Chapter 33: Diaphyseal Fractures of the Radius and Ulna

Philipp N. Streubel, Rodrigo F. Pesántez

Chapter Outline

Introduction to Diaphyseal Fractures of the Radius and Ulna

The forearm plays an important role in positioning of the hand in space by flexion and extension of the elbow and wrist as well as pronation and supination through the proximal and distal radioulnar joints. Fractures of the ulnar and radial shaft can therefore result in significant dysfunction if treated inadequately. 
This chapter will address fractures of the ulnar and radial shaft, including Galeazzi and Monteggia fracture dislocations. Radial shaft fractures are defined as those occurring between the radial neck proximally and the junction of the metaphysis and diaphysis distally, approximately 3 cm proximal to the distal articular surface. Ulnar shaft fractures are defined as those occurring between the distal aspect of the coronoid proximally and the ulnar neck distally. 

Epidemiology of Diaphyseal Fractures of the Radius and Ulna

Forearm shaft fractures are often referred to as being frequent fractures. However, only limited data on the epidemiology of these fractures have been reported in the literature. Several epidemiologic studies on forearm fractures include fracture occurring along the whole extent of the ulna and radius. Distal radius fractures are known as one of the most frequent fractures of the upper extremity and hence account for the vast majority of fractures occurring in the forearm.14,28,131,162 Diaphyseal forearm fractures on the contrary have been reported to be 10 times less frequent than distal radius fractures.90 
The incidence of distal radius fractures has increased over the past decades. However, the frequency of forearm shaft fractures appears to be stable over time.14 The average yearly incidence in adults has been reported to be 1.35 per 10,000 population, ranging from 0 to 4 per 10,000 population depending on age and gender. This is relatively infrequent compared to that of humerus shaft (0 to 10), femur (0 to 37), and tibia (0 to 21).176 Four-fifths of forearm shaft fractures occur in children. Above the age of 20, the yearly incidence of forearm shaft fractures remains below 2 per 10,000 people, predominating in males throughout all age groups.3,14 
Clinical studies on forearm fractures, without exception, show that forearm fractures predominantly occur in male patients. The proportion of males ranges from 63% to 91%.13,27,48,60,71,73,108,109 The mean age ranges from 24 to 37 years, and the vast majority of forearm fractures occur during the first four decades of life.13,27,32,36,48,49,60,64,71,73,74,108,109,113,119,135,156,163,166,179 Over half of all forearm shaft fractures occur in males within the ages of 15 and 39 years. This age group accounts for 80% of forearm fractures in males. As for femur and tibia shaft fractures, forearm shaft fractures have the highest incidence in males aged 15 to 40 years. In females, a lower incidence of forearm shaft fractures can be observed throughout life. A peak incidence has been reported in the seventh decade of life.28,176 The distribution of forearm fractures is type B (see Chapter 3). 
Among US high school athletes the incidence of forearm fractures is 4 per 10,000 athlete exposures, defined as one athlete participating in one practice or competition. The incidence is highest in male football and female soccer players at 6 per 10,000 athlete exposures and lowest for volleyball at 1 per 10,000 athlete exposures.183 
Motor vehicle accidents account for an important fraction of forearm shaft fractures. It is estimated that 4% of restrained front seat passengers involved in a motor vehicle collision suffer a fracture of the upper extremity. In this setting, forearm fractures account for one quarter of upper extremity fractures, a fraction that is equal to that of wrist and hand fractures.149 
Monteggia fractures account for 13% and Galeazzi fractures for 23% of forearm fractures.27 

Assessment of Diaphyseal Fractures of the Radius and Ulna

Mechanism of Injury of Diaphyseal Fractures of the Radius and Ulna

The vast majority of forearm shaft fractures occur in young males with good bone stock. Injuries therefore most frequently occur in the setting of high-energy trauma such as motor vehicle accidents or sports injuries.20,39,52,105,109,120,146 
The force applied by trauma can be applied either directly or indirectly onto the diaphysis of the radius and/or ulna. Direct injury frequently results from gunshot injuries or from blunt injury to the forearm. In both instances, injury to the soft tissues can be substantial (Figs. 33-1 and 33-2). Isolated ulnar shaft fractures almost invariably occur as a consequence of direct injury to the ulnar shaft as the arm is raised to protect the body from a blow,170 hence the descriptive term “night stick fractures” (Fig. 33-3). In this instance, given the subcutaneous location of the ulnar shaft, fractures may occur with only minor energy and exhibit a less significant soft tissue injury. However, the thinner overlying soft tissue envelope makes these fractures more prone to being open, especially when severely displaced. 
Figure 33-1
 
A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
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A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
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Figure 33-1
A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
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A and B: Segmental both-bone forearm fracture. Severe fracture of the forearm after direct blunt trauma with marked soft tissue injury. Note the widening of the interosseous space between the intermediate fracture segments suggesting concomitant longitudinal interosseous membrane disruption. C–F: Intraoperative fluoroscopic images. Initial fixation of the radius was performed because of a more simple fracture pattern. Two separate 2.7-mm plates were used for each fracture and augmented with a long 3.5-mm plate. A single 16-hole 3.5-mm plate was used for fixation of the ulna. G and H: Follow-up images 6 weeks after surgery.
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Figure 33-2
 
A and B: Gunshot fracture of the radial shaft. Note the marked comminution at the midproximal radial shaft. A paper clip marks the entry site with the fragmented projectile lodged in the soft tissues. C and D: Postoperative radiographs 2 weeks after fracture fixation with a bridging plate.
A and B: Gunshot fracture of the radial shaft. Note the marked comminution at the midproximal radial shaft. A paper clip marks the entry site with the fragmented projectile lodged in the soft tissues. C and D: Postoperative radiographs 2 weeks after fracture fixation with a bridging plate.
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Figure 33-2
A and B: Gunshot fracture of the radial shaft. Note the marked comminution at the midproximal radial shaft. A paper clip marks the entry site with the fragmented projectile lodged in the soft tissues. C and D: Postoperative radiographs 2 weeks after fracture fixation with a bridging plate.
A and B: Gunshot fracture of the radial shaft. Note the marked comminution at the midproximal radial shaft. A paper clip marks the entry site with the fragmented projectile lodged in the soft tissues. C and D: Postoperative radiographs 2 weeks after fracture fixation with a bridging plate.
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Figure 33-3
 
A and B: Nightstick fracture. Minimally displaced isolated ulna shaft fracture. Treatment consisted of a short arm brace for 6 weeks leading to uneventful healing.
A and B: Nightstick fracture. Minimally displaced isolated ulna shaft fracture. Treatment consisted of a short arm brace for 6 weeks leading to uneventful healing.
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Figure 33-3
A and B: Nightstick fracture. Minimally displaced isolated ulna shaft fracture. Treatment consisted of a short arm brace for 6 weeks leading to uneventful healing.
A and B: Nightstick fracture. Minimally displaced isolated ulna shaft fracture. Treatment consisted of a short arm brace for 6 weeks leading to uneventful healing.
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Indirect trauma on the other hand occurs either as bending or torsional forces. Bending forces can result in both-bone forearm fractures that are located at similar segments along the diaphysis of the ulna and radius (Fig. 33-4). In addition, bending forces can result in Monteggia fracture dislocation, in which the proximal ulna is fractured and the radiocapitellar and proximal radioulnar joints (PRUJs) dislocate in the direction of the ulnar deformity (Figs. 33-5, 33-9 and 33-12). Torsional forces with axial loading, such as those occurring during a fall with a hyperpronated forearm and wrist extension, can lead to both-bone forearm fractures at different levels or to Galeazzi fractures (Figs. 33-6 and 33-7). With this mechanism a fracture is generated through the radial shaft and progresses distally rupturing the interosseous membrane and finally injuring the triangular fibrocartilage complex (TFCC), thereby rendering the distal radioulnar joint unstable.6,8,57,120 Whereas hyperpronation of the wrist is considered to generate Monteggia fractures with anterior dislocation of the radial head, Monteggia fractures with a posterior radial head dislocation are believed to occur as a consequence of a hypersupination injury and a fall onto the outstretched hand.57 
Figure 33-4
 
A and B: Both-bone forearm fracture. Note that both displaced fractures occurred at the same level of the ulna and radius. A nondisplaced fracture of the distal ulnar shaft is present. C and D: Postoperative radiographs after open reduction and internal fixation. Compression at the fracture site was achieved with dynamic plating.
A and B: Both-bone forearm fracture. Note that both displaced fractures occurred at the same level of the ulna and radius. A nondisplaced fracture of the distal ulnar shaft is present. C and D: Postoperative radiographs after open reduction and internal fixation. Compression at the fracture site was achieved with dynamic plating.
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Figure 33-4
A and B: Both-bone forearm fracture. Note that both displaced fractures occurred at the same level of the ulna and radius. A nondisplaced fracture of the distal ulnar shaft is present. C and D: Postoperative radiographs after open reduction and internal fixation. Compression at the fracture site was achieved with dynamic plating.
A and B: Both-bone forearm fracture. Note that both displaced fractures occurred at the same level of the ulna and radius. A nondisplaced fracture of the distal ulnar shaft is present. C and D: Postoperative radiographs after open reduction and internal fixation. Compression at the fracture site was achieved with dynamic plating.
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Figure 33-5
 
A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
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A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
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Figure 33-5
A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
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A: Monteggia fracture dislocation. Note an apex anterior deformity of the ulnar shaft with anterior dislocation of the radial head. B: This patient had a concomitant humerus shaft fracture. C and D: Postoperative radiographs after open reduction internal fixation of both the ulna and humerus. Reduction of the radiocapitellar and proximal radioulnar joint was achieved with reduction of the ulnar fracture.
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Figure 33-6
 
A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
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A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
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Figure 33-6
A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
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A and B: Both-bone forearm fracture. The mechanism of injury of this fracture was likely torsional in nature, leading to fracture of the shafts of both the ulna and radius at different levels. A concomitant radial styloid fracture is present. C, D and E: Intraoperative fluoroscopic images. Fixation of the radius and ulna was achieved with 3.5-mm plates and screws. Alternatively, a lag screw could have been placed through the oblique fracture of the radius. The radial styloid was fixed with a headless compression screw. F and G: Postoperative radiographs.
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Figure 33-7
 
A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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Figure 33-7
A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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A–D: Galeazzi fracture dislocation. Note a displaced fracture of the distal radial shaft with pronounced shortening of the radius and an avulsion fracture of the ulnar styloid. E–H: Intraoperative fluoroscopic images showing fracture reduction onto the plate held by lobster clamps. Fixation is achieved with dynamic plate compression and a total of six cortices being engaged by screws on each side of the fracture. I–L: Postoperative radiographs 2 weeks after surgery. M and N: Radiographs at 3 months after surgery showing a healed fracture.
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Signs and Symptoms of Diaphyseal Fractures of the Radius and Ulna

With a fracture of the forearm there will be a history of a lower-energy injury such as a fall on to the outstretched hand or direct blow or of a higher-energy injury such as a fall from a height or a road traffic accident. The patient will complain of pain and swelling in the forearm and where there is displacement may also complain of a visible deformity. Neurologic injury should be suspected if there are neurologic symptoms. A history of distant pain suggests an associated injury in the ipsilateral limb or elsewhere. 
On examination there will be swelling in the forearm and deformity in cases with displacement. The skin should be inspected to rule out any open wounds, which most commonly occur on the ulnar side. In the absence of neurologic injury, tenderness at the area of the fracture is invariable in the conscious patient and is useful in raising clinical suspicion in the undisplaced fracture without deformity. A thorough neurologic examination should be performed to exclude peripheral nerve injury. The examiner should remember to look for the symptoms and signs of acute compartment syndrome which may occur after forearm fractures (see Chapter 29). 

Associated Injuries with Diaphyseal Fractures of the Radius and Ulna

Approximately one-third of forearm shaft fractures treated surgically occur as isolated injuries.27 The remaining fractures occur in the presence of at least one additional injury. Associated injuries can be grouped into those occurring adjacent to the forearm shaft fracture, those occurring in other sites of the musculoskeletal system, and those affecting other organ systems. Injuries occurring locally surrounding the diaphyses of the radius and ulna range from minor contusion of the soft tissue sleeve in isolated minimally displaced ulna (nightstick) fractures to marked soft tissue injury in both-bone fractures and fracture dislocations. With increasing energy, a greater extent of fracture comminution and displacement is seen, which in turn increases the risk of injury to the surrounding muscles. Direct trauma to the forearm causes blunt injury to the soft tissue sleeve, while fracture displacement will lead to laceration of the soft tissues by the sharp edges of the fracture and may injure the interosseous membrane, muscles, neurovascular structures, and skin. Rupture of the interosseous membrane occurs along the path connecting both shaft fractures in both-bone forearm fractures or the fracture and associated, either proximal or distal, radioulnar joint disruption in fracture dislocations. Monteggia fractures exhibit disruption of the interosseous membrane from the fracture site at the proximal half of the ulnar shaft to the PRUJ. The radial head dislocates in the direction of the deformity of the apex of the ulnar fracture, thereby disrupting the annular ligament. Occasionally, the radial head may buttonhole through the joint capsule, displacing but leaving the annular ligament intact.145 Galeazzi fracture dislocations most frequently present with a fracture of the distal half of the radius with an associated dislocation of the DRUJ. In this setting, disruption of the interosseous membrane occurs from the fracture site to the distal radioulnar joint. Associated injury of the TFCC usually occurs, occasionally leading to further disruption of the fifth and sixth extensor compartments of the wrist. Ring et al.155 established that in the setting of isolated radial shaft fractures, an associated distal radioulnar joint injury is present in 10 out of 36 cases. 
Although the exact incidence of elbow dislocations in the setting of both-bone forearm fractures is not known, this constellation has been reported in several case reports37,83,99,144 (Fig. 33-8). Similarly, radial head fractures may present at the same time as diaphyseal forearm fractures.52 
Figure 33-8
 
A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
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A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
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Figure 33-8
A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
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A–D: Both-bone forearm fracture with associated posterior elbow dislocation. E–H: After initial closed reduction of the elbow, open reduction internal fixation was performed. At 3 months after surgery fracture healing was observed. Ossification of the medial collateral ligament of the elbow could be seen radiographically, without limiting the patient’s range of motion.
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The frequency of open fractures ranges from less than 10% in isolated radial shaft fractures to 43% of fractures affecting both forearm bones.20,27,39,52,65,104,105,109,155 Open fractures most frequently are type I according to the Gustilo classification.61 They occur as a skin disruption from within, in which the sharp fracture edges pierce through the skin in an inside-out fashion. Displaced ulnar shaft fractures are at particular risk of being open given the subcutaneous location of this bone. Crush injuries and high-velocity gunshot wounds account for type III open fractures and are frequently accompanied by marked contamination, severe disruption of the muscular envelope, and injury to the neurovascular structures.89,107 
Whereas some regional variation is reported in the literature,108 around one-half of forearm shaft fractures occur in the setting of multisystem trauma.20,27 Associated injuries most frequently affect either the upper or lower extremities. Upper extremity injuries occur in up to 26% of forearm fractures and include humeral shaft fractures, proximal humerus fractures, elbow dislocation (Fig. 33-8), wrist injuries39,105,155 (Fig. 33-6), glenoid fractures,59 and contralateral forearm fractures.27,52,191 Distal biceps ruptures have been reported85 as well as traumatic rotator cuff tears.59 
Concomitant lower extremity fractures may occur, often affecting the tibial plateau, fibula, patella, femur,20,59 tibia and ankle,105 pelvis, and acetabulum.39 
The most frequent nonskeletal injury is closed head injury20,27,105,155 and peripheral neurologic injuries. In one series on forearm fractures, closed head injuries occurred in one quarter of patients.27 Forearm fractures can occur in the presence of injuries to the brachial plexus and radial, posterior interosseous, ulnar, and median nerves.20,105,154 Radial nerve injuries may occur either as a transection of the nerve from the forearm shaft fracture or as a consequence of an ipsilateral humerus shaft fracture.107 Neurologic injury has been reported in 38% of forearm fractures caused by low-velocity gunshot wounds. Of these, 43% resulted in permanent nerve palsy. Ulnar artery disruption was reported in only 3% of these cases.106 
Forearm fracture may occur in patients with abdominal and pelvic trauma with associated aortic transection, kidney laceration, and pelvic fractures.59,109 Goldfarb et al.59 reported 1 out of 23 patients included in a clinical study on both-bone forearm fractures who had suffered an aortic dissection and kidney laceration after a motor vehicle accident. 

Imaging and Other Diagnostic Studies for Diaphyseal Fractures of the Radius and Ulna

Forearm fractures are routinely diagnosed with posteroanterior (PA) and lateral radiographs of the forearm. These images should show the forearm from the elbow to the wrist. A standard PA view of the forearm is taken with the elbow in 90 degrees of flexion, the shoulder abducted, and the forearm in neutral rotation. A standard lateral radiograph is taken with the elbow flexed to 90 degrees and the forearm in neutral rotation (Fig. 33-9). This allows for two views that are orthogonal to each other. In some instances, additional oblique views may be helpful in case overlap of the ulna and radius on the lateral view do not clearly allow detailed fracture assessment. 
Figure 33-9
 
A–D: Monteggia fracture dislocation. E and F: Fixation was performed using two lag screws through the oblique fracture of the ulna and a neutralization plate. Secondary reduction of the radiocapitellar and proximal radioulnar joint was achieved.
A–D: Monteggia fracture dislocation. E and F: Fixation was performed using two lag screws through the oblique fracture of the ulna and a neutralization plate. Secondary reduction of the radiocapitellar and proximal radioulnar joint was achieved.
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Figure 33-9
A–D: Monteggia fracture dislocation. E and F: Fixation was performed using two lag screws through the oblique fracture of the ulna and a neutralization plate. Secondary reduction of the radiocapitellar and proximal radioulnar joint was achieved.
A–D: Monteggia fracture dislocation. E and F: Fixation was performed using two lag screws through the oblique fracture of the ulna and a neutralization plate. Secondary reduction of the radiocapitellar and proximal radioulnar joint was achieved.
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The position of the bicipital tuberosity of the proximal radius can aid in assessing the amount of pronation or supination of the proximal fragment. The tuberosity view is taken with the elbow bent 90 degrees, the lateral and medial epicondyles equidistant from the plate, and the x-ray tube angulated 20 degrees posteriorly from the normal AP trajectory. Depending on the morphology of the biceps tuberosity on this view the amount of pronation or supination of the proximal radius can be determined with the help of a reference image, so that distal segment rotational alignment can be adjusted.46 
Dedicated radiographs of the elbow and wrist are also recommended to rule out associated injuries to these joints187 (Figs. 33-7C, D and 33-8C, D). This is of special importance in isolated fractures of the ulna or radius to rule out Monteggia and Galeazzi fracture dislocations, respectively. However, even in both-bone forearm fractures, dislocation of the DRUJ, PRUJ, and elbow may occur. Unrecognized fractures of the proximal and distal ends of the ulna and radius, as well as injuries to the carpus and distal humerus may also be identified. AP and lateral elbow radiographs are required to demonstrate alignment of the axis of the radial neck and the humeral capitellum, which will confirm reduction of the PRUJ. PA and lateral wrist radiographs should show the ulnar head located within the sigmoid notch of the radius. Ulnar variance (see Chapter 32) should be quantified for objective assessment of the DRUJ. Dorsal displacement of the distal ulna and a change in ulnar variance of more than 5 mm suggests an injury to the DRUJ.155 This is supported by biomechanical data that has shown all stabilizers of the DRUJ to be ruptured with 5 mm of ulnar positive variance.126 Because of the variability of ulnar variance, contralateral wrist radiographs can be useful to determine the patient’s normal anatomy. Additional radiographic signs for disruption of the DRUJ are fracture of the base of the styloid, widening of the DRUJ on the PA view, and dislocation of the ulna seen on the lateral view57,125 (Fig. 33-7). 
Computed tomography and magnetic resonance imaging are rarely required for the assessment of acute forearm fractures. Computed tomography is useful in confirming the radiographic and clinical suspicion of a nonunion. Furthermore, it can be useful in the presence of rotational fracture malunions and instability at the DRUJ16 (Fig. 33-10). Magnetic resonance imaging can be used to diagnose injuries to the DRUJ and associated TFCC as well as to delineate disruption of the interosseous membrane.189 Ultrasound has been described to assess the integrity of the interosseous membrane.47,189 
There is little contact remaining between the dorsal articular surface of the distal ulna and the volar lip of the distal radial articular surface.
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Figure 33-10
Computed axial tomogram showing volar subluxation of the right distal radioulnar joint (arrow) and volar translation of the distal ulna in relation to the radius because of incomplete reduction of a fracture of the distal radial diaphysis.
There is little contact remaining between the dorsal articular surface of the distal ulna and the volar lip of the distal radial articular surface.
There is little contact remaining between the dorsal articular surface of the distal ulna and the volar lip of the distal radial articular surface.
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Classification of Diaphyseal Fractures of the Radius and Ulna

As in most extremities, fractures of the forearm are described according to their location, pattern, displacement, and associated soft tissue disruption. From a therapeutic perspective, the following are answered when assessing a fracture of the forearm. 
  1.  
    What bone(s) is (are) fractured?
  2.  
    In what location is the fracture (proximal, middle, distal third)
  3.  
    What is the fracture pattern (simple transverse, simple oblique, comminuted)?
  4.  
    Is there instability at the distal or proximal radioulnar joint?
  5.  
    Is the fracture open or closed?
  6.  
    Is a previous implant present?
  7.  
    Is a previous deformity present?
  8.  
    Is the bone stock normal?
No single classification takes into account all the above variables. In most instances forearm shaft fractures are classified according to location (proximal, middle, and distal third) or fracture comminution.27,114 Open fractures are classified according to Gustilo’s classification,61,62 whereas Monteggia and Galeazzi fractures have their own subclassifications.9,92,146 
The AO/OTA classification is the most widely used fracture classification of fractures of the forearm. Since forearm fractures affect the diaphysis of the forearm they are identified by the number 22 (2 for forearm, 2 for shaft).114 Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. Type A and B fractures involve either the ulna (type A1, B1), the radius (type A2, B2), or both bones (type A3, B3). Type C fractures involve both bones, with a simple fracture of the radius and segmental comminution of the ulna in type C1, a simple fracture of the ulna and segmental comminution of the radius in type C2, and segmental comminution of both bones in type C3. Monteggia fractures are classified as type A1.3 and B1.3, depending on whether the ulnar fracture is simple (A1.3) or wedged (B1.3). Furthermore, Monteggia fracture dislocations in which both the radius and ulna are fractured are classified as type A3.2 or B3.2. Conversely, Galeazzi fracture dislocations are classified as type A2.3 and B2.3 depending on whether the radial fracture is simple (A2.3) or wedged (B2.3). Galeazzi fracture dislocations in which both the radius and ulna are fractured are classified as type A3.3 or B3.3.114 Although the AO/OTA system has been widely adopted as the universal classification system for fractures, its utility in the management of forearm fractures is restricted mainly to research purposes because of the complexity of its nomenclature and low reliability88,128 (Fig. 33-11). 
Figure 33-11
Shaft fractures of the forearm according to the unified AO/OTA classification.
 
Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Figure 33-11
Shaft fractures of the forearm according to the unified AO/OTA classification.
Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Forearm shaft fractures are identified by the number 22 (2 for forearm, 2 for shaft). Type A fractures are simple fractures, type B are wedge fractures, and type C are complex (highly comminuted or segmental) fractures. See text for further detail. (From Marsh JL, Slongo TF, Agel J, et al. Fracture and dislocation classification compendium—2007: Orthopaedic Trauma Association classification, database and outcomes committee. J Orthop Trauma. 2007;21(10 Suppl):S1–S133.)
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Isolated ulna fractures are classified as stable or unstable. Stable fracture are those with less than 50% of displacement and less than 10 degrees of angulation.42 This simple classification method has been widely accepted for decision making between operative and nonoperative management of these isolated fractures.22,132,134,167,169,170,194 

Monteggia Fracture-Dislocation

Monteggia fracture-dislocations (or lesions) consist of a proximal radial dislocation and a fracture of the ulna.9 They are classified according to Bado9 based on the direction of the apex of the ulnar fracture and the direction of the proximal radial dislocation (Fig. 33-12): 
Figure 33-12
Bado’s classification of Monteggia fractures.
 
Type I: An anterior dislocation of the radial head with associated anteriorly angulated fracture of the ulna shaft. Type II: Posterior dislocation of the radial head with a posteriorly angulated fracture of the ulna. Type III: A lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with a fracture of the radius and ulna.
Type I: An anterior dislocation of the radial head with associated anteriorly angulated fracture of the ulna shaft. Type II: Posterior dislocation of the radial head with a posteriorly angulated fracture of the ulna. Type III: A lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with a fracture of the radius and ulna.
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Figure 33-12
Bado’s classification of Monteggia fractures.
Type I: An anterior dislocation of the radial head with associated anteriorly angulated fracture of the ulna shaft. Type II: Posterior dislocation of the radial head with a posteriorly angulated fracture of the ulna. Type III: A lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with a fracture of the radius and ulna.
Type I: An anterior dislocation of the radial head with associated anteriorly angulated fracture of the ulna shaft. Type II: Posterior dislocation of the radial head with a posteriorly angulated fracture of the ulna. Type III: A lateral or anterolateral dislocation of the radial head with a fracture of the ulnar metaphysis. Type IV: Anterior dislocation of the radial head with a fracture of the radius and ulna.
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Type 1: Anterior dislocation of the radial head, fracture of the ulnar diaphysis at any level with anterior angulation. 
Type 2: Posterior or posterolateral dislocation of the radial head, fracture of the ulnar diaphysis with apex posterior angulation. 
Type 3: Lateral or anterolateral dislocation of the radial head, fracture of the ulnar metaphysis. This occurs almost exclusively in children,9 but isolated cases in adults have been described.24 
Type 4: Anterior dislocation of the radial head with a fracture of the proximal third of the ulna and fracture of the radius at the same level. These occur exclusively in adult patients.9 
Several fracture “equivalents” have been described in the literature, affecting either the proximal ulna and radius and are hence beyond the scope of this chapter.9 
Understanding the deformity of the ulna and the direction of dislocation of the radial head is important for fracture reduction. In most instances, reduction of the ulnar fracture leads to reduction of the radial head. Whereas type 1 fractures are considered the most frequent type in children,152 type 2 account for up to 80% of Monteggia fracture dislocations in adults.139,140,151 Importantly, type 2 Monteggia fractures are frequently associated with radial head or coronoid fractures, therefore representing a more complex injury, potentially affecting elbow stability.151 Jupiter et al. noted that although the most frequent site of ulnar fracture in type 2 Monteggia fractures is at the proximal shaft, it may occur at the proximal epiphysis or metaphysis. Type 2 Monteggia fractures were therefore further subclassified into four different patterns as follows.92 
2A: Very proximal ulna fracture through the coronoid 
2B: Fracture at the junction of the proximal metaphysis and diaphysis of the ulna 
2C: Diaphyseal ulnar fracture 
2D: Complex fracture involving the ulna from the olecranon into the diaphysis 

Galeazzi Fractures

Galeazzi fractures consist of a fracture of the radial shaft with dislocation of the distal radioulnar joint. They are subclassified according to the distance of the radial fracture from the articular surface. Type 1 fractures occur within 7.5 cm of the articular surface of the distal radius and type 2 more proximally. The relevance of this classification lies in that type 1 are associated with a significantly higher rate of instability of the DRUJ, frequently requiring open repair of this joint.146 DRUJ dislocations associated with Galeazzi fractures can additionally be classified as simple or complex. Simple dislocations readily reduce after radial alignment has been restored, whereas complex dislocations are those in which the DRUJ is irreducible after anatomic reduction of the radial shaft fracture.23 Interposition of the extensor carpi ulnaris (ECU) or extensor digiti minimi (EDM) between the distal radius and ulna have been described as causes for DRUJ irreducibility.2,26,124,146,182 

Open Fractures

As for other bones, open forearm fractures are classified according to Gustilo.61,62 Type 1 fractures are those with a laceration of less than 1 cm and a clean wound. These are most frequently caused by an inside-out mechanism in which the displaced forearm shaft fracture pierces through the skin. Minimal comminution is usually present. Low-velocity gunshot wounds are an additional mechanism of injury for this fracture type. Type 2 fractures have a laceration of more than 1 cm, with minimal contamination. These are usually caused in an outside-in fashion.62 Type 3 fractures are open segmental fractures or those that involve skin disruption of more than 10 cm. They are further subclassified into 3A (fractures in which sufficient and adequate soft tissue envelope is present to allow bony coverage), 3B (fractures in which soft tissue loss has occurred that requires some type of soft tissue reconstructive procedure to allow bony coverage), and 3C (fractures with associated vascular injury that places at risk distal perfusion, thereby requiring vascular repair). In forearm fractures type 3C fractures by definition have disruption of flow through both the radial and ulnar arteries. 

Outcome Measures for Diaphyseal Fractures of the Radius and Ulna

Results after forearm fractures are assessed mainly based on complications, pain, range of motion, and radiographic alignment and evidence of healing.4,6,7,9,10,19,20,27,32,36,39,57,64,69 In addition, grip and pinch strength dynamometry, as well as range of motion in elbow and wrist flexion extension and forearm pronation supination are recorded.171 
Fracture healing is determined as fracture bridging seen on at least three out of four cortices on AP and lateral radiographs. Anderson et al.4 classified fractures healing within 6 months of surgery as unions, those healing after 6 months without additional intervention as delayed unions, and those that failed to heal after 6 months or required additional unplanned surgical intervention to achieve healing as nonunions. 
Infection is frequently subdivided into superficial, deep, and osteomyelitis. Superficial infections involve the skin and subcutaneous tissue, whereas deep infections are present below the fascia involving the fracture site and the implant.27 Infection is most frequently defined based on clinical signs of local infection, including erythema, hyperthermia, edema, and drainage. Furthermore, laboratory values including elevated erythrocyte sedimentation rate (ESR), C-reactive protein (CRP), leukocytosis, and positive cultures are used to confirm the clinical suspicion. Osteomyelitis is defined as infections that yield positive bone cultures after surgical intervention.27 
Anderson et al. devised an outcome scale by which results were based on final range of motion. An excellent rating was given to patients with less than 10 degrees loss of flexion–extension and less than 25 percent loss of pronation–supination. Patients with a satisfactory result achieved union with less than 20 degrees loss of flexion–extension and less than 50% loss of pronation–supination. Unsatisfactory results were those with union with more than 30 degrees loss of flexion–extension and greater than 50 percent loss of pronation–supination. A failure of treatment is determined by nonunion with or without loss of motion.4,20 Grace and Eversmann devised a similar outcomes tool in which an excellent result was given to a healed fracture with at least 90% of normal rotation determined by the uninjured contralateral side. A good result is defined as a healed fracture with 80 to 89% of normal rotation. An acceptable result is a healed fracture and 60 to 79% of normal rotation. Finally, an unacceptable result is defined as nonunions or fractures with less than 60% of normal forearm rotation. In the absence of an uninjured and normal contralateral side, normal pronation supination is considered to be 80-0-80.60 
More recently, clinical studies on forearm fractures have included the use of a patient-specific outcomes measure, the Disability of the Arm, Shoulder and Hand (DASH) questionnaire.20,39,52,71,191 Whereas this scale has not been validated specifically for forearm fractures, it has been widely validated for several conditions of the upper extremity and has been formally translated and validated in several languages. The DASH is a standardized questionnaire that assesses upper extremity function based on pain symptoms and physical, emotional, and social domains. It contains 30 questions, including 21 on physical function, 6 on symptoms, and 3 evaluating social function. Each question is answered with one of five possible multiple choice answers. A high DASH score indicates more severe disability.81 

Pathoanatomy and Applied Anatomy Relating to Diaphyseal Fractures of the Radius and Ulna

The anatomy of the forearm is complex and requires a detailed understanding to avoid neurovascular injury during surgical treatment. 

Osseous Plane

The osseous component of the forearm separates the anterior from the posterior aspect and is composed of the radius, ulna, and interosseous membrane (Fig. 33-13). 
Figure 33-13
Line diagram showing the soft tissue connections of the radius and the ulna to each other.
 
The proximal radioulnar joint is stabilized by the annular ligament. The distal radioulnar joint is stabilized by the dorsal and volar radioulnar ligaments and the triangular fibrocartilage complex. (From Richards RR. Chronic disorders of the forearm. J Bone Joint Surg. 1996;78:916–930.)
The proximal radioulnar joint is stabilized by the annular ligament. The distal radioulnar joint is stabilized by the dorsal and volar radioulnar ligaments and the triangular fibrocartilage complex. (From Richards RR. Chronic disorders of the forearm. J Bone Joint Surg. 1996;78:916–930.)
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Figure 33-13
Line diagram showing the soft tissue connections of the radius and the ulna to each other.
The proximal radioulnar joint is stabilized by the annular ligament. The distal radioulnar joint is stabilized by the dorsal and volar radioulnar ligaments and the triangular fibrocartilage complex. (From Richards RR. Chronic disorders of the forearm. J Bone Joint Surg. 1996;78:916–930.)
The proximal radioulnar joint is stabilized by the annular ligament. The distal radioulnar joint is stabilized by the dorsal and volar radioulnar ligaments and the triangular fibrocartilage complex. (From Richards RR. Chronic disorders of the forearm. J Bone Joint Surg. 1996;78:916–930.)
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Radius

The adult radius measures on average 25 cm in length (range 21 to 29 cm). At the junction of the proximal and middle third, the radius measures on average 13 mm in the AP dimension and 16 mm in the medial–lateral dimension. At the junction of the middle and distal thirds, the diameter of the radius is 12 mm in the AP dimension and 15 mm in the medial–lateral dimension. The proximal radius comprises the radial head, neck, and biceps tuberosity. The radial head articulates with the radial notch (lesser sigmoid notch) of the proximal ulna. The shaft of the radius extends distal to the biceps tuberosity. It is located on the lateral aspect of the forearm in supination and dorsally in pronation. It has a prismatic triangular shape that broadens from proximal to distal. It has two curvatures, one medial, the major radial bow, and one lesser anterior curvature. Distally, the radius broadens to articulate with the carpus. Medially, the distal radius articulates with the ulnar head through the sigmoid notch. 
The major radial bow extends from the bicipital tuberosity to the ulnar aspect of the articular surface of the distal radius. Schemitsch and Richards studied the importance of restoring the major radial bow after operative fixation of forearm fractures. The maximum radial bow on the uninjured side was found to be located on average at 60% of the distance between the biceps tuberosity and ulnar side of the distal articular surface. At this point, the maximum distance from the line connecting the biceps tuberosity and the ulnar aspect of the distal articular surface to the medial aspect of the radial shaft was on an average 15.3 mm. A higher deviation from this distance after operative fixation was related to a reduction in the normal range of rotation.171 
The nutrient artery to the radius enters the shaft on the volar aspect at an average of 9 cm distal to the radial head (range 6 to 12 cm). Proximal and distal cancellous bone in the metaphyses of the radius extends on an average 4 cm distal to the proximal articular surface and 5 cm proximal to the distal articular surface, respectively. The isthmus of the radial endomedullary canal is located in over 90% of cases at the midpoint of the radius.161 

Ulna

The ulna acts as the axis around which the radius rotates during pronation–supination110 (Fig. 33-14). Effectively, the axis of rotation of the radius is located on the line connecting the center of the radial head and the head of the ulna. The proximal ulna comprises the olecranon and coronoid that form the trochlear notch (greater sigmoid notch) that articulates with the distal humerus. The radial notch (lesser sigmoid notch) is located on the lateral aspect of the proximal ulna, just distal to the trochlear notch. This concavity serves as the articulating surface for the radial head and as the insertion both anteriorly and posteriorly for the annular ligament. 
Figure 33-14
During pronosupination, the radius rotates about the ulna (arrow).
 
The complex curvature of the radius and ulna allows approximately 150 degrees of rotation. (From Lindscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46–55.)
The complex curvature of the radius and ulna allows approximately 150 degrees of rotation. (From Lindscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46–55.)
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Figure 33-14
During pronosupination, the radius rotates about the ulna (arrow).
The complex curvature of the radius and ulna allows approximately 150 degrees of rotation. (From Lindscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46–55.)
The complex curvature of the radius and ulna allows approximately 150 degrees of rotation. (From Lindscheid RL. Biomechanics of the distal radioulnar joint. Clin Orthop Relat Res. 1992;275:46–55.)
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The ulnar shaft is located on the medial aspect of the forearm, with a minimal anterior concavity. It has a broader prismatic shape proximally, becoming rounded and thinner distally. Posteriorly, the ulna has a clearly defined ridge proximally that separates the insertion of the flexor carpi ulnaris (FCU) medially and anteriorly and ECU laterally and posteriorly. 
Before reaching the wrist, the ulnar shaft broadens again to form the head and styloid process. Distally and laterally, the ulnar head articulates with the sigmoid notch of the radius. Distally, the ulna serves as an insertion point for the TFCC. 

Interosseous Space

The ulna and radius create a space between their proximal and distal articulations that is somewhat oval in shape. The greatest distance between the two bones is seen in full supination. The space is occupied mainly by the interosseous membrane that establishes a distinct barrier between the anterior and posterior compartments. The interosseous membrane has a marked thickening with fibers running obliquely from proximal radial to distal ulnar known as the interosseous ligament or central band of the interosseous membrane. This structure is 3.5 cm wide and its fibers are oriented in an oblique fashion, approximately 20 degrees to the axis of the forearm.130 In the presence of a radius fracture, it acts as a constraint against radial shortening.172 Hotchkiss et al.79 determined that the central band is responsible for 71% of the longitudinal stiffness of the interosseous membrane after radial head resection (Fig. 33-15). 
Figure 33-15
Backlit photograph of a forearm specimen.
 
The central band of the interosseous membrane is indicated by arrows. (From Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am. 1989;14:256–261.)
The central band of the interosseous membrane is indicated by arrows. (From Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am. 1989;14:256–261.)
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Figure 33-15
Backlit photograph of a forearm specimen.
The central band of the interosseous membrane is indicated by arrows. (From Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am. 1989;14:256–261.)
The central band of the interosseous membrane is indicated by arrows. (From Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg Am. 1989;14:256–261.)
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Triangular Fibrocartilage Complex (TFCC)

The TFCC serves as the medial continuation of the distal articular surface of the radius as well as a static stabilizer of the distal radioulnar joint. It consists of an articular disc, the dorsal radioulnar ligament (DRUL), and palmar radioulnar ligament (PRUL), the meniscus homologue, the ulnar collateral ligament, and the sheath of the ECU.129,137 The articular disc extends from the distal rim of the sigmoid notch, along the ulnar edge of the lunate facet, blending in the periphery with the PRUL and DRUL. The PRUL and DRUL are the primary stabilizers of the DRUJ. They originate from the dorsal and palmar aspect of the sigmoid notch and converge in a triangular fashion toward the base of the ulnar styloid.80 

Proximal Radioulnar Joint

The radial head articulates with the radial notch of the proximal ulna. This joint is stabilized by the annular ligament which originates from the anterior and posterior limits of the radial notch (lesser sigmoid notch) of the proximal ulna. It blends with fibers from the lateral collateral ligament of the elbow. 

Muscles

The muscular plane of the forearm can be grossly divided into anterior and posterior muscles. 

Anterior Muscles

The anterior muscle group can be divided into three layers: superficial, intermediate, and deep. From lateral to medial, muscles from the superficial layer comprise the pronator teres (PT), flexor carpi radialis (FCR), palmaris longus, and FCU. The intermediate layer is composed of the flexor digitorum superficialis (FDS). Three muscles form the deep layer: flexor pollicis longus (FPL) laterally, flexor digitorum profundus (FDP) medially, and pronator quadratus (PQ) distally. 
The FCU and medial half of the FDP are innervated by the ulnar nerve. All remaining muscles of the anterior compartment are innervated by the median nerve or its branch, the anterior interosseous nerve. Specifically, the anterior interosseous nerve innervates the FPL, lateral half of the FDP, and PQ (Fig. 33-16). 
Figure 33-16
Anatomy of the anterior aspect of the forearm.
 
A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
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A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
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Figure 33-16
Anatomy of the anterior aspect of the forearm.
A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
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A: Superficial layer of the forearm muscles. Note the position of the radial artery between brachioradialis and flexor carpi radialis distally. B: Intermediate layer of the proximal forearm deep to extensor carpi radialis longus, brachioradialis, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris. The recurrent radial artery acts as a tether against ulnar translation of the radial artery during proximal dissection. The radial artery and superficial branch of the radial nerve continue distally on the undersurface of brachioradialis. Note the median nerve passing between the superficial and deep heads of the pronator teres continuing distally deep to the flexor digitorum superficialis. C: Deep layer of the forearm. The deep branch of the radial nerve passes under the proximal arch of the supinator muscle (arcade of Frohse). The ulnar artery and nerve and median nerve travel superficial to the flexor digitorum profundus. D: Muscular footprints on the anterior aspect of the forearm. The interosseous arteries are seen lying on the anterior and posterior surface of the interosseous membrane.
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Posterior Muscles

The posterior muscle group can be divided into two layers: superficial and deep. From lateral to medial, the superficial muscles are brachioradialis, extensor carpi radialis longus (ECRL), extensor carpi radialis brevis (ECRB), extensor digitorum, EDM, ECU, and anconeus. Proximally, the deep layer is composed of the supinator muscle and distally from lateral to medial by the abductor pollicis longus (APL), extensor pollicis brevis (EPB), extensor pollicis longus (EPL), and extensor indicis proprius (EIP). All posterior muscles are innervated by the radial nerve or its branch, the posterior interosseous nerve (Fig. 33-17). 
Figure 33-17
Anatomy of the posterior aspect of the forearm.
 
A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
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A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
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Figure 33-17
Anatomy of the posterior aspect of the forearm.
A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
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A: Superficial layer of muscles. Note the outcropper muscles (abductor pollicis longus and extensor pollicis brevis) emerging distally between extensor carpi radialis brevis and extensor digitorum communis). B: The radial nerve branches into superficial and deep branches at the level of the elbow. Note the superficial branch travelling distally deep to brachioradialis. The deep branch passes through the arcade of Frohse becoming the posterior interosseous nerve after emerging from the supinator muscle. C: Deep layer. Note the course of the deep branch of the radial nerve through supinator and the branching pattern of the posterior interosseous nerve.
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Forearm muscles are encased in four compartments: superficial volar, deep volar, dorsal, and mobile wad. The superficial volar compartment comprises FCU, FDS, FCR, and PT. The deep volar compartment is made up by FDP and PQ. The dorsal compartment includes supinator, ECU, extensor digitorum communis (EDC), EDM, APL, EPL, EPB, and EIP. The mobile wad comprises brachioradialis, ECRL, and ECRB. 

Deforming Forces

In the intact forearm, rotational muscle forces acting on the radius are balanced in a position of forearm pronation. Depending on the fracture location, the net deforming forces will tend to either pronate or supinate the proximal and distal radial segments. The main supinating forces are the supinator and biceps muscles. The main pronating forces are the PT and PQ. Besides exerting rotational forces on the radius, the supinator and both pronator muscles decrease the distance between the radius and ulna thereby shortening the interosseous space. The greatest rotational deformity of the radius can be expected in fractures that are distal to the supinating forces and proximal to the pronating forces. A radius fracture distal to the insertion of the supinator muscle and proximal to the PT will therefore lead to unopposed supination of the proximal segment and pronation of the distal segment, with a resultant severe rotational deformity. Fractures distal to the PT insertion will exhibit a less severe deformity, as the PT will counteract some of the supination forces of biceps and supinator. 

Nerves

Median Nerve

The median nerve reaches the antecubital fossa of the anterior proximal forearm together with the brachial artery medial to the biceps tendon. The antecubital fossa is represented by a line between the epicondyles proximally, and the biceps tendon and brachioradialis laterally. The floor of the antecubital fossa is the brachialis muscle, the roof is the bicipital aponeurosis. Together with its branch, the anterior interosseous nerve (AIN), the median nerve passes first between the two heads of the PT and then between the two heads of the FDS underneath the sublimis bridge. The AIN travels between FPL laterally and FDP medially, innervating these muscles and continuing distally on the anterior surface of the interosseous membrane. The AIN then innervates the PQ and ends in the capsule of the wrist joint. The main trunk of the median nerve travels distally deep to the FDS. At the level of the wrist it wraps around the lateral margin of the FDS and assumes a position that is superficial to the tendon of the FDS and medial to the tendon of the FCR, entering in this position into the carpal tunnel. Six centimeters proximal to the wrist it gives off the palmar cutaneous branch which travels deep and slightly radial to the palmaris longus tendon. 

Ulnar Nerve

The ulnar nerve enters the forearm through the cubital tunnel underneath Osborne’s ligament between the olecranon and the medial epicondyle. It passes underneath the two heads of the FCU travelling on the deep aspect of this muscle together with the ulnar artery until it reaches the wrist. In the forearm it innervates the FCU and ulnar half of the FDP. 

Radial Nerve

The radial nerve enters the forearm between the brachioradialis and brachialis muscles, innervating these two muscles and ECRL. At the level of the elbow it branches into the superficial branch, which continues deep to the brachioradialis distally to reach the skin of the lateral dorsum of the hand. The deep branch innervates ECRB and supinator muscle passing through the latter into the posterior compartment of the forearm. At this level or distally, the deep branch continues as the posterior interosseous nerve (PIN) traveling on the posterior surface of the interosseous membrane innervating ED, EDM, ECU, EPB, EPL, APL, and EIP. 

Arteries

The brachial artery reaches the forearm between the median nerve medially and the biceps tendon laterally. It branches into radial and ulnar and common interosseous arteries at the level of the antecubital fossa. The first branch of the radial artery is the radial recurrent artery (recurrent leash of Henry). This artery travels laterally and proximally, superficial to the supinator muscle to anastomose with the terminal branch of the profunda brachii artery between the brachialis and brachioradialis muscles. The radial artery continues distally along the proximal border of the PT onto the undersurface of the brachioradialis muscle. Proximal to the wrist it assumes a position between the FCR medially and brachioradialis laterally. It reaches the wrist deep to the APL tendon toward the floor of the anatomic snuff box. 
The ulnar artery passes deep to FDS to join the ulnar nerve on the deep surface of the FCU. The common interosseous artery travels straight posterior toward the proximal border of the interosseous membrane where it divides into an anterior and a posterior interosseous artery. Each interosseous artery travels along the anterior and posterior surface of the interosseous membrane. 

Treatment Options for Diaphyseal Fractures of the Radius and Ulna

General Considerations of Diaphyseal Fractures of the Radius and Ulna

The main goal of treatment of fractures of the shaft of the ulna and radius is to recover painless function of the forearm and upper extremity. Pain-free function is dependent on fracture healing; range of motion of the elbow, forearm, and wrist; and avoidance of complications. Fracture healing depends on patient characteristics, type of injury, and surgeon-controlled variables. Patient factors such as smoking and diabetes may decrease the likelihood of fracture union. Injuries with extensive soft tissue loss and contamination are at a higher risk for nonunion. Finally, selection of the appropriate treatment modality and its correct execution will provide the optimal environment for the fracture to heal. Given the delicate interplay between the radius and ulna during forearm pronation–supination, there is little room for residual deformity. Furthermore, significant comminution, extensive soft tissue dissection, and prolonged immobilization will increase the probability of posttraumatic stiffness. Complications such as infection, and unrecognized compartment syndrome with secondary contracture will negatively influence outcome. 

Principles of Treatment of Diaphyseal Fractures of the Radius and Ulna

As for most fractures, treatment of forearm fractures should follow these four key criteria. 
  1.  
    Obtain adequate reduction
  2.  
    Achieve and maintain fracture reduction
     
    while
  3.  
    Preserving biology
     
    and allowing
  4.  
    Early range of motion.
Although the basic tenet of diaphyseal fracture reduction is restoration of length, alignment and rotation without the absolute necessity of anatomic reduction, this does not hold true for shaft fractures of the forearm. The geometric relationship of the ulna and radius allow for the unique motion of pronation and supination rendering the forearm a functional joint.148 Anatomic reduction of the ulna and radius is therefore desirable whenever achievable to adequately restore the spatial relationship between these bones. Once adequate reduction has been achieved, stability is required to maintain reduction and allow early range of motion and allow healing to occur. Given the importance of reduction, stability, and early range of motion, nonoperative treatment of forearm fractures in adults is limited only to stable ulna fractures. In essentially all other instances, including both-bone fractures and fracture dislocations (Galeazzi and Monteggia), operative treatment is warranted. 

Nonoperative Treatment of Diaphyseal Fractures of the Radius and Ulna

Nonoperative treatment of fractures involving the forearm is mainly limited to isolated fractures affecting the distal two-thirds of the ulna with less than 50% of displacement and less than 10 degrees of angulation.170 Cadaver studies have shown that ulnar shaft fractures with displacement of greater than 50% have concomitant interosseous membrane disruption leading to fracture instability.42,134 When treated nonoperatively, displaced isolated ulna fractures affecting the proximal third of the shaft have been shown to lead to higher rates of loss of forearm rotation, higher rates of nonunion, and poorer outcomes.22,30,169 Furthermore, isolated displaced fractures of the proximal ulna shaft frequently occur in association with a PRUJ dislocation (Monteggia fracture). Anatomic reduction and rigid fixation is mandated in this setting to allow stable reduction of the PRUJ. Finally, up to 10 degrees of angulation can be tolerated without leading to a significant reduction in forearm rotation.115 
Nonoperative treatment of displaced radius shaft fractures and fractures involving the radius and ulna shaft has shown to lead to high rates of unsatisfactory results.82,95,138 Furthermore, prolonged healing time can be expected with nonoperative treatment of isolated radius shaft fractures.190 Because of the deforming forces acting on the radius and ulna and the importance of restoring the normal anatomy of the ulna and radius, operative treatment is considered the indicated treatment modality for unstable fractures of the forearm, including displaced isolated ulna fractures, displaced isolated radius fractures, both-bone forearm fractures, and fracture dislocations (Monteggia and Galeazzi). In this setting nonoperative treatment should only be pursued when operative fixation is contraindicated.167169 
For stable isolated ulna shaft fractures, below-elbow immobilization is considered the treatment of choice since it compares favorably to long arm casting and to ace bandaging.7,54 Immobilization may be obtained either with a short arm cast or with a below-elbow brace.33 

Indications/Contraindications

Techniques.
Initial immobilization for 3 weeks in a molded long arm cast has been recommended.168,194 The cast is applied on the day of injury in longitudinal gravity traction using finger traps. A well-molded cast is then applied with the elbow bent to 90 degrees and the forearm in neutral rotation. The cast is checked 48 hours after application and changed to a prefabricated ulnar fracture brace within 3 weeks of injury. The brace consists of two low-density polyethylene shells with a molded interosseous groove that theoretically provides increased fracture stability through compressive hydrostatic pressure along the interosseous membrane. The brace extends from the antecubital fossa to just proximal to the wrist crease. A layer of stockinette is applied directly onto skin and each shell is applied onto the volar and dorsal aspect of the forearm, snapped into place, and tightened with two Velcro straps. As swelling subsides, straps are adjusted to maintain adequate tightness at the fracture site (Fig. 33-18). Early range of motion of fingers, wrist, elbow, and shoulder are encouraged. Radiographic and clinical assessment is performed 1 week after initial brace application to confirm adequate alignment and brace tolerance by the patient. Monthly radiographic and clinical evaluation then follows until healing has occurred.168,194 
Figure 33-18
 
A and B: A functional brace fabricated for a nondisplaced ulnar shaft fracture. This allows motion at the wrist and elbow while stabilizing the fracture site.
A and B: A functional brace fabricated for a nondisplaced ulnar shaft fracture. This allows motion at the wrist and elbow while stabilizing the fracture site.
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Figure 33-18
A and B: A functional brace fabricated for a nondisplaced ulnar shaft fracture. This allows motion at the wrist and elbow while stabilizing the fracture site.
A and B: A functional brace fabricated for a nondisplaced ulnar shaft fracture. This allows motion at the wrist and elbow while stabilizing the fracture site.
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Alternatively, below-the-elbow bracing or splinting may be performed in the acute setting as well. Close serial radiographic follow-up in weekly intervals during the first 3 weeks after injury should however occur to allow early identification of secondary displacement.7,42,54,141 
Outcomes.
High rates of healing can be expected with nonoperative treatment of isolated ulnar shaft fractures.69 In the largest study on functional bracing of isolated ulnar shaft fractures, Sarmiento et al. reported 96.5% of good and excellent results and a healing rate of 99%. However 35% of patients were lost during follow-up.169 Similar results have been reported by other authors.7,33,54,132 De Boeck et al. reported a healing rate of 93% after short arm casting. Conversion to operative fixation because of complete fracture displacement was required in only one fracture.33 In a randomized controlled trial, Atkin et al. found optimal outcomes with 8 weeks of immobilization of isolated ulnar shaft fractures in a short arm cast. Ace bandage immobilization achieved unsatisfactory rates of pain control and was associated with high rates of fracture displacement. Long arm cast immobilization on the other hand led to high rates of elbow stiffness.7 Similar results were found by Gebuhr et al.54 who observed significantly higher satisfaction and wrist range of motion after immobilization of isolated ulnar shaft fractures in a prefabricated functional brace, compared to long arm casting. Pollock et al. on the other hand observed a shorter time to fracture healing in 59 isolated ulna shaft fractures treated either without or for a period of immobilization of less than 2 weeks compared to 12 fractures that were treated with a long arm plaster cast. Nonunion occurred in 8% of fractures treated with long arm immobilization compared to none in the group with minimal immobilization. In a small case series of 10 patients, de Jong and de Jong34 also achieved healing in all fractures and negligible loss of forearm rotation after treatment without immobilization and early exercises. 

Operative Treatment of Diaphyseal Fractures of the Radius and Ulna

Operative treatment represents the rule rather than the exception in the treatment of forearm shaft fractures. Indications for operative treatment of forearm shaft fractures are essentially all fractures except undisplaced fractures or isolated stable ulna shaft fractures. The purpose of operative treatment is to achieve anatomic reduction and obtain stable fixation to allow early range of motion while healing occurs. Careful soft tissue management is important to minimize disruption of bone viability and optimize the chances for healing to occur. 
Open reduction and internal fixation (ORIF) with plates and screws is the most widely used method of treatment for unstable forearm fractures. Fracture reduction is achieved with direct visualization of the fracture, allowing removal of interposed soft tissues and manipulation. Historically, intramedullary nailing of the forearm has been performed with the use of solid nails. Good outcomes are reported for pediatric forearm fractures. Less favorable results have been shown for adult forearm fractures, since adequate reduction is difficult to achieve and only marginal rotational stability is provided. Intramedullary nailing using interlocking nails has been proposed for several years and has recently gained new interest, since it allows fracture fixation with only minimal soft tissue disruption (Table 33-2). 
 
Table 33-1
Forearm Fracture
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Table 33-1
Forearm Fracture
Nonoperative Treatment
Indications Relative Contraindications
Stable isolated ulna fracture (less than 50% of displacement) Both-bone forearm fracture
Less than 10 degrees of angulation Fracture dislocations (Galeazzi, Monteggia)
Distal two-thirds of the ulna Displaced isolated radial shaft fracture
Unstable isolated ulna fracture
Isolated proximal third ulna shaft fracture
X
 
Table 33-2
Forearm Fracture
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Table 33-2
Forearm Fracture
Operative Treatment
Indications Relative Contraindications
Both-bone forearm fracture Severe contamination (may require staged procedure)
Proximal third displaced isolated ulna fracture Physiologically unstable patient not tolerating operative procedure
Fracture dislocation (Galeazzi, Monteggia) Dysvascular crush injury with low likelihood of limb salvage
Displaced isolated radial shaft fracture
Unstable isolated ulna fracture (e.g., angulation greater >10 degrees)
Pathologic fracture
X

Surgical Approaches

Whether forearm fractures are treated via percutaneous or open surgical methods, access to the radius and ulna shafts occur through the same soft tissue windows. Given the subcutaneous location of the ulna, the direct approach to this bone is universally used. The radius is approached either volarly in fractures of the mid- and distal diaphysis, or dorsally for fracture of the proximal and mid third.78 
Ulna.
The dorsomedial ridge of the ulna is easily palpated under the subcutaneous soft tissues. With the patient in the supine position, the incision may be performed with the elbow flexed on a hand table, thereby holding the forearm in a vertical position. The skin incision is centered over the fracture site and over the subcutaneous ulna. Once the skin is incised the ulnar ridge is again palpated and identified. The underlying fascia is then incised and the interval between ECU and FCU developed. This is a true internervous plane, since the ECU is innervated by the PIN and the FCU by the ulnar nerve. Plates are placed either onto the dorsal aspect of the ulna underneath ECU or the volar aspect under FCU. Plate placement on the subcutaneous border of the ulna should be avoided as it will become symptomatic and place soft tissue healing at risk (Fig. 33-19). 
Figure 33-19
Surgical approach to the ulna.
 
A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
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A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
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Figure 33-19
Surgical approach to the ulna.
A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
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A: With the patient supine the forearm may be placed across the patient’s chest or alternatively using a hand table and having the elbow flexed and the finger pointed towards the ceiling, especially when planning additional fixation of the radius. B: The ulna is exposed through the interval between extensor carpi ulnaris dorsally and flexor carpi ulnaris anteriorly. C: Location of the ulnar and radial nerve in the proximal aspect of the forearm.
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X
Radius
Volar Approach of Henry.
Exposure of the radius from the bicipital tuberosity to the distal articular surface of the radius can be achieved using the anterior approach72 (Fig. 33-20). However, exposure of the proximal end of the radius is limited by the distal biceps tendon as it wraps around into the bicipital tuberosity. Proximal radius fractures are therefore preferentially approached through a dorsal approach. 
Figure 33-20
Anterior (Henry) approach to the radius.
 
A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
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A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
View Original | Slide (.ppt)
A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
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Figure 33-20
Anterior (Henry) approach to the radius.
A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
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A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
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A: The patient is positioned in the supine position with the forearm supinated on a hand table. B: An incision is performed along a line from the lateral aspect of the distal biceps tendon proximally to the radial styloid distally. C: The interval between brachioradialis and flexor carpi radialis is identified in the midshaft. Distally, the interval between radial artery and brachioradialis is used. D: The interval between radial artery and brachioradialis is developed proximally by ligating branches from the radial artery to brachioradialis. The superficial branch of the radial nerve will be located on the undersurface of brachioradialis. E: From distal to proximal the radial shaft is covered by pronator quadratus, flexor digitorum superficialis, pronator teres, and supinator. Note that to gain proximal access to the radius the recurrent radial artery has to be ligated. F: Alternating between forearm pronation and supination will improve visualization of muscular insertions to allow bony exposure.
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Superficial dissection: The skin incision is performed on a line connecting the lateral aspect of the biceps tendon proximally with the radial styloid distally. This places the incision on the ulnar border of the brachioradialis muscle. Dissection proceeds between brachioradialis and the PT proximally and brachioradialis and FCR distally. The approach proceeds through a true internervous interval since the brachioradialis is innervated by the radial nerve and both PT and FCR are innervated by the median nerve. In the proximal and middle third of the forearm, the radial artery and its two venae comitantes run underneath the brachioradialis muscle, assuming a position between the FCR and brachioradialis in the distal third. To allow ulnar retraction of the radial artery and veins along with the FCR, several vascular branches to the brachioradialis have to be identified and either coagulated or ligated. The superficial sensory branch of the radial nerve, on the other hand, is retracted laterally along with brachioradialis as it runs under this muscle lateral to the radial vascular bundle. 
Deep Dissection.
Access to the proximal third of the radial shaft is gained by releasing the supinator muscle from the radius. In order to protect the PIN, the forearm is fully supinated, thereby rotating the PIN into a posterior position. The supinator muscle is then released from its radial origin. If access to proximal end of the radius is required, the bicipital bursa is incised lateral to the distal biceps tendon. This will avoid injury to the brachial artery and its bifurcation located medial to this tendon. Ligation of the radial recurrent artery may be required to allow medial retraction of the proximal aspect of the radial artery. Retraction around the radial neck should be avoided to prevent injury to the PIN. The middle third of the radial shaft is accessed by pronating the forearm and incising the radial origins of the PT and FDS distal to the supinator muscle. Complete detachment of the PT and FDS should be avoided if possible. The distal third of the radius is accessed by sweeping the FPL ulnarly and exposing the underlying PQ muscle. By supinating the forearm, the PQ can be released from its radial origin and reflected ulnarly. To allow complete elevation of the PQ, its distal border is sharply incised along the watershed line of the distal radius, just proximal to the volar wrist capsule. 
Posterior Approach to the Radius (Thompson). The posterior approach to the radius is a prolongation of Kaplan’s interval at the elbow. It allows exposure of the dorsum of the radius and is most frequently used for proximal and midthird fractures. The incision is performed on a line from the lateral epicondyle toward Lister tubercle. Proximally, the approach gains access to the radius between ECRB medially and EDC laterally. Distally, access is gained between ECRB and EPL. This does not represent a true internervous plane, since ECRB is innervated by the deep branch of the radial nerve and EDC and EPL by the PIN, which branches off the deep branch of the radial nerve. The interval between ECRB and EDC is clearly identifiable distally as APL and EPB emerge through this interval from deep to superficial and ulnar to radial. To complete the interval between ECRB and EDC, the approach is therefore best completed in a distal to proximal fashion. Isolating the APL and EPB tendons with vascular loops or a Penrose drain can help in assuring adequate orientation of the interval between ECRB and EDC. More proximally, the interval between the origin of ECRB and EDC cannot be clearly identified. Furthermore, the origin of ECRB is covered by the origin of ECRL. Careful elevation of the ECRL origin is required to gain access to ECRB origin.29 After splitting the interval between ECRB and EDC, the supinator muscle can be identified wrapping around the proximal radius. The PIN is identified at the distal edge of the supinator muscle. If access to the radial head and neck is not desired, the supinator muscle is elevated off its radial origin with the forearm in maximal supination. If on the other hand access to the radial head and neck is required, the supinator muscle is split in line with the course of the PIN. The ventral capsule and annular ligament are then incised in line with the axis of the radius. Distal to the crossing of EPB and APL, exposure proceeds between ECRB radially and EPL ulnarly. This approach gives direct access to the entire radius except where APL and EPB cross the bone. At this level, retraction of these muscles and submuscular sliding of plates are required to gain full access to the radial shaft. Because of the risk of tendon irritation at this level, distal third radius fractures are best approached through an anterior approach (Fig. 33-21). 
Figure 33-21
Posterior (Thompson) approach to the radius.
 
A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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Figure 33-21
Posterior (Thompson) approach to the radius.
A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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A: The patient is positioned in the supine position with the forearm pronated either across the chest or on a hand table. B: An incision is performed along a line from the lateral epicondyle of the humerus proximally toward Lister tubercle distally. C: The interval between extensor carpi radialis brevis and extensor digitorum communis is easiest identified distally as it is split by the passage of the outcroppers (abductor pollicis longus and extensor pollicis brevis). D: The interval is completed proximally by incising the common extensor origin. The supinator is identified deep to the extensor origin. The posterior interosseous nerve can be identified emerging from the distal edge of supinator. E: To fully expose the deep branch of the radial nerve the supinator muscle is split. This may be required to gain access to very proximal fractures of the radius. F: Alternatively, in fractures that are located distal to the neck of the radius the supinator is elevated from the radius without unroofing the deep branch of the radial nerve. This is best achieved by supinating the forearm. Note that distally the dorsal aspect of the radius can be exposed between the extensor carpi radialis brevis and extensor pollicis longus. The dorsal aspect of the second to most distal fifth of the radius remains covered by the outcropper muscles.
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Open Reduction with Plate and Screw Fixation

ORIF with plates and screws is considered the gold standard of operative treatment of forearm fractures.127 Open reduction allows removal of soft tissue interposed at the fracture site and anatomic reduction of the fracture, thereby allowing restoration of the radial bow and the normal spatial arrangement of the ulna and radius. In Galeazzi and Monteggia fracture dislocations, anatomic reduction of the radius and ulna respectively will in most instances lead to stable reduction of the associated dislocated radioulnar joints. Finally, if required, bone grafting can be performed. Plate and screw fixation provides immediate fracture stability, obviating the need for postoperative immobilization and allowing early range of motion.4,13,27,32,36,48,49,60,64,65,71,73,74,107,108,109,113,119,135,156,163,166,179,185 
Excellent healing rates for open reduction with plate and screw fixation have been reported by most clinical studies.4,13,27,32,36,48,49,60,64,65,71,73,74,107109,113,119,135,156,163,166,179,185 In 1965 Sargent and Teipner reported on 29 forearm shaft fractures that were treated with double plating using third tubular plates. Bone graft was not used and no postoperative immobilization was required. A 100% healing rate was achieved.166 In a subsequent study, Teipner and Mast showed a 100% healing rate using single compression plates in 48 patients, compared with 98% in 55 patients treated with double third tubular plates. The authors concluded that single compression plating offers equal healing rates, whereas reducing fracture stripping and reducing surgical time.185 Anderson et al.4 reported a healing rate of 98% for radius shaft fractures and 96% for ulna shaft fractures using compression plating in a total of 330 diaphyseal forearm fractures. Chapman et al. achieved fracture healing in 98% of 129 forearm shaft fracture treated with either 3.5 or 4.5 mm compression plates and screws.27 Multiple subsequent studies have consistently shown healing rates of above 90%.13,32,36,48,49,60,64,65,71,73,74,107,108,109,113,119,135,156,163,179 
Compression plating is therefore established as the standard method of fixation of forearm shaft fractures. Early studies on compression plating used 4.5 mm plates and screws.4,36,60 Subsequently, 3.5 mm plates were introduced with equally high healing rates and less periprosthetic fractures.13,27,65,73,107,135,163,185 Introduction of locking plates and screws aimed at improving the biologic environment for fracture healing have not shown any clinical benefit over standard compression plates.48,49,64,71,74,107,163 
Preoperative Planning.
The goal of operative treatment of any fracture is to achieve bony healing while avoiding complications and to allow return to a preinjury level of function. Preoperative planning plays a key role in optimizing conditions for fracture management. This includes defining surgical timing, patient positioning, the type of anesthesia, the surgical approach, a stepwise sequence of fracture reduction and fixation, postoperative wound management, and rehabilitation. 
Preoperative planning relies on a detailed understanding of the fracture and associated injuries. Associated injuries requiring prioritized management will affect the timing of treatment of forearm fractures. Whereas isolated fractures in fit patients are usually treated within 72 hours of injury, in the polytraumatized patient operative fixation may be delayed for several days to weeks. Historically, open fractures are treated in a more urgent manner, with debridement within 6 hours of injury. The decision on the timing of definitive fixation and the need for a staged procedure will depend on the amount of contamination and soft tissue loss, patient comorbidities, and hemodynamic status. 
Planning of definitive fracture fixation requires AP and lateral views of the forearm, wrist, and elbow to achieve a thorough understanding of the fracture and the presence of instability of either the DRUJ or PRUJ. Because of overlap of the radius and ulna on the lateral view, oblique radiographs may aid in defining whether the fracture pattern is simple or if comminution is present. This will determine the type of reduction and stabilization that will be used and the sequence in which fracture fixation will be performed. In most instances the bone with the more simple fracture pattern will be reduced and fixed first as this will aid in reduction of the other fractured bone, especially when comminution is present. The large majority of forearm fractures will be managed with 3.5 mm compression plates, which are available in most operating rooms. Simple fractures are fixed using compression but oblique fractures will in most instances require a lag screw and neutralization plate. Transverse fractures are stabilized with dynamic compression by eccentric drilling and screw fixation through dynamic compression plate holes. Butterfly fragments may be fixed using smaller 2, 2.4, or 2.7 mm screws in a lag mode (Fig. 33-22), while comminuted fractures will in most instances be fixed with a bridge plate (Fig. 33-2).192 Long distal radius plates may be useful for the treatment of distal radial shaft fractures (Fig. 33-23), while precontoured proximal ulnar plates may aid in fixation of proximal ulnar shaft fractures (Fig. 33-24). Segmental fractures may benefit from temporary fixation using smaller plates and screws (Fig. 33-1). Foreseeing the need for special implants during preoperative planning will allow intraoperative availability of these implants. 
Figure 33-22
A segmentally comminuted ulnar fracture stabilized with two plates.
 
A smaller plate was used for distal ulnar shaft fracture as it permitted fixation with more screws and offered a lower profile plate fit. Lag screws have been used for the butterfly fragments. (From Wright RD. Forearm fractures. In: Gardner MJ, Henley MB, eds. Harborview illustrated tips and tricks in fracture surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2010:98–106.)
A smaller plate was used for distal ulnar shaft fracture as it permitted fixation with more screws and offered a lower profile plate fit. Lag screws have been used for the butterfly fragments. (From Wright RD. Forearm fractures. In: Gardner MJ, Henley MB, eds. Harborview illustrated tips and tricks in fracture surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2010:98–106.)
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Figure 33-22
A segmentally comminuted ulnar fracture stabilized with two plates.
A smaller plate was used for distal ulnar shaft fracture as it permitted fixation with more screws and offered a lower profile plate fit. Lag screws have been used for the butterfly fragments. (From Wright RD. Forearm fractures. In: Gardner MJ, Henley MB, eds. Harborview illustrated tips and tricks in fracture surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2010:98–106.)
A smaller plate was used for distal ulnar shaft fracture as it permitted fixation with more screws and offered a lower profile plate fit. Lag screws have been used for the butterfly fragments. (From Wright RD. Forearm fractures. In: Gardner MJ, Henley MB, eds. Harborview illustrated tips and tricks in fracture surgery. Philadelphia, PA: Lippincott Williams and Wilkins; 2010:98–106.)
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Figure 33-23
 
A and B: Distal radius shaft fracture. This likely represents a Galeazzi fracture. Marginal radial shortening and the presence of an avulsion fracture of the ulnar styloid suggest possible disruption of the TFCC. C and D: Postoperative radiographs. Fixation was achieved with a long distal radius plate that allowed angle stable fixation from the distal radial epiphysis to the middle third of the radial shaft.
A and B: Distal radius shaft fracture. This likely represents a Galeazzi fracture. Marginal radial shortening and the presence of an avulsion fracture of the ulnar styloid suggest possible disruption of the TFCC. C and D: Postoperative radiographs. Fixation was achieved with a long distal radius plate that allowed angle stable fixation from the distal radial epiphysis to the middle third of the radial shaft.
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Figure 33-23
A and B: Distal radius shaft fracture. This likely represents a Galeazzi fracture. Marginal radial shortening and the presence of an avulsion fracture of the ulnar styloid suggest possible disruption of the TFCC. C and D: Postoperative radiographs. Fixation was achieved with a long distal radius plate that allowed angle stable fixation from the distal radial epiphysis to the middle third of the radial shaft.
A and B: Distal radius shaft fracture. This likely represents a Galeazzi fracture. Marginal radial shortening and the presence of an avulsion fracture of the ulnar styloid suggest possible disruption of the TFCC. C and D: Postoperative radiographs. Fixation was achieved with a long distal radius plate that allowed angle stable fixation from the distal radial epiphysis to the middle third of the radial shaft.
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Figure 33-24
 
A–C: Comminuted gunshot fracture to the proximal ulna with marked comminution and posterior dislocation of the radial head (Monteggia). D: Open reduction and internal plate and screw fixation was achieved in a bridging mode, restoring alignment of the proximal radius and capitellum by regaining ulnar length and alignment. A proximal ulna plate was used to facilitate plate apposition and screw placement into the proximal ulna.
A–C: Comminuted gunshot fracture to the proximal ulna with marked comminution and posterior dislocation of the radial head (Monteggia). D: Open reduction and internal plate and screw fixation was achieved in a bridging mode, restoring alignment of the proximal radius and capitellum by regaining ulnar length and alignment. A proximal ulna plate was used to facilitate plate apposition and screw placement into the proximal ulna.
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Figure 33-24
A–C: Comminuted gunshot fracture to the proximal ulna with marked comminution and posterior dislocation of the radial head (Monteggia). D: Open reduction and internal plate and screw fixation was achieved in a bridging mode, restoring alignment of the proximal radius and capitellum by regaining ulnar length and alignment. A proximal ulna plate was used to facilitate plate apposition and screw placement into the proximal ulna.
A–C: Comminuted gunshot fracture to the proximal ulna with marked comminution and posterior dislocation of the radial head (Monteggia). D: Open reduction and internal plate and screw fixation was achieved in a bridging mode, restoring alignment of the proximal radius and capitellum by regaining ulnar length and alignment. A proximal ulna plate was used to facilitate plate apposition and screw placement into the proximal ulna.
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Fracture location will determine what type of approach will be performed on the radius. Distal half fractures will most likely be fixed through a volar approach, while proximal half fractures are best managed using a dorsal approach. 
Most surgeons recommend the use of a tourniquet. This allows a bloodless field with improved visualization of the soft tissue planes and reducing blood loss. Increased tourniquet time may however significantly increase postoperative pain.133 ORIF of forearm shaft fractures may be performed without tourniquet. This may lead to an increase in surgical time during the initial exposure, as hemostasis has to be achieved in this part of the procedure. Higher blood loss may also be expected although in most cases is only marginal. Benefits include less postoperative pain and decreased risk of hematoma formation. Intraoperatively, the radial artery may be more easily identified as its pulsations are easily palpable (Table 33-3). 
 
Table 33-3
ORIF of Forearm Shaft Fractures
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Table 33-3
ORIF of Forearm Shaft Fractures
Preoperative Planning Checklist
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    OR Table: Standard table with radiolucent arm board.
  •  
    Anesthesia: General anesthesia. Avoid axillary block to allow clinical monitoring of postoperative compartment syndrome.
  •  
    Position/positioning aids: Patient supine, forearm placed on radiolucent arm board.
  •  
    Fluoroscopy location: Mini C-arm or standard C-arm coming in from the side.
  •  
    Equipment: 3.5 mm plates and screws for most fractures. 2, 2.4, and 2.7 mm screws and plates for complex fractures aiding in temporary fixation.
  •  
    Tourniquet: In most instances nonsterile tourniquet on the arm, inflated to 250 mm Hg. Tourniquet time should be kept below 2 hours to reduce postoperative pain. Fractures may be treated without a tourniquet. A sterile tourniquet is recommended when associated fractures are treated during the same operative procedure, e.g., humerus fracture.
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Positioning.
After undergoing general anesthesia, patients are positioned supine and the operative arm is placed on a radiolucent arm board. A nonsterile tourniquet is applied at the arm and the field prepped to the level of the mid arm. In the event of concomitant injuries being present at the operative upper extremity alternative positioning may be indicated. Concomitant humerus shaft fractures approached through a deltopectoral approach can be placed in the beach chair position and the forearm placed on a padded Mayo stand, with the use of a sterile tourniquet if desired. 
Surgical Approaches.
The ulna is almost universally approached through an ulnar approach between ECU and FCU. Plate positioning can be done either dorsally or volarly. Radius fractures of the distal half are approached through a volar Henry approach, whereas proximal half fractures are best approached through a dorsal Thompson approach. 
Technique.
In both-bone forearm fractures the sequence of fixation is usually determined by the amount of fracture comminution. If both fractures are simple, either fracture may be fixed first. However, because of the straight geometry of the ulna, it is frequently fixed initially, thereby facilitating radial shaft reduction and fixation. During surgical exposure, normal anatomy may be severely distorted because of displaced fracture fragments injuring the surrounding soft tissue planes. Furthermore, marked swelling may be present, often distorting the normal dissection planes. When using the Henry approach, the FCR is easily identified distally. If a tourniquet is not used, the radial artery can be palpated just radial to the tendon. The artery is then followed proximally, thereby identifying the branches into the brachioradialis muscle. Once these branches are ligated or coagulated, the plane between brachioradialis and FCR/radial artery can be easily identified. Once FPL and FDS are retracted ulnarly, the fracture can be easily palpated. In most instances PT and PQ are elevated subperiosteally and sufficiently to allow adequate fracture exposure and implant positioning. Similarly, during the dorsal Thompson approach, the interval between ECRB and EDC is easiest identified distally at the outcropping of APL and EPB. The interval is then followed proximally and the fracture site identified by palpation. Elevation of the supinator or its splitting after identification of PIN is performed according to fracture location. Ulnar exposure follows the ulnar approach as described earlier. As for the radius, the fracture site should be exposed by preserving as much of the attached soft tissues as possible. Plate positioning will require either dorsal or volar subperiosteal dissection of the ECU or FCU respectively. This should be decided before fracture exposure to avoid stripping of both surfaces of the bone. Frequently, exposure of both bones before fixation will grant easier access to the fracture site to remove interposed tissues. This is of special relevance in simple fracture patterns. Once the fracture has been debrided, the least comminuted fracture is reduced and fixed. 
It is generally recommended that screws should engage at least six cortices on each side of the fracture. Over the last decade several authors have studied the effect of number of screws at each side of the fracture. Biomechanical data has shown that similar construct stability can be obtained by using longer plates and fewer screws.87,165,186 Use of fewer screws does however reduce the torsional and bending stiffness of the construct.45 Clinically, Crow et al. reported on 78 forearm fractures that were managed with plate and screw fixation using screw fixation engaging less than six cortices. Despite a nonunion rate of 9%, no hardware failures were reported.32 Similarly, Lindvall and Sagi reported no hardware complications when using two screws with fixation into four cortices on each side of the 75 diaphyseal shaft fractures. One radius and one ulna nonunion occurred. The authors concluded that fixation of forearm fractures with standard length compression plates and four cortices of screw fixation can yield a stable construct for management of these fractures.109 Most importantly, however, the use of only two screws on each side of the fracture requires excellent purchase of every screw, since loosening on only one screw will lead to rotational instability of the construct and likely catastrophic failure which is a particular risk in osteoporotic bone in the older patient. It is therefore advisable to obtain fixation with three screws on each side of the fracture into an intact shaft segment.150 
Transverse Fractures.
Reduction of simple transverse fractures is easiest performed by using a lobster claw or pointed reduction forceps. Application of force is thereby minimized and accurate fragment manipulation and reduction facilitated. In most instances, the distal and proximal fracture segment can be accurately keyed in, thereby anatomically reducing the fracture. Forearm supination or pronation can aid in achieving reduction. As mentioned, plate length should allow for placement of three screws on each side of the fracture. In most instances either a six- or a seven-hole plate will achieve this goal in simple transverse fractures. When using a six-hole plate, attention has to be paid to plate positioning to avoid screw placement into the fracture site. Prebending the plate to a slight concavity facing the bone surface, with the apex located at the fracture site, will provide compression along the near and far cortices of transverse fractures. While the fracture is held reduced the selected plate is laid over the fracture site and the planned position visualized. By removing the clamps for plate positioning, reduction is at this point frequently lost. Fixation of the plate to one of the fragments at the visualized position will greatly aid in proceeding with renewed reduction and definitive fixation. Alternatively, the plate may be held in position with two clamps while reducing the fracture (Fig. 33-7E). This technique, however, may be cumbersome and difficult to hold while screws are placed. Once the plate has been fixed to the shaft on one side and the fracture reduced a single clamp will hold the opposite shaft fragment reduced. At this time, fluoroscopy may be used to confirm adequate fracture reduction and plate placement. The opposite shaft fragment is then fixed to the plate with a screw going through an eccentrically drilled hole, thereby achieving interfragmentary compression. The remaining screws on the side of the initially stabilized shaft segment are then placed in a neutral position, whereas an additional compression screw hole may be drilled in the opposite shaft segment. Prior to final screw seating, the initial compression screw will have to be loosened and the second compression screw tightened, thereby providing further compression at the fracture site. The first compression screw is then retightened and a third neutral screw placed. Alternatively, a tension device may be used to achieve compression at the fracture site. Once one shaft segment has been fixed to the plate, the tension device exerts compression at the fracture site by pulling the end of the plate on the opposite shaft segment while using an independent screw as a post. All remaining screws are then placed in a neutral position. As for dynamic compression plating, prebending of the plate is required when using a tension device to provide compression across the near and far cortices. 
Oblique Fractures.
In simple oblique fractures, fixation may be achieved using either compression plating as described above or by using lag screws and a neutralization plate. If compression plating is used, the plate should be first fixed to the shaft segment that will create an acute angle between the plate and the obliquity of the fracture. This will force the opposite shaft segment to be wedged into this acute angle when compression is applied. Application follows the same sequence as for transverse fractures. Plate prebending is not required. 
Frequently oblique fractures can be reduced using pointed reduction clamps. A lag screw is then placed in an orientation perpendicular to the obliquity of the fracture (Fig. 33-25). The near cortical hole is drilled to the size of the outer diameter of the threads of the planned screw size, whereas the far cortex is drilled to the size of the core of the screw threads. For a 3.5 mm cortical screw, the near cortex is drilled with a 3.5 mm drill bit, whereas the far cortex is drilled with a 2.5 mm drill bit. The near cortical hole is then countersunk and the screw length measured. Fixation at this point will allow removal of clamps and application of a neutralization plate that will allow placement of three screws on each side of the fracture to capture a total of six cortices on each shaft segment. Precontouring is not required and screws are applied in a neutral position, as no further compression can be obtained once a lag screw has been placed. Alternatively, the lag screw may be applied through a plate hole. To achieve this, a plate of appropriate length is selected. The plate is fixed to one of the shaft segments in a position that will allow adequate lag screw placement and again achieve fixation into six cortices on each shaft segment. The opposite shaft segment is then reduced to the plate with a lobster claw forceps, and a lag screw placed through the appropriate screw hole, perpendicular to the fracture site. The remaining screws are then placed in a neutral position. 
Figure 33-25
 
A and B: Isolated ulna midshaft fracture with a large butterfly fragment. C and D: Fixation was obtained with three interfragmentary lag screws and a neutralization plate.
A and B: Isolated ulna midshaft fracture with a large butterfly fragment. C and D: Fixation was obtained with three interfragmentary lag screws and a neutralization plate.
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Figure 33-25
A and B: Isolated ulna midshaft fracture with a large butterfly fragment. C and D: Fixation was obtained with three interfragmentary lag screws and a neutralization plate.
A and B: Isolated ulna midshaft fracture with a large butterfly fragment. C and D: Fixation was obtained with three interfragmentary lag screws and a neutralization plate.
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Comminuted Fractures.
Comminuted fractures may be fixed with multiple lag screws if the fragments are sufficiently large. For smaller fragments, 2 or 2.4 mm screws may be used. Fracture fragments are anatomically reduced and fixed to the neighboring shaft segment with a lag screw technique. Careful fragment manipulation is required to preserve soft tissue attachments and maintain fragment viability. If fragment manipulation risks excessive soft tissue stripping, the fracture site may be bridged with a plate that is fixed to the proximal and distal shaft segments. In this setting it is especially useful to obtain anatomic reduction of the other forearm bone to allow partial secondary reduction of the comminuted segment. When both the ulna and radius are comminuted, the ulna is approached first. Restoration of adequate length can be judged by the alignment and absence of excessive gapping between comminuted fracture fragments. Rotation should be judged by viewing a lateral view of the olecranon that shows a lateral view of the ulnar styloid at the wrist (Fig. 33-25D). A plate length is selected that will allow bridging of the fracture site, while providing screw fixation with three bicortical screws in each shaft segment. Temporary fixation of the bridging plate to the proximal and distal shaft segments should be followed with fluoroscopic assessment of reduction. It should be kept in mind that with a single screw on each shaft segment only angulation will be correctable. Change in rotation and length will require change of one of the two screws. Once adequate alignment, rotation, and length are verified the remainder of the screws is inserted. Once ulnar fixation has been achieved the radius is similarly fixed. Restitution of the radial bow may be difficult to achieve in comminuted fractures. When using a volar approach, one has to keep in mind that the ends of the plate will sit on the concave aspect of the radial bow, whereas the central plate segment bridging the fracture will lie on the concavity of the radius. Contouring of the plate may aid in restoring the normal concavity of the radius. As for the ulna temporary screw fixation should be followed by fluoroscopic verification of alignment, rotation, and length. Clinically, full pronation and supination confirm that adequate fracture reduction has been achieved. 
Segmental Fractures.
Segmental fractures may present as two simple fractures along the ulna and/or the radius. As for single simple fractures, oblique fractures may be managed with lag screw fixation, whereas transverse fractures will require compression plate fixation. The latter may add a significant challenge if compression of more than one fracture is to be achieved through a single plate. The use of short small fragment plates and screws to fix each transverse fracture independently followed by reinforcement of the construct with a long 3.5-mm plate may provide adequate stability and fixation for healing to occur (Fig. 33-1). 
Once fracture fixation has been completed the wounds are irrigated and, if used, the tourniquet is released to obtain hemostasis. This will reduce the risk of subsequent hematoma. The skin is then closed with interrupted nonabsorbable monofilament suture stitches. In most instances wound closure can be obtained without undue skin tension. If excessive tension prevents closure of both skin incisions the ulnar incision is closed first to provide coverage of the more subcutaneously located ulna and plate. The radial incision may be covered with a nonadhesive dressing or negative pressure wound therapy. Final wound coverage may be achieved 5 to 7 days later, either with primary closure or more frequently with partial thickness skin grafting. A soft dressing is applied to encourage early range of motion of the elbow and wrist. 
Bone grafting continues to be a topic of debate. Whereas some surgeons advocate routine grafting of comminuted fractures, including open fractures,4,27,60 others have shown reproducible healing rates in the absence of grafting13,32,48,49,64,71,73,74,107109,113,119,135,163,166,179 (Table 33-4). 
 
Table 33-4
ORIF of Forearm Shaft Fractures
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Table 33-4
ORIF of Forearm Shaft Fractures
Surgical Steps
  •  
    Upper extremity exsanguination by gravity or elastic bandage, insufflation of tourniquet to 250 mm Hg.
  •  
    Fracture exposure: ulnar approach for ulna, Henry approach for proximal half of radius shaft, Thompson approach for proximal half of radius
  •  
    Debridement, reduction, and fixation of the less comminuted fracture with minimal soft tissue disruption
  •  
    Release of tourniquet, control of hemostasis
  •  
    Closure with interrupted monofilament nonabsorbable suture
  •  
    Application of soft dressing
X
Postoperative Care.
Patients undergoing operative fixation of forearm fractures are admitted overnight for clinical monitoring of compartment syndrome. In the obtunded patient, intracompartmental pressure monitoring should be used if clinical suspicion of compartment syndrome is present. If adequate pain control is achieved during the first postoperative day, patients are discharged home and instructed to report back if they experience a progressive increase in pain. Elevation of the operative extremity is recommended over the first 72 hours after surgery to reduce swelling and improve pain. Early range of motion of the elbow, wrist, and fingers is encouraged as well as active pronation and supination. Early range of motion after plate and screw fixation of forearm fractures leads to significantly better functional outcomes than prolonged postoperative immobilization. This effect is most marked in both-bone forearm fractures and open fractures.60 
Sutures are removed at 2 weeks. Lifting with the affected extremity is limited to 2.27 kg (5 lb) until radiographic healing of the fracture is visible. This occurs on an average between 8 and 24 weeks after fixation, with open fractures taking a significantly longer time to unite.27,107,109,135 
Patients are informed before surgery that hardware removal is not routinely recommended. Except for plates placed subcutaneously on the ulna, hardware is rarely symptomatic. Furthermore, removal of hardware may lead to nerve injury, infection, wound hematoma, and re-fracture. On average hardware removal may lead to 3.4 weeks of time off work and may lead to an increase in the surgical scar.4,11,12,27,35,36,75,101,103,118,125,142,147,158,171,175 
Potential Pitfalls and Preventive Measures.
The most important part of treating forearm shaft fractures is restoring function by restoring normal anatomical relationships and form of the forearm by means of re-establishing length, alignment, rotation, and radial bow. 
Restoration of the radial bow is related to functional outcome, especially in regaining pronation and supination.171 Intraoperative assessment of unhindered pronation and supination and careful radiographic assessment of reduction and fixation either with fluoroscopy or full length x-rays should be performed. Comparative radiographs of the opposite uninjured side can help in further clarifying any remaining doubt of the achieved reduction, especially in complex forearm fractures. 
At the end of each case, especially in single-bone forearm fractures, examination of the stability of proximal and distal radioulnar joints is important to rule out occult instability of these joints. 
Good surgical technique is paramount to reduce excessive soft tissue trauma and achieve adequate fixation. Residual gapping at the fracture site can occur if implants are inadequately selected and implanted in an incorrect sequence (Table 33-5). 
 
Table 33-5
ORIF of Forearm Shaft Fractures
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Table 33-5
ORIF of Forearm Shaft Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Malreduction Start with the more simple fracture by “keying” in fragments under direct visualization
In comminuted fractures confirm correct alignment clinically by rotating the forearm and radiographically by checking radial bow and rotational alignment of proximal and distal radial segments
Postoperative gapping at simple fracture site Prebend compression plates for transverse fractures
If using dynamic plate compression for oblique fractures apply the plate first onto the shaft segment that will create an acute angle between the plate and the fracture line
Careful lag screw technique. Place independent lag screws orthogonal to the plane between the fracture line and the cortical surface
Follow correct sequence of screw placement. Do not lag the fracture after plate fixation on both sides of the fractures. Do not apply dynamic plate compression after lag screw placement
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Treatment-specific Outcomes.
A summary of outcomes after open plate and screw fixation of forearm shaft fractures is presented in Table 33-6.4,13,27,36,48,60,64,65,71,73,74,107109,135,166,185 
Table 33-6
Summary of Outcomes of Plate and Screw Fixation of Forearm Fractures
First Author Patients (n) Age (yr) Mean (range) Fractures (n) Open Fractures (n, %) Implant Healed (%) Infection Nerve Injury (%) Synostosis (%) Functional Measure Result
Sargent166 21 32 (14–78) 29 19 Double-third tubular plate 100 5 No
Dodge36 65 24 (13–59) 93 17 4.5-mm DCP 98 3% No
Anderson4 244 330 15 4.5-mm DCP 97 3% 2 1 Anderson E or S: 85%
Grace60 64 24 (15–66) 25 AO and slotted plate 97 3% 5 No
Teipner185 55 84 Double plate 97 4% No
48 70 Compression plate 100 0% No
Hadden65 108 24 3.5-mm DCP 97 6% 7 6 No
Chapman27 88 33 (13–79) 129 33 Mainly 3.5-mm DCP 97 2% 1 1 Anderson E or S: 91%
Hertel73 131 38 (16–63) 206 22 3.5-mm DCP 96 1% 0 1 No
Fernandez48 71 33 (14–69) 104 23 PC-Fix 100 1% No
Haas64 272 34 (11–94) 387 21 PC-Fix 96 2% 1 No
Hertel74 52 37 (11–87) 83 17 PC-Fix 95 1% No
Leung107 47 66 19 3.5-mm LC-DCP 100 2% 5 Anderson
Pain
E or S: 100% No pain: 98%
45 59 17 PC-Fix 100 2% Anderson
Pain
E or S: 100%
No pain: 86%
Leung108 32 35 (12–70) 45 3 3.5-mm LCP 100 3% Anderson
Pain
E or S: 100%
No pain: 94%
Lindvall109 53 33 (13–82) 75 30 3.5-mm LC-DCP 97 0% No
Ozkaya135 22 32 (18–69) 9 3.5-mm DCP 100 0 deep 0 Grace and Eversmann
DASH: Mean (range)
E or G: 82%; A: 18%
15 (4–30)
20 33 (18–70) 5 Locked IM nail 100 0 deep 0 Grace and Eversmann
DASH: Mean (range)
E or G: 90%; A: 10%
13 (3–25)
Henle71 53 84 3.5-mm LCP 92 DASH (mean) 14.9
Behnke13 27 32 (12–70) 54 22 3.5-mm DCP 96 0% 11 4 Grace and Eversmann E: 67%, G: 7%, A: 19%, UA: 3%
29 32 (15–62) 58 14 Hybrid (DCP radius, locked IM nail ulna) 96 0% 4 Grace and Eversmann E: 59%, G: 17%, A: 21%, UA: 3%
 

DCP, dynamic compression plate; PC-Fix, point contact fixator; LC-DCP, limited contact dynamic compression plate; LCP, locking compression plate; IM, intramedullary; E, excellent; S, satisfactory; G, good; A, acceptable; UA, unacceptable; DASH, Disabilities of the arm, shoulder, and hand questionnaire.

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Behnke et al. compared the treatment of both-bone forearm fractures in 27 patients who underwent plate and screw fixation in both ulna and radius with 29 patients who underwent IM nailing of the ulna and plate and screw fixation of the radius. All except one radius in each group healed and there were no differences with regards to final range of motion and time to union.13 Ozkaya et al. compared both-bone fractures in 22 patients treated with only plate and screw fixation and 20 patients who underwent intramedullary nailing only. All fractures healed. No differences were recorded with regards to operative time, the Grace and Eversmann score, or the DASH score. Since all fractures treated with intramedullary nailing were reduced closed, blood loss was reported as none, compared to a mean 60 cm3 (range 20 to 240 cm3) after open reduction and plate fixation, a difference that was found to be statistically significant. Furthermore, fractures treated with IM nailing healed on average in 10 weeks, a time frame that was significantly shorter than the average 14 weeks of healing reported after plate fixation. The major disadvantage of intramedullary nailing was the need for postoperative immobilization that ranged from splinting for 2 to 3 weeks to long arm cast immobilization until radiographic healing could be visualized.135 

Intramedullary Nailing

Intramedullary nailing of forearm shaft fractures has been described for over a century.173 Early implants were solid small-diameter nails including Kirschner wires, Steinmann and Rush pins, and larger V and U rods.159,160,178 Because of the wide variability of medullary canal sizes at the radius and ulna, small-diameter nails were frequently the only implantable nail, requiring adjuvant prolonged cast immobilization to maintain reduction.102,178 U and V rods introduced by Küntscher had the advantage of allowing interference fit because of the compressibility of the slotted nail design. In the forearm, however, this frequently led to nail entrapment and fracture distraction.181 Improved results were obtained with the use of square and triangular nails that improved rotational stability at the fracture site while allowing restitution of the radial bow.161,181 In 1986, Street reintroduced the concept that Schöne had described in 1913, of introducing a square nail into an intramedullary canal that had been reamed to a round cross area slightly smaller than the maximum diameter of the nail. Rotational stability was thereby obtained by interference of the corners of the nail into the round endomedullary canal. Street observed that with this implant design, nonunions decreased from 17% with Kirschner wire fixation and 11% with Rush nailing to only 3%.181 More recently, hybrid fixation, using IM nailing for the ulna and ORIF of the radius for both-bone forearm fractures, has been reported with similar outcomes as ORIF of both.13 
Currently available implants for intramedullary nailing of forearm shaft fracture include elastic titanium nails and intramedullary rods. Elastic nails rely entirely on interference fit based on the principle of three-point fixation. With this technique a bowed nail is in contact with the endomedullary canal at each end and at the lateral aspect of the bow. Maximization of stability is obtained with placement of two nails, providing resistance to bending forces and axial loads in simple fractures. However, rotational stability is not provided, so additional cast immobilization is required. Elastic nailing is recommended for pediatric fracture fixation where immobilization is better tolerated.164 In the adult population, elastic nailing is not considered a favorable method of treatment. 
Two types of intramedullary rods are currently available in the United States for the management of adult forearm shaft fractures. Both allow locking of the nail to the bone segment adjacent to the entry portal. They differ in the method by which rotational stability is provided at the tip of the nail. One design has a paddle-shaped blade tip that achieves an interference fit at the proximal aspect of the radius and distal segment of the ulna. The other design allows interlocking with screws distal to the entry site. Despite the advantage of theoretically allowing improved rotational stability of forearm shaft fractures, even with modern interlocking nails, some type of immobilization is required until early callus formation is seen radiographically.31 The benefits of a minimally invasive technique using intramedullary fixation should therefore be carefully weighed against the detriment of limb immobilization. 

Indications/Contraindications

Intramedullary nailing of forearm fractures is indicated for unstable forearm fractures. Interference fit nailing can be achieved in fractures with at least 5 cm of intact proximal or distal bone. For interlocking nails at least 2.5 cm of intact distal or proximal ulna and 2.5 cm of proximal and 4 cm of distal radius are recommended.31 
Although plate and screw fixation is considered the gold standard for treatment of forearm shaft fractures, intramedullary nailing may be considered in some fracture types. These include segmental fractures, open fractures, and those with a poor soft tissue envelope, polytrauma, and osteopenic bone. The benefit of nailing for these fractures is theoretical and has not been shown by scientific data. 
A contraindication for intramedullary nailing is obliteration of the medullary canal with a medullary diameter of less than 3 mm at the isthmus being a relative contraindication. In smaller medullary canals, more aggressive reaming will be required to allow placement of a nail of 3 mm diameter, potentially jeopardizing bone viability and risking thermal necrosis. In addition, small-diameter medullary canals place the fracture at risk of additional comminution during reaming and may lead to nail incarceration if insufficient reaming is performed. 
Preoperative Planning.
Scaled preoperative AP and lateral forearm radiographs of both the injured and the noninjured contralateral side should be available for preoperative planning. Preoperative selection of nail length is estimated by measuring the distance from the olecranon to the ulnar styloid on a radiograph of the uninjured side (Table 33-7). The ulnar nail should be 1 cm shorter than this distance, whereas the radial nail should be 3 cm shorter. A further option to determine nail length is the use of implant-specific radiographic templates. Intraoperatively, the nail may be overlaid on the fractured forearm, while traction is applied to re-establish normal length and implant size is assessed under fluoroscopic vision. Finally, if the ulnar nail length has been selected with the use of the intramedullary reamer, the radial nail is chosen 2 cm shorter.31 Nail diameter is determined by measuring the isthmus, which ranges from 2 to 7 mm. Depending on the type of implant used, nail diameters come in sizes ranging from 3 to 5 mm. The final nail diameter should be 0.5 to 1 mm smaller than the diameter of the isthmus after reaming. Reaming is therefore required in medullary canals that measure 3.5 mm or less. 
 
Table 33-7
Intramedullary Nailing of Forearm Shaft Fractures
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Table 33-7
Intramedullary Nailing of Forearm Shaft Fractures
Preoperative Planning Checklist
  •  
    OR Table: standard table with radiolucent side table
  •  
    Position: supine
  •  
    Fluoroscopy location: standard C-arm entering from the side
  •  
    Tourniquet: Tourniquet at the arm may be used
  •  
    Planned nail size: Measure nail size from preoperative radiographs
X
Positioning.
The patient is placed supine with a radiolucent armboard at the side and a pneumatic tourniquet at the level of the arm. An image intensifier is required for the procedure. 
Surgical Approach(es).
If an open nailing technique is chosen, the radius is exposed using the volar approach for fractures of the distal half, and the dorsal approach for fractures affecting the proximal half. The ulnar fracture is accessed via an ulnar approach. 
Technique.
For the radius a longitudinal incision just lateral to Lister tubercle is performed. Careful blunt dissection should proceed after skin incision to avoid injuring the sensory branch of the radial nerve. A low ridge between ECRB and ECRL is identified. This starting point is selected to reduce irritation and the subsequent risk of rupture of the EPL. An entry hole is created by drilling at 45 degrees to the distal radial articular surface and in line with the medullary canal (Fig. 33-26A).193 As a depth of 1 to 1.5 cm is reached, the drill is further aligned with the axis of the diaphysis and further advanced to a final depth of 2 to 4 cm.181 For the ulna, a 1-cm longitudinal incision over the tip of the olecranon is performed. The triceps insertion is splint and a starting point on the proximal ulna is created 5 to 8 mm from the dorsal cortex and 5 mm from the lateral cortex. This allows insertion of a straight nail despite the lateral bow of the ulna, while avoiding the articular surface of the greater sigmoid notch. The use of a drill guide during establishment of the starting points both at the distal radius and proximal ulna is recommended to avoid injury to the soft tissues. The ulnar nerve is at special risk during creation of the proximal ulna starting point. If an open reduction is performed, the medullary canal is reamed through the fracture site both proximally and distally (Fig. 33-26B). Reaming of the whole length of the medullary canal is recommended especially in the distal segment of the ulna, as cancellous bone present at this level may interfere with nail advancement and lead to fracture distraction. Obtaining a starting point with a retrograde technique is not recommended for either the radius or the ulna. In the radius, retrograde creation of the distal starting point from within the medullary canal will lead to disruption of the distal articular surface. On the other hand a proximal starting point created in a retrograde fashion from within the medullary canal of the ulna will create a curved nail path because of the lateral offset of the medullary canal with regards to the proximal ulna. Seating of a straight nail will then lead to fracture malalignment.181 In the setting of both-bone forearm fractures, the radius and ulna are reamed before fixation is started to allow easier access to the medullary canal. 
Figure 33-26
 
A: The entry point is just lateral to Lister tubercle, protecting EPL. To enlarge the entry portal, the surgeon introduces a 6-mm cannulated reamer over the 2-mm trocar wire. Note the 45-degree angle to the articular surface of the distal radius. B: To prepare the canal at the fracture site, the surgeon uses a power reamer during open nailing. C: A nail bender is used to contour the radial nail. D: A 1.5-cm incision is made to insert the driving-end interlocking screw. Drill and screw guides must be placed onto the bone to avoid injury to the radial nerve. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
A: The entry point is just lateral to Lister tubercle, protecting EPL. To enlarge the entry portal, the surgeon introduces a 6-mm cannulated reamer over the 2-mm trocar wire. Note the 45-degree angle to the articular surface of the distal radius. B: To prepare the canal at the fracture site, the surgeon uses a power reamer during open nailing. C: A nail bender is used to contour the radial nail. D: A 1.5-cm incision is made to insert the driving-end interlocking screw. Drill and screw guides must be placed onto the bone to avoid injury to the radial nerve. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
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Figure 33-26
A: The entry point is just lateral to Lister tubercle, protecting EPL. To enlarge the entry portal, the surgeon introduces a 6-mm cannulated reamer over the 2-mm trocar wire. Note the 45-degree angle to the articular surface of the distal radius. B: To prepare the canal at the fracture site, the surgeon uses a power reamer during open nailing. C: A nail bender is used to contour the radial nail. D: A 1.5-cm incision is made to insert the driving-end interlocking screw. Drill and screw guides must be placed onto the bone to avoid injury to the radial nerve. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
A: The entry point is just lateral to Lister tubercle, protecting EPL. To enlarge the entry portal, the surgeon introduces a 6-mm cannulated reamer over the 2-mm trocar wire. Note the 45-degree angle to the articular surface of the distal radius. B: To prepare the canal at the fracture site, the surgeon uses a power reamer during open nailing. C: A nail bender is used to contour the radial nail. D: A 1.5-cm incision is made to insert the driving-end interlocking screw. Drill and screw guides must be placed onto the bone to avoid injury to the radial nerve. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
View Original | Slide (.ppt)
X
Before stabilizing the radius, the nail geometry should be adjusted to mimic the lateral bow of the diaphysis. This step is not only important when using straight nails but also when using prebent nails, as the bow may not adequately align with the patient’s anatomy. The use of a nail bender is very useful in allowing adjustments to the nail’s geometry during surgery (Fig. 33-26C). 
Final seating is usually started with the ulnar nail. However, the less comminuted fracture should be nailed first as it will allow a more accurate reduction of the fracture and will guide subsequent assessment of fracture alignment of the other bone. With currently available implants, interlocking of the near end of the nail is performed with the aiming jig, whereas the far end of the nail is locked using a perfect circles technique under fluoroscopic vision (Fig. 33-26D). Interlocking of the nail at the proximal end of the radius should keep in mind the potential risk of injury to the PIN (Table 33-8). 
 
Table 33-8
Intramedullary Nailing of Forearm Fractures
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Table 33-8
Intramedullary Nailing of Forearm Fractures
Surgical Steps
  •  
    If closed reduction is planned start with obtaining starting point for the ulna and radius
  •  
    If open reduction is planned, the fracture is exposed first, followed by reaming and obtaining starting points
  •  
    The starting point is created proximally for the ulna and distally for the radius
  •  
    The surgical approach to the radius is dorsal for proximal half and volar for distal half. The ulna is approached with an ulnar approach.
  •  
    Shaft segments are reamed to 0.5 to 1 mm above final nail diameter
  •  
    Nail advancement is performed for the more simple fracture first to allow secondary alignment of the other fracture
  •  
    Ensure adequate apposition of the fracture surfaces, avoiding fracture gapping
  •  
    Perform near interlocking using aiming jig followed by far interlocking if required using perfect circle technique
  •  
    Confirm full pronation supination of the forearm and flexion–extension of the elbow and wrist
  •  
    Confirm adequate reduction and implant placement under fluoroscopic vision (Fig. 33-27).
  •  
    Wound irrigation, closure, immobilization in a long arm splint.
X
Postoperative Care.
It is generally recommended that additional immobilization of forearm fractures managed with intramedullary nails is maintained with a long arm splint or cast until early radiographic healing can be observed. This may take approximately 6 weeks.31 Thereafter, patients are allowed to use the affected extremity without weight bearing until solid radiographic healing has been achieved. 
Potential Pitfalls and Preventative Measures.
The main challenge with intramedullary nailing of forearm fractures is obtaining an anatomic fracture reduction. Careful bending of the nail will allow accurate restoration of the radial bow (Fig. 33-27). Careful canal preparation is required to avoid fracture gapping and nail incarceration. One of the most severe intraoperative complications is injury to the posterior interosseous nerve during interlocking at the proximal end of the radius. To reduce this risk, a straight lateral entry at less than 3 cm from the radial head with the forearm in neutral rotation should be chosen for proximal radial interlocking184 (Table 33-9). 
Figure 33-27
 
AP (A) and lateral (B) radiographs of preoperative radius and ulna, preoperative AP (C), and lateral (D) radiograph after closed reduction of a bone bone forearm fracture. Postoperative AP (E) and lateral (F) radiographs after closed nailing. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
AP (A) and lateral (B) radiographs of preoperative radius and ulna, preoperative AP (C), and lateral (D) radiograph after closed reduction of a bone bone forearm fracture. Postoperative AP (E) and lateral (F) radiographs after closed nailing. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
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Figure 33-27
AP (A) and lateral (B) radiographs of preoperative radius and ulna, preoperative AP (C), and lateral (D) radiograph after closed reduction of a bone bone forearm fracture. Postoperative AP (E) and lateral (F) radiographs after closed nailing. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
AP (A) and lateral (B) radiographs of preoperative radius and ulna, preoperative AP (C), and lateral (D) radiograph after closed reduction of a bone bone forearm fracture. Postoperative AP (E) and lateral (F) radiographs after closed nailing. (From Zinar DM. Forearm fractures: intramedullary nailing. In: Wiss DA, ed. Fractures. Philadelphia, PA: Lippincott Williams and Wilkins; 2006:157–168.)
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Table 33-9
Intramedullary Nailing of Forearm Fractures
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Table 33-9
Intramedullary Nailing of Forearm Fractures
Potential Pitfalls and Prevention
Pitfall Prevention
Fracture gapping Confirm adequate fracture apposition before far interlocking if performed
Nail incarceration Appropriate sizing of the nail with canal overreaming of at least 0.5 mm
Inadequate reduction Ensure adequate nail contouring prior to final seating
Posterior interosseous nerve injury Lateral entry for proximal interlocking of the radius at less than 3 cm from the radial head
X
 
Table 33-10
Forearm Fracture
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Table 33-10
Forearm Fracture
Common Adverse Outcomes and Complications
Infection
Malunion
Nonunion
Radioulnar synostosis
Re-fracture
Compartment syndrome
X
Treatment-specific Outcomes.
Gao et al. reported on 32 fractures of the forearm in 18 patients managed with an interlocking intramedullary nail. Healing was achieved in all fractures. Mean time to union was 10 weeks in patients managed with closed nailing, whereas those that required fracture exposure before nailing healed on average after 15 weeks. Mean forearm rotation was from 62 degrees of pronation to 80 degrees of supination. Functional outcome was rated as excellent or good in 13 patients, acceptable in 3, and unacceptable in 2. Complications included radioulnar synostosis in one patient and two patients with painful distal ulnar interlocking screws. Four superficial infections occurred, all in the patients requiring open reduction.52 Lee et al. reported on 38 forearm fractures treated in 27 adult patients with interlocking nails. Healing was achieved in all except one fracture at a mean of 14 weeks. No infections or radioulnar synostoses were observed and the functional outcome was graded as excellent or good in 92% of patients.105 Visna et al. achieved healing in all 78 patients with 118 forearm fractures treated with an interlocking intramedullary nail system. Average time to union was 14 weeks. Delayed healing occurred in four cases. Complications included one superficial infection, three incomplete radioulnar synostoses, and one compartment syndrome.188 Similar healing rates of 94% and 93% have been reported by Moerman et al.123 and Street.181 Weckbach et al. prospectively studied 32 patients treated with interlocking intramedullary nailing for 40 forearm shaft fractures. Healing was achieved in all except one patient. Additional complications included one nonunion and two radioulnar synostoses. No infections occurred.191 Ozkaya et al. compared the results of 22 patients undergoing ORIF and 20 patients undergoing IM nailing of forearm fractures. At final follow-up similar DASH scores were recorded. No significant difference with regards to surgical duration was observed.135 

Monteggia Fracture Dislocation

Monteggia fracture dislocations represent approximately 1% to 2% of forearm fractures.25,145 Simple Monteggia fracture-dislocations affecting the proximal ulnar shaft with isolated radial head dislocation can be addressed with ORIF using plate and screws, usually yielding satisfactory outcomes.145 In this setting, reduction and fixation of the ulnar shaft follows the same principles as discussed for both-bone forearm fractures. However, because of the frequent proximal location of the ulnar shaft fractures, precontoured proximal ulna plates may be helpful (Fig. 33-24). The surgical procedure may be performed with the patient supine and the forearm placed across the patient’s chest or with the patient in the lateral decubitus position and the arm placed over a bolster.43 The ulna is then exposed through a posterior approach and the plate placed onto the posterior surface of the proximal ulna to counter bending forces.43,92,151 Since the TFCC and the interosseous membrane distal to the ulnar fracture remain intact, once reduction of the ulna has been achieved the PRUJ is generally reduced spontaneously into a stable configuration.43,145 
However, Monteggia fracture-dislocations may yield a high rate of unsatisfactory results and complications, even after surgical treatment, when more complex injuries are present.5,18,111,139,140 Korner et al.97 and Egol et al.44 observed that Monteggia lesions with associated proximal radius or coronoid fractures were associated with poorer outcomes. Reynders et al. reported 46% fair or poor results in 76 Monteggia lesions in adults. According to the Bado classification, good or excellent results were the norm in type 1 and type 3 Monteggia lesions. Fair or poor results were most frequently seen in type 2 and type 4 fractures. Involvement of the olecranon process was found to lead to poorer outcomes and persistent radial head dislocation was present in 7 cases (9%).147 Similarly, Reckling found his best results in Bado type 1 fractures, with fair results as the rule for type 2, 3, and 4 fractures.145 Givon et al., on the contrary, found Bado type 1 fractures to be at higher risk for poor outcomes, especially in type 1 equivalents with fracture of the proximal radius. In their study, involvement of the olecranon did not affect outcomes.58 Jupiter et al. reported 45% fair or poor results after operative treatment of Bado type 2 Monteggia fracture dislocations. Of note, 10 of the 13 included cases had an associated radial head fracture, and the proximal ulna, including the coronoid, was frequently involved. Of the radial head fractures, seven underwent radial head excision, one was replaced with a silicone implant, and three managed with ORIF.92 In a subsequent study, Ring et al. reported the results of 48 adult patients treated for a Monteggia fracture over a 10-year period. Fractures were classified as Bado type 1 in 7, type 2 in 38, type 3 in 1, and type 4 in 2 cases. A radial head fracture was present in 68% of type 2 lesions, one-third of which had an associated coronoid fracture. Nine patients required a reoperation, all of which had a Bado type 2 lesion. Indications for reoperation included loosening of ulnar fixation, radial head resection, and painful hardware. Additional complications included radioulnar synostosis in three patients, posterolateral rotatory instability in one patient, and distal radioulnar joint instability in one patient. Overall, final results were graded as excellent or good in 40 patients (83%). Poor and fair results were found in four patients with a Bado type 2 lesion, in one patient with a Bado type 1 injury, and one patient with a Bado type 4 fracture. Poor outcomes occurred in the presence of coronoid or ulnar malreduction, radial head fracture, or radioulnar synostosis. 
In the setting of complex Monteggia fracture dislocations, careful reconstruction of the proximal ulna including the olecranon and coronoid may be required. Furthermore, fractures of the proximal radius will increase the likelihood of poor outcomes. If spontaneous reduction of the radial head does not occur after adequate reduction of the ulna, buttonholing of the proximal radius through the annular ligament or the anconeus muscle should be suspected.145 Where there is an irreducible radial head or an associated proximal radius fracture, including proximal radial shaft, neck or head, an independent radial approach should be performed. In the past a combined approach to the proximal ulna and radius has been recommended,21 but this approach places the elbow at unnecessary risk of a radioulnar synostosis.151 A detailed discussion of the Monteggia lesions affecting the proximal ulna and radius is provided in Chapter 34

Galeazzi Fracture Dislocations

An isolated radial shaft fracture with associated disruption of the DRUJ is commonly known as a Galeazzi fracture dislocation. Other eponyms for this injury include “fracture of necessity,” Piedmont fracture, and reverse Monteggia fracture.51,57,82 Forearm fractures that involve only the radial shaft occur in up to 75% of cases. The remaining 25% of radial shaft fractures present as a Galeazzi lesion with an associated dissociation of the DRUJ and disruption of the interosseous membrane distal to the fracture site.155 According to Rettig and Raskin146 isolated radial shaft fractures located within 7.5 cm of the lunate facet of the distal radius are at increased risk for DRUJ disruption. Disruption of the DRUJ may however also occur in the presence of both-bone forearm fractures and isolated ulna fractures.9,43,57,120,145 Galeazzi fractures represent around 7% of adult forearm fractures.125 
The principles of management of Galeazzi fractures follow those of both-bone forearm fractures. In adults, poor results can be universally expected with nonoperative treatment of these injuries because of inadequate control of deforming forces of the PQ, brachioradialis, and thumb abductors and extensors.15,57,6668,82 Anatomic reduction and stable fixation is required to restore the normal relationship between the radius and ulna to allow unrestricted forearm rotation and to avoid delayed arthritic changes in the DRUJ.57,82,120 
Plate and screw fixation is the preferred mode of fracture stabilization (Fig. 33-7). Operative treatment is performed with the patient supine and the forearm placed on a radiolucent side table. The radial shaft is approached either via a volar or a dorsal approach. In most instances the fracture will be located in the distal half of the radius, making the volar the most frequently used approach. However, some authors have reported a higher use of the dorsal Thompson approach to reduce a theoretical risk of reduced pronation associated with the volar approach.125 Reduction and fixation is obtained according to the fracture geometry. In most instances, anatomic reduction of the radial shaft will lead to stable reduction of the DRUJ.182 When adequate reduction of the DRUJ is obtained after fixation of the radial shaft, the DRUJ should be assessed for stability. A stable DRUJ will remain reduced when anteroposterior translation is applied. An unstable DRUJ on the other hand will allow dislocation of the DRUJ, even with the forearm in supination. Stable injuries are routinely immobilized for 3 to 6 weeks in a long arm splint or cast.57,125 However, Gwinn et al. recently reported on an early motion protocol for selected Galeazzi fractures. When the DRUJ was found to be clinically and radiographically stable after radial shaft fixation, patients could safely be allowed to start immediate elbow motion, followed by progressive forearm rotation starting 2 weeks after surgery.63 An unstable DRUJ caused by a soft tissue injury at this level may be treated with pinning of the DRUJ using Kirschner wires with or without open repair of the TFCC.112 Pinning of the DRUJ is best performed with two 2-mm Kirschner wires placed 1 cm apart, with the distal most wire just proximal to the sigmoid notch.97,180 Adequate postoperative immobilization should be provided. Inadvertent rotation of the forearm may lead to pin breakage at the DRUJ.121 An unstable DRUJ with an associated fracture of the base of the ulnar styloid is best addressed with ORIF of this fragment.121 
If DRUJ reduction is not achieved after ORIF of the radius, either inadequate fracture reduction has been performed or interposition of soft tissue or bony fragments may be present at the DRUJ. Interfering structures may include ECU, EDC, and EDQ tendons, periosteum, or an avulsed foveal fragment.2,17,70,84,86,94,136 In this instance, an open reduction of the DRUJ will be required. Stabilization of the DRUJ with primary repair of the TFCC may be performed. Postoperatively, immobilization for 3 to 6 weeks in a long arm cast is recommended. Galeazzi fractures with dorsal dislocation are immobilized in supination, whereas those with volar dislocation are immobilized in pronation.1,23,57,112,125 Some authors advocate immobilization in neutral after repair.121 Intraoperative assessment of the position in forearm rotation that provides the most stable DRUJ is selected for immobilization. 
If anatomic reduction of the radius and DRUJ is obtained, satisfactory results can be obtained in 80% to 92% of the cases.100,117,124 Excellent results have been reported with primary repair of associated DRUJ instability in 95% of patients.121 However, inadequate reduction of the radius and persistent incongruity of the DRUJ can lead to significant morbidity.57,82,120 

Open Fractures

The frequency of open fractures ranges between 10% in isolated forearm shaft fractures to 43% of both-bone forearm fractures.20,27,39,52,65,104,105,109,155 Of open forearm shaft fractures less than 10% are type IIIB or C according to the Gustilo classification, and the majority are type I.41,61,122 Type I and II account for almost 80% of open forearm fractures.122 
Satisfactory results have been reported with irrigation and debridement and definitive fixation within 24 hours of injury in 90% of type I, II, and IIIA open fractures.41 Poorer results can be expected with more severe soft tissue injuries such as seen in grade IIIB and C fractures.41,122 Jones studied a group of 18 patients with high-energy open forearm fractures. Seven patients had a type IIIA, eight a type IIIB, and three a type IIIC open fracture. All patients underwent irrigation and debridement and immediate plate and screw fixation followed by redebridement at 24- to 48-hour intervals as required. Bone grafting was performed in five patients at 8 to 10 weeks after the initial injury. Delayed reconstructive procedures including tendon transfer, arthrodesis, scar revision, and nerve reconstruction were required in eight patients. Minor wound complications occurred in three patients. One patient had a deep infection requiring repeat surgical intervention, one patient with a type IIIC fracture and prolonged warm ischemia required eventual amputation, and one patient required a second grafting procedure. Good or excellent results were obtained in 12 patients (66%).89 Moed et al. studied 50 patients with 20 type I, 19 type II, and 11 type III open forearm fractures. All fractures were treated with irrigation and debridement and immediate ORIF. Complications included two deep infections and six nonunions. Excellent or good results were obtained in 85% of cases. Because of the relatively high rate of nonunions, the authors recommended bone grafting in comminuted fractures in which interfragmentary compression could not be obtained.122 
Low-velocity gunshot injuries frequently cause isolated open fractures of the ulna or radius. As in their closed counterparts, non- or minimally displaced isolated ulna and radius fractures may be treated with immobilization, while displaced both-bone forearm fractures are best treated with immediate irrigation and debridement and ORIF (Figs. 33-2 and 33-24). Lenihan et al. studied 37 patients with such injuries. Only six (16%) affected both the ulna and radius. Fourteen were isolated ulna and seventeen isolated radius fractures. Twenty-three fractures were non- or minimally displaced. Almost 40% of patients had a nerve palsy before treatment. All except one nondisplaced and six displaced fractures were treated with casting, whereas the remainder underwent ORIF. All fractures healed, no infections occurred, and two patients developed a compartment syndrome. Sixty percent of nerve injuries resolved spontaneously. Poor results were observed in six patients, five of which had been in both-bone fractures treated with cast immobilization.106 
Most open forearm fractures can be treated with irrigation and debridement and immediate ORIF using plates and screws. The optimal type and duration of antibiotic management is still being debated. Commonly accepted regimens include immediate intravenous Gram-positive coverage for all open fractures. Concomitant Gram-negative coverage is recommended for type 3 fractures. Additional anaerobic coverage with penicillin or clindamycin has been advised for combat injuries and those occurring with contamination in the farm environment. Type 1, 2, and 3A open fractures can be adequately managed with a single wash out and immediate ORIF and closure provided there is no doubt about tissue viability or contamination. Whereas immediate fixation may be performed in 3B fractures, repeat irrigation and debridement may be required at 72-hour intervals until a definitive soft tissue coverage can be obtained, usually with some type of tissue transfer (Fig. 33-28). Type 3C fractures are managed with fixation followed by vascular repair in most instances. 
Figure 33-28
 
A and B: Type 3B open segmental fracture of the ulna and radius. Severe stripping of the intermediate fracture segment of the ulna was resected. A soft tissue flap was required to obtain adequate coverage and allow initial fixation (C and D). E: A vascularized fibula graft was used to bridge the fracture defect.
A and B: Type 3B open segmental fracture of the ulna and radius. Severe stripping of the intermediate fracture segment of the ulna was resected. A soft tissue flap was required to obtain adequate coverage and allow initial fixation (C and D). E: A vascularized fibula graft was used to bridge the fracture defect.
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Figure 33-28
A and B: Type 3B open segmental fracture of the ulna and radius. Severe stripping of the intermediate fracture segment of the ulna was resected. A soft tissue flap was required to obtain adequate coverage and allow initial fixation (C and D). E: A vascularized fibula graft was used to bridge the fracture defect.
A and B: Type 3B open segmental fracture of the ulna and radius. Severe stripping of the intermediate fracture segment of the ulna was resected. A soft tissue flap was required to obtain adequate coverage and allow initial fixation (C and D). E: A vascularized fibula graft was used to bridge the fracture defect.
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In selected cases in which massive soft tissue disruption with marked contamination is present, thereby precluding definitive plate and screw implantation, external fixation may be used. As for ORIF, understanding of the anatomy of the forearm is key for accurate and safe placement of external fixator pins.53 Pins should be placed in a location that will not interfere with definitive plate and screw placement because of potential contamination of the surgical field by pin tracks. With the patient supine, using a radiolucent side table, two 3-mm Schantz pins are placed into each main shaft segment with the help of an image intensifier. Ulnar pins are placed by palpation of the subcutaneous border of this bone. Pins are then introduced through stab incisions in the interval between ECU and FCU. Because of radial shift of the muscles during pronation, this position is chosen during pin placement to reduce overlying soft tissues. Radial pins are inserted using the interval described for Thompson’s dorsal approach. For the proximal half of the radius, pins are placed between the ECRB and EDC, while at the midshaft pins are placed in the interval between ECRB and EPL. Blunt spreading of the soft tissue after skin incision and the use of a soft tissue sleeve will aid in protecting the superficial branch of the radial nerve. At the distal radius, a distal dorsal pin can be placed proximal to Lister tubercle. This is easily palpated in most instances. A longitudinal skin incision followed by spreading of the soft tissues and pin insertion with a soft tissue sleeve will help protect the surrounding tendons. Associated soft tissue injuries may be covered with wet to dry dressings or managed with negative pressure wound therapy. Careful pin site care is required to avoid pin track infection and secondary loosening and possible osteomyelitis. Pins are covered with saline-soaked gauze. Any remaining tension between the pins and skin should be relieved with a skin cut perpendicular to the tension lines. After initial pin placement, pins may remain covered by the sterile dressing for 5 days, followed by twice daily pin site care.50 
Schuind et al. reported on 93 patients with acute fractures of the diaphysis of the forearm treated by a Hoffmann external fixator in a half frame configuration. After a mean time of 13 weeks of external fixation a healing rate of 91.5% was observed. One re-fracture occurred after frame removal.174 Smith and Cooney reported on the use of external fixation in complex upper extremity injuries in 40 patients, 32 of which were forearm fractures with both bones fractured in 27, the ulna in 4, and the radius in 1. All were open fractures: 29 Gustilo type III, 2 Gustilo type II, and 1 Gustilo type I. Associated vascular injuries were present in 13 and neurologic injuries in 11 cases. External fixation was maintained for 13 weeks on average but immobilization for a mean of 32 weeks. Sixteen of the thirty-two fractures were treated by ORIF with plates 3 to 5 days after frame removal. The authors reported the outcome of 28 of the 32 forearm fractures with excellent results in 14%, good in 57%, fair in 21%, and poor in 7%. Nonunion developed in 16% of cases and they were treated by ORIF with plates and bone grafting. Combining delayed union and nonunion requiring later treatment, 52% of patients required a second intervention.177 

Management of Expected Adverse Outcomes and Unexpected Complications of Diaphyseal Fractures of the Radius and Ulna

Infection

Infection has been reported to occur in between 0% and 3% of forearm fractures. Anderson et al. reported an infection rate of 3% in 330 fractures of the forearm treated with plate and screw fixation. Of the seven infections, three cleared with antibiotic treatment and achieved a good result. One patient required antibiotic treatment and hardware removal after fracture healing with resection of sequestra and suction/irrigation. Out of a total of nine nonunions in the whole series, three additional patients developed a septic nonunion that required subsequent surgery. Interestingly, all infections occurred in closed fractures, with Staphylococcus aureus being the most frequent infecting organism.4 Several studies have reported no infection after ORIF of forearm shaft fractures.13,109,135 The highest infection rate was reported by Hadden et al.65 with 6% of 108 patients having a deep infection after ORIF of forearm shaft fractures. 
In most instances infection is recognized by erythema, increased temperature, and swelling. Whereas these signs are usually seen during the early uneventful postoperative period, increasing pain and malaise may further prompt suspicion. Additional factors include fever and purulent drainage, under which circumstances there is little doubt about the diagnosis of infection. Superficial infections can in most instances be treated with a 10-day course of oral antibiotic. In uncomplicated fractures, Gram-positive coverage with a first generation cephalosporin or penicillinase resistant β-lactam such as oxacillin leads to uneventful resolution.52,64,73,108,188 In contrast deep infections require repeat interventions for irrigation and debridement. Careful debridement of devitalized or infected soft tissue and bone should be performed. Hardware should be retained if stable until fracture healing has been achieved. Intraoperative cultures should be obtained and broad-spectrum intravenous antibiotic coverage started. Antibiotics are adjusted according to culture growth and frequently continued for at least 6 weeks. In the presence of segmental bone loss, placement of antibiotic-loaded cement beads or spacer can be useful in achieving high local antibiotic concentrations. Resolution of infection can be monitored with laboratory markers such as CRP to assist in the timing of definitive reintervention for bone grafting and fixation. 

Nonunion

Nonunion rates after screw and plate fixation range between 0% and 10%.4,13,27,32,36,48,49,60,64,65,71,73,74,107109,113,119,135,156,163,166,179,185 Nonunions lead to a significant delay in functional recovery and are frequently associated with poor final outcomes.4 
Nonunions are generally secondary to inadequate biomechanics, inadequate biology, or both. Errors in achieving the adequate biomechanical environment for fractures to heal can be multiple. Fracture gapping after 3.5-mm screw and plate application because of inadequately followed principles of fixation will prevent primary bone healing and possibly result in nonunion.60 Selection of an implant that does not provide sufficient stability, such as third tubular plates, may lead to excessive motion at the fracture site, which in simple fractures may lead to nonunion. Too much rigidity in a construct may lead to inadequate healing when bridge plating is performed. Factors affecting the biomechanics of fracture healing include selection of a plate of inadequate length, inadequate plate placement, and screw insertion too close to the fracture site when using compression plating only.4 The second reason for nonunions is inadequate biology. High-energy injuries with open fractures, severe comminution, and excessive soft tissue stripping increase the risk of poor vascularity at the fracture site inhibiting healing. Furthermore, around one-third of nonunions occur in the presence of a deep surgical site infection.4 
When treating suspected nonunions of the forearm the surgeon should wait for 6 months to adequately monitor the fracture and ensure that there is no radiographic progress to healing. In our experience absence of healing in three subsequent radiographs taken at monthly intervals after 3 months of injury reliably predict that healing will not occur without repeat intervention. If the patient is asymptomatic, further watchful waiting may be advised but the patient should be informed that the hardware is at risk of fatigue failure. 
When planning the treatment of nonunions, infection should always be ruled out as a possible cause. In most instances a failure in the initial fixation mode can be observed and established as the likely cause for nonunion.153 A careful assessment of forearm rotation and elbow and wrist range of motion is necessary to determine whether any malreduction is present. Comparative radiographs of the contralateral uninjured arm may provide additional useful information on the normal anatomy. Standard preparation of the forearm as well as the ipsilateral iliac crest should be performed in case autologous bone graft is required. Alternatively, the distal femur may be prepared for grafting from the lateral femoral condyle. Careful nonunion exposure should be performed under a bloodless field to reduce profuse bleeding frequently seen from scar tissue. Careful dissection is required to avoid iatrogenic injury to neurovascular structures. Once the fracture site is identified, hardware is removed and the underlying membrane tissue sent for culture. Soft tissue stripping should be kept to a minimum. The nonunion site is carefully debrided down to viable bone. In most instances bone grafting is not required and fixation may proceed following the standard principles for reduction and plate and screw application. In the presence of bone loss autologous iliac crest or lateral femoral condyle bone graft is harvested. Infected nonunions require excision of nonviable bone as described for deep infections. Intravenous antibiotic treatment and local antibiotic therapy may be used to achieve control of the infection. If soft tissue coverage is poor, soft tissue transfer may be indicated, followed by staged refixation and bone grafting. 
Healing rates after surgical treatment of forearm nonunions have been reported to be as high as 100%. Kloen et al. reported on 47 patients with 51 forearm nonunions which were treated with ORIF alone in 30 cases, grafting alone in 7 cases, and a combination of ORIF and autologous bone grafting in 20 cases. All healed after a median of 7 months. Functional results were graded as excellent in 62%, satisfactory in 17%, and unsatisfactory in 21% of patients.95 In a similar study, dos Reis et al. reported on compression plating and autologous bone grafting of 31 patients with forearm nonunions. All except one patient achieved bony healing at a mean of 3.5 months after surgery. Good functional outcome was reported in 26 patients (84%).38 Ring et al. on the other hand reported on the use of ORIF and nonstructural autograft of nonunions with segmental defects. All of the 35 patients achieved bony union within 6 months of surgery. Functional outcomes were rated excellent in 5 patients, satisfactory in 18, unsatisfactory in 11, and poor in 1.153 Less favorable outcomes have been reported for open intramedullary nailing of forearm nonunions. Hong et al.77 reported almost 50% of unsatisfactory or failed results using this technique on 26 forearm nonunions. 
Prasarn et al. reported on 15 patients operated over a 16-year period for infected nonunions of the forearm using a standard approach of debridement, definitive fixation after 7 to 14 days, tricortical iliac crest bone grafting for segmental defects, leaving wounds open to heal by secondary intention, 6 weeks of cultures, specific antibiotics, and early active range of motion exercises. All patients achieved bony healing in the absence of infection at a mean of 13 weeks.143 

Radioulnar Synostosis

Complete radioulnar synostosis with a solid bony bridge occurs in 1% to 6% of forearm fractures.4,65 Hadden et al. reported 6 patients with synostosis in a series of 108 patients with forearm fractures. All synostoses occurred in patients with a closed head injury.65 Chapman et al. reported a single case of synostosis developing after operative treatment of forearm fractures in 88 patients. The affected patient had an associated closed head injury and had been treated with a 4.5-mm DCP plate for a Monteggia fracture. Haas et al. reported 2 patients who developed radioulnar synostosis out of 272 patients with forearm fractures treated using a minimal contact internal fixator. Both synostoses occurred in patients with high-energy fractures and required surgical release.64 
Both-bone fractures affecting the radius and ulna at the same location in the forearm, along with significant comminution have been found to be associated with this complication.4 When bone grafting is performed, care should be taken to avoid placement on the side of the interosseous membrane.60 
According to Jupiter and Ring, proximal radioulnar synostosis can be classified as follows: 
  1.  
    Distal to the bicipital groove
  2.  
    Involving the radial head on PRUJ
  3.  
    Extending to the distal aspect of the humerus
After simple excision of radioulnar synostosis in 18 patients, using an interposition fat graft in 8, the synostosis recurred in only one patient who had a closed head injury during the initial accident. Complications included one ulnar fracture, a broken pin from a hinged external fixator, and dislodgement of a fat graft. Final postoperative forearm rotation was on average 139 degrees in the 16 patients who did not have a recurrence.91 

Nerve Palsy

The most frequently injured nerve during operative treatment of forearm fractures is the radial nerve or its terminal motor branch, the PIN. Anderson et al. reported on five PIN palsies, all of which occurred after proximal radius fixation through a posterior Thompson approach. Four palsies recovered within 4 weeks, whereas one required 6 months to fully recover.4 Treatment of permanent nerve injury includes direct nerve repair and tendon transfers.76 Occasionally, loss of flexor pollicis longus function can be noted after plating of the radius through the anterior approach. This is likely due to traction neurapraxia of the AIN, which commonly resolves with observation.93 

Implant Removal and Re-Fracture

Less than 10% of plates require removal after ORIF of forearm fractures.4 Ulnar plates are at the highest risk for ongoing symptoms because of the subcutaneous location of this bone (Fig. 33-29). Plates should therefore be placed either on the dorsal or volar aspect of this bone to allow some muscle coverage. Some patients describe recurrent deep pain at the surgical site, especially related to changes in the weather and temperature, associating this pain to the presence of surgical hardware. Removal of hardware should however not be performed without taking into account the several risks involved with this procedure. Re-fracture rates have been reported to be as high as 18%, with fractures occurring either through the original fracture site or through one of the empty screw holes.4 Re-fracture through the original fracture site may be avoided by delaying hardware removal by 12 to 18 months and providing external protection in the form of a splint or prefabricated brace for 4 to 6 weeks.4 Fractures through screw holes usually occur after a more severe injury and may occur several months after hardware removal.75 Forearm fractures managed with 4.5-mm plates and screws are at higher risk for developing fractures through the screw holes. Early series using these implants reported re-fracture rates of 22% after removal, whereas some later series have shown no fracture after removal of 3.5-mm compression plates and screws.27 Finally re-fractures may occur even in the presence of the original plate and screws These re-fractures usually occur through the most distal or most proximal screw hole after significant trauma.101 
Figure 33-29
 
A: Peri-implant both-bone forearm fracture after a high-energy fall. Open reduction and internal fixation with plates and screws had been performed 3 years earlier. B and C: Long plates were used for both the radius and ulna to stabilize the fracture and splint the potential weak point of screw holes from the previous construct.
A: Peri-implant both-bone forearm fracture after a high-energy fall. Open reduction and internal fixation with plates and screws had been performed 3 years earlier. B and C: Long plates were used for both the radius and ulna to stabilize the fracture and splint the potential weak point of screw holes from the previous construct.
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Figure 33-29
A: Peri-implant both-bone forearm fracture after a high-energy fall. Open reduction and internal fixation with plates and screws had been performed 3 years earlier. B and C: Long plates were used for both the radius and ulna to stabilize the fracture and splint the potential weak point of screw holes from the previous construct.
A: Peri-implant both-bone forearm fracture after a high-energy fall. Open reduction and internal fixation with plates and screws had been performed 3 years earlier. B and C: Long plates were used for both the radius and ulna to stabilize the fracture and splint the potential weak point of screw holes from the previous construct.
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Several series have reported numerous complications that may occur after hardware removal. These include infection and nerve injury in up to 21% of cases. Additional costs should also be considered, as the hospital stay may range from 3 to 168 hours with associated absence from work averaging 3.4 weeks.4,11,12,27,35,36,75,101,103,118,125,142,157,158,171,175 

Acute Compartment Syndrome

Compartment syndrome of the forearm is a potentially devastating complication of radial and ulna shaft fractures. The incidence of forearm compartment syndrome is 2% after ORIF.107 Compartment syndrome most frequently affects the anterior compartment of the leg, followed by the volar compartment of the forearm.40,55,56 Young men are at especially high risk for developing this complication. A high level of suspicion should be present for this complication, even in fractures caused by seemingly minor trauma. We recommend overnight admission for patients undergoing surgical fixation of these fractures. in the presence of increased suspicion, intracompartmental monitoring should be performed. Emergent compartment release should be performed, if required, to reduce the risk of additional complications.40,116 A curvilinear volar incision and a straight dorsal incision provide adequate access to forearm compartments for their release.55 A detailed discussion of acute compartment syndrome is provided in Chapter 29

Author’s Preferred Treatment for Diaphyseal Fractures of the Radius and Ulna

 
 

With the patient supine and a nonsterile tourniquet on the arm, radial fractures are exposed through a volar approach for distal half to distal two-third fractures, whereas proximal third fractures are exposed via a dorsal Thompson approach. The ulna is exposed through a standard ulnar approach. The tourniquet is not routinely inflated to reduce postoperative pain and the theoretical risk of reperfusion edema, especially in longer cases. In both-bone forearm fractures, the less comminuted fracture is exposed and fixed first, followed by exposure of the other bone. This allows realignment not only of the fracture but also of the soft tissues, thereby improving orientation during exposure. Forearm shaft fractures are treated almost without exception with nonlocking plate and screw fixation using 3.5 mm implants. Dynamic plate compression, lag screw fixation with neutralization plating, and bridge plating are used according to the fracture geometry. A total of three bicortical screws are used as the norm, proximal and distal to the fracture site (Fig. 33-30). For fractures of the distal or proximal ends of the ulna or radius precontoured plates or smaller implants may be required (Figs. 33-24 and 33-31). Examination of the DRUJ and PRUJ for instability is performed once definitive stabilization has been achieved. Full pronation supination and elbow and wrist flexion–extension should be present as well.

 
Figure 33-30
 
A and B: Both-bone forearm fracture with segmental component of the ulna. C and D: A single long plate was used for the ulna. Fixation was obtained to a minimum of six cortices on each end of the fracture.
A and B: Both-bone forearm fracture with segmental component of the ulna. C and D: A single long plate was used for the ulna. Fixation was obtained to a minimum of six cortices on each end of the fracture.
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Figure 33-30
A and B: Both-bone forearm fracture with segmental component of the ulna. C and D: A single long plate was used for the ulna. Fixation was obtained to a minimum of six cortices on each end of the fracture.
A and B: Both-bone forearm fracture with segmental component of the ulna. C and D: A single long plate was used for the ulna. Fixation was obtained to a minimum of six cortices on each end of the fracture.
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X
 
Figure 33-31
 
A and B: Both-bone forearm fracture affecting the distal ulna. C and D: A 2.7-mm distal ulna locking plate was used to achieve fixation into the smaller distal ulna. E and F: Due to symptoms, the ulnar plate was removed once healing had been achieved.
A and B: Both-bone forearm fracture affecting the distal ulna. C and D: A 2.7-mm distal ulna locking plate was used to achieve fixation into the smaller distal ulna. E and F: Due to symptoms, the ulnar plate was removed once healing had been achieved.
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Figure 33-31
A and B: Both-bone forearm fracture affecting the distal ulna. C and D: A 2.7-mm distal ulna locking plate was used to achieve fixation into the smaller distal ulna. E and F: Due to symptoms, the ulnar plate was removed once healing had been achieved.
A and B: Both-bone forearm fracture affecting the distal ulna. C and D: A 2.7-mm distal ulna locking plate was used to achieve fixation into the smaller distal ulna. E and F: Due to symptoms, the ulnar plate was removed once healing had been achieved.
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X
 

Monteggia fractures are approached with the patient supine, a nonsterile tourniquet on the arm, and the upper extremity placed over the patient’s chest during exposure. This is the routine position for all elbow-related injuries, thereby standardizing anatomic orientation. This is of special importance when associated injuries to the proximal ulna or radius have to be addressed. In simple Monteggia fractures involving only the ulnar shaft fracture, a posterior approach is selected. An incision directly over the olecranon tip is avoided with the incision being directed radially at the level of the olecranon and redirected centrally more proximally. If the fracture affects the proximal ulnar metaphysis a proximal ulna plate is selected. Otherwise, a standard 3.5-mm plate is used and contoured as required. Care is taken not to penetrate the articular surface when proximal screws are placed. Once provisional fixation after anatomic ulnar reduction has been achieved, adequate reduction of the PRUJ is fluoroscopically confirmed. Final screw placement is then performed and the elbow checked for full elbow flexion–extension and forearm rotation. Careful examination of the DRUJ is also performed at this point.

 

Galeazzi fracture dislocations are addressed in a similar manner to radial shaft fractures in both-bone forearm fractures. Once anatomic reduction of the radius has been achieved, the DRUJ is examined. If reduction is not obtained or a “spongy” reduction is palpated, soft tissue interposition is suspected and the DRUJ exposed. At this point repair of the TFCC may be performed. If the DRUJ continues to be unstable after reduction of the radial shaft fracture, DRUJ translation is examined at different positions of forearm rotation. The position that allows the least amount of translation is selected and two 2 mm Kirschner wires are placed from the ulna into the radius. The most distal pin is placed just proximal to the distal ulnar facet of the radius. The second pin is placed 1 cm proximal to the first pin. Pins are then bent and cut and the forearm immobilized in a long arm splint without changing forearm rotation.

Summary, Controversies, and Future Directions in Diaphyseal Fractures of the Radius and Ulna

ORIF with nonlocking plate and screw fixation of forearm shaft fractures achieves a high rate of union and satisfactory functional outcomes. Although other treatment modalities, including locking plate fixation and intramedullary nailing have been extensively studied, no advantage has been shown over conventional screws and plates. External fixation is required in only rare exceptional circumstances. 
Outcomes after forearm shaft fractures depend on adequate restoration of the relationship between the ulna and radius to allow unrestricted forearm rotation and elbow and wrist flexion extension. Whereas bony geometry is a key aspect to restoring forearm function, identification and appropriate management of instability of the proximal and distal radioulnar joints is essential to achieve good outcomes. High-energy fractures with associated injuries to the proximal ulna and radius and disruption of the soft tissue sleeve continue to pose a challenge, as they are related to higher rates of complications and poorer outcomes. 

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