - supination and pronation of the forearm. With the other hand, the surgeon applies pressure to the head of the radius and slowly flexes the supinated forearm at the elbow joint. When the head is repositioned, a click is felt. After 2-3 minutes, the child calms down and independently makes movements in the elbow joint. The limb is immobilized for 2-3 days with a kerchief bandage. In case of recurrence of subluxation after reduction, a plaster splint is applied for 10-15 days.

Chronic dislocations and subluxations of the forearm

According to the experience of CITO, dislocations of the forearm two weeks ago are chronic. Before this period, it is necessary to make attempts at closed reduction under anesthesia.

The nature of the intervention for chronic dislocations of the forearm is determined both by the time elapsed since the moment after the injury, and by changes in the tissues of the joint that are revealed during the operation. In terms of up to 3-4 weeks, it is necessary to strive to reduce the dislocation. In later periods, with the development of coarse scar tissue in the joint, cartilage changes, deformation of the articular ends, arthroplasty is used to restore joint function. A median incision along the posterior surface of the lower third of the shoulder and the elbow joint, about 14 cm long, exposes the tendon of the triceps muscle of the shoulder. The ulnar nerve is isolated from the scars and taken on a holder. The triceps tendon is dissected wedge-shaped. After opening the joint, the rough scar tissue filling the cavity is excised, a block of the humerus is modeled with a grooved chisel with the removal of the surface layer of bone tissue up to 0.5 cm deep, and the head of the radius is resected. After achieving good congruence of the articular surfaces and sufficient diastasis between them, transarticular fixation is performed with two intersecting knitting needles. Restore the tendon of the triceps muscle of the shoulder. The ulnar nerve is immersed in the muscle bed created for it. The limb is immobilized with a plaster splint. 3 weeks after the operation, the pins are removed, the plaster splint is replaced with a polyethylene hinge-sleeve apparatus, in which the patients begin to do therapeutic exercises.

The disadvantages of this technique include the fact that it does not allow early movement in the newly created joint and does not provide long-term preservation of diastasis between the articular surfaces after removal of the pins.

A more progressive method of arthroplasty of the elbow joint is an operation using the Volkov-Oganesyan hinge-distraction apparatus. Such a device allows you to start active and passive movements in the joint early, while maintaining the diastasis created between the fragments for the time necessary to stabilize the joint.

In this case, after opening the elbow joint and excising the scar tissue that fills its cavity, an axial wire is passed through the distal part of the humerus, the ends of which are fixed in a special arc with a cutter built into it. Using a cutter, the articular surface of the humerus is formed in the form of a semicircle. The same cutter forms the articular surface on the olecranon. The head of the radius is resected. The newly created articular surfaces are compared. The tendon of the triceps muscle of the shoulder is restored, the ulnar nerve is placed in the bed formed for it. In addition to the axial one, 3 more needles are carried out: one - through the shoulder, 14 cm above the axial one, and two - through the proximal metaphysis and diaphysis of the ulna. Then an apparatus is applied in which all the knitting needles are firmly fixed. Adjustable nuts create the necessary diastasis between the articular surfaces. After 6-8 days, active-passive movements in the elbow joint begin. The device is removed 1-1.5 months after reaching a sufficient range of motion in the joint. After arthroplasty, the strength of the hand is significantly reduced, therefore, patients engaged in heavy physical labor undergo arthrodesis in a functionally advantageous position.

Open injuries of the elbow joint

Open injuries of the elbow joint area (dislocations, fractures, fracture-dislocations) are very rare. They account for 13.2% of all open intra- and periarticular injuries of other localizations.

The unique structure and function of the joints in general, and the elbow joint in particular, requires special attention to this type of injury. This is due to the fact that intra- and periarticular tissues differ widely in structure, blood supply, susceptibility to infection, and regenerative capabilities. Therefore, accurate diagnosis of lesions is essential for treatment and prognosis. It should be noted that the smaller size of the elbow joint compared to other large joints and a small amount of periarticular tissues cause a lower intensity of the inflammatory reaction in open injuries. Open injuries of the elbow joint usually occur either as a result of direct trauma or as a result of a skin puncture from the inside. Diagnosis of damage to the joint capsule is usually based on a visible joint wound or palpable joint entrance. On the x-ray, in this case, air is determined in the joint cavity. In the absence of these obvious signs, open intra-articular injury can be identified by the release of isotonic sodium chloride solution from the wound after its introduction by puncturing the joint through an intact area of the skin. The method is especially relevant for a combination of an intra-articular fracture with a burn of para-articular tissues. In this case, the area of necrosis can be excised to the synovial membrane, if there are no signs of damage, which, of course, is of great importance for the outcome.

The severity of the clinical course, complications, and the final result of the treatment of open injuries of the elbow joint depend both on the degree of soft tissue damage and on the degree of destruction of the articular ends.

For example, D. M. Collins, S. O. Temple distinguish 4 types of open set injuries:
type I - single penetrations without significant damage to soft tissues;
type II - single or multiple patchy or scaled lesions of the periarticular tissues;
type III - open intra- or periarticular fractures;
type IV - open dislocations or fracture-dislocations with damage to blood vessels and nerves.

In each case of an open joint injury, careful surgical treatment is of great importance. If necessary, the wound may be surgically continued to ensure adequate access. For the same purpose, it is possible to perform arthrotomy through intact skin. The skin edges are excised by 1-2 mm. Tendons, joint capsule, ligaments, despite the contamination, tend to be preserved. Loose cartilage fragments or flaps are removed and the cartilage defect is flattened with a scalpel or small curette. Bone and cartilage fragments less than 1 cm in size are removed. Osteosynthesis of large bone and cartilage fragments, especially supporting surfaces, is mandatory. This is due to the fact that the size of the cartilage defect and the degree of joint dysfunction are directly related. In addition, with a large cartilage Defect, degenerative changes develop on opposite articular surfaces. Therefore, bone and cartilage fragments must be thoroughly cleaned and firmly fixed. The same applies to bone fragments. They are carefully repositioned and firmly fixed. With crushed multi-comminuted fractures of the bones of the elbow joint, an economical resection is indicated.

Foreign bodies, regardless of their consistency and location, must be removed from the joint cavity. You can not remove small metal fragments that are located deep in the bone tissue of the articular end. Large metal fragments, the presence of which may further affect the condition of the joint, are removed regardless of the depth of their occurrence in the bone. In order to avoid additional damage to the articular cartilage, an extra-articular approach should be preferred.

Surgical treatment necessarily ends with washing the joint cavity and wounds with antiseptic solutions. The treated wound or the wound after arthrotomy can be sutured initially with suction drainage for 24–48 hours. If there are doubts about the usefulness of the surgical treatment or more than 12 hours have passed since the injury, the joint is left open. A delayed suture is applied after 3-7 days.

Closed debridement systems have been used for a long time, but their use in the treatment of open joint injuries has been declining recently. It has been proven that they carry out only mechanical cleaning of a closed articular cavity.

Extensive skin defects in open injuries of the elbow joint are an indication for primary skin grafting. Broad-spectrum antibiotics are prescribed for 72 hours. In the future, antibiotic therapy is continued depending on the general and local signs of the development of the infectious process, taking into account the result of sowing discharge from the wound. Immobilization of the joint is carried out in a plaster cast or with a device for transosseous osteosynthesis.

What is a dislocation of the forearm
Symptoms of dislocations of the forearm
Treatment of dislocations of the forearm

What is a dislocation of the forearm

Traumatic dislocations and subluxations of the forearm in frequency they take the second place after dislocations of the shoulder and make up 18-27%. They are observed more often in men 10-30 years old and in women 50-70 years old.

What Causes Dislocations of the Forearm

Dislocations and subluxations of the forearm occur as a result of direct and indirect trauma. The variety of occurring dislocations in the elbow joint is explained by the complexity of its anatomical structure.

Pathogenesis (what happens?) during Dislocations of the forearm

There are dislocations of the bones of the forearm backwards, anteriorly, outward, inward; dislocations and subluxations of the head of the radius anteriorly, posteriorly and outwards; divergent dislocation of the forearm. Subluxations are cases where there is partial contact between the articular surfaces.

The course and outcome of dislocation or subluxation of the forearm depend not only on the magnitude in the form of displacement, but also on the nature of the damage to the soft tissues surrounding it. Usually, a dislocation of the forearm is accompanied by a hematoma, damage to the capsular-ligamentous apparatus, muscles, periosteum, and, in some cases, compression of blood vessels and nerves. Soft tissue injuries are directly dependent on the magnitude and direction of the acting force. This can explain the fact why the same type of dislocation in different patients proceeds and ends far from the same.

Symptoms of dislocations of the forearm

The most common (90%) are posterior dislocation of the forearm. According to experimental data, they occur when falling on the arm, slightly bent at the elbow joint. With increased abduction of the forearm, the lateral ligaments are significantly damaged. Possible separations of the medial ligament with a fragment of the medial epicondyle or coronoid process, in children - epiphysiolysis of the medial epicondyle. Shearing compression forces in the glenohumeral joint result in fractures of the head of the radius, the capitate eminence, or the lateral epicondyle of the shoulder. With posterior dislocation, more often than with other types, damage to the radial, median and ulnar nerves, the brachial artery occurs, and the shoulder muscle is significantly injured.

At posterior dislocation of the forearm due to its displacement in the proximal direction, the impression of shortening of the forearm and lengthening of the shoulder is created. The axis of the forearm is deflected (often outwards) in relation to the axis of the shoulder. The olecranon will stand posteriorly, its apex is displaced upwards and is located above the level of the condyles of the shoulder. This distinguishes a dislocation from a supracondylar fracture of the shoulder, in which Gueter's triangle, formed by the tip of the olecranon and both epicondyles of the humerus, is not broken.

Dislocations of the forearm anteriorly are less common (about 4.5%). They occur when you fall on the most bent elbow joint. With an anterior dislocation, a retraction is noted at the site of the olecranon, the forearm seems elongated compared to the forearm of a healthy arm. This type of dislocation is characterized by damage to a greater or lesser extent to both lateral ligaments of the anterior and posterior sections of the joint capsule. Damage to the tendon of the triceps muscle of the shoulder, tearing of the muscles attached to the condyles of the shoulder are possible.

Lateral and medial dislocations of the forearm are very rare. The elbow joint is expanded in the transverse direction. The axis of the forearm is displaced, respectively, outward or inward. These types of dislocations of the forearm are often combined with a fracture of the medial or lateral epicondyle of the humerus, the head of the radius.

Extremely rare occurrence divergent dislocation. It occurs when the ulna and radius bones diverge back, forward, inward or outward, and is the result of a brute acting force. Not only the capsular-ligamentous apparatus of the elbow joint is damaged, but also the interosseous membrane.

Diagnosis of dislocations of the forearm

Diagnosis of dislocation of the forearm usually causes no problems. Patients are concerned about the forced position of the limb, the impossibility of movements in the elbow joint, severe pain in it. In all cases, there is a deformity of the elbow joint, depending on the type of dislocation, swelling of this area is pronounced. At attempt to make passive movements the symptom of "springy mobility" comes to light.

X-ray examination patients with dislocations of the forearm must be before and after reduction. Elbow radiographs show associated fractures of the coronoid process, radial head, capitate eminence, or medial epicondyle.

Dislocations of the forearm accompanied by damage to the capsular-ligamentous apparatus of the elbow joint. In this case, the lateral ligaments are damaged along or with the separation of the bone fragment. The main stabilizer of the elbow joint is the medial ligament. With its integrity, dislocation in the elbow joint does not occur. After elimination of the dislocation of the forearm, it is imperative to determine the latent instability of the elbow joint to prevent chronic instability.

Treatment of dislocations of the forearm

Reduction of the posterior dislocation of the forearm. The patient is laid on his back, the diseased arm is taken away from the body to a right angle. The surgeon stands outward from the abducted shoulder and with both hands grabs the lower part of the shoulder above the elbow joint, puts his thumbs on the olecranon and head of the radius. The assistant becomes on the same side to the right of the surgeon and takes the patient's hand with one hand, and the lower part of the forearm with the other. The surgeon and assistant produce a smooth extension of the arm while simultaneously bending it at the elbow joint. The surgeon, pressing on the olecranon and the head of the radius, moves the forearm anteriorly and the shoulder backwards. Reduction usually occurs without much effort, with a clicking sound.

In case of posterior external dislocation of the forearm, the surgeon uses his thumb to press on the olecranon and head of the radius not only anteriorly, but also medially.

Reduction of the anterior dislocation of the forearm. The patient is placed on the dressing table, the arm is taken to a right angle. The assistant fixes and counter-extends the shoulder, and the surgeon, pulling the forearm with one hand and pressing on the proximal part of the forearm downwards, outwards and backwards with the other hand, flexes the forearm at the elbow joint.

Reduction of dislocation of the forearm inwards. The patient is laid on the table, the shoulder is taken to a right angle. One assistant fixes and holds the shoulder, the other stretches the forearm along the axis. The surgeon with one hand presses on the proximal part of the forearm from the inside to the outside, and with the other hand simultaneously presses on the external condyle of the shoulder from the outside to the inside.

Reduction of external dislocation. The assistant fixes the abducted shoulder, and the surgeon with one hand stretches the forearm, the other presses the upper part of the forearm inwards and backwards, bending the elbow joint.

From the very first days, the patient is recommended to carry out active movements with the fingers of the hand, which contributes to the resorption of edema and hemorrhage in the area of the elbow joint. From the 2-3rd day, isometric tensions of the muscles surrounding the elbow joint begin.

After removing the gypsum splint, restorative treatment is carried out.

The indication for surgical treatment is lateral instability of the elbow joint II-III degree. At the same time, the lateral capsular-ligamentous apparatus is carefully sutured, rare sutures are applied to the capsule of the anterior and posterior sections. The period of immobilization is determined depending on the extent of damage to the capsular-ligamentous apparatus, the age and profession of the victim.

Treatment of dislocation of the forearm with detachment of the medial epicondyle of the shoulder. In the absence of displacement of the epicondyle after elimination of the dislocation of the forearm, the treatment is conservative. Displacement of the epicondyle greater than 2 mm and its possible infringement in the joint cavity are indications for surgical intervention. In this case, the epicondyle or its fragment is removed from the joint cavity and, depending on the size, fixed with a screw, knitting needles or transosseous lavsan sutures. Sutured interligamentary gaps.

Treatment of dislocation of the forearm with a fracture of the coronoid process. The size of the torn fragment and the stability of the joint are taken into account. If the joint is stable, after elimination of the dislocation of the forearm, conservative treatment is carried out. In the presence of lateral looseness, surgical treatment is indicated to avoid the development of chronic instability. The intervention is carried out through the anteromedial access. If the fragment of the coronoid process is large, it, together with the medial ligament attached to it, is fixed to the base with two or three transosseous lavsan sutures or a screw. Small fragments are removed, the ligament is sutured with transosseous sutures.

Treatment of dislocation of the forearm with a fracture of the head of the radius. In case of fractures of the head and neck of the radius without displacement, after elimination of the dislocation of the forearm, conservative treatment is carried out. If there is a displacement of the head or its fragment, resection of the broken head or removal of the fragment is indicated within the next 1-3 days after the injury. In this case, careful suturing of the damaged capsular-ligamentous apparatus is very important.

Which doctors should you contact if you have Dislocations of the forearm

Traumatologist
Surgeon

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Dislocations of the forearm in frequency are in second place after dislocation of the shoulder and account for approximately 25% of the total number of dislocations. Dislocations of the forearm occur mainly in adolescence, equally common in men and women.

There are dislocations of both bones of the forearm posteriorly, anteriorly, outwards, inwards, as well as isolated dislocations of the head, radius.

Dislocations of both bones of the forearm posteriorly are of the greatest importance, since they account for 93% of all dislocations of the forearm. When the dislocations are reduced, conduction anesthesia is performed or general anesthesia is given.

Posterior dislocation of the bones of the forearm occurs when falling on an abducted and unbent arm at the moment of its hyperextension in the elbow joint. When hyperextension in the elbow joint, the coronoid process departs from the anterior surface of the humerus, at the same time, the olecranon, resting against the posterior surface of the shoulder, pushes its distal anteriorly. The joint capsule in its anterior part is torn. The integrity of the lateral ligaments of the elbow joint, especially the internal one, is often violated. In this case, the bones of the forearm are displaced not only posteriorly, but also outwards, and then they speak of posterior-external dislocation. In rare cases, violations of the integrity of the external ligament of the elbow joint, the bones of the forearm are mixed posteriorly and medially. Sometimes the lateral ligaments are torn not along the length, but are torn off at the place of attachment to the epicondyles of the shoulder along with a piece of bone, which can then be pinched in the joint and sometimes interfere with the reduction of the dislocation.

Symptoms and Diagnosis. The position of the limb is passive. The arm is slightly bent at the elbow joint, and to reduce pain, the patient supports it with a healthy arm. Swelling is determined in the area of the elbow joint. The joint is deformed, which is especially evident in a comparative examination of both hands. The anteroposterior size of the elbow joint is increased. The axis of the forearm is displaced posteriorly, the olecranon protruding posteriorly is visible. With a posterior-external dislocation, the deviation of the forearm outward is determined.

Palpation reveals a violation of the normal relationship of bone protrusions. Normally, when the forearm is flexed at an angle of 90 °, the lines connecting the condyles of the shoulder and the olecranon form an isosceles triangle (Guther's triangle) with the top of the angle facing downwards. With a posterior dislocation due to the upward displacement of the olecranon, the isosceles triangle is violated, and its apex is turned to the proximal side. With posterior-external dislocations, it is also possible to palpate the head of the radius, which is determined with simultaneous rotation of the forearm. On the anterior surface of the elbow joint, the distal end of the humerus protruding anteriorly is palpated. Active movements in the elbow joint are impossible. Passive ones are "springy" in nature. The strength of the muscles of the forearm and hand is sharply weakened. It is necessary to study the sensitivity of the skin, the motor function of the hand and the pulse, since the possibility of compression of the neurovascular bundle is not excluded. Radiography of the elbow joint is required not only to confirm the diagnosis, but also to clarify a possible violation of the integrity of one of the bones.

Reduction of posterior dislocations of the forearm. The patient is placed on the dressing table, the injured arm is raised, and the assistant holds it by the hand, being on the opposite side of the table (Fig. 15). The surgeon covers the anterior surface of the shoulder above the elbow joint with two brushes, and with his thumbs presses on the olecranon, moving the shoulder backwards, and the forearm forwards, which, with simultaneous gradual flexion of the forearm by an assistant holding the hand, leads to the reduction of the dislocation.

Rice. 15. Technique for reducing the posterior dislocation of the forearm.

With a posterior-external dislocation, at the time of reduction, the forearm must be moved to the ulnar side. Thus, it is possible to set fresh dislocations. With stale dislocations (10-15 days old), this is not always possible. Then proceed as follows. With constant redressing movements, the elbow joint is hyperextended by simultaneous pressure on the olecranon and traction along the length in the same position. When it was possible to partially move the forearm, it is gradually bent with further traction and pressure on the olecranon.

Anterior dislocations also occur in most cases as a result of indirect effects. This usually happens when you fall on the forearm bent at the elbow joint, while the olecranon moves away from the back surface of the shoulder, and the coronoid process, resting against its front surface with the continued action of force along the axis of the shoulder, pushes the distal end of the humerus posteriorly.

The bones of the forearm are in front of the humerus. With anterior dislocations, the joint capsule is torn along the posterior surface. Usually both lateral ligaments are also damaged. Often, anterior dislocations are accompanied by a fracture of the olecranon. A sharp deviation of the forearm in the frontal plane can lead to the development of external or internal dislocation of the forearm, however, as already mentioned, they are extremely rare. Dislocation of the radial head occurs as a result of excessive pronation, while in some cases the head slips out from under the annular ligament, and in others it is accompanied by its rupture. The head of the radius, as a rule, is displaced anteriorly.

Reduction of anterior dislocations of the forearm. The patient is placed on the table, and the arm is removed and placed on a side table for ease of reduction. Three persons participate in the act of reduction. One assistant fixes the shoulder, the other holds the cloth loop superimposed on the proximal forearm. The surgeon produces gradual flexion at the elbow joint. With maximum flexion of the forearm and a fixed shoulder, traction is carried out for the proximal forearm using a cloth loop in the direction of the axis of the shoulder. As soon as the surgeon feels that the forearm has moved distally, he gradually unbends it. At this time, repositioning takes place.

After reduction of the posterior and anterior dislocation of the forearm, the elbow joint is fixed with a posterior plaster splint for a period of 5-7 days, after which therapeutic exercises (mainly active movements) and thermal procedures are performed. Massage of the elbow joint area, passive movements, mechanotherapy are contraindicated due to the possible calcification of the joint capsule and the development of ossifying myositis, which further lead to limited mobility in the elbow joint. Ability to work is restored within 2 months. Isolated dislocations of the head of the radius in adults, as a rule, are accompanied by a rupture of the lig. annularae radii, so they are easily displaced after reduction. Only surgical treatment with the formation of a new artificial ligament to hold the head is effective, for which a strip of the broad fascia of the thigh or a nylon tape (A.P. Skoblin) is used, strengthened transosseously to the ulna.

In children, especially at an early age of up to 5 years, there is often a dislocation or subluxation of the head of the radius, while the head slips out of the annular ligament covering it. Due to the fact that the forearm after dislocation is in the position of pronation, such dislocations are called pronational. Reduction is made easily, without anesthesia.

With chronic dislocations of the forearm, i.e., dislocations that are not reduced during the first 3 weeks after the injury, the function of the hand is sharply impaired. Treatment is open reduction. If more than 3 weeks have passed since the onset of the dislocation, pronounced dystrophic changes develop in the joint, detachment of the articular cartilage, and the appearance of cavities in the bone part of the epiphyses. In such cases, open reduction is ineffective and elbow arthroplasty is performed.

Approximately one-fifth of all dislocations treated by victims account for the dislocation of the forearm. Young people are most often affected by this type of injury. The basis for obtaining this type of injury is the fall of the victim on an outstretched arm, while the limb must be simultaneously bent at the elbow joint, resulting in overextension.

Today, there are several types of dislocation of the forearm, namely:

isolated dislocation of the ulna;
dislocation of the radius directly;
dislocation of the ulna, as well as the radius.

Most of the dislocations are dislocations of the ulna and radius bones posteriorly, as well as an isolated dislocation of the radius (anteriorly). In extremely rare cases, other types of dislocations of the forearm will occur.

Symptoms

In about 90% of cases of dislocation of the bones of the forearm, it is the posterior dislocation that occurs. The formation of such a dislocation can occur as a result of a fall on the arm, which at this time will be slightly bent at the elbow. In the event that there is an increase in forearm abduction, then there is a possibility of severe damage to the lateral ligaments.

There is a possibility that the medial ligament will tear off with a part of the medial epicondyle or coronoid process, and in young children, epiphysiolysis of the medial epicondyle.

As a result of shearing compression forces directly in the humeroradial joint, a fracture of the head of the radius occurs, as well as the lateral epicondyle or the capitate eminence of the shoulder.

In the case of a posterior dislocation, unlike other types of dislocation, characteristic damage to the ulnar, median, and radial nerve occurs. In this case, the brachial artery may also suffer, and the brachial muscle itself is severely injured.

In the event that the patient has received a posterior dislocation of the forearm, he will complain of the formation of a rather sharp and severe pain in the area of \u200b\u200bdamage. In this case, the injured arm will be in a forced position of slight flexion, a serious deformation of the joint occurs.

With a posterior dislocation, the joint itself increases significantly in volume, and all active movements in the area of the elbow joint become impossible. In the event that the patient tries to make even a passive movement, he feels a characteristic resistance, resembling a spring.

During the examination of the patient, the damaged forearm will look a little shortened, and the olecranon itself is displaced backwards and upwards. Also in the region of the elbow itself, the lower region of the humerus will be palpated.

Anterior dislocation is quite rare. The main reason that can provoke the formation of this type of dislocation is receiving a direct blow directly in the region of the elbow joint itself, while the arm must be bent at the joint. This type of dislocation can be combined in parallel with a fracture and the olecranon.

In the case of an anterior dislocation, the patient has a feeling of sharp and rather severe pain in the damaged area. During the examination, the elongation of the forearm becomes noticeable, which occurs directly from the side of the injury, and the forearm will also sink into the region of the olecranon.

With an anterior dislocation, all active movements in the elbow joint become impossible; during passive movement, a characteristic springy resistance will be felt, as with a posterior dislocation. Unlike a posterior dislocation of the forearm, the main functions of the joint will be significantly less limited.

Lateral dislocations of the forearm are extremely rare, while they can be accompanied by damage to the ulnar, as well as the median nerve, loss of sensitivity occurs in the innervation zone.

Like other types of dislocations, lateral dislocations will be accompanied by the formation of acute pain, and active movements in the area of the damaged joint also become impossible. Any movement in the area of the joint will be accompanied by a springy resistance, even during passive movements.

The formation of external dislocation occurs as a result of direct impact directly on the elbow joint from the inside out. In rare cases, this type of dislocation is complete, and deformity occurs, the damaged limb swells, and the axis of the joint itself may also move outward.

As a result of receiving a direct blow, there is a risk of dislocation of the forearm inwards, however, in this case, the blow must be directed inward from the outside. The victim has characteristic complaints about the appearance of sharp and severe pain in the area of damage. The elbow joint itself becomes edematous, it is deformed, and there will also be an inward displacement of the joint axis.

Diagnostics

In almost all cases, it is not difficult to make a diagnosis of dislocation of the bones of the forearm, since its formation will be accompanied by pronounced clinical symptoms. It is necessary to correctly distinguish between various types of dislocation of the forearm, because it is precisely on how accurately the diagnosis was made that the choice of treatment is determined.

A posterior dislocation of the forearm will be accompanied by a visible shortening of the forearm itself. At the same time, the olecranon of the ulna itself will protrude quite strongly posteriorly, at the same time it slightly shifts upward, which becomes possible to determine by the landmarks of the damaged humerus.

In the event that the forearm is in a bent state, and on the anterior surface of the elbow joint it becomes possible to feel the very head of the humerus.

A distinctive feature of the formation of an anterior dislocation from the posterior one is that with it the ulna itself is displaced anteriorly. But at the same time, it will be quite good to not only see from behind, but you can also feel the head of the humerus.

In the case of a lateral dislocation, it becomes possible not only to visualize, but also to feel the end of the radius, as well as the ulna, on the sides directly from the elbow joint.

It is quite difficult to diagnose a dislocation of the forearm if the head of the radius is isolated, and these signs will be mild, relative to the ulna.

There may be certain doubts about the correctness of the diagnosis for fractures and dislocations of bones, as well as dislocation of the forearm, which may be accompanied by the appearance of fragments of fragments of the humerus.

In almost all cases, the diagnosis is confirmed by X-ray, which must be done without fail for each victim.

Prevention

The basis for the prevention of dislocation of the forearm is the avoidance of injuries and blows, since it is these factors that can provoke its formation.

Treatment

In almost all cases, it is possible to eliminate dislocations of the forearm using a closed reduction. By traction directly behind the forearm, the radius is reduced, while the forearm is rotated, at the same time, pressure is exerted on the head of the forearm, which occurs in a certain direction.

In the event that the dislocation of the forearm is accompanied by the exit of the end of the ulna from the joint, then the reduction of the bone will be carried out taking into account what type of displacement has occurred.

All posterior dislocations of the forearm will be reduced under anesthesia. The patient himself should be in a prone position, the arm on the side of the injured forearm is bent at the joint so that the forearm is directed vertically upwards.

A posterior dislocation of the forearm will be reduced by axial traction, while at the same time pressure must be applied directly to the olecranon. After the doctor performs the reduction, the bent limb will be fixed with the help of a plaster splint and should remain in this position for one week.

The reduction of the anterior dislocations of the forearm is carried out under the condition of the same position of the limb, but in this case, the pressure will already have to be applied to the head of the humerus, and not to the ulna. Further, the anterior dislocation of the forearm will also have to be fixed for one week with the help of a splint.

In the event that a dislocation of the forearm has been diagnosed, X-ray data should be taken into account during its reduction, while X-rays will be taken before the start of reduction and after its completion.

About a week later, after the dislocation is set and the fixation is removed, the patient is prescribed a course of therapeutic massage, as well as special thermal procedures and gymnastics, UHF.

In the event that with the help of a closed reduction it was not possible to remove the displacement, as well as with late diagnosis of the injury, there is a need to eliminate the dislocation of the forearm by surgical intervention.

Dislocations of the forearm do not lead to the formation of serious health consequences, but at the same time, there is a possibility that severe damage to blood vessels and nerves will occur. The greatest danger is precisely damage to the radial artery. This phenomenon can occur not only during the injury itself, but also during the implementation of the reduction of the dislocation. That is why this procedure should be performed only by an experienced doctor.

Late diagnosed or chronic dislocations of the forearm will be very difficult to treat. It is worth considering the fact that as a result of the lack of timely treatment, the development of stiffness in the elbow joint may occur.

Reduction of the forearm is carried out under general or local anesthesia. The arm is abducted and slightly unbent at the elbow joint. The surgeon covers the victim's shoulder in the lower third with both hands so that the thumbs lie on the protruding olecranon.

The assistant holds the brush. Traction is performed along the axis of the limb, and the surgeon moves the olecranon and head of the radius anteriorly with his thumbs while pulling the shoulder backwards and using it as a fulcrum. If the forearm is set, free passive movements appear.

It is necessary to admit that the method of repositioning the posterior dislocation of the forearm on the bent elbow joint up to an angle of 90° is incorrect, since this can lead to a fracture of the coronoid process.

The limb is fixed with a posterior plaster splint from the upper third of the shoulder to the heads of the metacarpal bones. X-ray control is required. The term of immobilization is 5-10 days. Then rehabilitation treatment is prescribed: exercise therapy, physiotherapy, hydrotherapy. In the early stages of treatment, massage of the elbow joint, mechanotherapy, forced passive movements should not be prescribed, as they become gross irritants and increase the ossification of periarticular tissues.