Executive Editor: Peter Trafton

Authors: Kodi Kojima, Steve Velkes

Proximal forearm

back to skeleton

Glossary

Basic treatment techniques

Basic technique: Modular external fixation

Surgical procedures sorted by fracture type

Use this menu to jump directly into a specific classification (optional):
A1.1 A1.2 A1.3 A2.1 A2.2 A2.3 A3.1 A3.2/3 B1 B2 B3.1 B3.2 B3.3 C1 C2.1 C2.2/3 C3
A1.1

Extraarticular fracture of the ulna, avulsion of the triceps insertion

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Minimal displacement (< 2 mm). Active elbow extension. Immobilization desired. Basic surgical experience, no specialized skills Basic equipment only
Functional treatment Minimal displacement (< 2 mm). Active elbow extension. Immobilization unnecessary. Some specialized surgical experience Basic equipment only
Triceps reinsertion Small and/or multiple fragment(s). Osteoporotic bone. Some specialized surgical experience Basic equipment only
A1.2

Extraarticular fracture of the ulna, simple metaphyseal

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced, stable fracture. Basic surgical experience, no specialized skills Basic equipment only
Temporary external fixation Instability that can not be controlled with splint or cast. Significant soft-tissue injury or contamination. Some specialized surgical experience Simple surgical and imaging resources
Compression plate Transverse fracture. Some specialized surgical experience Simple surgical and imaging resources
Compression plate and lag screw Oblique fracture suitable for compression with both lag screw and plate. Some specialized surgical experience Simple surgical and imaging resources
Lag screw and protection plate Oblique fracture. Interfragmentary compression by lag screw, but not plate. Some specialized surgical experience Simple surgical and imaging resources
A1.3

Extraarticular fracture of the ulna, multifragmentary metaphyseal

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced, stable fracture. Basic surgical experience, no specialized skills Basic equipment only
Temporary external fixation Instability that can not be controlled with splint or cast. Significant soft-tissue injury or contamination. Some specialized surgical experience Simple surgical and imaging resources
Bridging plate Unstable, displaced fracture. Instability of radiocapitellar or proximal radioulnar joint. Highly experienced and skilled surgeon Simple surgical and imaging resources
A2.1

Extraarticular fracture of the radius, avulsion of bicipital tuberosity

Please select a treatment option:
Treatment Indication summary Skill Equipment
Functional treatment Excessive surgical risk. Low demand, elderly patient. Basic surgical experience, no specialized skills Simple surgical and imaging resources
Biceps reinsertion Loss of flexion and supination strength. Highly experienced and skilled surgeon Simple surgical and imaging resources
A2.2

Extraarticular fracture of the radius, simple radial neck

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced stable fracture. Immobilization desired. Basic surgical experience, no specialized skills Basic equipment only
Functional treatment Undisplaced fracture. >70% supination and pronation. Basic surgical experience, no specialized skills Basic equipment only
Lag screw fixation Oblique fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Compression with T-plate Displaced transverse fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
A2.3

Extraarticular fracture of the radius, multifragmentary radial neck fracture

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced fracture. Basic surgical experience, no specialized skills Basic equipment only
Temporary external fixation Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss. Some specialized surgical experience Simple surgical and imaging resources
Bridging plate (multifragmentary fracture) Displaced or unstable fracture. Stable fixation possible. Highly experienced and skilled surgeon Simple surgical and imaging resources
Replacement arthroplasty Unstable elbow joint. Associated interosseous membrane injury (Essex-Lopresti injury). Highly experienced and skilled surgeon Full specialized surgical and imaging resources
A3.1

Extraarticular fracture of both bones, simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Instability that can not be controlled with cast or splint. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss. Some specialized surgical experience Simple surgical and imaging resources
Compression plate for ulna Transverse fracture. Some specialized surgical experience Basic equipment only
Compression plate and lag screw for ulna Fracture suitable for compression with both plate and lag screw. Some specialized surgical experience Basic equipment only
Lag screw and protection plate for ulna Fracture suitable for compression with lag screw but not plate. Some specialized surgical experience Basic equipment only
Lag screw fixation for radius Oblique fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Compression with T-Plate for radius Transverse fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
A3.2/3

Extraarticular fracture of both bones, one or both multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss. Some specialized surgical experience Simple surgical and imaging resources
Compression plate for ulna Transverse fracture. Some specialized surgical experience Simple surgical and imaging resources
Compression plate and lag screw for ulna Fracture suitable for compression with both plate and lag screw. Some specialized surgical experience Simple surgical and imaging resources
Lag screw and protection plate for ulna Fracture suitable for compression with lag screw but not plate. Some specialized surgical experience Simple surgical and imaging resources
Bridging plate for ulna Multifragmentary fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screw fixation for radius Oblique fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Compression with T-plate for radius Transverse fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Bridging plate for radius Multifragmentary fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Replacement arthroplasty for radius Unstable elbow joint. Inability to fix the radial neck satisfactorily. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B1

Articular fracture of the ulna

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced B1.1 fracture. Immobilization desired. Basic surgical experience, no specialized skills Basic equipment only
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Major bone loss. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Tension band wiring Transverse simple fracture of the olecranon. Some specialized surgical experience Basic equipment only
Lag screw and protection plate Oblique fracture of the olecranon. Some specialized surgical experience Simple surgical and imaging resources
Tension band plate Unifocal, transverse olecranon fracture, or minimally comminuted but with similar stability. Some specialized surgical experience Simple surgical and imaging resources
Bridging plate Multifragmentary fractures. Highly experienced and skilled surgeon Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
B2

Articular fracture of the radius

Please select a treatment option:
Treatment Indication summary Skill Equipment
Circular cast or splint Undisplaced or minimally displaced fractures with acceptable supination and pronation range. Immobilization desired. Basic surgical experience, no specialized skills Basic equipment only
Functional treatment Undisplaced or minimally displaced fractures with acceptable supination and pronation range. Basic surgical experience, no specialized skills Simple surgical and imaging resources
Temporary external fixation Joint instability. Extensive soft-tissue damage. Some specialized surgical experience Simple surgical and imaging resources
Lag screw fixation Simple displaced fractures. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screws through plate Reconstructible multifragmentary fracture. Fracture where lag screws alone provide inadequate stability. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Excision of the radial head Isolated unreconstructable radial head fracture with stable elbow. Intact interosseous membrane and distal radioulnar joint (DRUJ). Some specialized surgical experience Basic equipment only
Replacement arthroplasty Inability to reconstruct radial head fracture so that it provides sufficient stability for elbow joint. Interosseous membrane injury (Essex-Lopresti injury). Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.1

Simple articular ulna, extraarticular radius

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Tension band wiring for olecranon Transverse simple fracture. No instability of radial fracture. Some specialized surgical experience Basic equipment only
Lag screw and protection plate for olecranon Oblique fracture. Some specialized surgical experience Basic equipment only
Tension band plate for olecranon Unifocal, transverse olecranon fracture, or minimally comminuted but with similar stability. Some specialized surgical experience Simple surgical and imaging resources
Lag screw fixation for radius Oblique fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Compression with T-plate for radius Transverse fracture. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate (simple, impacted fracture) for radius Shortened radial neck fracture with loss of bone volume (impaction). Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate (multifragmentary fracture) for radius Multifragmentary fracture with shortening. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Replacement arthroplasty for radius Inability to reconstruct radial head or neck fracture so that it provides sufficient stability for elbow joint. Interosseous membrane injury (Essex-Lopresti injury). Highly experienced and skilled surgeon Full specialized surgical and imaging resources
B3.2

Simple articular radius, extraarticular ulna

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Lag screw fixation for radius Simple fracture of the radial head. Some specialized surgical experience Simple surgical and imaging resources
Compression plate for ulna Transverse fracture. Some specialized surgical experience Basic equipment only
Compression plate and lag screw for ulna Simple oblique fracture, suitable for compression with both lag screw and plate. Some specialized surgical experience Basic equipment only
Lag screw and protection plate for ulna Fracture suitable for compression with lag screw but not plate. Some specialized surgical experience Basic equipment only
Bridging plate for ulna Multifragmentary fracture. Some specialized surgical experience Simple surgical and imaging resources
B3.3

Multifragmentary articular of one bone, extraarticular of the other

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate for olecranon Multifragmentary fracture. Some specialized surgical experience Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screws and plate for radius Reconstructible multifragmentary fracture of the radial head/neck. Fracture where lag screws alone provide inadequate stability. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Replacement arthroplasty for radius Unreconstructable fracture of the radial head or neck. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Compression plate for ulna Transverse fracture. Some specialized surgical experience Simple surgical and imaging resources
Compression plate and lag screw for ulna Oblique fracture, suitable for compression with both plate and lag screw. Some specialized surgical experience Simple surgical and imaging resources
Lag screw and protection plate for ulna Fracture suitable for compression with lag screw but not plate. Some specialized surgical experience Simple surgical and imaging resources
Bridging plate for ulna Multifragmentary extraarticular fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screw fixation for radius Oblique fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
Compression with T-plate for radius Transverse fracture. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate (simple, impacted fracture) for radius Shortened radial neck fracture with loss of bone volume (impaction). Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate (multifragmentary fracture) for radius Multifragmentary fracture with shortening. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C1

Simple articular fractures of both bones

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Lag screw and protection plate for olecranon Oblique fracture. Some specialized surgical experience Simple surgical and imaging resources
Tension band plate for olecranon Unifocal, transverse olecranon fracture, with restored stability or radial head fracture. Some specialized surgical experience Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screw fixation of radial head Single-fragment radial head fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
C2.1

Articular fracture of both bones, Olecranon multifragmentary, radial head simple

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate for olecranon Multifragmentary fracture. Some specialized surgical experience Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screw fixation of radial head Simple fracture. Highly experienced and skilled surgeon Simple surgical and imaging resources
C2.2/3

Articular fracture of both bones, olecranon or coronoid simple, radial head multifragmentary

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Lag screw and protection plate for olecranon Oblique fracture. Some specialized surgical experience Simple surgical and imaging resources
Tension band plate for olecranon Unifocal, transverse olecranon fracture, with restored stability or radial head fracture. Some specialized surgical experience Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screws and plate for radius Reconstructible multifragmentary fracture of the radial head. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Replacement arthroplasty for radius Unreconstructable fracture of the radial head. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
C3

Multifragmentary articular fractures of both bones

Please select a treatment option:
Treatment Indication summary Skill Equipment
Temporary external fixation Joint instability. Extensive soft-tissue damage. Severe contamination. Infection. Some specialized surgical experience Simple surgical and imaging resources
Hinged external fixation following ORIF Persistent elbow instability. Protection for weak fixation. Motion desired. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Bridging plate for olecranon Multifragmentary fractures. Highly experienced and skilled surgeon Simple surgical and imaging resources
Repair of coronoidal fracture Coronoidal fracture with elbow instability. Highly experienced and skilled surgeon Simple surgical and imaging resources
Lag screws and plate for radius Reconstructible multifragmentary fracture of the radial head. Highly experienced and skilled surgeon Full specialized surgical and imaging resources
Replacement arthroplasty for radius Unreconstructable fracture of the radial head. Highly experienced and skilled surgeon Full specialized surgical and imaging resources

Special considerations

Principles of management of open fractures
Complications
Infection
Compartment syndrome
*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

v1.0 2016-10-24