Executive Editor: Chris Colton

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

Forearm shaft Multifragmentary, fragmentary segmental fracture of both bones

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Glossary

General considerations

Multifragmentary fracture of both bones are challenging and fortunately rare fractures. The injuries are often associated with limb-threatening soft-tissue compromise, including neurovascular deficits and compartment syndrome. The delicate balance between achieving restoration of limb alignment and stability while minimizing soft-tissue damage should be maintained. Although open reduction and bridge plate fixation may be indicated in most of these fractures, other treatment methods should be considered as well.
In these fractures, the complex multifragmentary zone in each bone may preclude anatomical reduction and absolute stability.

Nonoperative treatment
Indication summary Skill Equipment
Severely injured polytrauma patients Basic surgical experience, no specialized skills Basic equipment only

In severely injured polytrauma patients, definitive fixation 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 will 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 one or both bones, as a temporary means of treatment for these high energy fractures associated with compromised soft tissues. Alternatively, in experienced hands, ring fixators of the Ilizarov type can be used for the definitive fixation of these injuries; this requires a high level of expertise in this field. This method will not be considered here in any further detail.

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

Intramedullary nailing is not widely used in adult forearm shaft fractures, due to difficulty in achieving anatomical reduction and rotational stability. In fragmentary segmental fractures of both bones, however, there may be an indication for nailing since, in these fractures, anatomical reduction is impossible, and absolute stability cannot be achieved.

The main advantage of nailing in these fractures is the reduction in the risks of both additional soft-tissue damage and further compromise of the blood supply. This is especially important when these high-energy injuries are associated with major soft-tissue damage.

The main disadvantage of nailing is that rotational alignment is difficult to achieve.

ORIF - Bridge plating
Indication summary Skill Equipment
Treatment of choice in the absence of severe soft-tissue injury Highly experienced and skilled surgeon Simple surgical and imaging resources

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

*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