Summary Radius and ulnar shaft fractures, also known as adult both bone forearm fractures, are common fractures of the forearm caused by either direct trauma or indirect trauma (fall). Diagnosis is made by physical exam and plain orthogonal radiographs. Treatment is generally surgical open reduction and internal fixation with compression plating of both the ulna and radius fractures. Epidemiology Demographics highest incidence in men between age 10 and 20 women over age of 60 Etiology Pathophysiology mechanism of injury direct trauma direct blow to forearm indirect trauma motor vehicle accidents falls from height axial load applied to the forearm through the hand Associated conditions elbow and DRUJ injuries Galeazzi fractures Monteggia fractures Essex-Lopresti injuries compartment syndrome evaluate compartment pressures if concern for compartment syndrome 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 Ligaments Interosseous membrane (IOM) occupies the space between the radius and ulna permits rotation of the radius around the 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, multi-fragmented displacement angulation rotational alignment OTA classification radial and ulna diaphyseal fractures Type A (simple) simple fracture that is spiral (A1), oblique (A2), or transverse (A3) Type B (wedge) wedge fracture that is intact (B2) or fragmentary (B3) Type C (multifragmentary) multifragmentary fracture that is intact segmental (C2) or fragmentary segmental (C3) Presentation Symptoms pain and swelling loss of forearm and hand function Physical exam inspection gross deformity open injuries check for tense forearm compartments neurovascular exam assess radial and ulnar pulses document median, radial, and ulnar nerve function provocative tests pain with passive stretch of fingers 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 AP and lateral of the wrist and elbow to evaluate for associated fractures or dislocation radial head must be aligned with the capitulum on all views Treatment Nonoperative cast or brace immobilization indications rare completely nondisplaced fractures in patients who are not surgical candidates modality bracing functional fracture brace casting Muenster cast with good interosseous mold outcomes high rates of non-union associated with non-operative management Operative external fixation indications severe soft tissue injury (Gustilo IIIB) ORIF indications nearly all both bone fractures in surgical candidates Gustilo I, II, and IIIa open fractures may be treated with primary ORIF outcomes goal is for cortical opposition, compression and restoration of forearm anatomy most important variable in functional outcome is to restore the radial bow > 95% union rates of simple both bone fractures with compression plating ORIF with bone grafting indications open fractures with significant bone loss bone loss that is segmental or associated with open injury (primary or delayed grafting in open injuries) nonunions of the forearm outcomes use of autograft may be critical to achieve fracture union IM nailing indications very poor soft-tissue integrity outcomes not preferred due to lack of rotational and axial stability and difficulty maintaining radial bow high nonunion rate IMN do not provide compression across fracture site Techniques Functional brace or Muenster cast technique cast/brace should extend just above elbow to control forearm rotation monitor very closely (~1 week) for displacement should be worn for at least 6 weeks. External fixation technique 2nd and 3rd metacarpal shaft can both be utilized for distal pin placement pin diameter should not exceed 4 mm ORIF approach fixation of the fracture with less comminution restores length and may facilitate reduction of other bone 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 fractures dorsal (Thompson) approach to radius can be utilized for proximal 1/3 radial fractures ulna subcutaneous approach to ulna shaft technique 3.5 mm DCP plate (AO technique) is standard 4.5 plates no longer used due to increased rate of refracture following removal longer plates are preferred due to high torsional stress in forearm may require contouring of plate compression mode preferred to achieve anatomic primary bony healing to minimize strain, six cortices proximal and distal to fracture should be engaged locked plates are increasingly indicated over conventional plates in osteoporotic bone bridge plating may be used in extensively comminuted fractures interfragmentary lag screws (2.0 or 2.7 screws) if necessary open fractures irrigation and debridement should be performed to remove any contaminated tissue or bony fragments without soft tissue attachments plate placement placement of plates on dorsal (tension) side is biomechanically superior but volar placement offers better place seating and soft tissue coverage 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 generally 6 weeks ORIF with bone grafting technique cancellous autograft is indicated in radial and ulnar fractures with significant bone loss vascularized fibula grafts can be used for large defects and have a lower rate of infection Masquelet technique (induced-membrane technique) can also be utilized in cases of non-union or open fractures with significant bone loss 2 stage technique 1st stage: I&D, cement spacer and temporizing fixation 2nd stage: placement of bone graft into induced membrane and definitive fixation IM nailing approach ulnar nail inserted through the posterior olecranon radial nail inserted between the extensor tendons near Listers tubercle technique nails may need to be bent to accommodate for the radial bow may use a small incision at fracture site to facilitate passing of nail Complications Synostosis incidence reported between 3 to 9% risk factors associated with ORIF using a single incision approach treatment 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 incidence 3% incidence with ORIF risk factors open fractures Compartment syndrome incidence up to 15% depending on mechanism and fracture characteristics risk factors high energy crush injury open fractures low velocity GSWs vascular injuries coagulopathies (DIC) Nonunion incidence < 5% after compression plating up to 12% in extensively comminute fractures treated with bridge plating risk factors extensive comminution poorly applied plate fixation IMN fixation treatment atrophic nonunions can be treated with 3.5 mm plates and autogenous cancellous bone grafting Infection and atrophic nonunions can also be treated with the Masquelet technique Malunion risk factors direct correlation between restoration of radial bow and functional outcome Neurovascular injury risk factors PIN injury with Monteggia fxs and Henry (volar) approach to middle and upper third radial diaphysis Type III open fxs treatment observe for three months to see if nerve function returns explore if no return of function after 3 months Refracture incidence up to 10% with early removal risk factors removing plate too early plates should not be removed < 1 year from implantation large plates (4.5 mm) comminuted fractures persistent radiographic lucency treatment wear functional forearm brace for 6 weeks and protect activity for 3 months after plate removal Prognosis Functional results depend on the restoration of radial bow malunion of the radius and ulna with angulation > 20 degrees is likely to limit forearm rotation
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. Both Bone Forearm Fracture ORIF Orthobullets Team Trauma - Radius and Ulnar Shaft Fractures
QUESTIONS 1 of 20 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ17SE.35) A 30-year-old plastic surgery resident fell from a height of 12' and sustained a right both-bone forearm fracture. The patient underwent open reduction and internal fixation with 3.5mm Limited Contact Dynamic Compression Plating. Three months after fixation the patient has no forearm tenderness and has full active range of motion of his fingers, hand, and wrist. However, pronation and supination are severely limited. This affects his ability to suture during surgery and knit, although he has returned to his other recreational activities. His most recent radiographs are shown in Figures A and B. What is the most likely cause for his lack motion? QID: 211490 FIGURES: A B Type & Select Correct Answer 1 Fracture nonunion 0% (6/1622) 2 Posterior interosseous nerve (PIN) palsy 0% (8/1622) 3 ECU interposition at the DRUJ 2% (29/1622) 4 Heterotopic ossification 5% (85/1622) 5 Loss of radial bow 91% (1483/1622) L 1 Question Complexity A Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ16.78) During proximal exposure for plating of a radial shaft fracture through a classic volar Henry approach, the radial artery should be retracted ______ and the supinator muscle should be retracted ______ with the forearm in ______. QID: 8840 Type & Select Correct Answer 1 medially; laterally; pronation 5% (117/2167) 2 laterally; medially; supination 29% (633/2167) 3 laterally; laterally; supination 15% (315/2167) 4 laterally ; medially; pronation 8% (167/2167) 5 medially; laterally; supination 42% (917/2167) L 5 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.59) Which of the following has been shown to be the greatest risk factor for refracture after plate removal from a radial shaft? QID: 3974 Type & Select Correct Answer 1 Removal of locking screws 4% (95/2611) 2 Removal of small fragment plates 2% (42/2611) 3 Removal of metaphyseal implants 5% (135/2611) 4 Removal of implants less than 1 year after insertion 84% (2203/2611) 5 Removal of protective splinting from limb earlier than 10 weeks postoperatively 4% (112/2611) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ12TR.101) An otherwise healthy young adult male sustains a transverse radial shaft and ulna fracture. He undergoes definitive surgical fixation with two non-locking compression plates (LCPs) as shown in Figure A. What is the principle of this fixation technique on bone healing? QID: 4016 FIGURES: A Type & Select Correct Answer 1 Absolute stability with direct healing by callus formation 3% (60/2250) 2 Relative stability with indirect healing by callus formation 3% (61/2250) 3 Absolute stability with direct healing by internal remodeling 83% (1873/2250) 4 Relative stability with indirect healing by internal remodeling 1% (20/2250) 5 Absolute stability with endochondral bone formation 10% (224/2250) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 3113 Type & Select Correct Answer 1 Central band ligament 1% (19/1982) 2 Accessory band ligament 2% (34/1982) 3 Annular ligament 91% (1794/1982) 4 Dorsal oblique accessory cord ligament 4% (84/1982) 5 Distal oblique bundle ligament 2% (42/1982) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 3292 Type & Select Correct Answer 1 Once ankylosis of the forearm or elbow occurs 3% (48/1524) 2 6 weeks 15% (229/1524) 3 6 months 63% (963/1524) 4 12 months 15% (227/1524) 5 18 months 3% (45/1524) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (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? QID: 2859 FIGURES: A Type & Select Correct Answer 1 External fixation 3% (105/3404) 2 Flexible intramedullary nailing 0% (16/3404) 3 Open reduction and internal fixation with acute bone grafting 19% (649/3404) 4 Open reduction and internal fixation 77% (2616/3404) 5 Closed reduction and functional bracing 0% (3/3404) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (OBQ08.65) A 25-year-old man sustains an open forearm fracture from an auger as depicted in Figures A and B. After debridement of nonviable bone, a 10cm 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 which of the following complications? QID: 451 FIGURES: A B Type & Select Correct Answer 1 Higher incidence of infection 77% (1830/2369) 2 Lower nonunion rate 6% (143/2369) 3 Decreased forearm arc of rotation 5% (123/2369) 4 Complex regional pain syndrome 1% (21/2369) 5 Synostosis 10% (236/2369) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 413 FIGURES: A Type & Select Correct Answer 1 Bone grafting 79% (1280/1625) 2 Tricalcium phosphate 6% (90/1625) 3 Calcium phosphate 10% (157/1625) 4 Calcium sulphate 2% (33/1625) 5 BMP-3 3% (55/1625) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (OBQ08.86) What is the primary advantage of two incisions compared to one for open reduction internal fixation of a both bones forearm fracture? QID: 472 Type & Select Correct Answer 1 lower risk of synostosis 80% (1545/1938) 2 lower risk of wound complications 2% (42/1938) 3 lower rate of radial neuritis 4% (77/1938) 4 less pronator teres denervation 4% (81/1938) 5 lower malunion rate 9% (182/1938) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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: QID: 808 Type & Select Correct Answer 1 initial fracture comminution 2% (23/1019) 2 initial fracture displacement 17% (170/1019) 3 use of 3.5 mm dynamic compression plate 64% (652/1019) 4 plate removal before 12 months 6% (57/1019) 5 immediate activity as tolerated following removal 11% (113/1019) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ07.141) Treatment of an atrophic nonunion of the radial diaphysis should include which of the following? QID: 802 Type & Select Correct Answer 1 Ilizarov fixation 1% (12/1301) 2 Electrical stimulation 1% (14/1301) 3 Ultrasound bone stimulator 5% (59/1301) 4 Plate exchange with autogenous cancellous grafting 89% (1154/1301) 5 Plate exchange with ulnar shortening osteotomy 4% (51/1301) L 1 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (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? QID: 240 FIGURES: A B Type & Select Correct Answer 1 Closed reduction and casting of left radius and ulna 1% (15/1197) 2 Temporary external fixation of the left radius and ulna 4% (48/1197) 3 Definitive external fixation of the left radius and ulna 1% (11/1197) 4 Open reduction and internal fixation of the left radius and ulna with delayed skin closure 5% (60/1197) 5 Open reduction and internal fixation of the left radius and ulna with immediate skin closure 88% (1056/1197) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic (OBQ05.152) During open reduction and internal fixation of a both bone forearm fracture, restoration of the radial bow has been most associated with which of the following? QID: 1038 Type & Select Correct Answer 1 Improvement in wrist extension strength 1% (27/2513) 2 Improvement in wrist flexion strength 1% (24/2513) 3 Restoration of forearm rotation 95% (2388/2513) 4 Restoration of elbow range of motion 1% (15/2513) 5 Decreased incidence of synostosis 2% (44/2513) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic
All Videos (14) Podcasts (2) Login to View Community Videos Login to View Community Videos Posterior Approach to the Radial Diaphysis.(Thompson Approach ) Kemal Gokkus Trauma - Radius and Ulnar Shaft Fractures 1/8/2023 99 views 0.0 (0) Login to View Community Videos Login to View Community Videos 7th Annual Frontiers in Upper Extremity Surgery Distal Ulna Fractures Associated with Distal Radius Fractures - H. Brent Bamberger, MS PT DO Brent Bamberger Trauma - Radius and Ulnar Shaft Fractures 11/3/2022 40 views 0.0 (0) 7th Annual Frontiers in Upper Extremity Surgery Case Review: Radial Head and Ulna Fracture in a 48 Years Old Male After a Cycling Injury - Peter Evans, MD Peter J. Evans Trauma - Radius and Ulnar Shaft Fractures 10/4/2022 516 views 4.0 (1) Trauma⎪Radius and Ulnar Shaft Fractures Team Orthobullets 4 Trauma - Radius and Ulnar Shaft Fractures Listen Now 11:9 min 10/15/2019 1124 plays 5.0 (10) Question Session⎪Radius and Ulnar Shaft Fractures Orthobullets Team Trauma - Radius and Ulnar Shaft Fractures Listen Now 17:8 min 11/6/2019 183 plays 5.0 (1) See More See Less
Open Both Bone Forearm Fracture in 52M (C101842) Travis Jones Bruce G. French Trauma - Radius and Ulnar Shaft Fractures A 11/9/2021 12791 24 13 Proximal ulna fracture (C101638) Jacob Triplet Trauma - Radius and Ulnar Shaft Fractures B 11/28/2020 122 9 0 Cleveland Clinic, Florida Proximal Both Bone Forearm Fracture in 28M (C101587) Peter J. Evans Trauma - Radius and Ulnar Shaft Fractures A 9/27/2020 15338 34 39 See More See Less