Forearm shaft Multifragmentary radial fracture with non-multifragmentary ulnar fracture

The only adult forearm shaft fractures in which a satisfactory functional outcome can be expected after nonoperative treatment are minimally displaced, or stably reduced, isolated ulnar fractures with no compromise of either radioulnar joint.

See:

• Mackay D, Wood L, Rangan A (2000) The treatment of isolated ulnar fractures in adults: a systematic review.Injury; 31(8):565-70.
• Sarmiento A, Latta LL, Zych G, et al (1998) Isolated ulnar shaft fractures treated with functional braces.J Orthop Trauma; 12(6):420-3; discussion 423-4.
• Handoll HH, Pearce P (2009) Interventions for isolated diaphyseal fractures of the ulna in adults.Cochrane Database Syst Rev; Jul 8;(3):CD000523.

In all other cases, if nonoperative treatment is necessary because of severe soft-tissue compromise or the patient being unfit for surgery, the functional outcome will inevitably be suboptimal.

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The basic principles of nonoperative treatment of adult forearm shaft fractures are:

1. Both wrist and elbow joints must be included in the cast
   Note: Mackay et al. and Sarmiento & Latta suggest that in isolated ulnar fractures, above elbow splintage is not necessary.
2. The cast should be well-padded and split along its whole length in any injury where progressive swelling is to be expected
3. The general form of the forearm should be restored
4. The elbow joint is immobilized in 90° flexion
5. The cast should not extend beyond the proximal palmar flexor crease, in order to permit full flexion of the MCP joints of the fingers.
6. The thumb should not be included in the cast
   

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Sarmiento and Latta (Closed Functional Treatment of Fractures, Springer Verlag, 1981, p.384) recommend that the cast be applied with the arm suspended from Chinese fingers traps and the elbow at a right angle. This results in a forearm posture of "relaxed supination": they combine this with careful moulding anteroposteriorly in such a manner as to separate the two bones and tension the interosseous membrane.

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Meticulous clinical observation for compartment syndrome must be undertaken. Watch out for increasing inappropriate pain, especially with passive stretching of the muscles of the affected compartment(s).

Additional authorities

• Charnley J (2003) The closed treatment of common fractures. 4th ed. Cambridge University Press.
• Tarr RR, Garfinkel AI, Sarmiento A (1984) The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg Am; 66(1):65-70.