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http://upload.orthobullets.com/topic/1025/images/Xray- AP - both bone fx (TGH)_moved.jpg
http://upload.orthobullets.com/topic/1025/images/radial bow.jpg
http://upload.orthobullets.com/topic/1025/images/interosseus membrae.jpg
http://upload.orthobullets.com/topic/1025/images/ota classification of radial and ulna shaft fractures.jpg
http://upload.orthobullets.com/topic/1025/images/ap and lateral radiographs of the forearm.jpg
http://upload.orthobullets.com/topic/1025/images/Both bone fx post op_moved.jpg
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
    • axis of rotation of forearm runs through radial head (proximal) and ulna fovea (distal)
      • distal radius effectively rotates around the distal ulna in pronosupination
  • 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(delayed grafting in open injuries)  
        • 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
        • locked plates are increasingly indicated over conventional plates in osteoporotic bone and in bridging comminuted fractures  
      • 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
      • should be managed with a period of non-weight bearing due to risk of secondary displacement of the fracture  
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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