Radius and Ulnar Shaft Fractures

Author: Deborah Allen

Topic updated on 01/07/13 1:57am

Introduction

"Both-bone" forearm fractures
Epidemiology
- more common in men than women
- ratio of open to closed fractures is higher than for any other bone except tibia
Mechanism
- direct trauma
  - often while protecting one's head
- indirect trauma
  - motor vehicle accidents
  - falls from height
  - athletic competition
Associated conditions
- elbow injuries
  - evaluate DRUJ and elbow for
    - Galeazzi fractures
    - Monteggia fractures
- compartment syndrome
  - evaluate compartment pressures if concern for compartment syndrome
Prognosis
- functional results depend on restoration of radial bow

Anatomy

Osteology
- the ulna acts as an axis around which the laterally bowed radius rotates in supination and pronation
Interosseous membrane (IOM)
- occupies the space between the radius and ulna
- comprised of 5 ligaments
  - central band is key portion of IOM to be reconstructed
  - accessory band
  - distal oblique bundle
  - proximal oblique cord
  - dorsal oblique accessory cord

Classification

Descriptive
- closed versus open
- location
- comminuted, segmental, multifragmented
- displacement
- angulation
- rotational alignment
OTA classification
- radial and ulna diaphyseal fractures
  - Type A
    - simple fracture of ulna (A1), radius (A2), or both bones (A3)
  - Type B
    - wedge fracture of ulna (B1), radius (B2), or both bones (B3)
  - Type C
    - complex fractures

Presentation

Symptoms
- gross deformity, pain, swelling
- loss of forearm and hand function
Physical exam
- inspection
  - open injuries
  - check for tense forearm compartments
- neurovascular exam
  - assess radial and ulnar pulses
  - document median, radial, and ulnar nerve function
- pain with passive stretch of digits
  - alert to impending or present compartment syndrome

Imaging

Radiographs
- recommended views
  - AP and lateral views of the forearm
- additional views
  - oblique forearm views for further fracture definition
  - ipsilateral wrist and elbow
    - to evaluate for associated fractures or dislocation
    - radial head must be aligned with the capitellum on all views

Treatment

Nonoperative
- functional fx brace with good interosseous mold
  - indications
    - isolated nondisplaced or distal 2/3 ulna shaft fx (nightstick fx) with
      - < 50% displacement and
      - < 10° of angulation
  - outcomes
    - union rates > 96%
    - acceptable to fix surgically due to long time to union
Operative
- ORIF without bone grafting
  - indications
    - displaced distal 2/3 isolated ulna fxs
    - proximal 1/3 isolated ulna fxs
    - all radial shaft fxs (even if nondisplaced)
    - both bone fxs
    - Gustillo I, II, and IIIa open fractures may be treated with primary ORIF
  - outcomes
    - most important variable in functional outcome is to restore the radial bow
- ORIF with bone grafting
  - indications
    - cancellous autograft is indicated in radial and ulnar fractures with bone loss
    - bone loss that is segmental or associated with open injury
    - comminution >1/3 length of shaft
    - nonunions of the forearm
- external fixation
  - indications
    - Gustillo IIIb and IIIc open fractures
- IM nailing
  - indications
    - poor soft-tissue integrity
    - not preferred due to lack of rotational and axial stability and difficulty maintaining radial bow (higher nonunion rate)

Techniques

ORIF
- approach
  - usually performed through separate approaches due to risk of synostosis
  - radius
    - volar (Henry) approach to radius
      - best for distal 1/3 and middle 1/3 radial fx
    - dorsal (Thompson) approach to radius
      - best for middle and proximal 1/3 radial fx
  - ulna
    - subcutaneous approach to ulna shaft
- technique
  - 3.5 mm DCP plate (AO technique) is standard
    - longer plates are preferred due to high torsional stress in forearm
  - bone grafting
    - vascularized fibula grafts can be used for large defects and have a lower rate of infection
- postoperative care
  - early ROM unless there is an injury to proximal or distal joint

Complications

Synostosis
- uncommon with an incidence of 3 to 9%
- associated with ORIF using a single incision approach
- heterotopic bone excision can be performed with low recurrence risk as early as 4-6 months post-injury when prophylactic radiation therapy and/or indomethacin are used postoperatively
Infection
- 3% incidence with ORIF
Compartment syndrome
- increased risk with
  1. high energy crush injury
  2. open fxs
  3. low velocity GSWs
  4. vascular injuries
  5. coagulopathies (DIC)
Nonunion
- commonly result from technical error or use of IM fixation
- atrophic nonunions can be treated with 3.5 mm plates and autogenous cancellous bone grafting
Malunion
- direct correlation between restoration of radial bow and functional outcome
Neurovascular injury
- uncommon except
  - PIN injury with Monteggia fxs and Henry (volar) approach to middle and upper third radial diaphysis
  - Type III open fxs
- observe for three months to see if nerve function returns
  - explore if no return of function after 3 months
Refracture
- increased risk with
  - removing plate too early
  - large plates (4.5 mm)
  - comminuted fx
  - persistent radiographic lucency
- do not remove plates before 15 mos.
- wear functional forearm brace for 6 weeks and protect activity for 3 mos. after plate removal

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Qbank (13 Questions)

TAG

(OBQ10.25) Longitudinal radioulnar dissociation, including Essex Lopresti fractures, requires disruption of the interosseous membrane (IOM). The interosseous membrane (IOM) consists of all of the following ligaments EXCEPT? Topic

Review Topic

1. Central band ligament
2. Accessory band ligament
3. Annular ligament
4. Dorsal oblique accessory cord ligament
5. Distal oblique bundle ligament

PREFERRED RESPONSE ▶

DISCUSSION: The IOM includes 5 types of ligaments: central band, accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord. The annular ligament is not a part of the IOM.

The IOM bridges the radius and ulna and acts as a hinge for rotation of radius about ulna. The central portion is thickened, and forms the central band which is the most important ligament for IOM load distribution characteristics.

Noda et al, in a cadaver study, identified the precise anatomical insertions and attachment points of each of the 5 IOM components. They found the most distal and proximal ends of the radial origin of the central band were 53% and 64% of total radial length from the tip of the radial styloid, whereas those of the ulnar insertion were 29% and 44% of total ulnar length from the ulnar head.

Pfaeffle et al also performed a cadaveric biomechanical study applying compressive loads to specimens with IOMs that are intact, cut, or cut/reconstructed with flexor carpi radialis allografts. They found that reconstruction of the IOM can restore the normal load transfer chararcteristics and that the central band of the IOM is the most important portion of the IOM to be reconstructed.

Illustration A shows the ligaments of IOM membrane: CB = central band, AB = accessory band, distal oblique bundle, proximal oblique cord, and dorsal oblique accessory cord

Incorrect Answers:
The annular ligament is a strong band of fibers, which encircles the head of the radius and keeps the radius in contact with the radial notch of the ulna, but is not a part of the IOM.

Illustrations: A

REFERENCES:

1. Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg Am. 2009 Mar;34(3):415-22. Epub 2009 Feb 11 PMID:19211201 (Link to Abstract)

2. Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers. J Hand Surg Am. 2005 Mar;30(2):319-25. PMID:15781355 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD,

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TAG

(OBQ10.85) A 25-year-old female sustains the isolated fracture seen in Figure A. The patient elects to have nonoperative management. When compared to operative treatment, which of the following is true of the clinical outcome following nonoperative management? Topic

Review Topic

FIGURES: A

1. Long arm cast immobilization is necessary
2. Twenty degree loss of forearm rotation
3. Loss of wrist motion
4. Loss of elbow motion
5. Equivalent clinical outcomes

PREFERRED RESPONSE ▶

DISCUSSION: Figure A shows a so called "night stick" fracture. Fractures treated nonoperatively with greater than 10 degrees of angulation or 50% displacement can result in loss of forearm rotation. For minimally displaced fracture, nonoperative treatment results in union with good function. Time to union has been found to be greater in nonoperative groups, but clinical outcomes equivalent. Pollock et al compared two patient groups treated with short term immobilization or long term cast treatment and found no significant difference between wrist and elbow motion between the two groups. The short term immobilization group in their study had a shorter time to union and lower non union rate as well.

REFERENCES:

1. Galatz LM. Shoulder reconstruction. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:301-311.

2. Pollock FH, Pankovich AM, Prieto JJ, Lorenz M. The isolated fracture of the ulnar shaft. Treatment without immobilization. J Bone Joint Surg Am. 1983 Mar;65(3):339-42. PMID:6826596 (Link to Abstract)

Question Authors:

Jan Szatkowski MD,

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TAG

(OBQ10.199) Excision of heterotopic bone about the forearm or elbow can be done with limited recurrence rates as early as which of the following after initial injury? Topic

Review Topic

1. Once ankylosis of the forearm or elbow occurs
2. 6 weeks
3. 6 months
4. 12 months
5. 18 months

PREFERRED RESPONSE ▶

DISCUSSION: Excision of heterotopic bone about the elbow and forearm was classically treated once the bone was mature and no further bone development was occuring (bone scan became negative). However, several studies have shown that earlier removal before this point in time is safe, when done in conjunction with radiation therapy (XRT).

The referenced study by McAuliffe et al is a retrospective review of heterotopic ossification (HO) about the elbow followed by 100 cGY (5 fractions over 1 week) of XRT as early as 3 months post-injury. They were able to achieve an average arc of motion > 100 degrees.

The other referenced study by Beingessner et al is a review of HO excision of the forearm. They found that excision and XRT, followed by 6 weeks of indomethacin, led to an increase of forearm motion from an average of 17 degrees to 136 degrees when the excision was done at 4 months post-injury.

REFERENCES:

1. Beingessner DM, Patterson SD, King GJ. Early excision of heterotopic bone in the forearm. J Hand Surg Am. 2000 May;25(3):483-8. PMID:10811753 (Link to Abstract)

2. McAuliffe JA, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am. 1997 May;79(5):749-55 PMID:9160948 (Link to Abstract)

Question Authors:

Ben Taylor MD, Patrick McCulloch MD, Michael Hughes MD,

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TAG

(OBQ09.46) A 22-year-old male sustains the closed injury seen in figure A. The injury is best treated with which of the following methods? Topic

Review Topic

FIGURES: A

1. External fixation
2. Flexible intramedullary nailing
3. Open reduction and internal fixation with acute bone grafting
4. Open reduction and internal fixation
5. Closed reduction and functional bracing

PREFERRED RESPONSE ▶

DISCUSSION: The xray shows a comminuted, high energy both bone forearm fracture. Open reduction and internal fixation without bone grafting is the most appropriate treatment. Acute bone grafting is only indicated if a large bony void, such as segmental bone loss of the radius, is present to allow the displaced bone ends to heal together despite their diastasis.

In Moed et al's review, primary internal fixation in open forearm fractures led to nearly a 90% union rate (44/50) and good/excellent results in 85%. Autogenous cancellous grafting was recommended if interfragmental compression could not be obtained.

In Wright et al's review, there was no significant difference between union rates in comminuted both bone forearm fractures whether or not autograft was used (97% v. 98%). However, these did not have bone loss per se, and only evaluated whether or not comminution was present.

REFERENCES:

1. Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294 PMID:9258828 (Link to Abstract)

2. Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 307-316

3. Moed BR, Kellam JF, Foster RJ, et al: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017 PMID:3745238 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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TAG

(OBQ08.27) A 27-year-old male sustains a type I open both bone forearm fracture as seen in Figure A. During irrigation and debridement a 1 cm of cortex is removed leaving a segmental gap. Which of the following adjuvants is recommended to supplement your internal fixation? Topic

Review Topic

FIGURES: A

1. Bone grafting
2. Tricalcium phosphate
3. Calcium phosphate
4. Calcium sulphate
5. TNF-alpha

PREFERRED RESPONSE ▶

DISCUSSION: Bone grafting in the primary fixation of fractures is typically limited to those with segmental defects. While the increased surface area of a comminuted fracture may aid in the healing potential, the segmental defect is a limiting factor to fracture healing. Calcium sulphate, tricalcium phosphate, TNF-alpha, and calcium phosphate are not indicated in this clinical picture. Two of the referenced studies evaluate the utility of bone grafting in all (Wei) and comminuted (Wright) forearm fractures. The authors concluded that bone grafting is only beneficial for those fractures with segmental defects. Finally, Schemitsch and Richards determined that optimal outcome post forearm fracture depends on restoration of the radial bow.

REFERENCES:

1. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting indiaphyseal forearm fractures: a retrospective review. J Orthop Trauma. 1997 May;11(4):288-94. PMID:9258828 (Link to Abstract)

2. Wei SY, Born CT, Abene A, Ong A, Hayda R, DeLong WG Jr. Diaphyseal forearm fractures treated with and without bone graft. J Trauma. 1999 Jun;46(6):1045-8. PMID:10372622 (Link to Abstract)

3. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992 Aug;74(7):1068-78. PMID:1522093 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD,

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TAG

(OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger depicted in Figures A and B. After debridement of non-viable bone a 7cm bone defect is left. In planning future, definitive treatment of the bone void, the use of an interposed strut allograft instead of transfer of a vascularized fibula graft would most likely result in the following complication: Topic

Review Topic

FIGURES: A

1. Higher incidence of infection
2. Lower nonunion rate
3. Decreased forearm arc of rotation
4. Complex regional pain syndrome
5. Synostosis

PREFERRED RESPONSE ▶

DISCUSSION: The patient has an open fracture with a large amount of bone loss. A higher incidence of infection would be expected with the interposed strut graft treatment option. Calkins et al conducted a Level 4 study of segmental bone defects and found a 60% rate of infection and 43% rate of union with use of corticocancellous strut grafts. Falder et al and Wood also have Level 4 evidence showing a 74% and 72% rate of union, respectively and a much lower infection rate with vascularized fibular graft transfers. Forearm motion, complex regional pain syndrome, and synostosis were not discussed in these articles.

REFERENCES:

1. Wood MB. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg Am. 1987 May;12(3):422-7. PMID:3584891 (Link to Abstract)

2. Falder S, Sinclair JS, Rogers CA, Townsend PL. Long-term behaviour of the free vascularised fibula following reconstruction of large bony defects. Br J Plast Surg. 2003 Sep;56(6):571-84. PMID:12946376 (Link to Abstract)

3. Calkins MS, Burkhalter W, Reyes F. Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of corticocancellous bone. J Bone Joint Surg Am. 1987 Jan;69(1):19-27 PMID:3543018 (Link to Abstract)

Question Authors:

Michael Hughes MD,

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TAG

(OBQ08.86) What is the primary advantage of two incisions compared to one for open reduction internal fixation of a both bones forearm fracture? Topic

Review Topic

1. lower risk of synostosis
2. lower risk of wound complications
3. lower rate of radial neuritis
4. less pronator teres denervation
5. lower malunion rate

PREFERRED RESPONSE ▶

DISCUSSION: Post-osteosynthetic synostosis is a known complication in both bone forearm fractures. The risk is increased in fractures of the proximal 1/3 of the ulna and radius. Other risk factors include severity of injury, head trauma, polytrauma. Vince et al found synostosis was often associated with bone fragments or hardware in the interosseous space. Bauer et al found 1/65 cases treated utilizing the two-incision approach developed synostosis, while 5/12 cases in which the fractures were stabilized using a single incision developed synostoses. They recommended a two incision approach to both bones ORIF.

REFERENCES:

1. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am. 1987 Jun;69(5):640-53. PMID:3110165 (Link to Abstract)

2. Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg. 1991;110(3):142-5. PMID:2059537 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ07.141) Treatment of an atrophic nonunion of the radial diaphysis should include which of the following? Topic

Review Topic

1. Ilizarov fixation
2. Electrical stimulation
3. Ultrasound bone stimulator
4. Plate exchange with autogenous cancellous grafting
5. Plate exchange with ulnar shortening osteotomy

PREFERRED RESPONSE ▶

DISCUSSION: Atrophic nonunions of the radius and ulna are fairly rare with modern techniques of fixation; the few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions. The referenced study by Ring et al noted a 100% healing rate and improved patient reported outcomes with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting for atrophic forearm nonunions.

REFERENCES:

1. Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am. 2004 Nov;86-A(11):2440-5. PMID:15523016 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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TAG

(OBQ07.147) All of the following have been shown to increase the risk of refracture following removal of forearm plates used for internal fixation EXCEPT: Topic

Review Topic

1. initial fracture comminution
2. initial fracture displacement
3. use of 3.5 mm dynamic compression plate
4. plate removal before 12 months
5. immediate weight bearing as tolerated following removal

PREFERRED RESPONSE ▶

DISCUSSION: The Rumball et al article reviewed factors which influenced refracture after removal of the forearm plates. The factors that appeared to influence the refracture rate were degree of initial displacement and comminution, physical characteristics of the plate, early removal and lack of postremoval protection. Plates removed under 15 months showed an increased risk of refracture. There were no fractures in this series using the 3.5 DCP plate. Deluca et al concluded that, in retrospect, radiolucency at the site of the original fracture was seen in most patients (with refracture) when the plate was removed. Chapman et al found that all the refractures in their group had been intially treated with a 4.5 DCP plate, and that none of the patients with a 3.5 DCP had a refracture.

REFERENCES:

1. Rumball K, Finnegan M. Refractures after forearm plate removal. J Orthop Trauma. 1990;4(2):124-9 PMID:2358925 (Link to Abstract)

2. Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am. 1988 Oct;70(9):1372-6. PMID:3182889 (Link to Abstract)

3. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am. 1989 Feb;71(2):159-69. PMID:2918001 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore,

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TAG

(OBQ06.229) An otherwise healthy 30-year-old male sustains a left forearm injury as a result of a fall from a ladder. Initial examination in the emergency room reveals a clean 2 centimeter laceration over the volar forearm associated with the radiographs shown in Figures A and B. Treatment should consist of irrigation and debridement of the wound followed by which of the following? Topic

Review Topic

FIGURES: A

1. Closed reduction and casting of left radius and ulna
2. Temporary external fixation of the left radius and ulna
3. Definitive external fixation of the left radius and ulna
4. Open reduction and internal fixation of the left radius and ulna with delayed skin closure
5. Open reduction and internal fixation of the left radius and ulna with immediate skin closure

PREFERRED RESPONSE ▶

DISCUSSION: The clinical scenario is consistent with an open fractures of the distal radial and ulnar shafts. Literature shows that definitive plating of an open forearm fracture followed by primary closure of the wound is acceptable treatment at the time of injury.

Chapman et al performed a retrospective review of 50 patients with immediate internal plate fixation of an open diaphyseal fracture of the forearm. The functional results were excellent or good in 85%.

The review by Levin is a comprehensive review of the literature on early versus delayed closure of open fractures, and covers the change in thought from previous literature, including change in technology, surgical techniques, and a more critical review of previous literature.

REFERENCES:

1. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am. 1989 Feb;71(2):159-69. PMID:2918001 (Link to Abstract)

2. Levin LS. Early versus delayed closure of open fractures. Injury. 2007 Aug;38(8):896-9. PMID:17585912 (Link to Abstract)

Question Authors:

Ben Taylor MD, Jan Szatkowski MD, Ben Taylor MD,

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TAG

(OBQ05.25) A 70-year-old woman with known osteoporosis sustains a distal radius fracture of her dominant arm with some metaphyseal comminution. Adequate maintenance of reduction by non-operative treatment is unsuccesful. Which plating option provides the most appropriate treatment of this fracture? Topic

Review Topic

1. semitubular
2. dynamic compression
3. limited-contact dynamic compression
4. peri-articular locked
5. pelvic reconstruction

PREFERRED RESPONSE ▶

DISCUSSION: Egol et. al. studied locked and conventional plates. They concluded that locked plates may be increasingly indicated for indirect fracture reduction, diaphyseal/metaphyseal fractures in osteoporotic bone, bridging severely comminuted fractures, and the plating of fractures where anatomical constraints prevent plating on the tension side of the bone. Conventional plates remain the fixation method of choice for periarticular fractures that demand perfect anatomical reduction, and certain types of non-unions that require increased stability for union.

REFERENCES:

1. Sommer C, Babst R, Muller M, et. al: Locking compression plate loosening and plate breakage: A report of 4 cases. J Orthop Trauma, 2004;18:571-577. PMID:15475856 (Link to Abstract)

2. Egol KA, Kubiak EN, Fulkersojn E, et. al: Biomechanics of locked plates and screws. J Orthop Trauma, 2004;18:488-493 PMID:15475843 (Link to Abstract)

Question Authors:

Greg Galano MD, Derek Moore, Patrick McCulloch MD,

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TAG

(OBQ05.152) During open reduction and internal fixation of a both bone forearm fracture, restoration of the radial bow has been associated with which of the following? Topic

Review Topic

1. Wrist extension strength
2. Wrist flexion strength
3. Forearm rotation
4. Elbow range of motion
5. Decreased incidence of synostosis

PREFERRED RESPONSE ▶

DISCUSSION: Restoration of the anatomy of the radial bow directly correlates with the range of motion postoperatively (pronation-supination). The referenced study by Schemitsch et al found that restoration of the normal radial bow was related to the functional outcome. A good functional result (more than 80 percent of normal rotation of the forearm) was associated with restoration of the normal amount and location of the radial bow. Similarly, the recovery of grip strength was associated with restoration of the location of the radial bow toward normal.

REFERENCES:

1. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992 Aug;74(7):1068-78. PMID:1522093 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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TAG

(OBQ05.178) A 42-year-old male sustains a closed, isolated ulna shaft fracture with 2mm displacement and 3 degrees valgus angulation. He is treated conservatively with early range of motion but presents at one year with a painful atrophic nonunion. What treatment is indicated at this time? Topic

Review Topic

1. Dynamic splinting
2. Open autogenous cancellous bone grafting
3. Open reduction internal fixation with autogenous bone grafting
4. Closed reduction and percutaneous pinning
5. Use of an implantable ultrasound device

PREFERRED RESPONSE ▶

DISCUSSION: Appropriate treatment of an atrophic nonunion of the ulna includes open reduction and internal fixation with autogenous bone grafting. The atrophic nature of the nonunion reveals that biology, and not necessarily stability, is the major issue of the nonunion. The referenced article by Ring et al reviews a case series of these patients and found that even in the face of significant preoperative bone resorption, good clinical outcomes and union rate is possible with open plating and grafting. The article by Street reviews intramedullary nailing/pinning of the forearm, and found a 7% nonunion rate with this technique.

REFERENCES:

2. Street DM. Intramedullary forearm nailing. Clin Orthop Relat Res. 1986 Nov;(212):219-30. PMID:3769288 (Link to Abstract)

Question Authors:

Ben Taylor MD,

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Cases

	Malunion of ulna with radio ulnar synostosis of dominant hand (C1171) Trauma - - Radius and Ulnar Shaft Fractures HPI - He had a gunshot injury 8 months back. Compound fracture of both radius & ulna.... What is the management?	3/11/2012 75 responses 4
	Segmental both bones forearm fracture with punctured wounds (C1265) Trauma - Treatment Consult - Radius and Ulnar Shaft Fractures HPI - Conveyor belt injury How will you manage this case?*	9/9/2012 363 responses 3
	segmental radius fracture with ulna fracture (C1284) General - Treatment Consult - Radius and Ulnar Shaft Fractures HPI - h/o fall from a height of 3 ft. sustained a closed fracture both bones forearm.... nailing or plate and screws	10/10/2012 39 responses 5
$http://upload.orthobullets.com/cases/1293/radius ulna plate fracture ap.jpg$ $http://upload.orthobullets.com/cases/1293/radius ulna plate fracture lat.jpg$	fracture ulna around plate distal screw (C1293) Trauma - Treatment Consult - Radius and Ulnar Shaft Fractures HPI - This patient had ORIF fracture ulna radius 3 years ago which united uneventfully... How will u manage this case?	10/17/2012 85 responses 4

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Posts

The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. Includes Poll

Wright RR, Schmeling GJ, Schwab JP
J Orthop Trauma. 1997 May;11(4):288-94. PMID: 9258828 (Link to Pubmed)

Trauma - Journal Club - Radius and Ulnar Shaft Fractures

3/28/2013

168 responses

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ABOS II: Radius and Ulnar Shaft Fractures

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992 Aug;74(7):1068-78. PMID:1522093 (Link to Abstract)

Level of Evidence 4 (Case Series)

Falder S, Sinclair JS, Rogers CA, Townsend PL. Long-term behaviour of the free vascularised fibula following reconstruction of large bony defects. Br J Plast Surg. 2003 Sep;56(6):571-84. PMID:12946376 (Link to Abstract)
Calkins MS, Burkhalter W, Reyes F. Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of corticocancellous bone. J Bone Joint Surg Am. 1987 Jan;69(1):19-27 PMID:3543018 (Link to Abstract)
Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am. 2004 Nov;86-A(11):2440-5. PMID:15523016 (Link to Abstract)
Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am. 1989 Feb;71(2):159-69. PMID:2918001 (Link to Abstract)
Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone-grafting. J Bone Joint Surg Am. 2004 Nov;86-A(11):2440-5. PMID:15523016 (Link to Abstract)
Street DM. Intramedullary forearm nailing. Clin Orthop Relat Res. 1986 Nov;(212):219-30. PMID:3769288 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of ligament attachment locations. J Hand Surg Am. 2009 Mar;34(3):415-22. Epub 2009 Feb 11 PMID:19211201 (Link to Abstract)
Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer in cadavers. J Hand Surg Am. 2005 Mar;30(2):319-25. PMID:15781355 (Link to Abstract)
Levin LS. Early versus delayed closure of open fractures. Injury. 2007 Aug;38(8):896-9. PMID:17585912 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Galatz LM. Shoulder reconstruction. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:301-311.

Undefined

Pollock FH, Pankovich AM, Prieto JJ, Lorenz M. The isolated fracture of the ulnar shaft. Treatment without immobilization. J Bone Joint Surg Am. 1983 Mar;65(3):339-42. PMID:6826596 (Link to Abstract)
Beingessner DM, Patterson SD, King GJ. Early excision of heterotopic bone in the forearm. J Hand Surg Am. 2000 May;25(3):483-8. PMID:10811753 (Link to Abstract)
McAuliffe JA, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am. 1997 May;79(5):749-55 PMID:9160948 (Link to Abstract)
Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop Trauma 1997;11:288-294 PMID:9258828 (Link to Abstract)
Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 307-316
Moed BR, Kellam JF, Foster RJ, et al: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am 1986;68:1008-1017 PMID:3745238 (Link to Abstract)
Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting indiaphyseal forearm fractures: a retrospective review. J Orthop Trauma. 1997 May;11(4):288-94. PMID:9258828 (Link to Abstract)
Wei SY, Born CT, Abene A, Ong A, Hayda R, DeLong WG Jr. Diaphyseal forearm fractures treated with and without bone graft. J Trauma. 1999 Jun;46(6):1045-8. PMID:10372622 (Link to Abstract)
Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992 Aug;74(7):1068-78. PMID:1522093 (Link to Abstract)
Wood MB. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg Am. 1987 May;12(3):422-7. PMID:3584891 (Link to Abstract)
Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am. 1987 Jun;69(5):640-53. PMID:3110165 (Link to Abstract)
Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg. 1991;110(3):142-5. PMID:2059537 (Link to Abstract)
Rumball K, Finnegan M. Refractures after forearm plate removal. J Orthop Trauma. 1990;4(2):124-9 PMID:2358925 (Link to Abstract)
Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am. 1988 Oct;70(9):1372-6. PMID:3182889 (Link to Abstract)
Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am. 1989 Feb;71(2):159-69. PMID:2918001 (Link to Abstract)
Sommer C, Babst R, Muller M, et. al: Locking compression plate loosening and plate breakage: A report of 4 cases. J Orthop Trauma, 2004;18:571-577. PMID:15475856 (Link to Abstract)
Egol KA, Kubiak EN, Fulkersojn E, et. al: Biomechanics of locked plates and screws. J Orthop Trauma, 2004;18:488-493 PMID:15475843 (Link to Abstract)

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Radius and Ulnar Shaft Fractures

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