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Forearm Fractures

Author
Gopikrishna Kakarala, MBBS, MS MRCSEd, Fellow, Department of Orthopedics, New
Cross Hospital, UK
Updated: Oct 30, 2015

Background
The forearm is a complex anatomic structure serving an integral role in upper-extremity
function. The dexterity of the upper limb depends on a combination of hand and wrist
function and forearm rotation. The forearm bones can be considered struts linking the
two halves of a condylar joint formed by the proximal and distal radioulnar joints. Thus,
any change in the geometry of the radius or ulna alters the congruency and range of
motion of this condylar joint.
Malunion, especially shortening and angulation of the radius or ulna, may cause
functional problems at the wrist or elbow. If functional disability is to be avoided after
fracture, precise anatomic reduction is necessary.
As a result of the complex arrangement of neurovascular structures surrounding the
radius and ulna, surgical approaches to the forearm for fracture fixation require
particular care in planning and execution. To restore the functional dynamics of the
upper limb, very careful attention must be paid to accurate reconstruction of injured
structures.
In children, rapid bone-healing times and the possibility of remodeling with growth allow
conservative treatment much of the time.[1] In adults, nonoperative treatment in the form
of plaster casting is often inadequate to ensure anatomic reduction and healing.
Achieving anatomic reduction by closed methods is difficult, and maintaining a reduction
is often impossible.
For an optimal result, the basic rule is that a stable anatomic reduction with preservation
of mobility must be achieved. Operative treatment is therefore the rule, rather than the
exception, in adults, the treatment principles of the AO group (Arbeitsgemeinschaft fr
Osteosynthese, or Association for the Study of Osteosynthesis) have revolutionized
treatment of radius and ulna fractures.
This article addresses injury to the diaphyseal radius and ulna, as well as associated
injury to the distal and proximal radioulnar joints.

Anatomy
The radius and ulna function as a unit, but they come into contact with each other only
at the ends. They are bound proximally by the capsule of the elbow joint and the
annular ligament and distally by the capsule of the wrist joint, the dorsal and volar
radioulnar ligaments, and the fibrocartilaginous articular disk.

The ulna is relatively straight, has stable articulation with the distal humerus at the
elbow, and runs virtually subcutaneously distally to the ulnar styloid at the wrist. The
radius is bowed along its length and thus angles at least 13 opposite to the bow to
articulate with the capitellum. The radius and ulna form a joint at the distal end, where
the strutlike radius sweeps and rotates around the relatively fixed ulna with pronation
and supination.
Between the shafts of the radius and ulna is the interosseous space. The fibers of the
interosseous membrane run obliquely across the interosseous space from their distal
insertion on the ulna to their proximal origin on the radius. The central portion of the
interosseous membrane is thickened and is approximately 3.5 cm wide. Hotchkiss et al
showed that making an incision on the central band reduces stability by 71%, whereas
making an incision of the triangular fibrocartilage complex and the interosseous
membrane proximal to the central band decreases stability by only 11%. [2]
In the treatment of fractures of the forearm, the radial bow and proper interosseous
space must be maintained for normal motion to be achieved. Schemitsch et al reported
that restoration of the radial bow is related in a linear fashion to the quality of the
outcome.[3] The normal maximal radial bow, measured from the area between the radius
and the ulna across the interosseous membrane, is 15 mm. To achieve 80% of the
normal range of movement, this bow must be within 1.5 mm of normal. The same
relationship also applies to grip strength. Both the amount and the location of radial bow
are crucial correlates to functional outcome.

Pathophysiology
Fractures of both bones of the forearm are usually classified according to the level of
fracture, the pattern of the fracture, the degree of displacement, the presence or
absence of comminution or segment bone loss, and whether they are open or closed.
Each of these factors may have some bearing on the type of treatment to be selected
and the ultimate prognosis.
Disruption of the proximal or distal radioulnar joints is of great significance to treatment
and prognosis. Determining whether the fracture is associated with joint injury is
imperative because effective treatment demands that both the fracture and the joint
injury be treated in an integrated fashion.

Etiology
The mechanism of injury is variable. The most common cause is a direct blow to the
forearm, producing a single (nightstick) fracture of the ulna, the radius, or both. The next
most likely mechanism is a fall on an outstretched hand with the forearm pronated.
Other mechanisms of injury include road traffic accidents and athletic injuries. The force
generated is usually much greater than that required to cause a Colles fracture. Most
forearm shaft fractures resulting from falls occur in athletes or in persons who fall from
heights.

Gunshot wounds can result in fracture of both bones of the forearm. These injuries are
commonly associated with nerve or soft-tissue deficits and frequently have significant
bone loss. Severely debilitating and mutilating injuries are caused by accidents involving
farmyard machines and industrial machinery. These severely mangled extremities pose
a challenge from the time the decision is made to salvage the limb until the final result.

Epidemiology
In 2010, according to data from the 2010 National Electronic Injury Surveillance System
(NEISS) database and the 2010 US Census, forearm fractures were the most common
type of fracture in the pediatric population (age range, 0-19 years) and accounted for
17.8% of all fractures.[4]
The literature provides few details regarding the incidence of fractures of the radius and
ulna in adults. McQueen et al comprehensively analyzed the incidence of forearm
fractures seen at the trauma unit of the Royal Infirmary of Edinburgh over a 3-year
period.[5] This unit caters exclusively to adult trauma cases in a specified area and
population and thus is a very good guide to the epidemiology of forearm fractures in a
westernized country.
In this analysis, the causes of injury included direct trauma, fall from a height, road
traffic accidents, and sporting injuries.[5] Unlike in other regions, injuries related to
gunshots and firearms are not prevalent as a cause of injury in this region. Of the 2812
fractures, just 5% were diaphyseal forearm fractures, and an overwhelming majority of
76% were distal radius fractures.
Data from the National Hospital Ambulatory Medical Care Survey showed that radius
and/or ulna fractures accounted for 44% of all forearm and hand fractures in the United
States.[6]

Prognosis
The prognosis for adults with fractures of the radius and ulna depends on many factors.
[7, 8, 9, 10]
However, the factors under the surgeon's control include choice of treatment
method, timing of internal fixation in open fractures, soft-tissue handling, and restoration
of osseous anatomy.
Anderson reported a union rate of 97.3% for fractures treated with open reduction and
internal fixation (ORIF) using compression plates. [11] Of these patients, 90% had
satisfactory or excellent function, and only 10% had unsatisfactory or poor function.
Sage reported a union rate of 93.8% for fractures treated with triangular nails. [12]
One study compared the complication rates in patients treated with external fixation
versus volar plating of distal radius fractures. The volar plate group experienced more
tendon and median nerve complications; however, the external fixation group had a
significantly higher overall complication rate. While there were no significant differences
between the groups in the scapholunate angle or palmar tilt measurements, the volar
plate group had significantly better arc of motion in pronation-supination and flexionextension and better grip strength.[13]

The important feature common to these studies, in which a union rate of more than 90%
was reported, was the rigidity of the fixation. If intramedullary nails are used, they must
control rotation of the fragments and be sturdy enough to resist angulatory forces. If
plates and screws are used, they must be long enough and strong enough to resist
loosening and breakage.
The prognosis is more guarded for open fractures of the shaft of the radius and ulna
with major skin and soft-tissue loss. In these cases, several operative procedures may
be necessary, including initial debridement and stabilization, skin grafting, pedicle or
free-flap applications,[14] late reconstruction of the bones, and, frequently, tendon
transfers.

History
Nondisplaced diaphyseal fractures of the shafts of both bones of the forearm are rare,
and the deformity is often obvious, with the patient supporting the deformed and injured
limb with the other hand. The symptoms include pain, deformity, and loss of function of
the forearm. In these cases, excessive manipulation of the arm should be avoided to
prevent further damage to the soft tissues.

Physical Examination
Clinical examination should include a careful neurologic evaluation of the motor and
sensory functions of the radial, median, and ulnar nerves. Check the vascular status
and amount of swelling in the forearm. A tense compartment with neurologic signs or
stretch pain should arouse the suspicion of compartment syndrome (see the first image
below), and compartment pressures should be measured and monitored. This may be
of significance in polytrauma patients or in comatose or obtunded patients. A low
threshold should be maintained when deciding whether a fasciotomy is needed in
patients with impending compartment syndrome.

Closed fracture of the forearm in the middle-third area is complicated by compartment syndrome,
with early blisters and a tense compartment.

Open fractures, especially those resulting from gunshot wounds, frequently have
associated nerve and major blood vessel involvement. This involvement must be
carefully evaluated. Urgent treatment is required for open fractures. A sterile dressing
should be placed over the wound, and formal debridement should be reserved for the
operating room.

The presence of ipsilateral fractures should be excluded, and a preliminary secondary


survey should be performed to rule out other skeletal injuries.

Imaging Studies
The configuration of midshaft fractures of the radius and ulna varies depending on the
mechanism of injury and the degree of violence involved. Low-energy fractures tend to
be transverse or short oblique, whereas high-energy injuries are frequently extensively
comminuted or segmented, often with extensive soft-tissue injuries.

Radiography
At least two radiographic projections (ie, anteroposterior and lateral) of the forearm must
be obtained. These show the fracture, the extent of displacement, and the extent of
comminution. Attention should be directed toward finding any foreign bodies in open
fractures and gunshot injuries.
Also imperative is to include the elbow and wrist joint in the radiographs of forearm
fractures to ensure that radial head and distal radioulnar joint injuries are not missed. A
line through the center of the radial shaft, neck, and head should pass through the
center of the capitellum in any view of the elbow.
A tuberosity view may help ascertain the rotational displacement of the fracture. This
would help in planning how much supination or pronation is needed to achieve accurate
anatomic reduction. The ulna is laid flat on the cassette with its subcutaneous border in
contact with the cassette; the x-ray tube is tilted toward the olecranon by 20. This
radiograph is then compared with a standard set of diagrams that show the prominence
of the radial tuberosity in various degrees of pronation and supination in order to
determine the scope of the rotational deformity.

Computed tomography
Computed tomography (CT) is useful in distal radius fractures and radioulnar joint
pathologies. One study examined whether the location of distal fractures of the radius
correlate with the areas of attachment of the wrist ligaments. [15] Using data from CT
scans of acute intra-articular distal radius fractures, the study noted that articular
fractures of the distal radius were statistically more likely to occur at the intervals
between the ligament attachments than at the ligament attachments. The most common
fracture sites were the center of the sigmoid notch, between the short and long
radiolunate ligaments, and the central and ulnar aspects of the scaphoid fossa dorsally.

These results suggest that CT may be used to identify the subsequent propagation of
the fracture and the likely site of the impaction of the carpus on the distal radius articular
surface.

Other modalities
Magnetic resonance imaging (MRI) is of limited utility in radioulnar injuries and is not
indicated in uncomplicated forearm fractures. Angiography or vascular Doppler
ultrasonography is useful to determine the level of vascular injury in selected cases in
which vascular injury is suspected.

Approach Considerations
All displaced adult forearm fractures should be stabilized because no other means of
management is available that provides a comparable result. The following are specific
indications for operative treatment:

Fracture of both bones (ie, radius and ulna)


Fracture dislocations, Monteggia fracture dislocations, and Galeazzi fracture dislocations
Isolated radius fractures
Displaced ulnar shaft fractures
Delayed union or nonunion
Open fractures
Fractures associated with a compartment syndrome, irrespective of the extent of
displacement
Multiple fractures in the same extremity, segmental fractures, and floating elbow
Pathologic fractures

A medically fit patient has few contraindications to operative fixation of a forearm


fracture. Highly contaminated compound fractures, particularly with bone loss, may be
managed with temporary external fixation followed by debridement and delayed internal
fixation.

Medical Therapy
In children, the usual plan is to attempt closed reduction followed by cast immobilization.
[16]
Childhood obesity appears to increase the risk of malreduction and subsequent
manipulations with closed reduction and casting.[17] In adults, treatment with
immobilization in a molded long arm cast can be used in those rare occasions of a
nondisplaced fracture of both bones of the forearm.

The cast should be applied with the elbow in 90 flexion. The stable position of
pronation or supination can be found by screening on the image intensifier, but in
general, fractures of the proximal third are stable in supination, fractures of the middle
third are stable in neutral position, and fractures of the distal third are stable in
pronation. Follow-up of these patients with radiography in both planes at weekly
intervals for the first 4 weeks is mandatory to detect early displacement of the fracture.
Sarmiento et al reported the results of a closed method of treatment for nondisplaced
fractures of one or both bones of the forearm.[18] Only in children does the salubrious
effect of growth and remodeling offer an alternative to the otherwise mandatory surgical
treatment of displaced or unstable forearm fractures, on the assumption that adequate
alignment and proper rotation of the fragments can be obtained and maintained by
closed methods.
Angulation in the plane of joint movement is most likely to improve with growth and
remodeling. However, rotational deformity and loss of normal interosseous space
cannot be expected to improve with growth and remodeling, even in very young
patients. The cutoff ages are in the range of 10-12 years in girls and 12-14 years in
boys. At these ages, surgical treatment must be strongly considered for displaced
fractures of the forearm. Children aged 10 years or older with proximal-third radius
fractures and ulna angulation less than 15 seem to be at highest risk for failure when
treated nonoperatively for both-bone forearm fractures. [19]

Surgical Therapy
Open reduction and internal fixation
When both bones of the forearm are fractured, they are both exposed and provisionally
reduced before fixation of either bone is completed. The fracture with the least
comminution (usually the ulna) is fixed first. After reduction and provisional fixation of
both bones, pronation and supination are examined; if normal, definitive fixation is
performed. The plate must be accurately centered over the reduced fracture and must
be of sufficient length to permit, preferably, six cortices to be secured by screws on each
side of the fracture (see the image below). The plates should be contoured to fit the
bone, especially the radius, to maintain the normal bow of the radius for restoration of
normal function.[20, 21]

Osteosynthesis using a dynamic compression plate for a closed midshaft fracture of both bones of
the forearm.

The general rule is that bone grafting is recommended when more than one third of the
circumference of the bone is comminuted. If this is instituted, it should be performed
away from the interosseous membrane to decrease the risk of synostosis. In their
review of 198 forearm fractures, Wright et al reported comparable results in union in
comminuted forearm fractures treated with bone grafting and without bone grafting. [22]
In a study of 59 cases of shaft fracture of both forearm bones, Kim et al suggested that
a combination of plate fixation and intramedullary nailing, though not generally
preferable to plate fixation alone, might be a useful option for these fractures when
treatment with plating by itself is not feasible. [23]

Intramedullary nailing
The first widely used and successful medullary forearm nail system was developed by
Sage in 1959.[12] The prebent radial nail maintains the radial bow, and the triangular
cross-sectional shape prevents rotational instability (see the image below).

Internal fixation using square nails for a segmental fracture of both bones of the forearm.

When intramedullary devices are used in persons with a fracture of both bones, fixation
of the radius must be stable enough to prevent collapse of the radial bow; otherwise,
elongation of the radius and distraction of the ulnar fracture can occur, resulting in
nonunion in either or both bones. The entry point for intramedullary nailing of the ulna is
made in the proximal ulna. The radial portal is usually into the radial styloid process
between the extensor carpi radialis longus and the extensor pollicis brevis. All radial
nails should be well seated to avoid fraying of the tendon and possible rupture. [24, 25, 26]
The indications for intramedullary nailing are as follows:

Segmental fractures
Poor skin condition
Selected nonunions or failed compression platings [27, 28]
Multiple injuries
Diaphyseal fractures in osteopenic patients

Open fractures of the forearm


The traditional theory was to not use internal fixation initially in open fractures of the
forearm; initial management was with irrigation and debridement. Current treatment
trends are to initiate immediate open reduction and internal fixation (ORIF) of all open
forearm fractures. Immediate ORIF of Gustilo type I and type II open diaphyseal forearm
fractures is appropriate, provided that thorough debridement is performed. [29] Duncan et
al reported 90% acceptable results in persons with Gustilo type I, type II, or type IIIA
open diaphyseal fractures treated in this manner; however, their results with IIIB and
IIIC injuries were poor.[30, 31]

Procedural details
Fractures are best internally fixed as soon after the injury as is practical, preferably
before the onset of swelling. With delayed fracture presentation, blisters secondary to
swelling can develop. Ruptured fracture blisters or abrasions older than 6-8 hours may
be a contraindication for surgery. At least 7-10 days may be required for abraded skin
and fracture blisters to heal and for swelling to subside.
Ulnar approach
An interneural approach between the extensor carpi ulnaris and the flexor carpi ulnaris
is used. The plate can be used on either the posterior or the anterior surface, though the
posterior surface is preferred because it is the tension side of the ulna. Care should be
taken to avoid damage to the dorsal sensory branch of the ulnar nerve in the distal part
of the incision.

Palmar approach of Henry


The palmar approach of Henry is the most common approach for fixation of the shaft of
the radius. It uses the interneural interval between the brachioradialis (radial nerve) and
the pronator teres (or the flexor carpi radialis distally, innervated by the median nerve).
For deep dissection, the arterial branches of the radial artery supplying the
brachioradialis are carefully ligated. Rotation of the forearm enhances the view during
this approach.
Dorsolateral approach
Access to the radial shaft runs in the septum between the extensor carpi radialis brevis
and the extensor digitorum muscles. It can be useful for fractures of the proximal and
middle thirds of the radius and to address injuries to the proximal radioulnar joint. The
dorsolateral approach (also called the Thompson approach) potentially involves less
soft-tissue stripping than the palmar approach, and patients may experience a more
rapid return of wrist and hand function. The two nerves vulnerable to injury with this
approach are the following:

The superficial radial nerve in the distal part of the incision along the brachioradialis
crossing the abductor pollicis longus in the subcutaneous layer
The posterior interosseous nerve running through the supinator in the proximal exposure

Reduction techniques
Periosteal stripping should be limited to a minimum, and circumferential stripping is to
be strictly avoided. Plates of 3.5 mm have been proved to be the ideal size for the
forearm bones. The purpose of the plate is to neutralize the torsional forces, and
purchase should be obtained at no fewer than six cortices in each main fragment in
order to achieve this objective. Interfragmentary lag screws, inserted either
independently or through a plate hole, should be used to strengthen the fixation if the
fracture configuration allows it.
Closure
Of utmost importance is to close only the subcutaneous tissue and skin. If the deep
fascia is sutured tightly, edema and hemorrhage may cause increased pressure in the
forearm compartments, which can lead to ischemic contracture. A suction drain can be
used to decrease the hematoma and resultant swelling. The drain is removed in 12-24
hours.

Postoperative care
If the rigidity of the fixation is sufficient, limited postoperative cast immobilization is
used. A posterior splint can be applied for 1-2 weeks for comfort. Patients are
encouraged to perform both active and active-assisted range-of-motion (ROM)
exercises of the shoulder and hand. Elbow ROM and pronation-supination exercises
should begin as soon as remission of pain and swelling of the forearm permits after the
plaster splint is removed. However, in the case of a noncompliant patient, external
immobilization (usually an above-the-elbow cast) is essential, along with supervised
physiotherapy until the fracture is deemed united on the basis of radiographic findings.

Complications
Nonunion and malunion
Nonunion of fractures of the shafts of the radius and ulna is relatively uncommon.
Anderson's series of forearm fractures treated with compression plates included nine
nonunions (2.7%) and four delayed unions (1.2%) in 330 fractures. [11] Almost all of the
nonunions and delayed unions appeared to have been caused by infection or errors in
surgical technique (see the images below). Accurate open reduction and rigid internal
fixation prevent most of these complications.[32]

Nonunion of the radius and ulna due to an error in surgical technique.

Nonunion treated with resection of approximately 2 cm of bone from both the radius and the ulna,
along with compression plating.

Infection
Stern et al reported a 3.1% rate of osteomyelitis in forearm fractures; both instances
occurred in patients with massive crush injuries (see the image below). [33]With good
technique and a contemporary operating environment, the rate is currently much lower.

Sequestrum of the proximal radius. Sequela to an open fracture of the radius and ulna and multiple
surgeries.

Superficial infections respond well to appropriate antibiotics. The general principles of


surgical debridement and copious irrigation are key in treating deep infections. The

internal fixation can be left in situ while the infection is being treated, and most fractures
proceed to union. The metal can be removed after union of the fracture.
Aggressive treatment is required for late infections, when fixation has been lost and
nonunion has developed. Metal should be removed along with any nonviable bone. The
wound can be left open for dressing changes, or an irrigation-suction system can be
instituted.
If an intercalary defect results, it can be spanned with a long plate and bone grafting
when the wound is healthy and after a period of dressing changes. Serial examinations
of the wound are required to determine the appropriate timing for the bone-grafting
procedure. If the intercalary defect is large (>6 cm), a vascularized fibular bone graft
should be considered to bridge the defect (see the image below).

Infected nonunion of a compound fracture, treated previously with bone grafting and replating. The
plates were removed; and dead, infected bone was debrided, leaving a gap of 5.5 cm in the radius.
Temporary external fixation was applied to the radius. Four weeks later, a free fibular graft was used
to reconstruct the radius, and the ulna was replated.

Compartment syndrome
Compartment syndromes (see the image below) can occur in the forearm either after
trauma or after surgery. Eaton et al reported 19 patients with Volkmann ischemia,

resulting from a volar compartment syndrome of the forearm. [34] An important early sign
is pain out of proportion to the injury and pain upon passive extension of the fingers.
The presence of the radial pulse is not a reliable diagnostic indicator; the radial pulse
was absent in only five of their 19 patients. Be aware that the presence of a palpable
radial pulse does not rule out the presence of a compartment syndrome.

Closed fracture of the forearm in the middle-third area is complicated by compartment syndrome,
with early blisters and a tense compartment.

In conscious patients, the diagnosis of compartment syndrome is made on the basis of


clinical findings. Compartment pressures can be measured to confirm the diagnosis of
compartment syndrome, provided that treatment is not delayed. Measurement is
especially valuable when making the diagnosis of compartment syndrome in
unconscious or obtunded patients.
Surgical treatment should be performed early and should include fasciotomy from the
elbow to the wrist, including division of the lacertus fibrosis proximally and the
transverse carpal ligament distally (see the image below). Delayed closure of the wound
is performed later. A residual defect may require split-thickness skin grafting.

The same patient as in image above, with fasciotomy and external fixation to the radius and
intramedullary nailing of the ulna.

Closed compartment syndromes that follow operations in the forearm are usually due to
inadequate hemostasis or closure of the deep fascia. They can usually be avoided by
releasing the tourniquet before wound closure to make sure hemostasis is adequate
and by closing only the subcutaneous tissue and skin.

Implant removal and refractures after implant removal


Removal of implants is not mandatory and is rarely indicated in an asymptomatic patient
because of the risk of complications, including neurovascular injury and refracture. If
indicated, implants should not be removed for at least 18 months to 2 years after
internal fixationand even then, only after careful consideration by an experienced
surgeon.
Removal of forearm fracture plates after healing is not a benign procedure. The rate of
refracture is 3.5-25%. Evidence indicates that the use of the 3.5-mm plate has
considerably reduced the rate of refracture. Comminuted fractures, open fractures, bone
defects, technical failure (excessive stripping, inadequate compression), and early plate
removal within 1 year after internal fixation increase the risk of refracture. [35]
Once a plate has been removed, the forearm should be protected by a splint for 6
weeks. It should then be protected from severe stress and torsion for 6 months. Patients
undergoing elective removal of implants should be warned of the potential for refracture
even later than 6 months. Mih et al reported an 11% refracture rate in 62 patients, with a
mean time to refracture of 6 months.[36]

Synostosis
Bauer et al reported that the highest risk of synostosis is associated with internal fixation
of fractures involving the proximal third of both the radius and the ulna. [37]Extensive softtissue dissection during exposure, the development of a radioulnar hematoma, the risk
of interosseous damage, and occasional malpositioning of the dorsal plate if the Boyd
approach is used also contribute to an enhanced risk of postosteosynthetic synostosis
(see the image below). In cases in which both bones are fractured, separate surgical
approaches for the radius and the ulna have been shown to minimize the risk of
radioulnar synostosis.

Postosteosynthetic synostosis.

Long-Term Monitoring

Follow-up radiographs are taken regularly during the postoperative phase until
progressive healing is documented. Determining when a rigidly plated fracture of the
forearm has healed on the basis of radiographic findings is difficult, partly because very
little external callus results when fractures are stabilized in a rigid manner as is the case
for plate-and-screw fixation of radius and ulnar fractures. Strenuous activity must be
prohibited until bone trabeculae cross the fracture.