Updated: 11/17/2018

Radius and Ulnar Shaft Fractures

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https://upload.orthobullets.com/topic/1025/images/Xray- AP - both bone fx (TGH)_moved.jpg
https://upload.orthobullets.com/topic/1025/images/radial bow.jpg
https://upload.orthobullets.com/topic/1025/images/interosseus membrae.jpg
https://upload.orthobullets.com/topic/1025/images/ota classification of radial and ulna shaft fractures.jpg
https://upload.orthobullets.com/topic/1025/images/ap and lateral radiographs of the forearm.jpg
https://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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Technique Guides (1)
Questions (19)
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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? Review Topic

QID: 2859
FIGURES:
1

External fixation

3%

(58/2182)

2

Flexible intramedullary nailing

0%

(8/2182)

3

Open reduction and internal fixation with acute bone grafting

20%

(434/2182)

4

Open reduction and internal fixation

77%

(1674/2182)

5

Closed reduction and functional bracing

0%

(0/2182)

ML 2

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PREFERRED RESPONSE 4
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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: Review Topic

QID: 808
1

initial fracture comminution

2%

(10/509)

2

initial fracture displacement

16%

(82/509)

3

use of 3.5 mm dynamic compression plate

66%

(334/509)

4

plate removal before 12 months

5%

(25/509)

5

immediate activity as tolerated following removal

11%

(56/509)

ML 3

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PREFERRED RESPONSE 3
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(OBQ07.141) Treatment of an atrophic nonunion of the radial diaphysis should include which of the following? Review Topic

QID: 802
1

Ilizarov fixation

1%

(8/700)

2

Electrical stimulation

1%

(7/700)

3

Ultrasound bone stimulator

6%

(41/700)

4

Plate exchange with autogenous cancellous grafting

88%

(615/700)

5

Plate exchange with ulnar shortening osteotomy

4%

(25/700)

ML 1

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PREFERRED RESPONSE 4

(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? Review Topic

QID: 3173
FIGURES:
1

Long arm cast immobilization is necessary with nonoperative management

16%

(185/1140)

2

Twenty degree loss of forearm rotation is expected with nonoperative management

6%

(65/1140)

3

Loss of wrist motion is expected with nonoperative management

2%

(19/1140)

4

Loss of elbow motion is expected with nonoperative management

3%

(29/1140)

5

Equivalent clinical outcomes

73%

(837/1140)

ML 2

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PREFERRED RESPONSE 5
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(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? Review Topic

QID: 1064
1

Dynamic splinting

1%

(5/714)

2

Open autogenous cancellous bone grafting

2%

(13/714)

3

Open reduction internal fixation with autogenous bone grafting

96%

(686/714)

4

Closed reduction and percutaneous pinning

0%

(1/714)

5

Use of an implantable ultrasound device

0%

(3/714)

ML 1

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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?
Review Topic

QID: 413
FIGURES:
1

Bone grafting

80%

(678/849)

2

Tricalcium phosphate

5%

(45/849)

3

Calcium phosphate

9%

(79/849)

4

Calcium sulphate

2%

(19/849)

5

BMP-3

3%

(24/849)

ML 2

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PREFERRED RESPONSE 1

(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? Review Topic

QID: 3113
1

Central band ligament

1%

(11/1282)

2

Accessory band ligament

1%

(18/1282)

3

Annular ligament

91%

(1167/1282)

4

Dorsal oblique accessory cord ligament

5%

(58/1282)

5

Distal oblique bundle ligament

2%

(25/1282)

ML 1

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 1038
1

Improvement in wrist extension strength

1%

(15/1848)

2

Improvement in wrist flexion strength

1%

(12/1848)

3

Restoration of forearm rotation

96%

(1769/1848)

4

Restoration of elbow range of motion

1%

(12/1848)

5

Decreased incidence of synostosis

2%

(29/1848)

ML 1

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 3292
1

Once ankylosis of the forearm or elbow occurs

3%

(22/712)

2

6 weeks

15%

(110/712)

3

6 months

62%

(440/712)

4

12 months

15%

(110/712)

5

18 months

3%

(21/712)

ML 3

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PREFERRED RESPONSE 3

(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? Review Topic

QID: 240
FIGURES:
1

Closed reduction and casting of left radius and ulna

1%

(8/600)

2

Temporary external fixation of the left radius and ulna

3%

(16/600)

3

Definitive external fixation of the left radius and ulna

1%

(7/600)

4

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

7%

(44/600)

5

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

87%

(520/600)

ML 1

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PREFERRED RESPONSE 5

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

QID: 472
1

lower risk of synostosis

81%

(1007/1246)

2

lower risk of wound complications

2%

(23/1246)

3

lower rate of radial neuritis

4%

(51/1246)

4

less pronator teres denervation

4%

(49/1246)

5

lower malunion rate

9%

(109/1246)

ML 2

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PREFERRED RESPONSE 1
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