Executive Editor: Chris Colton

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

Forearm shaft 22-C1 Plating of one (C1.1) or both (C1.2/.3) bones

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Glossary

1 Indications top

The preferred treatment of the simple fractures of the radius in these injury configurations is compression plating (with or without lag screw), leading to absolute stability and direct bone healing.

The preferred treatment of the bifocal fractures of the ulna is compression plating leading to anatomical restoration of length, rotational alignment, and absolute stability. The blood supply of the intermediate fragment must be meticulously preserved throughout.

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

Some bifocal fractures can not be treated by compression plating for technical reasons and occasionally, bridge plating of the ulna is indicated in C1.1 and C1.2 fractures; in such circumstances, the blood supply of the intermediate fragment must be meticulously preserved.

Anatomical reduction cannot be achieved in complex multifragmentary C1.3 fractures of the ulna, but maintaining relative stability using bridge plating is widely accepted. Either a conventional plate, or a locked plate, can be used as long as the principles of minimizing soft-tissue stripping and achieving both length and alignment are respected.

2 Principles top

Principles enlarge

Order of fixation

Normally, in both bone fractures (C1.2, C1.3), the simpler radial fracture will be approached first and preliminary fixation undertaken.

Fixation of the fractures involving both bones proceeds as follows:

  1. Reduction and preliminary fixation usually starts with the radius
  2. Reduction and definitive fixation of the ulna
  3. Definitive fixation of the radius

Never commit yourself to the definitive fixation of one bone until you have assured yourself that you can reduce the other bone.

Throughout this module, the fixation of each bone will be described to completion but the surgeon is reminded not to complete the first fixation until the second bone has been definitively fixed.


When both bones need to be reduced and fixed, a separate approach to each bone should be performed in order to reduce the risk of heterotopic bone formation.

For proximal radial shaft fractures, the anterior approach (Henry) is most often used to minimize the risk of damage to the posterior interosseous nerve, which crosses the proximal radius within the supinator muscle.

In mid and distal radial shaft fractures, either the anterior approach (Henry) or posterolateral approach (Thompson) can be used, depending on surgeon’s preference.

The ulna shaft is exposed by the standard subcutaneous approach between the flexor and extensor muscle compartments.

The approach for nailing of the ulna in C1.3 injuries is through the posterior face of the olecranon.

3 Detailed procedures top

Detailed procedures enlarge

In C1.1 fractures, the radius is intact and the there is a bifocal fracture of the ulna. The possibility of a Monteggia dislocation of the radial head (C1.1.2) must always be considered: this will be likely to relocate following anatomical reduction and fixation of the ulna, but must be checked at the end of the procedure.


Detailed procedures enlarge

In the absence of a Monteggia injury, the only option to be considered is compression plating of the bifocal ulnar fracture.

If the radial head is dislocated, see the section on Monteggia injuries.


Detailed procedures enlarge

In C1.2 fractures, the radius has a simple or a wedge fracture and there is a bifocal fracture of the ulna.

The sequence of fixation is likely to be

  1. Preliminary fixation of the radial fracture
  2. Definitive fixation of the bifocal fracture of the ulna
  3. Definitive fixation of the radial fracture

The required techniques are:


Detailed procedures enlarge

In C1.3 fractures, the radius has a simple or a wedge fracture and there is a complex multifragmentary (irregular) fracture of the ulna.

The sequence of fixation is likely to be

  1. Preliminary fixation of the radial fracture
  2. Definitive fixation of the complex multifragmentary fracture of the ulna
  3. Definitive fixation of the radial fracture

The required techniques are:

4 Completed osteosynthesis top

Completed osteosynthesis enlarge

This illustration shows an example of a completed C1.3 osteosynthesis.

5 Check of osteosynthesis top

Check of osteosynthesis enlarge

Check the completed osteosynthesis by image intensification. Make sure that the plate is at a proper location, the screws are of appropriate length and a desired reduction was achieved.


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The elbow should be stabilized at the epicondyles and the forearm rotation should be checked between the radial and ulnar styloids.

6 Assessment of Distal Radioulnar Joint (DRUJ) top

Before starting the operation the uninjured side should be tested as a reference for the injured side.

After fixation, the distal radioulnar joint should be assessed for forearm rotation, as well as for stability. The forearm should be rotated completely to make certain there is no anatomical block.


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Method 1

The elbow is flexed 90° on the arm table and displacement in dorsal palmar direction is tested in a neutral rotation of the forearm with the wrist in neutral position.

This is repeated with the wrist in radial deviation, which stabilizes the DRUJ, if the ulnar collateral complex (TFCC) is not disrupted.


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This is repeated with the wrist in full supination and full pronation.


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Method 2

In order to test the stability of the distal radioulnar joint, the ulna is compressed against the radius...


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...while the forearm is passively put through full supination...


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...and pronation.

If there is a palpable “clunk”, then instability of the distal radioulnar joint should be considered. This would be an indication for internal fixation of an ulnar styloid fracture at its base. If the fracture is at the tip of the ulnar styloid consider TFCC stabilization.

v2.1 2017-04-03