Forearm Fractures

Derek J. Donegan, M.D.

University of Pennsylvania
Revised 2014
Previous Author: Steven I. Rabin; Aug 2009
 Problem
• Fractures of adult forearm are inherently
unstable
• According to the AO documentation center,
forearm fractures accounted for 10-14% of all
fractures between 1980 and 1996
• Mistreatment can lead to malunions and
nonunions
– Cosmetically unappealing
– Functionally impeding
 Anatomy
• Radial Bow
– Critical for rotation
• Interosseous
Membrane
– Tethers Distal Ulna to
Proximal Radius
 Radial Nerve
• PIN
– Proximal Radial
Neck
• Superficial Branch
Distal
 Radial Artery

• Posterior to
Brachioradialis
Median Nerve

• Midline
• At risk with Carpal
Tunnel
• AIN along IOM
 Mechanism
• Low Energy
– Direct blow (i.e.
Nightstick fx)
– Indirect
• Galleazzi
• Monteggia
• High Energy
– Associated injuries
– open
 Clinical Findings
• PE
– Floppy, Swelling, Pain
– Assess Elbow and Wrist
– Neurovascular Examination
• AIN, PIN, radial/ulna arteries
– Soft Tissue
• Open Wounds
• Compartments
 Compartments
• Dorsal: Extensors
• Volar: Flexors
– Superficial
– Deep
• Mobile Wad
– BR
– ECRB
– ECRL
 Compartment Syndrome
• Pain
– Passive Extension
• High energy injury
• Tx
– Dorsal Approach
– Volar Approach
– Carpal Tunnel
 Work-up
• X-rays in 2 planes
(AP and lateral)
– Be sure to image
joint above and
below
• Wrist and elbow
• CT and MRI
– Typically
unnecessary
– Add little clinical
information
 Classification
• AO/OTA
– 22
– Fracture type
• A=simple
• B=Wedge
• C=complex
– Involved bones
• 1=ulna
• 2=radius
• 3=both bones
Type A
• Simple Fracture
– Ulna alone, Radius
intact
– Radius alone, Ulna
intact
– Both Bones broken

• Ex: Transverse radius

fracture
 Type B
• Wedge Fractures
– Ulna alone
– Radius alone
– Both bones

• Ex: Both Bones

 Type C
• Complex Fractures
– Ulna alone
– Radius alone
– Both bones

• Ex: both bones

 Non-Operative Treatment
• Non-operative • Non-operative
– Poor – Functional Brace /
Cast
– Nonunion
– Ulna
– Malunion
• Stable
• Closed
• Distal 1/3
• < 10 Degrees
– Radius
• Nondisplaced
• Radial bow maintained
 Operative Treatment
• Operative • All Unstable
– Functional • All Open
– Anatomic • Non-operative
treatment rare
 Treatment
• Early surgical intervention (within the
first 6-8 hours) is optimal to avoid
radioulnar synostosis
• Goals
– Anatomic reduction
– Rigid fixation
– Stable construct
– Restoration of radial bow
 Timing of Surgery
• Early Surgery is Desirable but not Essential
– Easier reduction especially if shortening
– Avoids pre-op immobilization
• Delayed Surgery
– If poor soft tissues
– If other injuries or medical problems prevent
 Open Fractures
• Antibiotics
• Tetanus
• Debridement
• Irrigation
• Surgical Tx
– ORIF: Type I, II, IIIA
– Ex-Fix: Type IIIB,
IIIC
 Treatment
• Fixation options include
– IM nailing
– External fixation
– plate fixation
 Treatment
• IM Fixation
– Not routinely used
– Soft tissue injury
– Pathologic Fracture
 Treatment
• External Fixation
– open type IIIb
– open type IIIc
 Treatment
• Plate Fixation • Obtain anatomic
– provides stable strong reduction
anatomic fixation • Restore ulna & radial
– eliminates need for length
external casting
– Prevents subluxation of
– allows early functional
either proximal or distal
motion with union rates
radioulnar joints
over 95%.
• Restore rotational
alignment
• Restore radial bow
– Essential for rotational
function of forearm
 Approaches
• Ulna
– exposed along the
subcutaneous border
between the flexor and
extensor carpi ulnaris
– dorsal cutaneous
branch of the ulnar
nerve
• ≈5 cm proximal to the
wrist joint
• identify and protect
 Approaches
• Radius
– Two approaches
• Henry
– Volar
– Good for middle to distal third fractures
• Thompson
– Dorsal
– Good for proximal to middle third fractures
 Approaches-Henry (volar)
• incision begins 1 cm lateral
to the biceps insertion
• extends distally to the radial
styloid
• Interval between
brachioradialis and FCR
• Identify radial artery and
superficial radial n.
• Protect PIN proximally
 Approaches-Thompson
(dorsal)
• Incision begins just anterior
to the lateral epicondyle
• Extends distally towards the
ulnar side of Lister’s
tubercle
• interval is developed
between the ECRB and the
EDC, exposing the supinator
muscle
• Identify PIN
– 1cm proximal to its distal edge
of supinator
 Intra-op Tips
• Check and modify reduction of
• Supine w/ hand table other bone
• Tourniquet • Plate with LCDC or LCP in
• Approach simpler fx 1st compression mode
• Goal of 6 cortices above and
• Reduce and provisionally fix below with3 screws over 4
• Approach other fx holes on each side
• Reduce and plate with LCDC • Confirm reduction with c-arm
or LCP in compression mode • Irrigate and close ulna wound
first
• Goal of 6 cortices above and • Irrigate and close radial wound
below with 3 screws over 4 • If unable to close, VAC and
or more holes on each side return in 3-5 days to close vs
STSG
 The Role of Bone Grafting
• Bone Graft if there is Severe Bone Loss or the patient has
an Open Fracture Severely Compromising Local Biology
– If >1/3 cortical circumference is lost, consider bone grafting
because interfragmentary compression becomes impossible
• But the standard teaching that >30% comminution “requires” grafting
has been challenged where newer biologic techniques are used.
– Wright, RR, Schmeling, GJ, and Schwab, J.P. The necessity of acute
bone grafting in diaphyseal forearm fractures: a retrospective review. J.
Orthop Trauma 11:288-94, 1997.
Technical Tips for Plate Fixation
of Forearm Fractures
• Use Indirect Reduction Techniques
Preserving Soft Tissue Attachments
– Periosteal stripping must be minimized
– Narrow retractors placed to avoid penetration
of interosseous membrane
• Close or Skin Graft Open Wounds within 3-
5 days
 Post-op
• Sterile dressing and sugartong splint
• Closely monitor compartments
• Low threshold to split dressing
• POD#1
– Initiate digital ROM
• Delay Wrist/Elbow ROM 3-5 days
– Prevents hematoma formation
 Follow-up
• Forearm rotation is initiated as the patient's
comfort allows
– Usually 1st or 2nd week post-op
• RTC @ 2 weeks, 6 weeks, 12 weeks, and 4-6
months postoperatively
– AP/lat X-rays each visit
• Activity modification to ADL’s only until fracture
healed
– 8-12 weeks
• progressively return to a normal lifestyle.
 Complications
• Refracture after plate removal
• Symptomatic hardware
• Nonunion
• Malunion
• Infection
• Neurologic injury
• Compartment syndrome
• Radioulnar synostosis
 Pain & Hardware Removal
• Two Years • Post-removal
• Bone Density Does Not – 67% Residual Symptoms
Normalize for 21 months – 9% Worse
– Rossen, JW et al, JBJS
1991:73B:65-7.
– Weather
• 4 to 20% Refracture Risk – Exercise
– Usually through original – Skin or Tendon Irritation
fracture or screw hole – Mih, AD et al, CORR
1994:299:256-8
– Large plate (4.5 mm DCP)
– Nonunion
– Infection & Nerve Injury
– Pain may persist after
plate removal
 Malunion
• Loss of motion with >10◦
of angulation
• 5◦ loss of radial row =
15◦ loss of sup/pro
• Decreased grip strength
occurs with loss of the
radial bow
• Schemitsch, EH &
Richards RR JBJS
1992:74A:1068-78

• Tx: Osteotomy and

Repair
 Nonunion
• Poor biomechanics • Tx
• Poor Technique
– Stable construct – Revision Fixation
• Too few screws
• Improper compression
– Bone Grafting
– Soft tissue – Segmental bone
management
loss
• Initial Fracture • Iliac crest <3.5cm
– Open Injury
• Consider
– Comminuted vascularized fibular
fracture graft >3.5cm
 Neurologic Injury
• Closed Fracture
– Usually Iatrogenic
– PIN: Proximal approach
– AIN: Vigorous Radial Reduction
– Radial Sensory Branch: Anterior dorsal
exposure
• Open Fracture
– AIN Most Common
Synostosis
• Incidence 1-8%
• Risks
– BBFFx at same level
– TBI
– Surgical delay (> 2 wks)
– Single incision
– IOM Penetration
• Tx
– Early resection
 Outcomes
• Closed Fractures
– 98% Union, 3% infection, 92% good
function
– Chapman, M et al: JBJS 1989:71A:159-69
– 96% Union, >85% good function
– Anderson, LD et al: JBJS 1975:57A:287-97

• Open Fractures
– 93% Union, 4% infection, 85% good
function
– Moed, BR et al: JBJS 1986:68A:1008-17
 Outcomes
• Motion
– Near Normal
• Grip Strength
– 30% Reduced
• Disability is Pain
Related
• Goldfarb et al JBJS
Br 2005
Mar;87(3):374-9
• Droll et al JBJS Am
2007
Dec;89(12):2619-24
 Special Cases
• Fractures Associated with Joint Disruption
– Galleazzi Fracture
– Monteggia Fracture
– Combined Patterns
• Fractures Associated with other Injury
– Floating Elbow (Ipsilateral Humerus Fracture)
– Open Fractures
 Fractures Associated with Joint
Disruption
Galeazzi & Monteggia
• Best Treatment
– ORIF w. Plate Fixation of Diaphyseal Fracture
– Joint Usually Reduces Indirectly and is stable
– If Unstable: require open reduction of joint
– If irreducible – it is usually because the
diaphyseal fracture has been mal-reduced
 Galeazzi Fractures
• Classic: Fracture of
distal 1/3 radial shaft
with Dislocation Distal
Radioulnar Joint

• Variants: Fracture can

occur anywhere along
the radius or associated
with fractures of both
bones with DRUJ
disruption
 Galleazzi Fractures
Radiographic Signs of DRUJ
Injury:
• Fracture at Base of Ulnar Styloid
• Widened DRUJ on AP x-ray
• Subluxed Ulna on Lateral x-ray
• >5 mm Radial Shortening
• Radius Fracture < 7.5cm from
the wrist joint
– (unstable DRUJ in 55%)
 Galleazzi Fractures
• Always require Plate
fixation of the Radius
– Distal Medullary canal too
wide/funnel shaped for
intramedullary fixation
– Sometimes require
temporary pin fixation of
DRUJ or repair of the ulnar
styloid when fractured
• Postop:
– If DRUJ stable – early
motion
– If DRUJ unstable –
immobilize forearm in
supination for 4-6 weeks in
a long arm splint or cast
– DRUJ pins are removed at
6-8 weeks
 Galeazzi fractures
• May be associated damage to triangular
fibrocartilage, which may require early or
late repair with open or arthroscopic
techniques

– Can Occur with Low Velocity Gunshots

• Lenihan, MR et al J.O.T. 1992:6:32-35.
 Monteggia Fractures
Classic: Fracture of Proximal 1/3 Ulna with Dislocation of
Radial Head
Type % Description
I 60% Both Anterior: Dislocation
Radial Head & Angulation Ulna
Fracture: Equivalent: Radial
Head or Neck fractured
II 20% Both Posterior: Dislocation
Radial Head + Angulation Ulna
Equivalent: Posterior Elbow Dx.
III 15% Lateral Dislocation Radial Head
+ Any Fracture of Proximal Ulna

IV 5% Anterior Dislocation Radial

Head + Fractures Proximal
Shafts of Both Bones are at the
same level
 Monteggia Fractures
Radiographic Findings:
Normal:
– Line Drawn through Radial
Head & Shaft should always
line up with Capitellum
– Supinated Lateral: lines drawn
tangential to head anteriorly and
posteriorly should enclose the
Capitellum
Monteggia Fracture:
These radiographic findings
are disrupted
 Monteggia Fractures
• After fixation of the ulna, the
radial head is usually stable
(>90%)
– If radial head not reduced recheck
ulna length
• If open reduction is required for
the radial head, the annular
ligament is repaired
– Failure of the radial head to reduce
with ulnar reduction is usually due
to interposed annular ligament or
rarely the radial nerve
• Associated Radial Head Fractures
may require fixation/replacement
 Monteggia Fractures
• Postoperative treatment depends on rigidity
of ulnar fixation and stability of the radial
head
– Casting with more than 90 degrees of elbow
flexion is rarely needed to maintain the radial
head reduction (6 weeks)
 Literature
• Calkins MS, Burkhalter W, Reyes F. Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of
corticocancellous bone. J Bone Joint Surg Am. 1987 Jan;69(1):19-27 PMID:3543018 (Link to Abstract)
• Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint
Surg Am. 1989 Feb;71(2):159-69. PMID:2918001 (Link to Abstract)
• Falder S, Sinclair JS, Rogers CA, Townsend PL. Long-term behaviour of the free vascularised fibula following reconstruction of large bony
defects. Br J Plast Surg. 2003 Sep;56(6):571-84. PMID:12946376 (Link to Abstract)
• Ring D, Allende C, Jafarnia K, Allende BT, Jupiter JB. Ununited diaphyseal forearm fractures with segmental defects: plate fixation and
autogenous cancellous bone-grafting. J Bone Joint Surg Am. 2004 Nov;86-A(11):2440-5. PMID:15523016 (Link to Abstract)
• 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. PMID:1522093 (Link to Abstract)
• 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. PMID:1522093 (Link to Abstract)
• Street DM. Intramedullary forearm nailing. Clin Orthop Relat Res. 1986 Nov;(212):219-30. PMID:3769288 (Link to Abstract)
• Wei SY, Born CT, Abene A, Ong A, Hayda R, DeLong WG Jr. Diaphyseal forearm fractures treated with and without bone graft. J Trauma.
1999 Jun;46(6):1045-8. PMID:10372622 (Link to Abstract)
• Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting indiaphyseal forearm fractures: a retrospective review. J Orthop
Trauma. 1997 May;11(4):288-94. PMID:9258828 (Link to Abstract)
• Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)
• Levin LS. Early versus delayed closure of open fractures. Injury. 2007 Aug;38(8):896-9. PMID:17585912 (Link to Abstract)
• Noda K, Goto A, Murase T, Sugamoto K, Yoshikawa H, Moritomo H. Interosseous membrane of the forearm: an anatomical study of
ligament attachment locations. J Hand Surg Am. 2009 Mar;34(3):415-22. Epub 2009 Feb 11 PMID:19211201 (Link to Abstract)
• Pfaeffle HJ, Stabile KJ, Li ZM, Tomaino MM. Reconstruction of the interosseous ligament restores normal forearm compressive load transfer
in cadavers. J Hand Surg Am. 2005 Mar;30(2):319-25. PMID:15781355 (Link to Abstract)
 Literature
• Bauer G, Arand M, Mutschler W. Post-traumatic radioulnar synostosis after forearm fracture osteosynthesis. Arch Orthop Trauma Surg.
1991;110(3):142-5. PMID:2059537 (Link to Abstract)
• Beingessner DM, Patterson SD, King GJ. Early excision of heterotopic bone in the forearm. J Hand Surg Am. 2000 May;25(3):483-8.
PMID:10811753 (Link to Abstract)
• Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am. 1988
Oct;70(9):1372-6. PMID:3182889 (Link to Abstract)
• Egol KA, Kubiak EN, Fulkersojn E, et. al: Biomechanics of locked plates and screws. J Orthop Trauma, 2004;18:488-493 PMID:15475843
(Link to Abstract)
• Koval KJ (ed): Orthopaedic Knowledge Update 7. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2002, pp 307-316
• McAuliffe JA, Wolfson AH. Early excision of heterotopic ossification about the elbow followed by radiation therapy. J Bone Joint Surg Am.
1997 May;79(5):749-55 PMID:9160948 (Link to Abstract)
• Moed BR, Kellam JF, Foster RJ, et al: Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am
1986;68:1008-1017 PMID:3745238 (Link to Abstract)
• Pollock FH, Pankovich AM, Prieto JJ, Lorenz M. The isolated fracture of the ulnar shaft. Treatment without immobilization. J Bone Joint
Surg Am. 1983 Mar;65(3):339-42. PMID:6826596 (Link to Abstract)
• Rumball K, Finnegan M. Refractures after forearm plate removal. J Orthop Trauma. 1990;4(2):124-9 PMID:2358925 (Link to Abstract)
• Sommer C, Babst R, Muller M, et. al: Locking compression plate loosening and plate breakage: A report of 4 cases. J Orthop Trauma,
2004;18:571-577. PMID:15475856 (Link to Abstract)
• Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am. 1987 Jun;69(5):640-53.
PMID:3110165 (Link to Abstract)
• Wood MB. Upper extremity reconstruction by vascularized bone transfers: results and complications. J Hand Surg Am. 1987 May;12(3):422-
7. PMID:3584891 (Link to Abstract)
• Wright RR, Schmeling GJ, Schwab JP: The necessity of acute bone grafting in diaphyseal forearm fractures: A retrospective review. J Orthop
Trauma 1997;11:288-294 PMID:9258828 (Link to Abstract)
 Literature
• Bado JL. The Monteggia lesion. Clin Orthop Relat Res 1967;50:71-86. PMID:6029027 (Link to Abstract)
• Fowles JV, Sliman N, Kassab MT. The Monteggia lesion in children: Fracture of the ulna and dislocation of
the radial head. J Bone Joint Surg Am 1983;65:1276-1282 PMID:6654941 (Link to Abstract)
• Tan JW, Mu MZ, Liao GJ, Li JM. Pathology of the annular ligament in pediatric Monteggia fractures. Injury.
2008 Apr;39(4):451-5. Epub 2007 Nov 19. PMID:18005963 (Link to Abstract)
• Korompilias AV, Lykissas MG, Kostas-Agnantis IP, Beris AE, Soucacos PN. Distal radioulnar joint
instability (Galeazzi type injury) after internal fixation in relation to the radius fracture pattern. J Hand Surg
Am. 2011 May;36(5):847-52. Epub 2011 Mar 23. PMID:21435802 (Link to Abstract)
• Rettig ME, Raskin KB. Galeazzi fracture-dislocation: a new treatment-oriented classification. J Hand Surg
Am. 2001 Mar;26(2):228-35. PMID:11279568 (Link to Abstract)
• Biyani A, Bhan S: Dual extensor tendon entrapment in Galeazzi fracture-dislocation: A case report. J Trauma
1989;29:1295-1297. PMID:2769817 (Link to Abstract)
• Budgen A, Lim P, Templeton P, Irwin LR. Irreducible Galeazzi injury. Arch Orthop Trauma Surg.
1998;118(3):176-8. PMID:9932197 (Link to Abstract)
• Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin. 2007 May;23(2):153-63, v.
PMID:17548007 (Link to Abstract)
• Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin. 2007 May;23(2):153-63, v.
Review. PMID:17548007 (Link to Abstract)
• Paley D, McMurtry RY, Murray JF. Dorsal dislocation of the ulnar styloid and extensor carpi ulnaris tendon
into the distal radioulnar joint: The empty sulcus sign. J Hand Surg Am 1987;12:1029-1032. PMID:3693829
(Link to Abstract)
 Conclusion
• Forearm fxs are inherently unstable fxs
• Vast majority require operative fixation
• Goal is anatomic reduction with stable fixation
• Restore ulna length
• Restore radial bow
• Respect the soft tissue
• Don’t miss injury to joint above or below

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