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Contents:
CHAPTER I Introduction
1
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2 Hypothesis and purpose of the paper
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4
CHAPTER II Theoretical-scientific foundation of the work
2
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1
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1
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8
2
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3 Muscles of the forearm
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9
2
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Fractures of the bones of the forearm
2
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1 Fractures of the upper extremity of the radius
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2
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14
2
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3 Olecranon fractures
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2
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17
2
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5 Fractures of the lower extremity of the Pouteau Colles radius
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2
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2
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2
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19
2
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9 Monteggia-Stănciulescu fracture
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1 Subjects and place of research
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2 Presentation of patients
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28
CHAPTER IV Conducting the research
4
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2 Kinetic program applied to patients
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3 Evaluation of patients
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39
CHAPTER V Presentation and interpretation of results
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46
CHAPTER VI Discussions
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47
CHAPTER Conclusions
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48

BIBLIOGRAPHY
...
49

CHAPTER I – INTRODUCTION
forearm it has the shape of an elongated cone trunk, with a large base towards the
elbow, slightly flattened anteroposteriorly, having the shape of an oval on the cross section
...
In women and children, due to less muscle development and a richer adipose tissue,
the forearm has a more cylindrical shape
...
The ulna has a discrete curvature in the sagittal plane and the shape of an "S" with
slightly accentuated curves in the frontal plane
...

Fractures in the bones of the forearm can affect any of the two bones of the forearm:
the ulna and the radius
...
It is important to know how to recognize
fractures of the upper limb, because only prompt therapeutic intervention can ensure healing
accompanied by full recovery of functionality
...
A simple
fracture can be treated by applying a support bandage, an ice pack and physical rest, while a
complicated fracture requires surgery to realign the bone fragments and may even involve the
implantation of metal plates fixed with screws to the bones
...
1
...
In the case of the forearm fracture, it can be said that it is a double fracture because
2
bones
are
involved:
the
radius
and
the
ulna
...


2

I chose this theme because during my practice at the County Emergency Clinical
Hospital, Polytraumatology Casa Austria; I have been interested in forearm bone fractures and
have seen them reoccur after surgery
...
2
...

In the theoretical part, I tried to describe the notions regarding the anatomy,
physiology, biomechanics, pathology, symptomatology, complications and diagnosis of
forearm fractures
...

I also introduced some theoretical notions related to fractures-dislocations which, although rarely
encountered, pose multiple problems in case of lack of a correct diagnosis
...

The purpose of the work was to highlight the particularities of these fractures as well as to draw a
parallel between the theoretical principles related to these injuries and their application possibilities in everyday
orthopedic practice
...
1
...
1
...
The skeleton of the forearm
The skeleton of the forearm consists of two long bones
...

The ulna (cubitus) is a long, paired bone located in the medial part of the forearm, in
the extension of the little finger
...
The diaphysis has a
prismatic triangular shape, so it has three faces and three edges
...
The posterior face has, in the upper part, an insertion surface for
the anconeus muscle, and the lower part gives insertion to the extensor carpi ulnar muscle and
the abductor pollicis longus, extensor pollicis brevis, extensor pollicis longus, extensor
indexis and supinator muscles, in the side lateral
...
The lower or distal epiphysis contains two projections,
the head and the styloid process, between which a groove is formed through which the tendon
of the extensor carpi ulnar muscle passes
...


Fig
...
The superior or proximal epiphysis has three anatomical elements: the head has the
appearance of a cylinder; in the upper part it articulates with the humeral head; the
circumference of the head corresponds to the radial hollow on the ulna; the neck connects the
head to the radial shaft; the tuberosity of the radius is a protuberance located antero-medially,
below the neck, which gives insertion to the biceps brachii muscle
...
The lateral face
has relations with the radial nerve in the upper part, and in the middle part it gives insertion to
the round pronator muscle
...
The inferior or distal epiphysis is larger than the superior epiphysis;
on the medial face it articulates with the ulna; the lateral face has a groove where the tendons
of the forearm muscles pass and it continues inferiorly with an extension called the styloid
process on the base of which the brachioradialis muscle is inserted; the posterior face has
ridges delimiting grooves through which the tendons of the extensor muscles of the hand and
fingers pass; the pronator square muscle is inserted on the anterior face; the base, located
inferiorly, continues laterally with the styloid process; the lower face of the epiphysis has

5

relationships in the medial part with the crescent, and in the lateral part with the scaphoid
...
1
...
Anatomy and biomechanics of elbow joints
The humerus, radius and ulna participate in the formation of this joint
...

Humeroantebrachial joint
The articular surfaces of this joint are represented by the humeral condyle (the trochlea
corresponds to the articular surface of the ulna, and the head and intermediate groove, the
radius), the fossa and the edge of the fossa of the radial head, as well as the trochlear incision
of the ulna
...

 radial collateral ligament: joins the lateral epicondyle of the humerus to the anterior
and posterior parts of the radial notch of the ulna
 annular ligament: is the main means of strengthening the radioulnar ligament and
detaches from the posterior end of the radial notch of the ulna
 the quadrate ligament is a four-sided fibrous sheet that runs between the lower edge of
the radial notch of the ulna and the medial side of the radial neck
...

The distal radioulnar joint is part of the same category of joints as the distal one, that
of the trochoids
...


6

In the sagittal plane and frontal axis - the axis of movement is perfectly transverse but
oriented from outside to inside from front to back and from top to bottom passing through the
middle of the trochlea of the humerus and through the middle of the humeral head
...

- Flexion – is the movement by which the anterior face of the forearm approaches the anterior
face of the arm
...
The limitation of the flexion movement is determined by the closure of the posterior
part of the capsule, the brachial triceps muscle, the soft tissues at the level of the elbow fold as
well as by the penetration of the coronoid process into the corresponding fossa
...

- Extension – is the movement by which the anterior face of the forearm moves away from the
anterior face of the arm, it is practically the movement of returning to zero
...
The extension movement is limited by
the tip of the olecranon which is stopped by the olecranon fossa as well as by the anterior
ligament of the elbow which is put under tension
...
The muscles that perform
the extension are: triceps brachii, anconeus and the extensor muscles of the fingers as a
secondary action
...

Means of attachment are: the joint capsule, the joint disc, the interosseous membrane
and a fibrous formation called the oblique chord
...

Biomechanics of the proximal radioulnar joint (fig
...
These are trochoid joints, with a single axis of
motion
...
In pronation, the radius crosses the ulna anteriorly so that the distal radial epiphysis
reaches medial to the ulnar one
...

- pronation - is the movement by which the forearm is pointed inwards, the palmar side of the
hand being oriented downwards and the phalanx medially
...
It is
provided by the muscles: pronator teres, pronator quadratus and carpi radialis flexor
...
The amplitude is 0º - 85º
...


7

Fig
...
1
...
Muscles of the forearm ( fig
...

● the muscles of the anterior region of the forearm are 8 in number, arranged on four planes,
numbered from surface to depth (I-IV)
...

- 2nd plane: superficial flexor of the fingers
...

- 4th plane: pronator plate
...

- the superficial plane consists of four muscles with a flattened appearance, which originate on
the lateral epicondyle and go infero-medially; from the lateral to the medial side, they are: the
extensor comulus of the fingers, the extensor of the little finger, the ulnar extensor of the
carpus, the anconeus
...

● the muscles of the lateral region of the forearm are four, also arranged on two planes:
- superficial: brachioradialis, long radial extensor carpi, short extensor al
wrist
- deep: supinator
...
4 forearm muscles

2
...
Fractures of the bones of the forearm
2
...
1
...
They are rare in adults (6%)
and more common around the age of 10 (1)
...

Mechanism of production - It is usually indirect
...
The impact between them causes a fracture
...
Morrey believes that the fracture occurs only due to
axial compression if the humerus is in pronation and valgus stress is not required
...
5 – Fracture of the upper extremity of the radius
Pathological anatomy (fig 6) - There is a difference between bone lesions in adults and those
in children, where the cartilage is cartilaginous and the fracture occurs at the level of the neck
...


Fig
...
Fractures with minimal displacement (step less than 2 mm) can also be included in this
category
...
8% and will not affect the motion of
pronosupination
...
The separated fragment is this time important (
1/3, 1/ 2, 2/3 ) the gap at the level of the articular surface greater than 2 mm
...
The
location of the fracture (anterior or external), the size of the fragment and the displacements
will limit the pronosupination movement
...
The frequency of this type of fracture is estimated at 41
...
7%, but of particular gravity because the
fracture with multiple trajectories (polyfragmentary, comminuted), displaced, will usually
affect the pronosupination movement
...

The Mason classification is exclusively radiographic and refers only to the fracture
...
Thus, Radin and Riseborough add a type
IV fracture in which an elbow injury is associated (unspecified), and Morrey maintains in his
classification type IV stating that the association refers to a dislocation of the elbow, with or
without a fracture of the coronoid apophysis
...

According to R
...
Judet, radial neck fractures in children are of four
degrees:
 first degree fractures without displacement ("in green wood");
 grade II fractures with moderate displacement (translation below half of the diameter, tilt
below 35 degrees);
 grade III fractures with significant displacement (translation over half the diameter of the
fracture surfaces and a tilt up to 60 degrees);
 grade IV fractures with loss of contact between the fractured surfaces (and a tilt of more
than 60 degrees)
...
Among the associated bone lesions,
we will mention those at the level of the external humeral condyle
...
Fracture of the
upper extremity of the ulna may also be associated with fracture of the clavicle
...
By emphasizing the physiological valgus when falling with support on the
palm, the internal capsuloligamentary plane of the elbow is tensed
...
In about 1/3 of the cases the internal capsuloligamentous plane breaks
and the fracture is accompanied by a posterior dislocation of the elbow
...
This
triple association (comminuted fractured radial head, rupture of the intercapsuloligamentary
plane and coronoid fracture) is called the "unfortunate triad" of the elbow and was described
by Morrey
...
In violent trauma the radial head is comminutedly fractured and if the traumatic energy
has not been exhausted, the force continues to exert pressure from below upwards, the entire
radial diaphysis ascends and the fracture moves
...
lower and interosseous
membrane
...
We are
dealing with the presence of the Essex-Lopresti syndrome known in the specialized literature
as ALRUD (Acute Longitudinal Radioulnar Dissociation)
...
The patient reports a fall with support on the palm, with the elbow in extension
...
On inspection, we will notice how the elbow is slightly
deformed, especially on the external side, and the patient maintains the joint in a vicious
attitude of 30-40º extension
...
Mobilization is
possible in flexion-extension, but attempted rotation of the forearm will be painful, limited, or
impossible
...
the research of the vascularization, but especially of the
innervation in the territory of the radial nerve will not be neglected
...
The diagnosis
of a fracture associated with elbow sprain can be suggested by the discovery of some painful
points on the inner side of the joint, but the dislocation of the elbow marks the signs of the
fracture and the diagnosis becomes impossible
...
An incomplete examination risks these injuries
remaining unknown
...

RADIOGRAPHIC EXAMINATION
The standard radiograph, in profile, is sufficient to detect the fracture, but may miss
some type I fractures
...
Tomography is able to highlight

11

the cracks of the cup
...
the CT
examination, MRI at the level of the elbow, forearm and fist, arthrography or arthroscopy of
the fist, may sometimes be necessary to support a motivated therapeutic decision
...
The radiographic examination provides enough
information for a definite diagnosis, but also to classify the fracture as a calcification
...

EVOLUTION AND PROGNOSIS
The evolution and prognosis are related to the type of fracture, but also to the presence
or absence of associated injuries
...

COMPLICATIONS
Among the immediate complications, we will note the open fracture, an exception in
the case of an isolated fracture
...
Later we will note, as in any articular fracture, the return of the elbow
...
Compression
of the ulnar nerve by calcifications on the inside of the elbow, necrosis of the head after
osteosynthesis, cubitus valgus after resection, lower radioulnar dislocation, are other possible
complications in this case
...

TREATMENT (fig
...
In this way, it is involved in the flexion-extension movement, but decisively participates
in the pronosupination movement
...
The maneuver is particularly useful in Masson
type II fractures
...
Next, a small amount of anesthetic will be injected into the joint
...

The test is positive if the rotational movement is partially or totally blocked
...
If the active pronosupination can
reach the amplitude of 70º, then the surgical treatment is not justified
...
Based on all this information, the treatment of the clavicle fracture can be
schematized as follows, in adults and children
...
7 Treatment of scabies
Treatment in adults
In adults, treatment varies from conservative to surgical
...
Immobilization will be followed by careful
retraining, avoiding full elbow extension at first
...
Reconstruction of the anatomy by osteosynthesis is included
if osteosynthesis proves impossible, then the primitive excision of the radial head is
performed
...
Grade V and II fractures will be treated by
immobilization and re-education
...
Grade III fractures are
reduced and immobilized in children up to eight years old, they are treated as in grade IV
...
However, the results of the operations are
unfavorable in 2|3 cases
...
2
...
Radial head fracture (fig
...

13

Etiology - Indirect trauma is most commonly involved in these fractures
...
At the same time, the bone nucleus of the humeral condyle can be damaged, a
radiologically undetectable lesion
...
Judet:
• type I: without displacement or with minimal displacement;
• type II: lateral displacement of the bone fragment less than half of the fractured surface, the
angle formed by the diaphyseal axis and the axis of the fractured fragment being below 35
degrees;
• type III: the angle formed between the axis of the radial diaphysis and that of the fractured
fragment is between 35 and 60 degrees, the fragments remaining in contact;
• type IV: the fractured fragment is totally detached from the rest of the radial diaphysis
...
Gentle
palpation sometimes reveals an abnormal depression under the humeral condyle
...

Radiological examination - Performing two clichés, front and profile, highlights the type of
fracture and sometimes the injury of the humeral condyle
...

In type II and III fractures, under general anesthesia, orthopedic redecision
...
the forearm is brought into varus, and the operator pushes with both
arms from the bottom up and out into the fractured fragment
...
If attempted orthopedic reduction has failed, bleeding reduction will
be performed
...
Bleeding and repair of the annular ligament are sufficient
to stabilize the fractured fragment
...
The cast immobilization will be removed after 3 weeks, and active mobilization
will be resumed
...
8 Radial head fracture

14

2
...
3
...
9)
Definition
It is a fracture found especially in teenagers and young adults, less often in children
and the elderly
...
and the insertion of the triceps brachii muscle explains the lack of spontaneous
consolidation and the important displacement of the ligaments
...

The fracture path, oblique or transverse, is completed by the displacement of bone fragments
...

symptoms
Inspection of the elbow reveals a more pronounced swelling posteriorly, and
sometimes a depression on the olecranon relief that corresponds to the interfragmentary space
...
Active and passive flexion-extension movements are very painful
...

Treatment
In forms with minimal displacement or no displacement, immobilization in a cast
device with the elbow in extension for 3 weeks is sufficient, after which articular re-education
begins
...
Through a posterior
incision, the focus of the fracture is discovered and after evacuation of the hematoma and
inventory of the lesions, reduction and osteosynthesis are practiced with the help of the wire
mounted in ʺ8ʺ according to the principle
ʺ wowʺ
...


Fig
...
2
...
Diaphyseal fractures of the forearm bones
Definition
These fractures are located at the level of the diaphysis of the forearm bones, more
precisely between a horizontal line passing under the bicipital tuberosity of the radius and
another located approximately 4 cm above the radiocarpal joint
...
Between 1989 and 1998, 1553 children with fractures of the forearm
bones were admitted to the orthopedic clinic of the Grigore Alexandrescu Hospital
...
Much less often, the vulnerable agent hits the
forearm directly: road accidents, fall with the forearm on a blunt body
...

• fractures of the middle third:
• fracture in the "green wood" occurs in two thirds of cases in children under 7-8 years of age
...

complete fracture, with displacement, breach, or gap when both bones are involved
...

• fractures of the upper third, quite rare, 2%
...

symptoms
The inspection detects a swelling of the respective region, and in the case of
displacement or angulation, a change in the longitudinal axis of the forearm is observed
...
Gentle palpation
reveals pain in a fixed point, abnormal mobility, bony crepitations
...
The radiological examination, carried
out in the two incidences, completes the diagnosis by specifying the location, trajectory and
displacement of the fragments
...
The most
formidable complication is Volkman's anterior compartment syndrome, but fortunately its
incidence has decreased spectacularly
...

Treatment
Fractures in the "green wood", those without displacement, benefit from
immobilization in a posterior brachio-antebrachio-palmar plaster cast maintained for 4 weeks
...
If, after a correct
reduction, the fragments do not maintain their containment, percutaneous pin fixation will be
practiced under radiological control
...
fractures of the middle
third and those of the proximal third, with displacement, have a surgical indication
...
The
most used osteosynthesis material is the Kirschner pin passed transmedullary and externalized
through the styloid process and the olecranon, respectively
...
The post-operative plaster cast is
removed after 4 weeks, at which time the pins are removed
...


2
...
5
...

Etiology The indirect mechanism, as usual, is the most often blamed, the fracture occurring
by falling either on the palm or on the back of the hand
...

- Goyrand fracture, or through flexion, much rarer, in 10% of cases
...
The Gozrand fracture, also called the inverted
Pouteau fracture, recognizes the reverse mechanism, the fall occurring on the back of the
hand, the convexity of the angulation being dorsal
...
Palpation of the
region is very painful, highlighting abnormal mobility and bony crepitations
...
The late ones are related to the recovery of the fist joint
...
Under general anesthesia, under radiological
visualization, orthopedic reduction is performed, followed by plaster immobilization for 4
weeks
...


2
...
6
...
Clinically, the region is slightly
swollen, painful to palpation
...

Immobilization in a plaster cast for 2-3 weeks is the treatment of choice
...
Clinically,
the swelling and deformation of the axis is observed at this level
...

The immediate complications refer mainly to the open fracture that can occur in the
case of a stronger trauma
...

The treatment consists of emergency orthopedic reduction followed by immobilization
in a plaster cast for 2 weeks with the hand flexed on the forearm
...


2
...
7
...
Clinically, swelling, ecchymosis,
pain in a fixed point are observed
...
Surgery is rarely indicated
...
2
...
Volkmann syndrome
Definition
Described by Volkmann in 1869, this syndrome represents a progressive postischemic
retraction of the muscles of the anterior lobe of the forearm
...

etiopathogeny
Volkmann's syndrome can occur in supracondylar humerus fracture, forearm bone
fracture, or traumatic elbow dislocations
...

The physiopathological mechanism is as follows: bone trauma causes perifocal
bleeding and edema, which together with the fractured bone fragments compress the arterial
vessels (brachial artery, ulnar artery or radial artery)
...
The circle
ends by hindering the venous return which accentuates the edema amplifying the "tourniquet"
effect
...

Symptomatology , the premonitory or alarm signs, recognized and well interpreted, have
recently made Volkmann's syndrome no longer appear in all its complexity: intense pain,
localized or diffuse, in the forearm, cyanosis of the fingers accompanied by the absence of
capillary pulse, swelling of the fingers , marked edema of the hand or arm or distal to the cast
device, the fingers are cold and have paresthesias
...
The condition period is characterized by the
presence of three syndromes
...

The claw can be described as follows: the hand is flexed on the forearm, the proximal
phalanges are in extension, and the middle and distal phalanges are flexed on the first

18

phalanx
...

b2) the nervous syndrome characterized by the presence of paresis, paresthesias or even
paralysis of one or all nerves related to the flexor muscles and the hand (radial, ulnar or
medial nerve)
...

Positive diagnosis
Intense pain, appearing after orthopedic reduction and immobilization in a plaster cast,
accompanied by marked edema of the fingers, cyanosis, paresthesias, absence of capillary
pulse in the nail bed, are definite signs of the onset of a Volkmann syndrome
...

Differential diagnosis It addresses the moment of installation of scaffolds and is done with:
spastic hand, vicious post-burn scar, neurological diseases, Little's syndrome, ankylosis of the
hand, Dupuytren's syndrome
...
The supracondylar fracture of the humerus, which is
most often involved in the occurrence of Volkmann's syndrome, must be reduced as quickly
and anatomically as possible
...
Hospitalization is mandatory, so that surveillance during the first 2-3 days after the
fracture is done continuously
...
If after this maneuver, the
vasculo-nervous phenomena do not recede or tend to worsen, surgical intervention will be
performed by making a release incision on the volar face of the forearm that will involve the
skin and aponeurosis
...
A supracondylar fracture of the humerus or
forearm in a child, correctly diagnosed, treated and supervised, will never generate the
installation and constitution of a Volkman syndrome
...
e
...
The
surgical intervention of choice is disinsertion and lowering of the proximal insertion of the
epitrochlea muscles (Scaglietti-Gosset-Sedon operation)
...
2
...
Monteggia-Stănciulescu fracture (fig 10)

19

Fig 10 Monteggia Stănciulescu fracture
Definition
Fracture of the ulna in the proximal third accompanied by traumatic dislocation of the
radial head was described in 1814 by Monteggia
...

etiopathogeny
The Monteggia fracture occurs more frequently in children and adolescents, the
maximum incidence being between 5-10 years, but it is also found in adults
...

Pathological anatomy Two distinct lesions are described for the Monteggia fracture:
the fracture of the proximal third of the ulna, the location of the trajectory may be right at the
base of the olecranon
...
Dislocation of the radial head, most often anterior,
ruptures the annular ligament and anterior joint capsule
...

On the postero-external face of the elbow, there is a depression next to the lateral condyle,
and anteriorly, a hard swelling on palpation, it is the radial head that comes out from under the
humeral condyle
...
On gentle palpation of the ulnar relief, there is pain at a fixed point and bony
crepitations
...
The injuries of this type of fracture being located in a richly
vascularized and innervated area, signs of a peripheral vasculo-nervous inversion, the pulse at
the radial artery, the coloration, the mobility and sensitivity of the fingers, the movements in
the fist joint must be looked for
...
often an incorrectly performed X-ray reveals the

20

fracture of the ulna while the dislocation of the radial head goes unnoticed
...

Evolution and prognosis
Well reduced and immobilized, the fracture has a good prognosis, with the exception
of a slight limitation of pronation-supination and flexion-extension movements of the elbow,
but in children functional recovery is almost always complete
...

• The functional prognosis is aggravated by: periarticular ossification, radio-ulnar synostosis
a possible lower radio-ulnar subluxation, which causes embarrassment in the movements of
the hand joint, nerve damage by damaging the deep radial nerve
...
Reduction is then maintained by
immobilizing the forearm in flexion and semipronation
...
If early intervention is not taken, the capsular tear and the annular ligament retract, the
ulna consolidates viciously, and the dislocation of the radial head is impossible to reduce
...

Surgical treatment
It is always indicated in adults and in cases of failure of orthopedic treatment, in
children
...
The bleeding
replacement of the radial head requires the removal of the elements interposed between it and
the ulna, as well as the reconstruction of the ring ligament through plastic surgery (triceps
band or fascia lata)
...

Kinesiotherapeutic treatment
1
...

Maintaining the mobility of unaffected joints
...

So :
• abductions-antepulses and rotations are performed at the shoulder;
• flexion-extension punch and lateral ulnar and radial deviations;

21

• for the hand, but especially for the fingers, plasticine, small balls, rubber coils, handles with
springs are used
...

2
...
Due to the innervation rich
in sensitive fibers of the joint capsule, the pain occurs especially during movement, leading to
the limitation of mobility
...

Pain management methods:
1 medication: analgesic, anti-inflammatory, sedative
2 physical therapy with analgesic effects, low and medium frequency currents, local heat,
massage consisting only of smoothing
...

These must be treated early, because they cause severe secondary phenomena: edema, stasis,
slowing of the anterior-capillary circulation, hypotrophy of the skin, phenomena occurring at
the level of the elbow, forearm and hand
...


C) Regaining joint mobility is the basic objective of recovery
...
Pronosupination has an amplitude of 170º (when the elbow is in 90º flexion)
...
Pronation can be
compensated by internal abduction at the shoulder
...

Methods of regaining mobility:
• passive movements are allowed, only self-passive ones, with the help of pulleys
...
The
elbow is fixed to the trunk and pronosupination begins
...

before starting the actual active exercises, it is recommended to carry out a global reeducation of the gestures
...

• It is performed: abductions, adductions, by bringing objects close to the body, in the sitting
position
the exercise of throwing a weight involves flexion and then extension of the elbow striking
movements in different directions the exercise of climbing
...

Flexion-extension movements in the floating position of the elbow with the help of floats are
recommended

22

• free gymnastics exercises, combinations of flexion-supination, extension-pronation are
recommended
• extension-flexion exercises
• prono-supination exercises
• proprioceptive neuromuscular facilitation exercises
• occupational therapy (ergotherapy)
The goal: the activity requires, through multiple repetitions, a wide range of motion
...

The athletes will practice: swimming, basketball, table tennis
...

D) Increasing muscle strength to facilitate muscle toning, certain optimal positions are
preferred:
- for flexors: the shoulder in the rest position, the elbow at 90º, flex the elbow with resistance,
simultaneously with the antepulse of the arm;
- for extensors: the shoulder in 90º antepulsion, the elbow flexed at 30º, the neck is extended
with resistance, simultaneously with the retropulsion of the arm;
- for pronosupination: arm close to the body, elbow in 90º flexion, perform pronation with
resistance simultaneously with arm abduction or supination (with resistance) associated with
arm adduction
...
1
...
10
...
04
...

Distribution of patients after sex :
- female: 5 subjects
- male: 7 subjects
● Distribution of patients by age groups:
- between 22 and 30 years: 7 patients:
- 3 women
- 5 men
- between 31-50 years: 5 patients:
- 2 women

23

- 3 men
● Distribution of patients according to the type of fracture :
- elbow fractures: 3 patients:
- 2 women
- 1 men
- radius fractures: 3 patients:
- 2 women
- 1 men
- ulnar+radius fractures: 6 patients:
- 1 women
- 5 men
 Breakdown of patients by production mechanism:
- fall trauma: 7 patients:
- 3 women
- 4 men
- road accident trauma: 5 patients:
- 2 women
- 3 men

Table no
...


Age

Sex

Occupation

1

INITIA
L
DR

25

F

2

HR

49

3

KE-I

4

5

6

-

Sport
practiced
Tennis

The
type
of
fracture
- iterative cubitus
fracture dr
...


30

F

Manager

Tennis

- bifocal type II
open fracture with
minimal
cubitus
displacement dr

-multiple
rib
fractures C5, C6
right
-fracture of the
sacral wing dr
-fracture
1/3
middle clavicle dr
- right frontal
cerebral
contusion
- chest contusion

ZL

43

F

Secretary

Fitness room

OE-R

25

F

Trade
worker

Football

-

Tennis

-fr
...

● Distribution of patients according to the affected forearm :
- right: 9 patients:
- 3 women
- 6 men
- left: 3 patients
...
2
...
Initials : KI

25

apophyseal
fracture L2, L3,
L4

contusion
wound right leg
- intolerance to
MOS basin
-costal fracture
C2 stg axillary
arch

-luxation
metacarpophalan
geal police stg

Date of birth : 18
...
1986
Diagnosis : - fracture 1/3 proximal both forearm bones dr
- road accident trauma (6 weeks)
Surgical intervention :
- bleeding reduction and osteosynthesis with plates and sutures radius and cubitus dr
...

Surgical intervention is performed, performing the bleeding reduction and osteosynthesis with
2 Reco plates and screws in both bones of the right forearm + extraction of the pelvic external
fixator, curettage, washing of the remaining holes, sterile dressing
...

The patient is discharged with the recommendations: functional recovery in a specialized
center
...
Initials: CD
Date of birth: 20
...
1983
Diagnosis: - type III open fracture of both forearm bones dr
- metacarpophalangeal luxation of right stg
- trauma due to road accident
Surgery: bleeding reduction and osteosynthesis with plates and screws both forearm bones
Dr
...

Epicrisa: the patient is the victim of a road accident
...

- orthopedic repair of metacarpophalangeal luxation poly stg
...
Initials: GD-V
Date of birth: 11
...
1977
Diagnosis: - fracture 1/3 medial radius diaphysis with distal radio-ulnar dislocation dr
- fall trauma
Surgical intervention: bleeding reduction and osteosynthesis with plate and screws radius dr
...

The patient is discharged with the recommendations:
- avoiding intense physical exertion for 4 weeks
- avoidance of para supination dr forearm movement for 3 weeks
- sterile dressings through the family doctor
- functional recovery in a specialized center
4
...
11
...

- hemostasis, suture, dressing
Epicrisis: After postoperative preparation, surgical intervention is performed by bleeding
reduction and osteosynthesis with plate and screws + "lag screw" screws for cubitus fracture
dr
...
Initials: ZL
Date of birth: 19
...
1969
Diagnosis: - comminuted fracture distal epiphysis radius dr
- trauma by accidental fall
Epicrisis: surgical intervention is carried out bleeding reduction and plate and screw
osteosynthesis distal epiphysis radius dr
The patient is discharged with the recommendations :
- daily dressings with thread suppression 14 days postoperatively
- drug treatment according to Rp
- starting functional recovery in a specialized center
6
...
04
...
Toilet, suture, bandage wound contusion right leg
Epicrisis: in the emergency department of the Orthopedics clinic, the following is performed:
the toilet and the suture of the contused wound of the right leg
...

The patient is discharged with the recommendations :
- functional recovery of the movements of the affected limb
- drug treatment with Trombo Ass 2x1/day, Mydocalm 2x1/day
7
...
10
...

Epicrisa: patient victim of a road accident with right hemithoracic pain, pain+total functional
impotence forearm dr
...
Initials : HR
Date of birth: 19
...
1963
Diagnosis:
- distal epiphysis fracture radius+cubitus stg
- multiple rib fractures C5, C6 right
- sacral wing fracture dr
- road accident trauma
Surgical intervention: closed focus reduction and percutaneous osteosynthesis with 2 "K"
brooches distal epiphysis radius stg
...
6 axial arch
right
...
Initials: OE-R
Date of birth: 10
...
1987
Diagnosis:
- articular fracture with displacement distal epiphysis radius stg
- fall trauma
Surgery:
- bleeding reduction and plate and screw osteosynthesis
- immobilization antebrachio-palmar cast splint right
Epicrisis: it is surgically intervened by practicing bleeding reduction and osteosynthesis with
plate and screws distal epiphysis radius stg
...
Initials: KE-I
Date of birth: 27
...
1982
Diagnosis:
- type II bifocal open fracture with minimal cubitus displacement dr
- fracture 1/3 middle clavicle dr
- right frontal brain contusion
- chest contusion
- road accident trauma
Surgical intervention: immobilization for cubitus fracture dr
Epicrisis: the patient is the victim of a road accident with a bruised wound on the right
forearm, chest pain, pain in the shoulder and right arm
...
Initials: DR
Date of birth: 07/08/1987
Diagnosis:
- interactive fracture cubitus dr
- consolidated pelvic fracture
- fall trauma
Surgery:
- extracted MOS plate with screws from the forearm Dr
...
Initials: SP-V
Date of birth: 28
...
1984
Diagnosis:
- distal radius epiphysis fracture
- transverse apophyseal fracture L2, L3, L4
- fall from height
Epicrisis: the patient suffers from polytraumatism due to a fall from a height in a domestic
environment, resulting in a fracture of the distal epiphysis of the radius and transverse
apophyseal fractures shown by X-ray and UPU
...

The patient is discharged with the recommendations:
- avoiding physical exertion and lifting weights
- return in 7 days for clinical and radiological orthopedic reevaluation
- treatment according to Rp, Ketoprofen 2x1 tb/day, Mydocalm 2x1 tb/day, omeran 2x1
tb/day
- functional recovery in a specialized center

CHAPTER IV - CONDUCT OF THE RESEARCH
The study was carried out between 17
...
2011 and 12
...
2012
...


4
...
Recovery objectives
- recovery after suspension of immobilization
- pain relief
- combating vasomotor and trophic disorders
- regaining joint mobility
- increase in muscle strength
- recovery of soft tissue trophicity through the application of recuperative exercises,
electromagnetic waves in order to strengthen the fracture, massage of the hand and forearm

29

4
...
Kinetic program applied to patients (applied 3 times a week)
It starts by warming up the joints of the hands:
- flexion of hands on forearm
- forearm flexion on the arm
- hand flexion and extension
- hand and elbow joint rotations
- supination and pronation of the hand
Global re-education exercises:
- from sitting on the bed; an object is grabbed from the bed, placed next to it, at various
distances, in such a way that the arm does a retropulsion-abduction-internal rotation, the
elbow is flexed variably (depending on the distance to the object), the fist is in pronationflexion ulnar, hand open
...
The exercise is
repeated at various levels (arm abductions) and distances from the body
...

- weight throwing exercise
...

"Launch" movements are made before throwing the stone
...

- the "hitting" movement
...
From this position, a movement is
performed as if to hit, namely the movement towards retropulsion-abduction-internal
rotation, elbow extension with pronation and ulnar inclination of the fist
...

- the "climbing" exercise
...
The patient in a sitting position
...

This exercise can be improved by pulling on the shaft by the assistant (the counter-grip is
on the arm)
...

- the patient has a wheeled support in his hand, which he brings towards the body and
removes
...
Always
try to touch the shoulder with the hand
...

- from sitting, one imitates boxing movements by extending the arm and squeezing it to the
chest
...

from sitting, standing or supine, the hand goes to the opposite shoulder and then the forearm
is extended diagonally
...
As a variation,
grab a bar at chest level and bend your body back
...
Feet in fixed point
...

Variations: with elbows to the side, with elbows close to the trunk
...

Pronosupination exercises:
- elbow stuck to the trunk, the pronosupination movement is performed
...
Rotations are performed, the fingers look down, then the hands are
rotated so that they end up looking up
...

- with a stick in hand, pronosupination is performed
...
You
can also work with a dumbbell, which, through its weight, exerts a greater traction force
during pronosupination
...
A movement, for example flexion, is
performed against resistance
...
Suddenly,
the resistance is suppressed and the patient alone will immediately perform an active
flexion, which will generally have a greater amplitude than up to that point
...
The
basic condition in choosing the concrete modalities of occupational therapy is that this activity
requires, in multiple repetitions, as wide a range of motion as possible
...

Physiotherapy is assisted with a series of physical procedures, which have the role of
increasing tissue elasticity, improving the sliding of cleavage planes, reducing contractures
and retractions
...
5 w/cm² (at these doses bone protrusions
are avoided) the massage done with good technique, in the form of frictions and or the deep
one with the tips of the fingers
...
3 Evaluation of patients
Joint balance of the forearm
There are 3 radioulnar joints:
- proximal (superior) radioulnar art which is part of the elbow joint complex;
- distal (inferior) radioulnar joint and the interosseous membrane
...
Full insupination, the 2
bones are parallel; the radius being placed laterally decubitus along its entire length
...

The radial head rotates around its own axis, changing its position, and the distal radial
epiphysis is placed at the end of the pronation movement medial to the ulnar one
...

Pronation - amplitude 90 degrees
...
The goniometer - from
the intermediate position, a pencil is held in the hand
...
The fixed arm perpendicular to the ground and the mobile arm parallel to the
pencil or pencil
...


31

Supination - amplitude 90 degrees, is the movement that orients the hand with the palm up
and the shelf sideways
...
The functional
position of the forearm is semi-pronation at 30-45 degrees
...
2 – Joint balance values for pronation movement in patients with radius
fracture
No
...
5
maximum
29
35
minimum
27
34
standard deviation
1
0
...
31 x 10 -6

Student's t test

From the statistical analysis of the articular balance values for the pronation movement
in the case of patients with radius fracture, we obtained p = 4
...

The statistical estimation of the results was carried out for a minimum significance
threshold accepted in biology p = 0
...
05 – indicates insignificant differences - NS
p < 0
...
01 – indicates very significant differences – FS
p < 0
...
3 – Joint balance values for pronation movement in patients with ulnar
fracture
No
...
6
32
31

37
38
36
0
...
89

2
...
50 x 10 -5 with the Student t test , which
indicates extremely significant differences
...
4 – Joint balance values for pronation movement in patients with radius +
cubitus fracture
No
...
31
4
...
00x10 7

From the statistical analysis of the values of the joint balance for the pronation movement in
the case of patients with fracture of the radius + ulna at the Student's t test we obtained p =
7
...

Table no
...
crt
INITIAL
Joint balance supination movement
Initial
Final
1
OER
9
13
2
SPV
10
14
arithmetic mean
9
...
5

33

maximum
minimum
standard deviation
Student's t test

10
9
0
...
5

7
...
16 x with the Student's t test
10 7 , which indicates extremely significant differences
...
6 – Joint balance values for the supination movement in patients with
ulna fracture
No
...
3

13
...
35

1
...
66x10 6

Student's t test

From the statistical analysis of the articular balance values for the supination movement in the
case of patients with ulnar fracture, we obtained p = 1
...


Table no
...
crt

INITIAL

1
2
3

HR
GDV
HD

Joint balance pronation movement
Initial
Final
7
10
10
13
9
13

34

4
5
6
arithmetic mean
maximum
minimum
standard deviation

KI
MC
CD

Student's t test

10
11
9
9
...
47

16
18
15
14
...
97

2
...
51 x with the Student
t test 10 5 , which indicates extremely significant differences
...
Opening a tight or new jar:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
2
...
Turn a key in the door:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □Impossible
4
...
Pushing or opening a heavy door:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
6
...
Carrying out heavy household chores (washing floors, etc
...
Gardening:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
9
...
Carrying a shopping bag or briefcase:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
11
...
Changing an overhead light bulb:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □Impossible
13
...
Wash your back:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
15
...
Using a knife to cut food:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □Impossible

36

17
...
Recreational activities that require the use of the hand, shoulder and arm (golf, tennis):
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
19
...
To drive:
□ No difficulty □ Easy difficulty □ Medium difficulty
□ Moderate difficulty □ Impossible
21
...
During the past week, to what extent did your arm, hand, or shoulder affect your social
life with friends, family, or neighbors?
□ Not at all □ A little □ Moderate □ A lot
□ Very much
23
...
Hand, shoulder or arm pain:
□Not at all □A little □Moderate □Severe
□ Extremely
25
...
Tingling in the arm, shoulder or hand:

37

□ Not at all □ A little □Severe
□ Extremely
27
...
Stiffness in the arm, hand or shoulder:
□ Not at all □ A little □ Moderate □ Severe
□Extremely
29
...
Do you feel less capable, insecure or less useful because of your hand, arm or shoulder
problem?
□ Disagree □ Mild Disagree □ Slightly Agree
□ Approval □ Strongly agree

Table no
...
3
99
...
3

Final
14
...
2
14
...
7

15

38

OER
SPV
GDV
HD
KI
MC
NBS
CD

96
...
2
98
...
8
96
...
8
98
...
5
14
...
2
14
...
2
14
...
2

maximum

99
...
1

14
...
48

Student's t-test

0
...
29 x 10 10

From the statistical analysis of the initial and final values of the DASH scale in the patients of
46
the studied group with the Student t test we obtained p = 1
...
In this type of
socket, the palmar face of the last phalanx of the phalanx and the index finger participate
...
g
...

Type IV: latero-lateral prehension, between index and medius (eg grabbing a cigarette)
Type V: digito-palmar prehension, in which the fingers do not participate, but only the palmar
side of the fingers and the palm (e
...
grasping the steering wheel)
Type VI: poly-digital-palmar prehension, which involves the entire palmar side of the
polycus, the other phalanges and the palm
...
9 - Assessment of prehension in patients
initial
INITIAL
Type I
Type II
Type III
DR
Impossibl Impossibl Impossibl
e
e
e
HR
Impossibl Impossibl Impossibl
e
e
e

39

of the group studied in the stage
Type IV
Difficult

Type V
Difficult

Difficult

Difficult

Type VI
Average
diff
Average
diff

KEI
ZL
OER
SPV
GDV
HD
KI
MC
NBS
CD

Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e

Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e

Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e
Impossibl
e

Difficult

Difficult

Average
diff
Small diff

Average
diff
Average
diff
Difficult

Average
diff
Average
diff
Difficult

Difficult

Difficult

Average
diff
Average
diff
Difficult

Average
diff
Average
diff
Difficult

Difficult

Difficult

Difficult

Difficult

Difficult

Difficult

Small diff
Average
diff
Average
diff
Small diff
Average
diff
Difficult

Table no
...
1 Repartiția pacienților după sex

Feminin
42%

Masculin
58%

r

41

grafic
...
3 Repartiția pacienților după tipul de
fractură

Fracturi de
cubitus+radi
us
Fracturi de
20%
cubitus
40%
Fracturi de
radius
40%

42

grafic
...
5 Repartiția pacienților după sportul practicat

Practică tenis
25%

Nesportivi
62%

Practică fotbal
Practică
Practică13%
basket
handbal
0%
0%

43

grafic
...
7 Valorile bilanțului articular pentru mișcarea de
pronație la pacienții cu fractură de radius

40
30
20
10
0

O
...
R

S
...
V

Inițial

27

34

Final

34

35

44

grafic
...
R

32

37

K
...
I

31

36

grafic
...
R

26

33

G
...
V

28

33

H
...
I

33

43

45

grafic
...
E
...
P
...
11 Valorile bilanțului aticular pentru
mișcarea de supinație la pacienții cu fractură de
cubitus
15

10

5

0

Inițial

Final

D
...
E
...
N
...
12 Valorile bilanțului articula pentru
mișcarea de supinație la pacienții cu fractură de
radius+cubitus
20

10

0

Inițial

Final

H
...
D
...
D

9

13

K
...
C

11

18

47

GRAFIC
...
R

98,3

14,2

H
...
E
...
L

96,7

15

O
...
R

96,7

15

S
...
V

99,2

15

G
...
V

98,3

14,5

H
...
I

95,8

14,2

M
...
N
...
D

98,3

14,2
48

CHAPTER VI - DISCUSSIONS
Basu S , Khan SH
Department of Radiology, East Lancashire Hospitals NHS Trust, Blackburn,
Lancashire
...

These injuries frequently result from a fall on an outstretched hand
...
The factors affecting injuries to the forearm
and wrist depend on the age of the patient, the severity of the injury, the exact mechanism and
the direction of the force on the injury
...
It is essential to identify the lesions early
so that appropriate management implement early recovery and normal function is seen
...

J Orthop Surg (Hong Kong)
...

Kirschner wires are much cheaper than plates and screws and require minimal expertise for
insertion and removal
...

Goldfarb CA , Ricci WM , Tull F , Ray D , Borrelli J Jr
...

Functional result after fracture of both forearm bones
...
We
evaluate 23 patients (24 fractures) subjectively, objectively and radiologically at a mean of 34
months (11-72)
...
Forearm and wrist strength
range of motion, grip and grip were measured objectively and assessed radiographically
...
However, pronation and grip and grip strength decreased
significantly (p < 0
...
These deficiencies correlated with poorer subjective outcomes
...
However, despite these generally satisfactory results, the outcome worsened
with reduction in forearm and wrist range of motion
...

Department of Orthopedic Surgery, University of Rome Tor Vergata and IRCCS Santa
Lucia Institute, Italy
...
None of the patients who returned to
follow-up complained of any symptoms related to their previous injury, not even those
involved in heavy manual work
...


Chapter VII - CONCLUSIONS
49

1
...

2
...

3
...
All this
facilitates the achievement of well-established goals in post-fracture recovery
...
The results of the recovery depend on the objective factors, such as: the severity of the
fracture, the patient's age, his biological capacity for regeneration as well as the subjective
factors: the patient's cooperation, conscientiousness and punctuality in carrying out the
treatment, on the means and methods used
...
Drawing up a strictly individualized recovery program for each patient allows an adequate
recovery with results appearing in the shortest possible time
...
This type of fracture is prevalent in both sexes, with a higher incidence among males
...
The most used surgical technique was bleeding reduction with plate and screw
osteosynthesis
...
The postoperative recovery is fast with the possibility of integration into the activity in the
shortest possible time, which explains the current trend for the application surgical
treatment
...
From the statistical analysis of the articular balance values for the pronation movement in
the case of patients with radius fracture, we obtained p = 4
...

10
...
50 x 10 -5 with the Student t test ,
which indicates extremely significant differences
...
From the statistical analysis of the values of the joint balance for the pronation movement
in the case of patients with fracture of the radius + ulna at the Student's t test we obtained
p = 7
...

12
...
16 x with the Student's t
test 10 7 , which indicates extremely significant differences
...
From the statistical analysis of the articular balance values for the supination movement in
the case of patients with ulnar fracture, we obtained p = 1
...

14
...
51 x with the
Student t test 10 5 , which indicates extremely significant differences
...
Antonescu DM "Pathology of the locomotor apparatus", vol I, Medical Publishing House,
Bucharest 2006,
2
...
-" Human anatomy vol I " Bucharest Medical Publishing House, 1991, 61-63, 131-134,
3
...
T
...
Sbenghe T
...
http://ortopediaonline
...
http://www
...
nlm
...
gov/pubmed?term=Basu%20S%5BAuthor%5D&cauthor=true&cauthor_uid=
20551885 ,
7
...
ncbi
...
nih
...
http://www
...
nlm
...
gov/pubmed?term=Ricci%20WM%5BAuthor%5D&cauthor=true&cauthor_ui
d=15773649 ,
9
...
ncbi
...
nih
...
http://www
...
ro/search?hl=ro&client=firefoxa&hs=Wpm&rls=org
...
http://www
...
com/ap/muscularsystem/wristhanddigits/menu/menu
...
http://www
...
com/scorepages/disabilities_of_arm_shoulder_hand_score_d
ash

---