Segmental fractures 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 plate fixation are indicated in most of these fractures, other treatment methods may have to be considered as well.
Intramedullary nailing of forearm fractures is currently limited to pediatric fractures and severe multifragmentary injuries of one or both forearm bones in the presence of devastating soft-tissue damage. Pediatric fractures are not included in this module of AO Surgery Reference. Discussion of nailing in adult forearm shaft fractures is confined to multifragmentary fractures of both bones in adult AO Surgery Reference.
|Severely injured polytrauma patients|
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 highly likely to be suboptimal.
|A means of temporary fixation for severely open fractures|
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.
|ORIF - Compression plating|
|Treatment of choice|
Anatomical reduction can be achieved in segmental fractures provided the soft-tissue condition permits open procedures. Either conventional, or locked, plates can be used, if the principles of minimizing soft-tissue stripping and achieving both length and alignment are respected.
|Basic surgical experience, no specialized skills|
|Some specialized surgical experience|
|Highly experienced and skilled surgeon|
|Basic equipment only|
|Simple surgical and imaging resources|
|Full specialized surgical and imaging resources|