Executive Editor: Chris Colton

Authors: Dominik Heim, Shai Luria, Rami Mosheiff, Yoram Weil

Forearm shaft Multifragmentary radial fracture with non-multifragmentary ulnar fracture

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Glossary

General considerations

Multifragmentary fractures of the radius may be associated with an intact ulna or a simple fracture of the ulna. With an intact ulna shortening at the radial fracture, in association with a torn interosseous membrane, can result in distal axial migration of the ulnar head at the distal radioulnar joint (DRUJ). The treating surgeon should pay attention to this possibility.

When both bones are fractured, a simple ulnar fracture should be treated with compression plating (with or without lag screw) achieving absolute stability.
In the radius, most segmental fractures are treated by compression plating, leading to absolute stability, but the complex multifragmentary fractures may be treated using bridge plating or intramedullary nailing, applying the concept of relative stability. Intramedullary nailing causes less disturbance to the soft tissues. These latter cases are problematic since the goals of restoration of the radial curvature and its rotational alignment are difficult to achieve because of a lack of anatomical landmarks in the multifragmentary zone. However, the reduction of the simple ulnar fracture may assist in the further goal of restoration of the radial length and thereby distal radioulnar articular alignment.
Nonoperative management is not the method of choice for both bone forearm fractures, but may become necessary in patients whose medical condition precludes surgery, or when operation is delayed because of soft-tissue compromise.
External fixation is rarely used in the forearm but may be indicated for the radius in the presence of severe soft-tissue compromise, or as damage control surgery in polytrauma patients.

Nonoperative treatment
Indication summary Skill Equipment
Severely injured polytrauma patients Some specialized surgical experience Basic equipment only

In severely injured polytrauma patients, definitive fixation of such injuries is delayed until physiological stabilization has been achieved. In the interim, the forearm and elbow should be placed in a well-padded splint. Neurovascular and muscle compartment status, and soft-tissue conditions should be closely monitored.

Nonoperative treatment may be necessary in patients who are medically unfit for surgery.

The outcome of nonoperative treatment of both bones fractures is likely to be suboptimal.

External fixation
Indication summary Skill Equipment
A means of temporary fixation for severely open fractures Some specialized surgical experience Simple surgical and imaging resources

External fixation can be indicated in severely open fractures. A monolateral frame configuration can be used on the radius as a temporary means of treatment, in the presence of compromised soft tissues. Alternatively, in experienced hands, ring fixators of the Ilizarov type can be used for the definitive management of these injuries; this requires a high level of expertise in this field. This method will not be considered in any further detail.

ORIF - Plating of one or both bones
Indication summary Skill Equipment
Treatment of choice Some specialized surgical experience Simple surgical and imaging resources

The preferred treatment of simple fractures of the ulna is compression plating (with or without lag screw) leading to absolute stability and direct bone healing.

The preferred treatment of segmental fractures of the radius is compression plating (with or without lag screw) leading to anatomical restoration of length and radial curvature, rotational alignment, and absolute stability. The blood supply of the intermediate fragment must be meticulously preserved throughout.

In certain circumstances, compression plating of the radius may not be achievable and other management options should be considered.

Some segmental fractures cannot be treated by compression plating for technical reasons and occasionally, bridge plating of the radius is indicated; in such circumstances, the blood supply of the intermediate fragment must be meticulously preserved.

Anatomical reduction cannot be achieved in fragmentary segmental fractures, but maintaining relative stability using bridge plating is widely accepted. Either conventional, or locked (if available), plates can be used if the principles of minimizing stripping, and restoring both length and alignment are respected.

Intramedullary nailing
Indication summary Skill Equipment
Treatment option in the presence of severe soft-tissue injury Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Nailing is the preferred option only in pediatric fractures. The role of intramedullary nailing in adult forearm shaft fractures is still to be defined. Rotational stability was long a limiting factor against the use of nails in forearm shaft fractures. Several locking options exist today and may lead to a wider use in forearm fractures in the future. So far, there is no strong evidence available to support nailing in most adult forearm fractures. Even though rotational stability is achievable nowadays, the risk of rotational malunion following closed reduction will persist. If there is poor soft tissue coverage, intramedullary nailing may offer some benefit.

Discussion of nailing in adult forearm shaft fractures is limited to multifragmentary fractures of both bones in AO Surgery Reference, until further evidence emerges.

Pediatric fractures are not included in this module of AO Surgery Reference.

*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v2.0 2013-07-09