GREENSTICK FRACTURE WITH DISLOCATION DISPLACEMENT

P.

OF

OF THE UPPER END THE RADIO-HUMERAL SUPERIOR

MARGATE,

OF

THE JOINT

ULNA OR

OF
R.

THE
WRIGHT,

RADIAL
ENGLAND

EPIPHYSIS

The
notice in

purpose the

of this

paper

is to describe
CASE

an

injury

of childhood

which

has

received

little

literature.
REPORTS

Case

1-A

boy

of

four

fell

on

to

his

right

arm,

injuring

his

elbow.

Radiographs

showed

greenstick displacement

fracture ofthe

of upper

the

upper end ofthe

end

of

the (Fig.

ulna I).

with The

extension fracture was

deformity, reduced

and

forward

radius

by manipulation for five weeks. of movement of

under general anaesthesia Two weeks after removal the elbow and the forearm.

and the arm was immobilised of the plaster he had regained

in plaster-of-Paris a full, painless range

Case

1-Greenstick

fracture

of the ulna

with extension deformity the upper end of the radius.

and

forward

displacement

of

Case 2-Greenstick

fracture

of the ulna

F... 2 with extension deformity the upper end of the radius.

and

forward

displacement

of

Case 2-A greenstick displacement

VOL.

girl of fracture of the

NO.

two fell from of the upper upper end

1963

a chair, end of radius

injuring the ulna (Fig. 2).

her left elbow. with extension Manipulative

Radiographs deformity, reduction

and was

showed forward performed

of the

45 B,

4,

NOVEMBER

727

728

P.

R.

WRIGHT

under
plaster

general
the child

anaesthesia, in plaster
had regained

and was

although maintained
a full range

reduction for three

of painless

was

incomplete Two
movement

the weeks
of the

position after
elbow

was removal
and
at

accepted. of the
forearm.

Immobilisation

weeks.

Case
upper

3-A
end

boy of
of the

of pain

six
ulna

injured in the
with

his elbow,
varus

right and of was

arm

while
and

doing showed
lateral

physical
displacement

training

school.

He

complained of
was

radiographs this injury but followed

extension

a greenstick
of

fracture
the upper

of the

the
end

deformity manipulation.

the

radius and

(Fig.

3).

The reduction

extent

was
Eight

not
days

at

first
later

recognised
the correct

and
diagnosis

arm
was

immobilised

in plaster

without

made ulnar the but

manipulative was
was removed

attempted and

without by four
and

success. weeks
supination

Open
was

reduction
rapidly

of the After
regained,

fracture plaster pronation

therefore
a full

carried
range

out,

immobilisation. on the other

offiexion,

remained

slightly

limited

(70 degrees

compared

with

90 degrees

side).

Case

3-Greenstick

fracture ment

FIG. 3 of the ulna with varus deformity of the upper end of the radius.

and

lateral

displace-

Case
and

4-A

girl

of

ten

fell
of

down
the for

a flight
fracture upper radial weeks. incomplete Flexion

of

steps
upper epiphysis

at

school
end (Fig.

and
of the 4). the was of the

injured
ulna with Open

her
valgus

right

elbow.
of the that to

Radiographs epiphysis
ill

showed was was of the This but carried maintained ulnar

a greenstick out,

of the

deformity

fracture-separation plaster

reduction

together
three was accepted. supination the ulnar

with

manipulation
On and and involved

ofthe
removal that extension limited. the there

ulnar
of

fracture,
plaster about elbow

and

immobilisation
clear returned four joint in view almost months (Fig. of cubitus

it became 1 5 degrees rapidly

reduction valgus. normal after

fracture was and that

position pronation showed

remained fracture

Further superior nerve extension was

radiographs radio-ulnar

injury

5),
the but 6).

and
months

this

explained
after injury

a gradually
anterior

decreasing
tralispOsition of

range
the flexion

of
ulnar and

pronation

and

supination.

Eighteen
of full, (Fig.

performed remained

cubitus

valgus.

Thirty

months

after

injury

supination
Radiographs

and

pronation
suggested that

were
fusion

absent,
of the

the

forearm
superior

being
radio-ulnar

fixed

at 45 degrees
joint had taken

of supination.
place

Case
unknown.

5-A

boy
and

of thirteen
a fracture-separation

sustained showed

an
of the

injury
upper

to his
radial

left ofthe

elbow, upper

the end
There

details ofthe
was

of which ulna
also

were valgus

Radiographs epiphysis anaesthesia

of the

a greenstick humeral by three

in Figure

fracture

with

deformity of the general

removal

epiphysis.

separation

of the medial followed

plaster is shown

epicondyle. Treatment weeks immobilisation

7. Recovery of movement
THE

was by in plaster.
of the
OF

manipulation under The position on

elbow
AND

and
JOINT

forearm
SURGERY

JOURNAL

BONE

GREENSTICK

FRACTURE

OF THE UPPER

END OF THE ULNA

729

FIG.
Case 4-Greenstick fracture of the ulna

4
with valgus deformity and fracture-

separation

of the upper

radial

epiphysis.

FIG.

Case 4-Radiographs
and involvement

after attempted of the superior

reduction, radio-ulnar

showing incomplete reduction joint by the ulnar fracture.

FIG.
Case 4-Radiographs taken thirty months

6
after injury suggesting fusion of

the

superior

radio-ulnar

joint.

VOL.

45 B,

NO.

4,

NOVEMBER

1963

730 was slow and four months after injury

P.

R.

WRIGHT

there

was

still

30 degrees

loss

of extension

and

40 degrees

loss time

of flexion. it became

Pronation clear that

was traumatic

limited ulnar

to 20 degrees neuritis was radiographs radio-ulnar

and

supination and that not

to 70 degrees. anterior the ulnar occurred

At

this had

developing showed joint had

transposition fracture (Fig. 8).

of the united

ulnar nerve was performed. and that involvement of the

Further superior

Case

5-Radiographs

after

reduction.

rr.,
,.

I
_#

L.

Case

5-Radiographs

showing union of the superior

of the ulnar radio-ulnar

fracture joint.

without

involvement

DISCUSSION

Hume associated showed

fracture

(1957)

described

three

cases

of undisplaced

fracture

of the

olecranon

in children

with anterior dislocation that in one of the cases

and

of the head of the radius. there was a varus deformity was displaced described the ulna two with other
the

The radiographs in his paper of the ulna at the site of the to the displacement type, was injury.
of the ulna may be, the

the head

ofthe

radius (1960)

laterally, cases varus reports

direction

similar of the deformity of this same

described a greenstick by lateral

in Case 3 above. Beddow and fracture dislocation The

It

Corkery upper end

in which

of

the

of

accompanied

of the literature
seems clear

radio-humeral joint. does not contain any

that, no matter what

of angulation

ulna and the radius remain in a fixed relationship to one another while the injury place. Only in this way can the correspondence between the direction of angulation ulna and the direction of displacement of the upper end of the radius be explained.

is taking of the For the

same reason it seems clear that this position must be one of full supination. The most probable mechanism therefore seems to be a fall on to the outstretched hand during which the forearm is held supinated (as it might be ifthe child were falling backwards). The direction of angulation
THE JOURNAL OF BONE AND JOINT SURGERY

GREENSTICK

FRACTURE

OF

THE

UPPER

END

OF

THE

ULNA

731 which may

radius

of the
varus,

ulna
valgus

will
or (1957)

then

be determined
strain that

by the
on the anterior

exact

direction
(Fig. of

of the
9). the

fall,
of

produce
might

a
be

hyperextension suggested

forearm

Hume

displacement

head

the

explained

by

a hyperextension

strain

on

the

ulna

while by Evans however,

the

radius

is in

the

position

of

pronation-a mechanism similar to that described Monteggia fracture-dislocation. Such an explanation, with medial and lateral displacement. It
seems group, ing the result the exact from more injury direction failure likely the that all three the fall. types arm same, form durbut a in which position ofthe

(1949) could

in the production of the not apply to those cases

is essentially

the direction Complications-l) nature Even ment

by

ofangulation
of the

is determined reduction
the

by may
true

Imperfect
to

recognise

of the when of the ulna

injury may
(Cases

when not

it is first the be easy

4).

seen.

it is recognised,
2 and

displaceto correct
2) Trau-

manipulation

matic ulnar neuritis is a considerable danger in those cases with valgus deformity if reduction is imperfect. injury was not seen
occurred in one and

in radial

3) this

Radial series with head

(1960).

nerve but it lateral

They

of the

patients

displacement
by from Beddow

of the

described resulting radius on through the but

GREENSTICK

Corkery

considered the

it to be a neurapraxia traction by the displaced nerve muscle. as must it winds occur 4) Injury to the only ulnar

radial

FRACTURE

OF

MONTEGGIA

INJURY

supinator radio-ulnarjoint complete in one appeared

superior occurred fracture

ULNA WITH VARUS

DEFORMITY

in all cases

loss of movement case, in which the to have involved

AND LATERAL DISPLACEMENT OF RADIAL HEAD To illustrate the mechanism

9
of this injury and the

the joint.
SUMMARY

Monteggia

injury.

1.

Five

cases

of greenstick joint the end

fracture

of

the

upper

end

of the

ulna

with

dislocation

of

the

radio-humeral Although of the upper

2.

are described. direction of angulation of the fracture and the of the radius may be lateral, medial or anterior,
in which a fall on the the mechanism outstretched ofinjury hand is essentially with the forearm

corresponding it is suggested
the same. held This

displacement that all five

mechanism

cases

form

a group to be

is considered
3.

in supination.

The

complications
I should like

of the

injury
Mr

are
W. A.

described.
Watt Maney for permission to include Case 5.

to thank

REFERENCES
BEDDOW,

F. E. A. M.

H.,

and

CORKERY,

P. H.

Fracture
EVANS,

of the Upper
(1949):

End

(1960): of the Ulna.

Injuries of the

Lateral
Journal Forearm.

Dislocation
of Bone and Journal

of the Radio-humeral
Joint ofBone Surgery, andJoint 42-B,

Joint
782. Surgerv,

with
31-B,

Greenstick
578.

Pronation

HUME,

C. (1957): of the Olecranon

45 B,
NO.

Anterior Dislocation in Children. Journal

NOVEMBER

of the Head
of Bone and

of the
Joint

Radius
Surgery,

Associated 39-B, 508.

with

Undisplaced

Fracture

VOL.

4,

1963