Middle Third Forearm Fractures Treatment & Management
- Author: Janos P Ertl, MD; Chief Editor: Harris Gellman, MD more...
Early surgical intervention (within the first 6-8 hours) is optimal for avoiding radioulnar synostosis. Fixation options include the following[12, 13] :
Intramedullary (IM) nailing
Plate fixation with anatomic reduction is thought to produce the best functional results in closed or open fractures. (See the images below.)
External fixation is primarily indicated for open grade IIIb and IIIc fractures with severe soft-tissue injury. Additional secondary procedures are often necessary, and when used for definitive fracture treatment, external fixation results in a 67% adequate functional result.
The role of IM nailing is not clearly defined; however, several implant options are currently available.[14, 15, 16]
Restoration of the radial bow is the goal and is best achieved with stable internal fixation techniques using 3.5-mm compression plates. The ulna is fairly straight and may be treated with relative stability techniques.
Displaced fractures of the middle forearm in the adult are best treated with open reduction and internal fixation (ORIF). The surgeon should be familiar with several surgical approaches to the forearm because of the wide variety of fracture patterns that can occur. The soft-tissue injury of closed and open fractures may dictate the exposure utilized, with the length of the incision being determined by the fracture.
The diaphysis of the middle third of the radius may be exposed via the Henry approach or the Thompson approach.
The Henry approach, also known as the anterior approach or the volar approach, is extensile and may be extended from the wrist to the elbow. This approach exposes the flat tension surface of the radius, which is ideal for plate application. In addition, fasciotomies for compartment syndromes are best implemented through this approach.
The incision begins 1 cm lateral to the biceps insertion and extends distally to the radial styloid. The fascia is split, and the brachioradialis and the extensor wad (the extensor carpi radialis brevis and longus) are radially retracted. The radial artery, which must be protected, is identified as it extends along the flexor digitorum superficialis.
The radial sensory nerve may be found on the undersurface of the brachioradialis. The median nerve can be found between the palmaris longus and the flexor carpi radialis. The flexors and the median nerve can be retracted toward the ulna, and the middle third of the radius is exposed.
An alternative means of exposing the radius is to employ the Thompson, or dorsolateral, approach. This approach is best suited for exposure of the proximal and middle thirds of the radius; however, it is not an extensile approach.
The incision begins at the lateral epicondyle and extends along the extensor wad over the dorsolateral border of the radius. The fascia is incised, and the interval is developed between the mobile wad and the extensor digitorum, exposing the supinator muscle. In the proximal third of the exposure, the posterior interosseous nerve (PIN) passes through the supinator at right angles to the muscle fibers. The forearm is supinated, protecting the PIN, and the insertion of the supinator is elevated, exposing the subcutaneous tension surface of the radius.
The ulna is exposed along the subcutaneous border between the flexor and extensor carpi ulnaris. Depending on the fracture pattern, the extensor or the flexor is elevated from the ulna in preparation for plating. The dorsal cutaneous branch of the ulnar nerve is found 6-8 cm proximal to the ulnar styloid and must be identified and protected.
A preoperative plan should be determined. The fracture is outlined on the radiograph, cut out, reduced or realigned, and drawn on another sheet, with the definitive fixation placed in the best position.
Depending on the fracture type and the soft-tissue injury, the operating room staff should be prepared for the specific procedure planned. It is important to be ready to harvest an iliac crest bone graft if necessary. Primary bone grafting is controversial but is recommended when comminution exceeds 33% of the bone circumference. The surgical team should have available a 3.5-mm fracture reduction set, a radiolucent hand table, a C-arm, and, if necessary, an allograft bone graft.
The plate that has gained widespread acceptance is the 3.5-mm dynamic compression plate. The development of indirect reduction techniques and a more biologic approach to plate fixation of forearm fractures has been enhanced by newer plate designs, such as the limited contact dynamic compression plate.
In most cases, a plate of adequate length, applied with appropriate technique, is of sufficient strength to support functional load while the fracture heals. At least eight cortices above and below the fracture are usually required, except in the case of a pure transverse fracture, which is effectively held with six cortices on each side. In cases of comminution, 10- or 12-hole plates are typically required.
An external fixator may be necessary in high-energy and high-grade open fractures. The choice of fixator is determined by the surgeon's experience and comfort.
The operative consent document should be written in such a way that it covers all possibilities and fixation options. The risks of the operative procedure must be thoroughly explained to and fully understood by the patient and, if present, the family.
Most middle third forearm fractures are easily approached with the patient in the supine position and the arm extended on an arm board or hand table. The surgical events proceed in a logical sequence, as follows.
Review the history and physical examination findings for possible antibiotic allergies, and administer a broad-spectrum antibiotic for prophylaxis. Although support for prophylactic antibiotics is limited in the literature, 1 g of a first-generation cephalosporin is usually given preoperatively and continued for three doses postoperatively. If the patient has a penicillin allergy, give vancomycin 1 g intravenously (IV) or clindamycin 600 mg IV.
Ensure appropriate pain relief, commonly with local or regional anesthesia (eg, nerve block or IV regional analgesia). Lidocaine is frequently employed for axillary nerve block; a study by Yaghoobi et al suggested that adding dexamethasone may significantly prolong the action of lidocaine in this setting, without causing any adverse hematologic consequences.
Pad all upper- and lower-extremity bony prominences outside the surgical field (ie, the elbows, wrists, knees, peroneal areas, greater trochanters, heels). Apply the appropriately sized padded tourniquet to the patient. Carry out sterile preparation and draping. Elevate the extremity and exsanguinate the arm; raise the tourniquet 100 mm Hg above systolic pressure.
The radial approach, volar or dorsal, exposes the radius. Reduce the radius fracture with sharp or dull fracture reduction forceps as the assistant applies longitudinal traction. Apply a compression plate, and place an interfragmentary compression screw through or outside the plate, as the fracture dictates. A C-arm radiograph can be used quickly to check alignment and screw placement.
Approach the subcutaneous border of the ulna with the arm flexed 90 º. Reduce the ulna fracture. Apply a small-fragment 3.5-mm dynamic compression plate or a limited-contact dynamic compression plate. A minimum of six cortices above and below the fracture site is indicated. Whenever possible, interfragmentary compression screw fixation should be performed, either through or outside the plate fixation. Check with the C-arm as needed.
If necessary, perform a bone graft. Although it is controversial, bone grafting may be applied to grossly comminuted fractures. Retrospective comparison of comminuted forearm fractures has led to questions regarding the need for acute bone grafting. No differences in healing rates and time to union are apparent in these small series, suggesting that routine bone grafting is not indicated. Larger, prospective studies are required.
Should the surgeon decide to place a supplemental autogenous bone graft, this may be harvested from the olecranon, the distal radius, and/or the drill bit on each screw placement. Care in bone graft placement is necessary to avoid violation of the interosseous membrane and to prevent synostosis.
Release the tourniquet, and obtain hemostasis. Drains may be used, according to the surgeon's preference.
Close the wound. If the tension is too great, leave the wound open and return in 2-3 days for delayed primary closure. Apply sterile dressings, and protect the forearm with a sugar-tong splint or a functional fracture brace for support.
The patient's neurovascular status and forearm swelling should be monitored for possible compartment problems. The neurovascular status is monitored in the operating room and in the postanesthesia recovery room. Beginning on postoperative day 1, a physical therapist is consulted to assist in digital range of motion. To avoid hematoma formation, progressive wrist and elbow motion are delayed for 3-5 days.
If any question exists regarding the stability of internal fixation or patient reliability, external functional bracing should be instituted to provide support for the forearm skeleton—and still permit functional use of the extremity—through a careful interosseous mold created by the splint.
Forearm rotation is initiated as the patient's comfort allows, often between the first and second postoperative weeks. The patient is monitored on an outpatient basis at 2 weeks, 6 weeks, 12 weeks, and 4-6 months postoperatively with anteroposterior and lateral radiography.
In terms of activity modification, the patient should be limited to activities of daily living during fracture healing, which should be completed by 3-4 months postoperatively. Once the fracture is healed (as demonstrated radiographically), the patient may progressively return to sports and resume a normal lifestyle.
Restoration of the radial bow is important to the functional outcome. Failure to restore the radial bow to within 5% of the contralateral side results in a 20% loss of forearm rotation, as well as loss of grip strength. Complications of forearm fractures include the following:
Refracture after plate removal
Radioulnar synostosis 
The incidence of refracture of the forearm after plate removal is unknown but is reportedly 4-25%. Factors contributing to refracture include premature plate removal at less than 1 year, delayed union, nonunion, the use of 4.5-mm dynamic compression plates, and poor surgical technique. Plate removal can be considered when cortical remodeling under the plate is radiographically present, typically after 18 months. Forearm protection after plate removal is recommended for 6 weeks, and a return to sports or other activities is delayed for 3-4 months.
Forearm plate removal is not without risk, including infection and nerve injury. The incidence of these complications is 10-20%, and plate removal is not routinely recommended.
Since the use of compression plating became a standard treatment, malunion and nonunion of forearm fractures have been occurring less commonly. With proper technique and a compliant patient, the nonunion rate is approximately 2%.
Infection after operative treatment of forearm fractures is uncommon. The incidence of infection in open fractures has been reported to be 0-3%. Acute infections require standard treatment with irrigation and debridement, and the hardware should not be removed if the fixation is stable. When the hardware is stable, it maintains length, rotation, and alignment and assists in wound care. In late infections, treatment is similar, and plate removal may be performed if the fracture is healed.
During the initial injury that causes a forearm fracture, neurovascular injury also may occur. Vascular injuries usually involve one major artery and do not lead to loss of hand viability. Nerve injuries are usually neurapraxias, and recovery occurs spontaneously. In complete nerve transection, exploration and primary repair, delayed primary repair, or nerve grafting is performed when appropriate.
The results of nerve repair are variable depending on the nature of the wound and the extent of the nerve injury. Iatrogenic nerve injury most often involves a branch of the radial nerve. The PIN can be injured during the dorsal approach, and the radial sensory nerve can be injured during the volar approach.
Compartment syndrome usually occurs in high-energy injuries but may occur in low-energy injuries as well. A high index of suspicion is necessary, and expedient compartment releases are performed (see Chronic Exertional Compartment Syndrome).
The incidence of radioulnar synostosis has been reported to be 0-11% (most commonly, 3%). Risk factors include the following:
Fracture of the radius and ulna at the same level
Single-incision surgical approach
Bone graft within the interosseous space
Screws that are too long
Delay of 2 weeks in operating
Bone scanning should be used to monitor the maturity of the bony synostosis. Once the activity has decreased, the synostosis can be resected within 1-2 years after the fracture.
Outcome and Prognosis
Since the introduction of compression plating, the goal of forearm fracture treatment has been fracture union and the return of normal function.
In 1975, Anderson et al reported their experience with 4.5-mm compression plating of forearm fractures and noted a 97.9% rate of union for the radius and a 96.3% rate of union for the ulna. Time to fracture union averaged 7.4 weeks and 7.3 weeks for radial and ulnar fractures, respectively. Additionally, the authors reported a 2.9% infection and nonunion rate. In this report, they developed a functional outcome evaluation scale, as follows:
Excellent - Union, less than 10º elbow and wrist flexion/extension loss for each joint, and less than 25% rotation loss
Satisfactory - Union, less than 20º elbow and wrist flexion/extension loss for each joint, and less than 50% rotation loss
Unsatisfactory - Union, more than 30º elbow and wrist flexion/extension loss, and more than 50% rotation loss
Failure - Malunion, nonunion, and unresolved chronic osteomyelitis
Using this scale, the authors recorded a combined 85% rate of excellent and satisfactory results for the treatment of 330 acute fractures in 244 patients.
In 1989, Chapman et al reported their results from the treatment of 129 diaphyseal fractures of the radius and/or ulna using standard 3.5-mm compression plates. They recorded a fracture union rate of 98%, an infection rate of 2.3%, and a 92% rate of excellent or satisfactory results using the Anderson forearm evaluation scale.
Similar results have been reported by a number of other authors. Complications in most series were thought to be associated with errors in judgment, with technique, and with a lack of attention to detail. Immediate ORIF is recommended for all open, both-bone middle third forearm fractures. Results have reportedly been excellent or good in 85% of fractures, with an infection rate of 4% and a nonunion rate of 7%.
Prasarn et al described a protocol for repair of infected nonunions of diaphyseal forearm fractures, consisting of aggressive surgical debridement, definitive fixation after 7-14 days, tricortical iliac crest bond grafting for segmental defects, leaving wounds open to heal by secondary intention, 6 weeks of culture-specific IV. antibiotics, and early active range-of-motion exercises. Of 15 patients, 12 had at least 50º of supination/pronation and 30-130º of flexion/extension arc. Aside from one failure (46 months to resolution), average time to union was 13.2 weeks.
Guitton et al described 13 pediatric patients with an isolated diaphyseal fracture of the radius, of whom 10 were treated with manipulative reduction and immobilization with an above-elbow cast and three were treated with plate-and-screw fixation. All 13 patients, with at least 1-year follow-up, regained full elbow flexion and extension and full forearm rotation. According to the authors, treatment of isolated diaphyseal radius fractures in skeletally immature patients is associated with a low complication rate and excellent functional outcome.
Teoh et al compared the differences in radiographic and functional outcomes in children with unstable both-bone diaphyseal forearm fractures after treatment with either IM fixation or plate fixation with screws. Plate fixation and IM nailing both resulted in good or excellent functional and radiologic outcomes.
For the patients with plates, radiographs showed complete healing, with reconstitution of the radial bow. Three patients in the IM group did not regain their natural radial bow. No nonunion or malunion was observed, and there were no significant differences in the loss of forearm motion and grip strength between the two groups. Osteomyelitis was more likely to occur in the IM fixation group, and ulnar nerve palsy occurred in the plate-fixation group.
Du et al conducted a study to compare outcomes of single– and double–elastic stable intramedullary nailing (ESIN) in the treatment of pediatric both-bone forearm fractures. They retrospectively analyzed 49 children with both-bone forearm fractures treated with ESIN, of whom 24 were treated with single-ESIN (S-ESIN) to fixate the radius only and 25 with double-ESIN (D-ESIN) to fixate both the radius and ulna.
In this study, duration of surgery, times of fluoroscopy, and cost of hospitalization were significantly lower in the S-ESIN group than in the D-ESIN group. The average period of castoff was longer in the former, and the incidence of delayed union of the ulna was significantly higher in the latter. Mean angulation deformity of the ulna was significantly larger in the S-ESIN group than in the D-ESIN group, though both were acceptable (< 10°), and there was no difference in loss of forearm motion or complication rates between the two groups.
Future and Controversies
A minimally invasive approach, IM stabilization through nailing is an attractive alternative to formal ORIF, but indications for it are not yet clearly defined. IM fixation may be performed by either open or closed reduction in unstable transverse fractures.
IM devices provide an internal splint, which is able to control bone length and alignment. With newer interlocking nails, rotational alignment can be controlled and maintained. The theoretical advantages of providing longitudinal and angular stability through a minimally invasive approach are less need for soft-tissue dissection and abundant callus formation.
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