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Updated: 11/7/2022

Radius and Ulnar Shaft Fractures

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Images and lateral radiographs of the forearm.jpg bone fx post op_moved.jpg
  • 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 Guides (1)
Flashcards (43)
1 of 43
Questions (20)
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(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

Fracture nonunion



Posterior interosseous nerve (PIN) palsy



ECU interposition at the DRUJ



Heterotopic ossification



Loss of radial bow



L 1 A

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(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

medially; laterally; pronation



laterally; medially; supination



laterally; laterally; supination



laterally ; medially; pronation



medially; laterally; supination



L 5 B

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(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

Removal of locking screws



Removal of small fragment plates



Removal of metaphyseal implants



Removal of implants less than 1 year after insertion



Removal of protective splinting from limb earlier than 10 weeks postoperatively



L 2 C

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(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

Absolute stability with direct healing by callus formation



Relative stability with indirect healing by callus formation



Absolute stability with direct healing by internal remodeling



Relative stability with indirect healing by internal remodeling



Absolute stability with endochondral bone formation



L 1 B

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(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

Central band ligament



Accessory band ligament



Annular ligament



Dorsal oblique accessory cord ligament



Distal oblique bundle ligament



L 1 C

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(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

Once ankylosis of the forearm or elbow occurs



6 weeks



6 months



12 months



18 months



L 1 C

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(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

External fixation



Flexible intramedullary nailing



Open reduction and internal fixation with acute bone grafting



Open reduction and internal fixation



Closed reduction and functional bracing



L 2 C

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(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

Higher incidence of infection



Lower nonunion rate



Decreased forearm arc of rotation



Complex regional pain syndrome






L 2 D

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(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

Bone grafting



Tricalcium phosphate



Calcium phosphate



Calcium sulphate






L 2 C

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(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

lower risk of synostosis



lower risk of wound complications



lower rate of radial neuritis



less pronator teres denervation



lower malunion rate



L 2 C

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(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

initial fracture comminution



initial fracture displacement



use of 3.5 mm dynamic compression plate



plate removal before 12 months



immediate activity as tolerated following removal



L 1 C

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

QID: 802

Ilizarov fixation



Electrical stimulation



Ultrasound bone stimulator



Plate exchange with autogenous cancellous grafting



Plate exchange with ulnar shortening osteotomy



L 1 B

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(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

Closed reduction and casting of left radius and ulna



Temporary external fixation of the left radius and ulna



Definitive external fixation of the left radius and ulna



Open reduction and internal fixation of the left radius and ulna with delayed skin closure



Open reduction and internal fixation of the left radius and ulna with immediate skin closure



L 1 C

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(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

Improvement in wrist extension strength



Improvement in wrist flexion strength



Restoration of forearm rotation



Restoration of elbow range of motion



Decreased incidence of synostosis



L 1 C

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Evidence (71)
CASES (27)
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