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Forearm Fractures

  • Author: Gopikrishna Kakarala, MBBS, MS; Chief Editor: Harris Gellman, MD  more...
 
Updated: Oct 30, 2015
 

Background

The forearm is a complex anatomic structure serving an integral role in upper-extremity function. The dexterity of the upper limb depends on a combination of hand and wrist function and forearm rotation. The forearm bones can be considered struts linking the two halves of a condylar joint formed by the proximal and distal radioulnar joints. Thus, any change in the geometry of the radius or ulna alters the congruency and range of motion of this condylar joint.

Malunion, especially shortening and angulation of the radius or ulna, may cause functional problems at the wrist or elbow. If functional disability is to be avoided after fracture, precise anatomic reduction is necessary.

As a result of the complex arrangement of neurovascular structures surrounding the radius and ulna, surgical approaches to the forearm for fracture fixation require particular care in planning and execution. To restore the functional dynamics of the upper limb, very careful attention must be paid to accurate reconstruction of injured structures.

In children, rapid bone-healing times and the possibility of remodeling with growth allow conservative treatment much of the time.[1] In adults, nonoperative treatment in the form of plaster casting is often inadequate to ensure anatomic reduction and healing. Achieving anatomic reduction by closed methods is difficult, and maintaining a reduction is often impossible.

For an optimal result, the basic rule is that a stable anatomic reduction with preservation of mobility must be achieved. Operative treatment is therefore the rule, rather than the exception, in adults, the treatment principles of the AO group (Arbeitsgemeinschaft für Osteosynthese, or Association for the Study of Osteosynthesis) have revolutionized treatment of radius and ulna fractures.

This article addresses injury to the diaphyseal radius and ulna, as well as associated injury to the distal and proximal radioulnar joints.

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Anatomy

The radius and ulna function as a unit, but they come into contact with each other only at the ends. They are bound proximally by the capsule of the elbow joint and the annular ligament and distally by the capsule of the wrist joint, the dorsal and volar radioulnar ligaments, and the fibrocartilaginous articular disk.

The ulna is relatively straight, has stable articulation with the distal humerus at the elbow, and runs virtually subcutaneously distally to the ulnar styloid at the wrist. The radius is bowed along its length and thus angles at least 13° opposite to the bow to articulate with the capitellum. The radius and ulna form a joint at the distal end, where the strutlike radius sweeps and rotates around the relatively fixed ulna with pronation and supination.

Between the shafts of the radius and ulna is the interosseous space. The fibers of the interosseous membrane run obliquely across the interosseous space from their distal insertion on the ulna to their proximal origin on the radius. The central portion of the interosseous membrane is thickened and is approximately 3.5 cm wide. Hotchkiss et al showed that making an incision on the central band reduces stability by 71%, whereas making an incision of the triangular fibrocartilage complex and the interosseous membrane proximal to the central band decreases stability by only 11%.[2]

In the treatment of fractures of the forearm, the radial bow and proper interosseous space must be maintained for normal motion to be achieved. Schemitsch et al reported that restoration of the radial bow is related in a linear fashion to the quality of the outcome.[3] The normal maximal radial bow, measured from the area between the radius and the ulna across the interosseous membrane, is 15 mm. To achieve 80% of the normal range of movement, this bow must be within 1.5 mm of normal. The same relationship also applies to grip strength. Both the amount and the location of radial bow are crucial correlates to functional outcome.

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Pathophysiology

Fractures of both bones of the forearm are usually classified according to the level of fracture, the pattern of the fracture, the degree of displacement, the presence or absence of comminution or segment bone loss, and whether they are open or closed. Each of these factors may have some bearing on the type of treatment to be selected and the ultimate prognosis.

Disruption of the proximal or distal radioulnar joints is of great significance to treatment and prognosis. Determining whether the fracture is associated with joint injury is imperative because effective treatment demands that both the fracture and the joint injury be treated in an integrated fashion.

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Etiology

The mechanism of injury is variable. The most common cause is a direct blow to the forearm, producing a single (nightstick) fracture of the ulna, the radius, or both. The next most likely mechanism is a fall on an outstretched hand with the forearm pronated. Other mechanisms of injury include road traffic accidents and athletic injuries. The force generated is usually much greater than that required to cause a Colles fracture. Most forearm shaft fractures resulting from falls occur in athletes or in persons who fall from heights.

Gunshot wounds can result in fracture of both bones of the forearm. These injuries are commonly associated with nerve or soft-tissue deficits and frequently have significant bone loss. Severely debilitating and mutilating injuries are caused by accidents involving farmyard machines and industrial machinery. These severely mangled extremities pose a challenge from the time the decision is made to salvage the limb until the final result.

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Epidemiology

In 2010, according to data from the 2010 National Electronic Injury Surveillance System (NEISS) database and the 2010 US Census, forearm fractures were the most common type of fracture in the pediatric population (age range, 0-19 years) and accounted for 17.8% of all fractures.[4]

The literature provides few details regarding the incidence of fractures of the radius and ulna in adults. McQueen et al comprehensively analyzed the incidence of forearm fractures seen at the trauma unit of the Royal Infirmary of Edinburgh over a 3-year period.[5] This unit caters exclusively to adult trauma cases in a specified area and population and thus is a very good guide to the epidemiology of forearm fractures in a westernized country.

In this analysis, the causes of injury included direct trauma, fall from a height, road traffic accidents, and sporting injuries.[5] Unlike in other regions, injuries related to gunshots and firearms are not prevalent as a cause of injury in this region. Of the 2812 fractures, just 5% were diaphyseal forearm fractures, and an overwhelming majority of 76% were distal radius fractures.

Data from the National Hospital Ambulatory Medical Care Survey showed that radius and/or ulna fractures accounted for 44% of all forearm and hand fractures in the United States.[6]

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Prognosis

The prognosis for adults with fractures of the radius and ulna depends on many factors.[7, 8, 9, 10] However, the factors under the surgeon's control include choice of treatment method, timing of internal fixation in open fractures, soft-tissue handling, and restoration of osseous anatomy.

Anderson reported a union rate of 97.3% for fractures treated with open reduction and internal fixation (ORIF) using compression plates.[11] Of these patients, 90% had satisfactory or excellent function, and only 10% had unsatisfactory or poor function. Sage reported a union rate of 93.8% for fractures treated with triangular nails.[12]

One study compared the complication rates in patients treated with external fixation versus volar plating of distal radius fractures. The volar plate group experienced more tendon and median nerve complications; however, the external fixation group had a significantly higher overall complication rate. While there were no significant differences between the groups in the scapholunate angle or palmar tilt measurements, the volar plate group had significantly better arc of motion in pronation-supination and flexion-extension and better grip strength.[13]

The important feature common to these studies, in which a union rate of more than 90% was reported, was the rigidity of the fixation. If intramedullary nails are used, they must control rotation of the fragments and be sturdy enough to resist angulatory forces. If plates and screws are used, they must be long enough and strong enough to resist loosening and breakage.

The prognosis is more guarded for open fractures of the shaft of the radius and ulna with major skin and soft-tissue loss. In these cases, several operative procedures may be necessary, including initial debridement and stabilization, skin grafting, pedicle or free-flap applications,[14] late reconstruction of the bones, and, frequently, tendon transfers.

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Contributor Information and Disclosures
Author

Gopikrishna Kakarala, MBBS, MS MRCSEd, Fellow, Department of Orthopedics, New Cross Hospital, UK

Disclosure: Nothing to disclose.

Coauthor(s)

Adrian W Simons, MBBS, FRCS Consulting Staff, Department of Orthopedic Surgery - Hand Surgery, New Cross Hospital, UK

Adrian W Simons, MBBS, FRCS is a member of the following medical societies: British Orthopaedic Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Thomas R Hunt III, MD Professor and Chairman, Joseph Barnhart Department of Orthopedic Surgery, Baylor College of Medicine

Thomas R Hunt III, MD is a member of the following medical societies: American Orthopaedic Association, American Orthopaedic Society for Sports Medicine, Southern Orthopaedic Association, AO Foundation, American Academy of Orthopaedic Surgeons, American Association for Hand Surgery, American Society for Surgery of the Hand, Mid-America Orthopaedic Association

Disclosure: Received royalty from Tornier for independent contractor; Received ownership interest from Tornier for none; Received royalty from Lippincott for independent contractor.

Chief Editor

Harris Gellman, MD Consulting Surgeon, Broward Hand Center; Voluntary Clinical Professor of Orthopedic Surgery and Plastic Surgery, Departments of Orthopedic Surgery and Surgery, University of Miami, Leonard M Miller School of Medicine, Clinical Professor, Surgery, Nova Southeastern School of Medicine

Harris Gellman, MD is a member of the following medical societies: American Academy of Medical Acupuncture, American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Society for Surgery of the Hand, Arkansas Medical Society

Disclosure: Nothing to disclose.

Additional Contributors

Michael S Clarke, MD Clinical Associate Professor, Department of Orthopedic Surgery, University of Missouri-Columbia School of Medicine

Michael S Clarke, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Arthroscopy Association of North America, American Academy of Pediatrics, American Association for Hand Surgery, American College of Surgeons, American Medical Association, Clinical Orthopaedic Society, Mid-Central States Orthopaedic Society, Missouri State Medical Association

Disclosure: Nothing to disclose.

References
  1. Singh S, Bhatia M, Housden P. Cast and padding indices used for clinical decision making in forearm fractures in children. Acta Orthop. 2008 Jun. 79(3):386-9. [Medline].

  2. Hotchkiss RN, An KN, Sowa DT, et al. An anatomic and mechanical study of the interosseous membrane of the forearm: pathomechanics of proximal migration of the radius. J Hand Surg [Am]. 1989 Mar. 14(2 Pt 1):256-61. [Medline].

  3. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 1992 Aug. 74(7):1068-78. [Medline].

  4. Naranje SM, Erali RA, Warner WC Jr, Sawyer JR, Kelly DM. Epidemiology of Pediatric Fractures Presenting to Emergency Departments in the United States. J Pediatr Orthop. 2015 Jul 14. [Medline].

  5. McQueen MM. Epidemiology of fractures of the forearm. McQueen MM, Jupiter JB. Radius and Ulna. Oxford: Butterworth-Heinemann; 1997. 1-11.

  6. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg [Am]. 2001 Sep. 26(5):908-15. [Medline].

  7. Nagy L, Jankauskas L, Dumont CE. Correction of forearm malunion guided by the preoperative complaint. Clin Orthop Relat Res. 2008 Jun. 466(6):1419-28. [Medline].

  8. Souer JS, Lozano-Calderon SA, Ring D. Predictors of wrist function and health status after operative treatment of fractures of the distal radius. J Hand Surg [Am]. 2008 Feb. 33(2):157-163. [Medline].

  9. Osada D, Kamei S, Takai M, Tomizawa K, Tamai K. Malunited fractures of the distal radius treated with corrective osteotomy using volar locking plate and a corticocancellous bone graft following immediate mobilisation. Hand Surg. 2007. 12(3):183-90. [Medline].

  10. Mackenney PJ, McQueen MM, Elton R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006 Sep. 88(9):1944-51. [Medline].

  11. Anderson LD. Fractures. In: Crenshaw AH, ed. Campbell's Operative Orthopaedics. 5th ed. Vol 1. St Louis, Mo: Mosby; 1971:477-691.

  12. Sage FP. Medullary fixation of fractures of the forearm. A study of the medullary canal of the radius and a report of fifty fractures of the radius treated with a prebent triangular nail. J Bone Joint Surg Am. 1959 Dec. 41-A:1489-516. [Medline].

  13. Mandziak DG, Watts AC, Bain GI. Ligament contribution to patterns of articular fractures of the distal radius. J Hand Surg Am. 2011 Oct. 36(10):1621-5. [Medline].

  14. Mullett H, Hausman M, Zaidemberg C. Recalcitrant distal humeral and proximal forearm nonunion: salvage using an extended pedicled radial forearm osseous flap. J Trauma. 2008 Apr. 64(4):E60-4. [Medline].

  15. Richard MJ, Wartinbee DA, Riboh J, Miller M, Leversedge FJ, Ruch DS. Analysis of the complications of palmar plating versus external fixation for fractures of the distal radius. J Hand Surg Am. 2011 Oct. 36(10):1614-20. [Medline].

  16. Samora JB, Klingele KE, Beebe AC, Kean JR, Klamar J, Beran MC, et al. Is There Still a Place for Cast Wedging in Pediatric Forearm Fractures?. J Pediatr Orthop. 2013 Sep 15. [Medline].

  17. Auer RT, Mazzone P, Robinson L, Nyland J, Chan G. Childhood Obesity Increases the Risk of Failure in the Treatment of Distal Forearm Fractures. J Pediatr Orthop. 2015 Sep 20. [Medline].

  18. Sarmiento A, Cooper JS, Sinclair WF. Forearm fractures. Early functional bracing - A preliminary report. J Bone Joint Surg Am. 1975 Apr. 57(3):297-304. [Medline].

  19. Bowman EN, Mehlman CT, Lindsell CJ, Tamai J. Nonoperative treatment of both-bone forearm shaft fractures in children: predictors of early radiographic failure. J Pediatr Orthop. 2011 Jan-Feb. 31(1):23-32. [Medline].

  20. Droll KP, Perna P, Potter J, Harniman E, Schemitsch EH, McKee MD. Outcomes following plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am. 2007 Dec. 89(12):2619-24. [Medline].

  21. Henle P, Ortlieb K, Kuminack K, Mueller CA, Suedkamp NP. Problems of bridging plate fixation for the treatment of forearm shaft fractures with the locking compression plate. Arch Orthop Trauma Surg. 2010 Jun 3. [Medline].

  22. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma. 1997 May. 11(4):288-94. [Medline].

  23. Kim SB, Heo YM, Yi JW, Lee JB, Lim BG. Shaft Fractures of Both Forearm Bones: The Outcomes of Surgical Treatment with Plating Only and Combined Plating and Intramedullary Nailing. Clin Orthop Surg. 2015 Sep. 7 (3):282-90. [Medline].

  24. Shah AS, Lesniak BP, Wolter TD, Caird MS, Farley FA, Vander Have KL. Stabilization of Adolescent Both-Bone Forearm Fractures: A Comparison of Intramedullary Nailing versus Open Reduction and Internal Fixation. J Orthop Trauma. 2010 Jul. 24(7):440-7. [Medline].

  25. Dietz JF, Bae DS, Reiff E, Zurakowski D, Waters PM. Single bone intramedullary fixation of the ulna in pediatric both bone forearm fractures: analysis of short-term clinical and radiographic results. J Pediatr Orthop. 2010 Jul-Aug. 30(5):420-4. [Medline].

  26. Memeo A, Verdoni F, De Bartolomeo O, Albisetti W, Pedretti L. A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma. Injury. 2013 Sep 20. [Medline].

  27. Reinhardt KR, Feldman DS, Green DW, Sala DA, Widmann RF, Scher DM. Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children. J Pediatr Orthop. 2008 Jun. 28(4):403-9. [Medline].

  28. Krzykawski R, Król R, Kaminski A. The results of locked intramedullary nailing for non-union of forearm bones. Ortop Traumatol Rehabil. 2008 Jan-Feb. 10(1):35-43. [Medline].

  29. Mseddi MB, Manicom O, Filippini P, Demoura A, Pidet O, Hernigou P. [Intramedullary pinning of diaphyseal fractures of both forearm bones in adults: 46 cases]. Rev Chir Orthop Reparatrice Appar Mot. 2008 Apr. 94(2):160-7. [Medline].

  30. Duncan R, Geissler W, Freeland AE, Savoie FH. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma. 1992. 6(1):25-31. [Medline].

  31. Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Trauma Surg. 2010 Mar 9. [Medline].

  32. McQueen MM, Wakefield A. Distal radial osteotomy for malunion using non-bridging external fixation: good results in 23 patients. Acta Orthop. 2008 Jun. 79(3):390-5. [Medline].

  33. Stern PJ, Drury WJ. Complications of plate fixation of forearm fractures. Clin Orthop Relat Res. 1983 May. 25-9. [Medline].

  34. Eaton RG, Green WT. Volkmann's ischemia. A volar compartment syndrome of the forearm. Clin Orthop Relat Res. 1975 Nov-Dec. 58-64. [Medline].

  35. Vopat B, Kane P, Fitzgibbons P, Got C, Katarincic J. Complications Associated with Retained Implants After Plate Fixation of the Pediatric Forearm. J Orthop Trauma. 2013 Oct 3. [Medline].

  36. Mih AD, Cooney WP, Idler RS, Lewallen DG. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop Relat Res. 1994 Feb. 256-8. [Medline].

  37. Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg. 1991. 110(3):142-5. [Medline].

  38. Colaris J, van der Linden M, Selles R, Coene N, Allema JH, Verhaar J. Pronation and supination after forearm fractures in children: Reliability of visual estimation and conventional goniometry measurement. Injury. 2010 Jun. 41(6):643-6. [Medline].

 
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Closed fracture of the forearm in the middle-third area is complicated by compartment syndrome, with early blisters and a tense compartment.
The same patient as in image above, with fasciotomy and external fixation to the radius and intramedullary nailing of the ulna.
Osteosynthesis using a dynamic compression plate for a closed midshaft fracture of both bones of the forearm.
Internal fixation using square nails for a segmental fracture of both bones of the forearm.
Nonunion of the radius and ulna due to an error in surgical technique.
Nonunion treated with resection of approximately 2 cm of bone from both the radius and the ulna, along with compression plating.
Sequestrum of the proximal radius. Sequela to an open fracture of the radius and ulna and multiple surgeries.
Infected nonunion of a compound fracture, treated previously with bone grafting and replating. The plates were removed; and dead, infected bone was debrided, leaving a gap of 5.5 cm in the radius. Temporary external fixation was applied to the radius. Four weeks later, a free fibular graft was used to reconstruct the radius, and the ulna was replated.
Postosteosynthetic synostosis.
 
 
 
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