Radius/Ulna Fracture Repair

Milan Milovancev, DVM* and S. Christopher Ralphs, DVM, DACVS†

Fractures of the radius and ulna are commonly encountered in the small animal population.
Diaphyseal fractures are the most common location and are often repaired with the use of
external fixators or a bone plate. Select patients, such as young large breed dogs, may be
managed with external coaptation. Extremely proximal and distal fractures require special
consideration, especially if articular involvement is present.
Clin Tech Small Anim Pract 19:128-133 © 2004 Elsevier Inc. All rights reserved.

KEYWORDS radius, ulna, fractures, orthopedics

F ractures of the radius and ulna occur relatively frequently

in the small animal population, representing 17 to 18%
of all fractures in dogs and cats.1 Depending on their location
and configuration, these fractures vary greatly in their treat-
ment complexity and potential outcomes.
Clinical Anatomy
The radius and ulna are the paired long bones of the antebra-
chium (Fig. 1). The radius is the main weight bearing bone of
the pair. Its proximal articulation at the elbow is with the
humerus via the articular fovea and the ulna via the ulnar
notch. The distal articulation at the carpus is primarily with
the radial carpal bone, the ulnar carpal bone to a lesser extent,
and the ulna laterally. The radial styloid process is important
because of its function as an attachment for the distal radial
collateral ligament, which provides medial carpal stability.2
The ulna, though not as significant in weight bearing, is an
important component of the antebrachium. Proximally, it
articulates with the humerus via the trochlear notch and the
radius via the radial notch. Its distal articulation is with the
ulnar and accessory carpal bones and radius. The olecranon
acts as a lever arm, serving as an attachment point for the
extensor muscles of forelimb: the triceps brachii, anconeus,
and tensor fasciae antebrachii caudally, and the flexor carpi
ulnaris medially. The ulnar styloid process is important be-
cause of its function as an attachment for both the ulnar
collateral and the palmar ulnocarpal ligaments that provide
lateral and palmar carpal stability, respectively.2
The distal two-thirds of antebrachium are largely uncov-
ered by any significant musculature. The major blood supply
to the radius and ulna is provided by the diaphyseal arteries,
*Veterinary Referral & Emergency Center, Norwalk, CT.
†Pittsburgh Veterinary Specialists, Pittsburgh, PA.
Address reprint requests to Milan Milovancev, DVM, Veterinary Referral &
Emergency Center, 123 West Cedar St., Norwalk, CT 06854. E-mail:
milo0010@hotmail.com
entering via the nutrient foramen. These arise as branches of
the palmar interosseous artery.3
There are a number of clinically relevant factors to con-
sider in radius/ulna fracture repair of the immature animal.
The distal physes of both bones are responsible for the ma-
jority of their bone length, approximately 60% and 85%,
respectively. The distal ulnar physis is cone shaped and con-
sequently prone to asymmetric damage by laterally applied
forces. Additionally, young animals may have contributing
blood supply from vessels in the pronator quadratus muscle
that originates between the radius and ulna on their medial
surfaces.2
Proximal Ulnar Fractures
Proximal ulnar fractures are most frequently seen in young
dogs and usually involve the olecranon. Although multiple
treatment options exist, pin and figure-of-eight tension band
wire fixation is usually the treatment of choice. In a young
animal with open growth plates, the tension band wire
should ideally be removed 4 weeks postoperatively to avoid
premature closure of the physis. The 2 Kirschner wires (K-
wires) or Steinmann pins can be left in place an additional 4
to 6 weeks to provide further stability. A proximal ulnar
fracture with concurrent luxation of the radial head, often
resulting from trauma to the caudal antebrachium, is referred
to as a Monteggia fracture in the human literature and has
been reported in the small animals.1
Radial Head Fractures
Radial head fractures, which are fairly uncommon, usually
occur secondary to trauma. These often involve articular frac-
tures, necessitating perfect anatomical reduction to minimize
formation of degenerative joint disease. When evaluating ra-
diographs for fractures of the radial head, it is important not
to confuse small, variably present, ectopic bones around the

128 1096-2867/04/$-see front matter © 2004 Elsevier Inc. All rights reserved.
doi:10.1053/j.ctsap.2004.09.005
Radius/ulna fracture repair
Figure 1 Schematic illustration of a normal radius and ulna.
head of the radius with fractures. Radiographs of the con-
tralateral limb are useful for comparison.1
Diaphyseal Fractures
The diaphysis is the most common site for fractures of the
radius and ulna. Specifically, the distal third of the diaphysis
is often involved. This is thought to be a result of poor blood
supply and the minimal soft tissue coverage of the distal
antebrachium. Ulnar fractures are almost always found con-
currently with radial fractures.1,4
Small breed dogs often suffer fractures because of landing
on their forelimbs from a height, such as jumping from their
owner’s arms. In comparison, radius/ulna fractures in the
large breed dog usually result from more severe trauma, such
as a vehicular accident. Caudolateral displacement of the dis-
tal fragment is most common because of contraction of the
flexor muscles of the antebrachium. Because of the minimal
soft tissue coverage, open fractures are relatively common.4
Treatment recommendations depend on the patient’s size,
age, condition of the fracture site, and the severity and con-
figuration of the fracture itself. Clinically viable options are
discussed below.
Conservative Management
Conservative management consists of external coaptation
coupled with strict activity restriction. This treatment modal-
ity is reserved for recent, closed, minimally to nondisplaced
or greenstrick fractures in immature medium to large breed
animals. A custom molded cylinder cast or Thomas splint is
129
recommended, and general principles of external coaption
apply. Most importantly, it is critical to immobilize the elbow
and carpal joints. Generally, at least a 50% overlap of the
bone fragments on orthogonal radiographic views is required
for successful bony healing to occur.1 When applying a cast,
the limb should be kept in a normal walking position. To
avoid a valgus deformity, place the animal in lateral recum-
bancy with the affected forelimb down and with a slight varus
position.
External coaptation of antebrachial fractures is most effec-
tive for transverse fractures because they neutralize bending
forces very well and help reduce torsional forces. However,
this form of fixation does very little to eliminate compressive,
shearing, or tensile forces. Therefore, oblique and spiral frac-
tures often fail to heal properly with external coaptation
alone.1
Small and toy breed dogs are not good candidates for ex-
ternal coaptation. Reportedly, up to 83% of radial fractures in
small and toy breed dogs treated with external coaptation
developed serious complications including malunions and
nonunions.5,6 This is primarily because of decreased in-
traosseous blood supply to the distal third of the radius.
Small breed dogs show decreased vascular density and ar-
borization of vessels in the distal metaphysis as compared
with medium breed dogs.7 Additionally, inherent biome-
chanical instability because of the small bone size and short
oblique or transverse orientation of many fractures contrib-
utes to the difficulty in managing distal radius and ulna frac-
tures in small and toy breed dogs.7-9
Internal Fixation
All unstable fractures and most stable fractures of the radius
and ulna respond best to internal fixation. Once adequate
fracture reduction is achieved, either via closed or open tech-
niques, an internal fixation method must be chosen. The 2
commonly recommended methods include either an external
fixator or bone screws and plate.
Smaller dogs require near anatomic reductions with ade-
quate stability to minimize chances of a malunion or non-
union. Generally, the larger the dog, the less need there is to
have perfect anatomical reduction of the fracture. Younger
animals with open physes will heal more completely than
mature animals.1,4
Intramedullary pinning of the radius is not feasible nor is it
recommended. Pin placement generally necessitates invad-
ing either the carpal or elbow joints, resulting in severe future
degenerative changes of the affected joint. Additionally, the
narrow medullary cavity of the radius does not lend itself to
the intramedullary pinning. Finally, the anterior curvature of
the radius is such that a straight pin is very difficult to pass. In
contrast, intramedullary pinning of the ulna is a feasible and
practical option for providing ancillary support of a radial
repair. The pin is driven antegrade from the proximal surface
of the olecranon distally as far as possible without penetrating
the cortex. Radiographs are useful in estimating proper pin
length and diameter for this purpose.10
External Fixators
External fixators are a good option to consider for open
fractures (Figs. 2-4). Their use potentially avoids invasion
130 M. Milovancev and S.C. Ralphs

rior curve of the radius often precludes their use and uni-
lateral pins may be substituted. Type Ia frames are applied
to the medial or craniomedial aspect of the radius to avoid
penetration of major muscle masses. Type II frames are
inherently stronger constructs, but require penetration of
muscle masses that may result in increased implant loos-
ening and morbidity. If additional rigidity is required, a
type III fixator may be considered.1,12 A recent study has
suggested that lower stiffness constructs (ie, type Ia or Ib
with or without an intramedullary pin) may be adequate
for fracture healing to occur in small to medium sized
patients.13
Circular external fixators are also an option but require
special tensioning equipment and careful presurgical con-
struction of rings based on radiographs. These constructs
allow for axial micromotion, which has been shown to pro-
mote bone healing. Anderson and coworkers reported good
long term results in a case series of 14 dogs with radius and
ulna fractures repaired using a circular external fixator, de-
spite a high incidence of complications during the recovery
period.14
Use of polymethylmethacrylate (PMMA) connecting bars
allow versatile placement of fixation pins, optimizing good
quality bone purchase without regard for clamp compatibil-
ity or uniplanar pin placement. These are particularly useful
in distal diaphyseal fractures in small breeds, in part because
of their low weight compared with traditional stainless steel
rods.
Complications associated with external skeletal fixation
include pin loosening, pin tract drainage, infection, valgus or
rotational malalignment, delayed union or nonunion, and
pin breakage.15

Figure 2 Preoperative lateral and cranial-caudal radiographs of com-

minuted, diaphyseal radius, and ulna fractures.

of the fracture site and allows for implant removal after

healing is complete. External fixators can be less techni-
cally demanding to place, less expensive, are potentially
re-usable, and cause less damage to the existing blood
supply and tissues.
It is important to note that closed reduction, although
preferred, can be challenging. Manual distraction of transfix-
ation pins, hanging the limb, and use of a fracture distractor
are all methods used to aid in closed reduction. If an open
approach is necessary, a minimal approach is made in an
attempt to preserve blood supply and avoid causing further
tissue trauma. A recent case series of 6 dogs with radius and
ulna fractures reports good results using closed reduction Figure 3 (A) Intraoperative lateral radiograph of the fracture in Fig.
and a very limited open approach with type II external fix- 2, showing temporary stabilization of transfixation pins with a stain-
ators and an ulnar intramedullary pin.11 less steel connecting bar to check fracture alignment and pin place-
Bilateral transfixation pins are preferred, but the ante- ment before placing (B) PMMA connecting bars.
Radius/ulna fracture repair 131

nuted fractures can be addressed with a buttress plate once

the bone is realigned. For extremely distal fractures, a T plate
is useful in small dogs and cats, as it allows placement of 2
screws in a transverse plane.1
Another option for small dogs is the use of veterinary cut-
table plates. These plates have the advantage of the holes
being close together to allow maximal holding power in small
bone fragments and can be stacked to overcome the fact that
they are weaker than dynamic compression plates.18
A recent study examined bone plate fixation of distal ra-
dius and ulna fractures in 22 small and miniature breed dogs
and found long term outcome to be generally favorable, with
owners reporting normal use of the limb in 11 dogs. An
occasional lameness was reported in 5 dogs, a moderate
lameness was evident in 1 dog, and 1 dog was nonweight
bearing while running.19
Stress protection induced osteopenia is often mentioned as
a concern with the use of bone plates, especially in small and

Figure 4 Follow up cranial-caudal radiograph of the fracture in Fig.

2, repaired using an external fixator with PMMA connecting bars,
showing bone healing with formation of a callus.

Bone Plate and Screws

Application of bone screws and plate for radial fractures is an
adaptable and very stable method of fixation allowing for
immediate weight bearing (Figs. 5 and 6). This method of
fixation requires a standard surgical approach. The disadvan-
tage of the surgical approach is that it results in some disrup-
tion of local blood supply, but the approach is beneficial
because it facilitates fragment reduction, plate application,
and allows placement of an autogenous cancellous bone
graft.
Bone plates are applied either to the cranial or medial
aspects of the radius (Fig. 7). Exceptions to this are fractures
of the proximal radius, as the medial aspect of this bone is not
suitable for plating.16 Screws applied in a medio-lateral plane
are significantly stronger than screws placed in a cranio-cau-
dal plane.17
Multiple types of plates may be used. Temporary fixation is
often achieved before plate placement with the use of cer-
clage wire or bone screws. A dynamic compression plate is
recommended for transverse fractures. Long oblique or spiral
fractures are amenable to lag screw or cerclage fixation with Figure 5 Preoperative lateral and cranial-caudal radiographs of com-
subsequent neutralization plate application. Severely commi- minuted, midshaft, diaphyseal radius, and ulna fractures.
132 M. Milovancev and S.C. Ralphs

Ulnar Styloid Process Fractures

Ulnar styloid process fractures are often incomplete and not
intra-articular, allowing for external coaptation as the sole
method of fixation. If complete, the fracture requires internal
fixation with a tension band wire to preserve lateral and pal-
mar carpal joint stability.1

Radial Styloid
Process Fractures
Radial styloid process fractures are usually intra-articular and
therefore, require perfect anatomical alignment and internal
fixation. These fractures also compromise medial joint stabil-
ity. Fixation is achieved using a tension band wire or lag
screws.1

Case Example 1
A 1.5-year-old female intact Doberman Pinscher presented
for evaluation of nonweightbearing lameness of the right
forelimb after being hit by a car. The dog had no prior ill-
nesses and was systemically stable. General physical exami-
nation was unremarkable. Orthopedic evaluation revealed
obvious pain and crepitance on manipulation of the right
antebrachium. A complete blood count, chemistry profile,
and thoracic radiographs were within normal limits. Radio-
graphs of the right antebrachium revealed a severely commi-
nuted midshaft diaphyseal fracture of the radius and ulna
(Fig. 5).
Surgery was performed to reduce and stabilize the fracture.

Figure 6 Postoperative lateral and cranial-caudal radiographs of the

fracture in Fig. 4, repaired with cerclage wire, bone screws, and a
bone plate.

toy breed dogs. However, Glennon and coworkers reported

no significant differences in radial cortical bone density be-
tween a plated limb and the contralateral limb of the same
dog, after taking into account the effect of the bone plate itself
on photodensitometry readings.20

Distal Diaphyseal Fractures

Distal diaphyseal fractures are commonly found in young
dogs and are often incomplete. Because of the rapid growth of
these animals, external coaptation is often chosen as the
method of fixation. Because young animals rapidly lay down
new bone, application of a cast should be performed as soon
as possible after a fracture occurs. Premature closure of the
physis on the affected forelimb is a concern. The cast should
be kept clean, dry, and regularly rechecked, including radio-
graphic evaluation for union. A complete cylindrical cast can
be converted to a clamshell style to accommodate for growth Figure 7 Schematic illustration of a standard cranial approach to the
of the animal.1 shaft of the radius.
Radius/ulna fracture repair
A cranio-medial approach to the shaft of the radius was per-
formed. The skin was incised from the medial epicondyle of
the humerus to the styloid process of the radius. Subcutane-
ous fascia was incised along the same line. While avoiding the
brachial artery and vein and median nerve, the deep antebra-
chial fasci was incised between the pronator teres muscle and
the extensor carpi radialis muscle. The extensor carpi radialis
was retracted laterally, and the pronator and supinator mus-
cles were elevated to fully expose the fracture site.
Multiple bone fragments were identified. Ancillary fixation
was achieved using surgical cerclage wire. Rigid fixation was
achieved using a 3.5-mm dynamic compression bone plate
applied in buttress fashion (Fig. 6). The deep fascial layer was
closed separately from the subcutaneous layer. Skin staples
were used to close the skin incision. The dog recovered from
anesthesia uneventfully.
A light compression bandage was placed for the first 24
hours postoperatively to reduce soft tissue swelling. The dog
was kept in the hospital 2 days postoperatively for recovery,
monitoring, and supportive care. She was discharged from
the hospital on oral antibiotics and nonsteroidal anti-inflam-
matory pain medications with instructions on strict activity
restriction for the subsequent 6 weeks. At a 6-month follow
up telephone conversation with the owner the dog was re-
portedly doing well with no evidence of lameness on the
affected limb.
An acceptable alternative method of fixation for this pa-
tient would have been an external fixator. The proximal and
distal fragments were both large enough to accommodate 3 to
4 transfixation pins each. An intramedullary pin could have
been placed in the ulna for additional stability. Bone screws
would have been an acceptable alternative to the surgical
cerclage wire that was used for temporary stabilization of
fracture fragments. External coaptation would not have been
a good option in this case because of the dog’s age and frac-
ture configuration.
References
1. Egger EL: Fractures of the radius and ulna, in Slatter DH (ed): Textbook
of small animal surgery, Vol 2 (ed 2). Philadelphia, WB Saunders, 1993,
pp 1462-1463
2. Evans HE: The skeleton, in Evans HE (ed): Miller’s anatomy of the dog
(ed 3). Philadelphia, WB Saunders, 1993, pp 188-192
3. Hermanson JW, Evans HE: The muscular system, in Evans HE (ed):
133
Miller’s anatomy of the dog (ed 3). Philadelphia, WB Saunders, 1993,
pp 333-343
4. Hulse DA, Johnson AL: Management of specific fractures, in Fossum
TW (ed): Small animal surgery. St. Louis, Mosby, 1997, pp 803-818
5. Lappin MR, Aron DN, Herron HL, et al: Fractures of the radius and ulna
in the dog. J Am Anim Hosp Assoc 19:643-650, 1983
6. Waters DJ, Breur GJ, Toombs JP: Treatment of common forelimb frac-
tures in miniature and toy breed dogs. J Am Anim Hosp Assoc 29:442-
448, 1993
7. Welch JA, Boudrieau RJ, DeJardin LM, et al: The intraosseous blood
supply of the canine radius: Implications for healing of distal fractures
in small dogs. Vet Surg 26:57-61, 1997
8. Vaughan LC: A clinical study of nonunion fractures in the dog. J Small
Anim Pract 5:173-177, 1964
9. Herron MR: Repair of distal radio-ulnar fractures in toy breed dogs.
Canine Pract 1:12-17, 1974
10. DeYoung DJ, Probst CW: Methods of internal fracture fixation, in Slat-
ter DH (ed): Textbook of small animal surgery, Vol 2 (ed 2). Philadel-
phia, WB Saunders, 1993, pp 1610-1640
11. Ozsoy O, Altunatmaz K: Treatment of extremity fractures in dogs using
external fixators with closed reduction and limited open approach. Vet
Med-Czech 48:133-140, 2003
12. Egger EL: External skeletal fixation, in Slatter DH (ed). Textbook of
small animal surgery, Vol 2 (ed 2). Philadelphia, WB Saunders, 1993:
1641-1661
13. Gemmill TJ, Cave TA, Clements DN, et al: Treatment of canine and
feline diaphyseal radial and tibial fractures with low-stiffness external
skeletal fixation. J Small Anim Pract 45:85-91, 2004
14. Anderson GM, Lewis DD, Radasch RM, et al: Circular external skeletal
fixation stabilization of antebrachial and crural fractures in 25 dogs.
J Am Anim Hosp Assoc 39:479-498, 2003
15. Johnson AL, Kneller SK, Weigel RM: Radial and tibial fracture repair
with external skeletal fixation: Effects of fracture type, reduction and
complications on healing. Vet Surg 18:367-372, 1989
16. Sardinas JC, Montavon PM: Use of a medial bone plate for repair of
radius and ulna fractures in dogs and cats: A report of 22 cases. Vet Surg
26:108-113, 1997
17. Linn LL, Rochat MC, Brusewitz GH, et al: Extraction Resistance of 2.7
mm medio-lateral-placed cortical screws compared with 2.7 mm and
3.5 mm cranio-caudal-placed cortical screws in canine cadaver radii.
Vet Comp Ortho Trauma 14:1-6, 2001
18. Brinker WO, Piermattei DL, Flo GL: Fractures of the radius and ulna, in
Brinker WO, Piermattei DL, Flo GL (eds): Handbook of small animal
orthopedics and fracture treatment. Philadelphia, WB Saunders, 1990,
pp 195-209
19. Larsen LJ, Roush JK, McLaughlin RM: Bone plate fixation of distal
radius and ulna fractures in small- and miniature-breed dogs. J Am
Anim Hosp Assoc 35:243-250, 1999
20. Glennon JC, Flanders JA, Beck KA, et al: The effect of long-term bone
plate application for fixation of radial fractures in dogs. Vet Surg 23:
40-47, 1994