Executive Editor: Chris Colton

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

Forearm shaft Multifragmentary, intact segmental fracture of one bone, fragmentary of the other

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1 Principles top


Order of fixation

Normally, the less challenging of the two bones (the segmental injury) will be approached first and preliminary fixation undertaken, unless the condition of the soft tissues determines otherwise.

Most often, fixation of these fractures proceeds as follows:

  1. Reduction and preliminary fixation usually starts with the segmental fracture
  2. Reduction and definitive bridge fixation of the multifragmentary fracture of the other bone
  3. Definitive fixation of the segmental fracture

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.

Note on approaches

When both bones need to be reduced and fixed, a separate approach to each bone should be performed 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 is exposed by the standard subcutaneous approach between the flexor and extensor muscle compartments.

2 Detailed procedures top

In fractures where either the radius or the ulna has an intact segmental fracture pattern, whereas the other bone has a complex multifragmentary fracture, at either of the two fracture sites of the segmental injury, the fracture morphology may be either oblique or transverse (short oblique). Possible techniques are:

Detailed procedures enlarge 1) Compression plating of segmental ulnar fracture

Note: one long (as illustrated) or two short plates can be used (see detailed technique).

Detailed procedures enlarge 2) Compression plating of segmental radial fracture

Note: one long (as illustrated) or two short plates can be used (see detailed technique).

Detailed procedures enlarge

3) Bridge plating of fragmentary ulnar fracture

Detailed procedures enlarge

4) Bridge plating of fragmentary radial fracture

3 Completed osteosynthesis top

Completed osteosynthesis enlarge

This illustration shows an example of a completed osteosynthesis.

4 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.

Check of osteosynthesis enlarge

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

5 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.


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.


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


Method 2

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


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


...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.

v2.0 2013-07-09