Rockwood & Green’s Fractures in Adults
6th Edition

Chapter 27
Fractures of the Shafts of the Radius and Ulna
Ralph Hertel
Dominique A. Rothenfluh
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Forearm fractures can be regarded as articular fractures as slight deviations in the spatial orientation of the radius and ulna will significantly decrease the forearm’s rotational amplitude and thereby impair the positioning and function of the hand. Thus, the management of these fractures and their associated injuries deserve special attention as their treatment is not the same as the treatment of other diaphyseal fractures. Imperfect treatment of fractures of the radius and ulna diaphyses leads to a loss of motion as well as muscle imbalance and poor hand function.
This chapter gives an overview of the different treatment options. The inherent difficulties associated with the management of forearm fractures have long been recognized and several different strategies of treatment have been developed. The most significant impact on the treatment of forearm fractures was the development of compression plate osteosynthesis. Several studies will be presented which indicate that plate osteosynthesis provides a good treatment option which has a very predictable outcome. However, it is important to realize that the choice of implant is not the only parameter that governs outcome. It is important to evaluate the patient and to understand the type of surgery that is involved in the management of these fractures.
PRINCIPLES OF MANAGEMENT
Mechanism of Injury
Of the many mechanisms of injury that cause fractures of the radius and ulna, a direct blow is the most common. These are not infrequently associated with road traffic accidents and result in high-energy trauma associated with significant soft tissue damage and with a high incidence of open fractures. Other direct blows occur in fights in which the defender uses the forearm for protection. A direct blow under these circumstances may cause a fracture of both bones of the forearm but may also cause an isolated ulnar fracture, often called a “night stick” fracture, or a Monteggia fracture dislocation. Gunshot injuries may also cause high energy trauma to the forearm. These cause open fractures which are commonly associated with significant bone loss, major soft tissue damage, and injury to the neurovascular structure.
Less frequently fractures of the forearm may result from falls from a height or from sports injuries. However, the force required to cause fractures of the diaphyses of the radius and ulna is much higher than that required to cause a distal radial fracture. Consequently, forearm fractures in sportsmen and women are uncommon and if diagnosed the surgeon should always suspect the possibility of associated ligamentous and soft tissue damage (1).
Signs and Symptoms
Generally speaking displaced fractures of the radius and ulna are obvious clinically. Undisplaced forearm fractures are relatively uncommon because the high-energy nature of the injury is usually sufficient to cause displacement. However, pain, swelling, and loss of function of the forearm and hand together with local tenderness strongly suggests the diagnosis even if gross deformity is absent. It is important that a complete examination of the forearm and the adjacent joints is undertaken. A checklist that can be used in the emergency room to aid in the assessment of forearm injuries is given in Table 27-1.
A careful neurologic examination of the extremity must be undertaken. This should include examination of the sensory and motor function of the median, radial, and ulnar nerves. This is particularly important in undisplaced fractures or when closed reduction and nonoperative management is planned, for example, in children. Nerve damage is relatively unusual in forearm fractures and generally necessitates surgical exploration. The vascular status of the arm should be assessed either by palpation or by using Doppler studies if the swelling is too severe and palpation is not possible.
In closed fractures, a tense swelling of the forearm may suggest compartment syndrome. Pain on passive stretch of the fingers strongly suggests the possibility of a compartment syndrome of the forearm. However, in displaced fractures, any manipulation of the forearm and fingers will inevitably elicit pain; and if compartment syndrome cannot be ruled out clinically, it is important to measure the compartment pressure. If a diagnosis of compartment syndrome is made, immediate fasciotomy is mandatory.
Open fractures of the forearm have to be examined carefully for associated neurovascular injury. These are frequent, especially in gunshot injuries. It is a mistake to examine the wound in the emergency room where it is likely to be further contaminated. Attempts to reduce the open fracture should be avoided to minimize the risk of further soft tissue and neurovascular damage and to reduce the possibility of further wound contamination. Open fractures require urgent treatment. The wound should be protected by a sterile dressing and the patient taken to the operating room once all the diagnostic tests have been completed.
Table 27-1 Emergency Room Checklist for Assessment of Forearm Injuries
Assessment of Soft Tissue Injury
Assessment of peripheral nerve function (sensory function as well as intrinsic and extrinsic motor function of the hand)
  • Making a fist (median and ulnar nerve)
  • Wrist and finger extension (radial nerve)
  • Abduction of extended fingers (ulnar nerve when radial nerve is intact)
  • Extension in the interphalangeal joint of the thumb (posterior interosseous nerve)
  • Flexion in the interphalangeal joint of the thumb (anterior interosseous nerve)
Assessment of Blood Supply
  • Lesion of the medial collateral ligament complex of the elbow?
  • Lesion of the lateral collateral ligament complex of the elbow?
  • Lesion of radio-carpal ligaments?
  • Pending or established compartment syndrome?
Assessment of Bony Injury
Proximal radio-ulnar joint
  • Dislocation or abnormally wide joint space?
  • Direction of the dislocation?
  • Is the annular ligament probably torn or has the radial head just slipped out of the intact annular ligament?
Interosseous membrane
  • Is the membrane torn? If so, proximally or distally?
Distal radio-ulnar joint
  • Dislocation
  • Abnormal separation
  • Shortening of the radius relative to the ulnar head
Associated Injuries
The high-energy nature of most forearm injuries means that there is a high incidence of associated musculoskeletal injuries. These often take the form of ipsilateral ligamentous or soft tissue injury, but other fractures may occur and these are commonly seen at the level of the wrist and elbow. In a prospective study of 119 patients with forearm fractures a second injury was found in all but five cases (2). This study showed associated ligamentous injury in 79 patients; and in nine patients in which an isolated forearm fracture was initially diagnosed on x-ray, a second bony injury was detected by bone scanning. An associated injury of the distal radio-ulnar joint was found in 71 patients.
Galeazzi Fracture
Galeazzi drew attention to the dislocation or subluxation of the distal radio-ulnar joint in association with a solitary fracture of the radius at the junction of the middle and distal third in 1934 (3,4). He pointed out that dislocation or subluxation at the level of the distal radio-ulnar joint (DRUJ) is not necessarily present initially but may develop gradually in the course of treatment. Hughston published a series of 41 cases of fractures of the distal shaft of the radius in combination with dislocation of the DRUJ (5). Of 38 patients treated initially by closed reduction and cast immobilization, only three patients were found to have had a satisfactory result–-this being union with perfect alignment, no loss of length, no subluxation of the DRUJ, and full pronation and supination. Thus, recent strategies for the management of fractures associated with instability of the DRUJ aim at early diagnosis and appropriate treatment of the injury to avoid a chronic DRUJ disorder (6). Injuries to the DRUJ are generally subdivided into stable, partially unstable (subluxation), and unstable (dislocation) lesions. If a reduction cannot be obtained or proves to be unstable, open exploration looking for a trapped tendon or soft tissue may be required (7). Open reduction and internal fixation of the radius depends on DRUJ stability. A forearm fracture with associated DRUJ disruption is shown in Figure 27-1.
Monteggia Fracture
Fractures between the proximal third of the ulna and the base of the olecranon combined with an anterior dislocation of the proximal radio-ulnar joint were described by Monteggia in 1814 (8). Bado (9) coined the term “Monteggia Fracture” in 1967 and described four different patterns of the Monteggia lesion. The Bado classification is shown in Figure 27-2. Bado extended Monteggia’s original description to include any fracture of the ulnar with an associated dislocation of the proximal radio-ulnar joint. He divided Monteggia lesions into four types with the classification depending on the direction of the radial head. In type I lesions the head is anterior to the distal humerus. In type II lesions it is posterior and in type III lesions it is lateral. In type IV fracture dislocations there is a dislocation of the radial head associated with a fracture of both the radius and ulna.
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Most authorities indicate that about 60% of Monteggia fracture dislocations are type I, 15% are type II, 10% are type III, and 10% are type IV. Type III lesions virtually only occur in children. Figure 27-3 shows pre- and postoperative x-rays of a Monteggia fracture dislocation.
FIGURE 27-1 Forearm fracture with an associated disruption of the distal radio-ulnar joint.
FIGURE 27-2 The Bado classification of Monteggia fracture dislocations. See text for details.
FIGURE 27-3 A. AP and lateral x-rays of a type 1 Monteggia fracture dislocation. B. Treated by compression plating using a LC-DCP.
The posterior Monteggia fracture dislocation (type II) has been studied in detail. Jupiter et al (10) recognized an anterior triangular or quadrilateral fracture fragment (Fig. 27-4) in proximity with the coronoid process in these fracture dislocations. A radial head fracture may often be found in association with the radial head dislocation. This injury combination represents a potentially unstable fracture pattern, which may lead to impaired forearm rotation as well as flexion and extension. Any fixation method has to counteract the tendency for anterior angulation to occur if the anterior cortex is not intact (10).
FIGURE 27-4 The arrow is pointing to the anterior quadrilateral fragment in this comminuted Monteggia fracture. This fragment must be looked for in noncomminuted fractures.
Neurovascular Injuries
Nerve injuries in closed forearm fractures are relatively uncommon. Although injuries to the median, ulnar, and radial nerves can occur injuries of the posterior interosseous nerve have been most commonly reported, particularly in association with Monteggia fracture dislocations (11,12). There have been a few reports of ulnar nerve injury following forearm fractures in children. In one report the injury resolved spontaneously with nonoperative management of the fracture (13). In another injury secondary ulnar nerve exploration was undertaken when no evidence of recovery was observed (14).
Most nerve injuries are neuropraxias commonly caused by contusion or compression. Rarely the nerve is trapped in the fracture or in scar tissue (14), or is transected by the fracture fragments (15). Neuropraxias generally resolve spontaneously (13). However, as most forearm fractures, and particularly Monteggia fracture dislocations, are treated operatively, we advocate exploration of the injured nerve if damage is suspected clinically prior to surgery. In open fractures nerve exploration should be carried out during the initial debridement.
Collateral circulation of the forearm in the presence of either isolated radial or ulnar arterial damage is usually sufficient to maintain viability of the hand and forearm. Viability may even be maintained if both the radial and ulnar arteries are damaged because the longitudinally orientated collateral vessels may still provide sufficient blood supply (16). If one major artery is intact and there is adequate perfusion to the hand, the damaged vessel does not have to be repaired. However, in combination with nerve injuries, it has been argued that recovery of the associated nerve lesion will be improved by an enhanced blood supply and vascular repair is therefore advocated (17).
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Compartment Syndrome
A compartment syndrome of the forearm may develop following a fracture of the diaphyses of the radius and ulnar, but it may also follow soft tissue crush injuries and supracondylar humeral fractures as well as nontraumatic causes. Compartment syndrome is discussed further in Chapter 13. Swelling and significant pain may suggest a developing compartment syndrome. Passive stretch of the fingers generally elicits pain and is highly suggestive of the presence of a compartment syndrome. However, if there is a displaced closed forearm fracture, this finding may only be of limited use as all manipulation may be painful. The presence or absence of the radial pulse is not a reliable diagnostic sign (18). The presence of a palpable radial pulse never excludes a compartment syndrome of the forearm as the intra-compartmental pressures may have risen high enough to occlude muscle and nerve blood flow but may still be below the systolic blood pressure.
Although compartment pressure measurement is recommended for early diagnosis of compartment syndrome, the critical threshold pressure which indicates that fasciotomy is necessary is controversial and values between 30–45 mm Hg have been suggested (19,20,21). Whitesides et al (22) commented on the importance of the pressure differential between compartment pressure and the diastolic blood pressure. Ischemia was thought to begin when the pressure rose to within 10–30 mm Hg of the diastolic blood pressure. Generally, if there is a pressure difference of less than 10 mm Hg, muscle histology shows scattered areas of infarction and fibrosis, whereas if there is a difference of at least 20 mm Hg there are no such changes in the muscle (23). McQueen and Court-Brown (24) reported on a series of 116 patients with tibial fractures in which continuous monitoring of compartment pressures was carried out for 24 hours. Two patients had a differential pressure of below 30 mm Hg and underwent fasciotomy. Although absolute pressures above 30 mm Hg were observed in 53 patients in the first 12-hour period and in 28 patients in the second 12-hour period, none of these patients had any sequelae of acute compartment syndrome. Had they used absolute pressures of 30 mm Hg as a threshold, 53 patients would have had unnecessary fasciotomy.
The authors concluded that absolute compartment pressure is an unreliable indicator of the requirement for fasciotomy and that a pressure differential of less than 30 mm Hg between the diastolic blood pressure, and the compartment pressure indicates that immediate fasciotomy is required. However, we believe that the diagnosis of acute compartment syndrome should not be delayed by waiting for the differential pressure to drop below 30 mm Hg if clinical signs are present. In borderline cases when continuous monitoring is chosen, the indication for treatment is not just the absolute pressure or pressure differential but rather the evolution of the pressure differential over time. Increasing compartment pressures require action, and if there is any doubt about the presence of an acute compartment syndrome we advocate fasciotomy rather than temporizing, missing the diagnosis, and risking the serious sequelae of this condition.
Diagnosis and Classification
Forearm fractures are usually classified according to the location of the fracture, the fracture pattern, degree of displacement, degree of comminution, the involvement of the radio-ulnar joints, the amount of bone loss, and the degree of soft tissue injury in both closed and open fractures. The presence or absence of the associated injuries described above has significant implications on the method of treatment. Diagnostic algorithms therefore have to include not only x-rays of the forearm but also true antero-posterior and lateral x-rays of the wrist and elbow. Involvement of the proximal or distal radio-ulnar joints carries particular significance because effective therapy requires integrated treatment of both the fracture and the associated joint injury. Thus these injuries must be looked for. CT scans are usually only required for the assessment of radio-ulnar joint injury and not for the primary diagnosis of forearm fractures.
The most commonly used classification for forearm diaphyseal fractures is that of the AO group (25), which has also been adopted by the Orthopaedic Trauma Association (OTA). This classification is shown in Figure 27-5. As with all AO classifications this is an alpha-numeric classification. Type A fractures are simple fractures of the ulna, radius, or both bones. In A1 fractures there is a simple fracture of the ulna and the radius is intact. In A2 fractures there is a simple fractures of the radius and the ulna is intact. In both these groups, .1 refers to an oblique fractures, .2 to a transverse fracture, and .3 to a fracture associated with the dislocation. The A1.3 fracture represents a Monteggia fracture dislocation and the A2.3 fracture represents a Galeazzi fracture dislocation. In the A3 group, .1 refers to a radial fracture in the proximal third of the bone, .2 to a radial fracture in the middle third, and .3 to a radial fracture in the distal third.
Type B fractures are wedge fractures of either the ulna (B1), the radius (B2), or both the radius and ulna (B3). In groups B1 and B2, .1 refers to an intact wedge, .2 to a fragmented wedge, and .3 to an associated dislocation with B1.3 fractures being Monteggia fracture dislocations and B2.3 fractures being Galeazzi fracture dislocations. In the B3 group, B3.1 fractures have an ulnar wedge and a simple fracture of the radius, B3.2 fractures have a radial wedge and a simple fracture of the ulna, and B3.3 fractures have radial and ulnar wedges.
Type C fractures are complex fractures. C1 fractures are complex fractures of the ulna, C2 fractures involve the radius, and C3 fractures involve both the radius and ulna. In C1.1 fractures there is a bifocal fracture of the ulna with an intact radius, in C1.2 fractures there is a bifocal fracture of the ulna with a radial fracture, and in C1.3 fractures the ulnar fracture is irregular. In C2.1 fractures the radial fracture is bifocal and the ulna is intact. In C2.2 fractures the radial fracture is bifocal but the ulna is fractured, and in C2.3 fractures the radial fracture is irregular. In C3.1 fractures both bones show a bifocal fracture and in C3.2 fractures there is a bifocal fracture of one bone with an irregular fracture of the other. In the rare C3.3 fracture, both fractures are irregular or comminuted. It should be noted
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that while the AO (OTA) classification is useful for scientific and epidemiological purposes, it does not consider the full spectrum of lesions associated with radius and ulnar diaphyseal fractures.
FIGURE 27-5 The AO (OTA) classification of radius and ulnar diaphyseal fractures. See text for details.
FIGURE 27-6 The method of Schemitsch and Richards (30) for quantifying the maximum radial bow and its location relative to the length of the entire radius.
Rationale for Treatment
Although the radius and ulna function as a unit, they only come into contact proximally and distally at the radio-ulnar joints. The proximal radio-ulnar joint consists of the radial head which articulates with the corresponding articular facet of the ulna and is fixed to it by the annular ligament, which itself serves as an extension of the ulnar articular surface. It is stabilized by the capsule of the elbow joint.
At the distal end the radius articulates with the ulna in a sigmoid notch which is stabilized mainly by the triangular fibro-cartilage complex and the capsule of the wrist. The proximal and distal radio-ulnar joints articulate closely with their neighboring joints, the elbow, and wrist joints. The interosseous membrane spans the space between the radio-ulnar joints joining the radius and ulna. Its fibers run in an oblique fashion from distal ulna to proximal radials and they show a centrally thickened portion, 3.5 cm in width, that accounts for about 70% of actual stability of the forearm bones (26).
While the ulna is a straight bone which allows the radius to rotate around it, the anatomy of the radius is very complex (27,28,29,30). The rotation of the forearm depends on the ability of the radius to rotate around the ulna. Forearm rotation is vulnerable to any malalignment of the radius and accurate rotational as well as axial reduction is necessary.
To investigate the effect of angular malalignment on the subsequent loss of range of motion (ROM) of the forearm Matthews et al (28) tested forearm ROM with simulated fractures in cadavers. They showed that 10 degrees of angulation of one or both bones of the forearm resulted in a loss of ROM of 20 degrees of pronation and supination. With 20 degrees of angulation significant restriction in passive rotation of the forearm was observed, mediated either by direct radio-ulnar impingement or by extreme tension in the interosseous membrane. Tarr et al (29) found that loss of forearm rotation with a given deformity also depended on the location of the deformity. They observed a significantly greater loss of ROM in forearms with middle-third deformities than with distal-third deformities, with more supination being lost than pronation. They also observed a significant decrease of ROM with 15° of angulation. The greater decrease of ROM in middle-third deformities was attributed to the loss of the radial bow where the two forearm bones overlap at the extremes of pronation and supination. Schemitsch and Richards (30) undertook an outcome study correlating function with the radial bow. They described a method of quantifying the normal radial bow and reduction after fixation (Fig. 27-6). In the normal forearm, the maximal radial bow is reported to be about 15 mm and located at 60% of the radial length from the distal end (30). In patients who had rotation of the forearm of at least 80% of the opposite side, the normal radial bow differed on average by 1.5 mm and its location differed by 9% from that of the normal arm (Table 27-2). In patients with less satisfactory results, these differences were significantly greater.
Simple rotational deformities of either the radius or the ulna were reported to produce a loss of ROM equal to the extent of the rotatory deformity (29). However, in accordance with the findings stated above, simple rotational deformity of the radius results in a more pronounced loss of ROM in supination than
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pronation (31). Dumont et al (31) reported that combined deformity in the same direction decreased the ROM similarly to that of an equivalent isolated rotatory deformity of the radius. The highest loss of ROM is observed in combined rotatory deformities in an opposite direction, with one bone in supination and the other in pronation. These investigations show the detrimental effects of incorrect axial and rotational alignment on forearm rotation, and they have implications for the method of treatment.
Table 27-2 Radial Bow*
Range of
Motion (ROM)
Maximum
Radial Bow
Location of Maximum
Radial Bow
Normal 15.3 ± 0.3 mm 59.9 ± 0.7%
≥80% of normal ROM 15.3 ± 1.5 mm 59.9 ± 4.3%
<80% of normal ROM 15.3 ± 2.8 mm 59.9 ± 8.9%
According to Schemitsch and Richards (30).
SURGICAL APPROACHES AND APPLIED ANATOMY
Surgical Approaches to the Radius
Anterior Approach (Henry)
The anterior approach to the radius was first described by Henry (32). It allows a wide exposure of the anterior surface of the radius and exposes the bone over its entire length, if this is required. The approach can be extended across the elbow and into the hand. Care has to be taken not to harm the radial artery as it runs down the forearm under the brachioradialis muscle with the superficial branch of the radial nerve. The posterior interosseous nerve is vulnerable during deep dissection proximally if the radial neck needs to be accessed as the nerve winds round the radial neck within supinator muscle. The distal part of the approach is also used to access the distal radius for internal fixation of distal radial fractures, and the approach can also be easily extended if more proximal exposure is required.
Surgical Anatomy
The anterior part of the forearm is basically subdivided into two groups of muscles. Henry termed the group consisting of brachioradialis, extensor carpi radialis longus, and extensor carpi radialis brevis as the mobile wad (32). These muscles define the lateral aspect of the proximal forearm and are supplied by the radial nerve. The flexor-pronator group is found on the medial aspect and consists of three muscular layers supplied by the median and ulnar nerves. Superficially, from lateral to medial, the pronator teres, flexor carpi radialis, palmaris longus, and flexor carpi ulnaris muscles are found. The middle layer consists of flexor digitorum superficialis and the deep layer of flexor digitorum profundus, flexor pollicis longus and, more distally, pronator quadratus. To expose the forearm by a Henry approach, the inter-nervous plane between the radial and median nerves has to be found between the mobile wad, with brachioradialis lying most medially and pronator teres proximally and flexor carpi radialis distally in the flexor-pronator group.
FIGURE 27-7 After the interval between brachioradialis and flexor carpi radialis is exposed and the radial artery retracted medially, supinator, pronator teres, flexor pollicis longus, and flexor digitorum superficialis can be seen.
FIGURE 27-8 The insertion of supinator should be released with the patient’s arm held in supination. The posterior interosseous nerve should be left within the muscle.
FIGURE 27-9 By continuing the dissection distally with the arm held in pronation, the entire radius is exposed. The dissection should be extraperiosteal in order not to strip the periosteum off the bone.
Surgical Technique
The patient is placed supine on the operating table with the arm abducted on an arm board and the forearm supinated. Before the incision is made the mobile wad, with its medial border adjacent to the biceps tendon, and the styloid process of the radius should be palpated. A straight incision is made along the medial border of the mobile wad. The length and axial location of the incision depends on where and to what extent the bone needs to be exposed. The incision is carried down to the fascia while protecting the lateral cutaneous nerve. The fascia is incised and the inter-nervous plane between the radial and median nerves is developed. The radial artery lies just beneath, or just ulnar to the brachioradialis. It is exposed and retracted medially. The superficial branch of the radial nerve is retracted laterally (Fig. 27-7). Care has to be taken not to harm this nerve because it has a tendency to develop painful neuromata (Table 27-3).
Further dissection depends on what length of bone needs to be exposed to reduce and fix the fracture. In the middle third of the radius pronation of the arm exposes the insertion of
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pronator teres. Its tendon is detached from proximal to distal in order not to split the muscle. The flexor pollicis longus, pronator quadratus, and/or supinator muscles are also partially detached from their origin in order to provide adequate exposure to insert the plate. In general muscles should be detached extra-periosteally and the periosteum left intact where possible.
Table 27-3 Pearls and Pitfalls of Surgery of Radius and Ulna Diaphyseal Fractures
Pearls
Anterior Approach (Henry)
The anterior approach is an extensile approach.
Avoid damage to the posterior interossoeus nerve by supinating the forearm.
Proximal dissection should be lateral to biceps tendon.
Dorsolateral Approach (Thompson)
Most suitable for fractures in the middle third of the forearm.
In 25% of patients the posterior interosseous nerve is in an extraperiosteal location.
Ulna Approach
Allows exposure of the entire length of the bone.
Pitfalls
Anterior Approach
The radial artery is vulnerable under brachioradialis.
The posterior interosseous nerve can be damaged during proximal dissection.
Damage to the superficial nerve may cause painful neuromata.
Dorsolateral Approach
The dorsolateral approach is not extensile and proximal and distal exposure is difficult.
If used for proximal fractures, the posterior interosseous nerve must be exposed.
Ulna Approach
Ulna nerve damage may occur in distal dissection.
To gain access to the proximal third of the radius, the supinator muscle has to be partially or totally detached from the bone. The deep branch of the radial nerve, the posterior interosseous nerve, passes through supinator on its way to the dorsal compartment of the forearm. To avoid damage to this nerve the forearm is held in supination (Fig. 27-8). This maneuver is important as it exposes the insertion of supinator. It also displaces the nerve laterally and posteriorly away from the operative field. The muscle is then detached extra-periosteally and retracted laterally. The supinator, with the posterior interosseous nerve, must be handled with caution, especially when using retractors as it is easy to put excessive traction on the nerve. More proximally the dissection should always be carried out on the lateral side of the biceps tendon for anatomic reasons and not just to stay away from the radial artery and the median nerve. The radial recurrent vessels are ligated if necessary.
In the distal two-thirds the radius is mainly covered by flexor pollicis longus and pronator quadratus muscles. When extending the exposure to the distal end of the radius (Fig. 27-9), the surgeon must be aware that the radial artery is relatively fixed distally where it passes posteriorly after giving off the superficial palmar branch.
Dorsolateral Approach (Thompson)
This approach was originally described by Thompson in 1918: it provides access to the posterior aspect of the radius (33). It is particularly suited for fractures of the middle third of the radius. In our experience the approach is less well suited if extension to the distal third or the proximal third of the radius is required. In the distal third the abductor pollicis longus and extensor pollicis brevis muscles cross the surgical field. Although it is technically possible to tunnel the plate under the muscles after carefully lifting the muscles from their origins, we consider that the potential morbidity of this approach is too great. In the proximal third the approach is limited by supinator muscle with the enclosed posterior interosseous nerve. The dorsolateral approach requires exposure of the posterior interosseous nerve as it exits the supinator canal. The approach may be useful in posterior interosseous nerve palsy when the nerve needs to be explored. If this is the case, the supinator canal can be split in order to expose the entire length of the nerve.[pa[jf4]Surgical Anatomy[cmThe posterior muscles of the forearm can be split into three groups. On the radial side the mobile wad (32) consists of brachioradialis and extensor carpi longus and brevis. The mobile wad is supplied by the radial nerve. On the ulnar aspect of the forearm, the superficial extensors comprise extensor digitorum communis, extensor digiti minimi, extensor carpi ulnaris, and anconeus. The anconeus muscle does not extend the wrist but is an important dynamic stabilizer of the elbow. While the three extensor muscles are supplied by the posterior interosseous nerve the neural pedicle of anconeus originates directly from the radial nerve and travels in the triceps muscle to enter anconeus proximally deep to the lateral epicondyle. There are five deep muscles, three of which supply the thumb, these being abductor pollicis longus and extensor pollicis brevis and longus. The remaining two deep muscles are supinator and extensor indicis. All the deep muscles are supplied
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by the posterior interosseous nerve. Two inter-nervous planes can be found on the posterior aspect of the forearm, although they are not inter-nervous planes between two different nerves as they consist of planes between two branches of the radial nerve. There is a proximal inter-nervous plane between the mobile wad (radial nerve) and extensor digitorum communis (posterior interosseous nerve). A second internervous plane is found between extensor carpi ulnaris (posterior interosseous nerve) and anconeus (branch of radial nerve). This is generally called the Kocher interval and is used to access the radial head.
The critical step in the dorsolateral approach is to identify and preserve the posterior interosseous nerve. The nerve is protected in the mass of supinator when the muscle is detached from the bone and retracted as it mainly travels within the substance of the muscle. However, in 25% of patients, the posterior interosseous nerve actually runs extra-periosteally (34,35) and is potentially at risk if the supinator is detached and retracted
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without prior identification and dissection of the nerve. Therefore, deep dissection of the proximal radius should always include prior identification of the posterior interosseous nerve.
FIGURE 27-10 After incising the deep fascia, the interval between the extensor carpi radialis brevis and the extensor digitorum communis muscles should be identified.
Surgical Technique[cmThe patient is placed supine on the operating table with the arm abducted on an arm board and the forearm pronated. Before the incision is made the mobile wad of Henry, the lateral epicondyle of the humerus, and Lister’s tubercle are palpated. The skin is incised from the lateral epicondyle along the ulnar border of the mobile wad to Lister’s tubercle, the length of the skin incision depending on the location of the fracture. The incision is deepened down to fascia which is incised in line with the skin incision. The interval between extensor carpi radialis brevis and extensor digitorum comminus is developed and followed distally to where abductor pollicis longus crosses (Figs. 27-10 and 27-11). If it is difficult to find the interval between the muscles, it can also be developed from distal to proximal where the abductor pollicis longus and extensor pollicis brevis cross. More proximally, the common apponeurotic origin of extensor carpi radialis brevis and longus is split, revealing the underlying supinator muscle (Fig. 27-12). Distal to abductor pollicis longus and extensor pollicis brevis, the interval between extensor carpi radialis brevis and extensor pollicis longus is developed which exposes the extraperiosteal posterolateral aspect of the distal radius (Fig. 27-13).
FIGURE 27-11 The interval between extensor carpi radialis brevis and extensor digitorum is developed.
In the proximal two-thirds of the forearm, deep dissection to expose the bone involves identification and protection of the posterior interosseous nerve. In the proximal third the nerve can be identified where it exits supinator. If access to the radial nerve is required, the nerve is dissected through the substance of supinator while preserving its motor branches. Once the nerve is identified, the forearm is supinated to expose the anterior insertion
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of supinator where it is detached extra-periosteally. The muscle can then be retracted to gain access to the proximal radius (Fig. 27-14). To undertake deep dissection distally into the middle third of the forearm, abductor pollicis longus and extensor pollicis brevis have to be detached extraperiosteally from the underlying radius and mobilized proximally and distally to gain access to bone (Fig. 27-14).
FIGURE 27-12 Further dissection of the interval proximally with splitting the aponeurotic origin of the extensors reveals supinator and the posterior interosseous nerve as it leaves the arcade of Frohse.
Surgical Approach to the Ulna
Exposure of the shaft of the ulnar is the most straightforward approach in the forearm. It permits exposure of the entire length of the bone. The approach relies on the plane between flexor and extensor carpi ulnaris. Careful dissection has to be carried out distally where the dorsal branch of the ulna nerve crosses the interval.
Surgical Anatomy
On the medial side the ulna is covered by flexor and extensor carpi ulnaris. Extensor carpi ulnaris is the most medial muscle supplied by the posterior interosseous nerve and flexor carpi ulnaris is the most medial muscle supplied by the ulnar nerve. The two muscles therefore form the borders of the inter-nervous plane used to approach the ulna. The ulnar nerve runs underneath flexor carpi ulnaris between flexor digitorum superficialis and profundus with the ulnar artery on its lateral side. Proximally, the nerve is fixed to flexor carpi ulnaris as it leaves the sulcus ulnaris and enters the flexor muscle between its humeral and ulnar origins. The ulnar nerve divides into four branches distally, one of which is the dorsal branch which runs across the surgical field distally. It may be encountered if dissection is continued to the distal end of the ulna.
FIGURE 27-13 Development of the interval between extensor carpi radialis brevis and extensor pollicis longus reveals the radius distal to extensor pollicis brevis. Proximally, the nerve can be mobilized where it exits supinator if required. The posterior interosseous nerve should be identified and protected throughout the whole procedure.
Surgical Dissection
The patient is placed supine on the operating table with the arm abducted on an arm board. The forearm is held in a neutral position and the arm flexed at the elbow. Alternatively, the arm may be placed across the chest. For isolated fractures of the ulna a lateral decubitus position with the arm on an arm rest
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offers the best option. Before the incision is made the subcutaneous border of the ulna is palpated along its entire length and the surgeon can usually palpate the fracture. The incision is centered over the fracture site and is made longitudinally slightly anterior or posterior to the palpable subcutaneous crest. The length of the incision depends on the degree of exposure that is required. The incision is deepened down to fascia which is incised in line with the skin incision. Distally, care must be taken to identify and protect the dorsal branch of the ulnar nerve which passes onto the dorsal surface of extensor carpi ulnaris. The plane between extensor and flexor carpi ulnaris is developed to expose the underlying bone extraperiosteally. At the level of the olecranon the anconeus is found on the extensor side instead of extensor carpi ulnaris. The muscles are detached extraperiosteally depending on whether access to the anterior or posterior aspects of the bone is required. Anteriorly flexor carpi ulnaris has to be retracted carefully as the ulnar nerve and the ulnar artery run underneath between flexor digitorum superficialis and profundus. If the bone is exposed extraperiosteally by detaching and retracting flexor carpi ulnaris together with flexor digitorum profundus, the neurovascular structures are not endangered.
FIGURE 27-14 After identification of the posterior interosseous nerve, the forearm can be supinated in order to release supinator, which then exposes the proximal radius.
CURRENT TREATMENT OPTIONS
Several methods are available for treatment of fractures of the radius and ulna. While there are some indications for nonoperative management, operative treatment with internal fixation is generally acknowledged to be the most appropriate treatment method in most cases because it permits the most precise anatomic reduction of the fracture fragments. As functional outcome closely correlates with the restoration of anatomical alignment (28,29), particularly with reference to the maximum radial bow (30), the technique providing the most accurate restoration of the osseous anatomy will theoretically yield the best functional results. However, functional outcome also depends on how any associated injuries are managed and how soft tissue management and rehabilitation is carried out. Thus, all aspects of the injury have to be taken into account when selecting the most appropriate treatment method. Table 27-4 gives an overview of the advantages and disadvantages of the different treatment options.
Nonoperative Treatment
As the treatment of fractures of the radius and ulnar diaphyses is mainly operative, there are only a few indications for nonoperative
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treatment, such as isolated undisplaced fractures of the ulna (36,37) or if operative treatment is contraindicated because of the patient’s general condition. The patient should be advised that open reduction and internal fixation may be required to obtain anatomic reduction and that the quality of the reduction is the key element for restoration of full function.
Table 27-4 Nonoperative vs Operative Treatment
Nonoperative Treatment No control of fracture fragments
High rate of secondary displacement
Uncertain time to union
Poor functional results in most cases
Intramedullary Nailing Poor control of fracture fragments
Anatomical re-alignment difficult
More difficult to explore neurovascular structures
High rate of nonunion
High rate of unsatisfactory results
Open Reduction and Plate Osteosynthesis Excellent control of fracture fragments
Perfect anatomical re-alignment possible
Possibility of treating concomitant injuries
Can explore neurovascular structures
Very low rate of nonunion
Good to excellent functional results
Very predictable outcome
Closed Reduction and Cast Immobilization
Undisplaced fractures of both bones of the forearm can be treated by cast immobilization. In displaced fractures a number of investigators have been unable to achieve satisfactory results with closed reduction and cast immobilization (5,38,39). In one of the best series discussing nonoperative treatment, Evans (40) reported loss of forearm rotation of more than 50 degrees in 30% of patients. Knight and Purvis (38) showed that in their 100 patients with forearm fractures, 71% of patients treated with closed methods had unsatisfactory results with a high incidence of malunion and nonunion. Closed reduction and cast immobilization seems to be an unreliable method of achieving full forearm function. Even in initially undisplaced fractures of both bones of the forearm, functional outcome has been reported to be poor due to secondary loss of reduction (41). It is difficult to obtain and maintain reduction with closed treatment. It is of interest that most series discussing nonoperative management were published before 1960 and the current treatment of choice is open reduction and internal fixation (42,43,44,45,46).
Functional Bracing
While unsatisfactory results with nonoperative management of displaced and undisplaced forearm fractures are common (5,38,39), Sarmiento et al (47,48) reported on a series of 44 patients in which good results were obtained using functional bracing. In 39 patients, fractures of both bones of the forearm united in an average of 16 weeks with a reported loss of motion of only 8 degrees in 10 patients who had fractures in the distal third of the forearm (48). Distal fractures are most prone to heal with poor forearm rotation. In Sarmiento’s method closed reduction was obtained under anesthesia and the forearms were immobilized in long-arm casts. After an initial period of immobilization of about 18 days the forearms were placed in a functional brace which limited pronation and supination and permitted some flexion and extension of the elbow (48). Despite the fact that some patients had imperfect reduction, good functional results were reported. This contrasts with the results of biomechanical studies on the effect of malalignment on forearm function (28,29,30). So far no other study has reproduced similar functional outcomes after closed treatment.
In our opinion the results of both functional bracing and/or simple casts are unpredictable. Closed functional bracing may be indicated in isolated fractures of the shaft of the ulna (36) with less than 10 degrees of angular displacement (28). In these fractures Sarmiento et al (37) reported a union rate of 99% and good to excellent functional results in more than 96% of patients.
Operative Treatment
External Fixation
There are only a few indications for the use of external fixation in forearm fractures (Table 27-5). It is usually used for the initial management of open fractures of the radius and ulna associated with extensive soft tissue damage and/or bone loss. While several types of external fixation devices exist (49), none of them have been found to be clearly superior to any of the others (50). However, if it is used, external fixation confers adequate stability to the fracture (51). Although encouraging results have been reported, external fixation of forearm fractures is associated with pin tract infection with an incidence of 19% being quoted (52). Therefore, once the condition of the patient and the soft tissues have improved, the external fixator should be removed and appropriate internal fixation undertaken (51,52,53).
In addition to complex open fractures, another indication for temporary external fixation is in the multiply-injured patient, especially if there is co-existing severe trauma in other body systems. It is usually better to apply an external fixator rather than to subject a patient to a longer surgical procedure. Damage control surgery is discussed further in Chapter 3.
Intramedullary Nailing
Initially the results of intramedullary nailing of unstable forearm fractures were discouraging (54), with 20% nonunion and a high incidence of malunion and poor function in those fractures that united. After studying the osseous anatomy of the forearm, especially the radius, Sage et al (27) devised triangular intramedullary nails for the forearm. While the ulnar nail was straight, the radial nail was bent to restore the radial bow. Despite this improved intramedullary technique, nonunion occurred in 6.2% of patients with delayed union in 4.9%.
Since the Sage nail, many different implants have been introduced (27,55,56). Although their use has been reported to produce acceptable results (55,56), intramedullary nails are not as strong and do not maintain forearm reduction as well as plate osteosynthesis (57,58). Moreover, the use of intramedullary nails is limited by the configuration of the fracture and the presence and severity of associated injuries. Selection of the correct length and diameter of the nail with reference to the configuration of the fracture is critical (27).
Table 27-5 Indications for Temporary External Fixation
Open fractures with severe soft tissue damage until reconstruction is undertaken
Maintaining the length in fractures with severe bone loss (mostly open fractures)
In some cases of multiply injured patients (damage control surgery)
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If closed intramedullary nailing is chosen, the anatomical reduction cannot be as accurate as can be achieved with plating. If open reduction is chosen intramedullary, nailing combines the disadvantages of open reduction with the disadvantages of the implant itself. Although intramedullary nailing is still widely used to treat unstable forearm fractures in children (59,60), we do not advocate its use in displaced, unstable fractures in adults.
Plating
Internal fixation with plates allows excellent control of the fracture fragments and therefore permits accurate restoration of the anatomy, which remains the key principle in treating forearm fractures as it preserves maximal forearm function (42,43,57). In their classic study Anderson et al (42) reported on a series of 258 adults treated with the AO compression plate (61) for displaced fractures of the radius and ulna. A total of 244 patients were followed for an average of 13.2 months. In these patients, 193 radial fractures and 137 ulnar fractures were treated with AO plates. Compression plate fixation resulted in a union rate of 97.9% for fractures of the radius and 96.3% for fractures of the ulna. In 63 (25.9%) patients autologous iliac crest bone grafts were used. The union rate for patients who had bone graft was identical to those who did not have bone graft. Final results showed that 59 of patients had excellent functional results, 30% had satisfactory functional results, and only 11% had fair or poor results. More recent studies have also indicated that routine bone grafting is not indicated in plate fixation of forearm fractures (62).
Other authors have also reported on the superior union rates and functional outcome of compression plating (43,45,63,64). Hertel et al (64) presented a retrospective review of 132 fractures of one or both bones of the forearm treated over a 10-year period. All patients were treated with 3.5 mm dynamic compression plates and there was a 92% long-term follow-up. In 127 fractures (96.2%) union occurred before 6 months. There were two nonunions and two delayed unions. Three of these underwent repeat osteosynthesis and subsequently healed. Seventy patients had their plates removed at a mean of 33 months and three of these (4.3%) had a refracture at a mean of 4.3 months after plate removal. No patient in whom the plates were not removed had a refracture. The infection rate in this series was only 0.7%. Plate osteosynthesis is superior to other treatments because it permits anatomical reconstruction but also is associated with improved function. Schemitsch and Richards (30) reported good functional results with a forearm ROM greater than 80% of the opposite normal side if the radial bow was restored to its normal size and location.
The plates most widely used for internal fixation of forearm fractures are the 3.5 dynamic compression plate (DCP) and the 3.5 limited contact-dynamic compression plate (LC-DCP) (Fig. 27-15) (42,44,45,63,64,65,66). In comparison to the DCP, the contact area between the bone and the LC-DCP is reduced by about 50% (67,68). This theoretically improves the blood supply to the underlying bone cortex and lessens the risk of partial bone necrosis (69). This in turn may be associated with improved healing and lower infection rates. The concept of limited contact between the plate and the bone has lead to the development of the point contact-fixator (PC-Fix) in which the contact area between the plate and the underlying bone is reduced to two contact points every 16 mm (70). Fixation is therefore not achieved by friction between the plate and the bone but rather by shear between the screws and the bone, like an external fixator. The screws of the PC-Fix have conical heads to fit the identically formed fixator holes exactly, therefore giving them angular stability when they are locked in their plate. The PC-Fix and the later locking compression plates (LCP) were designed to be used with unicortical screws.
FIGURE 27-15 LC-DCP osteosynthesis of a forearm fracture with an associated DRUJ injury. This image shows the operative treatment of the fracture shown in Figure 27-1.
To evaluate the practical application of the PC-Fix, Hertel et al (71) reported on its use in six centers. Unlike with the LC-DCP, they found that the screw hole configuration does not permit compression of the implant to the bone or compression of the fracture, which means an additional compression device must be used. The configuration of the screw hole makes inclination
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of the screws in the holes impossible and therefore lag screws cannot be used (Fig. 27-16). Although the use of unicortical screws was considered more biological, the fixation is less good and potentially more screws are required compared to the LC-DCP (Fig. 27-17).
FIGURE 27-16 A typical indirect reduction with a PC-Fix plate. Note that the screw hole configuration doesn’t allow inclination of the screws, thereby limiting the surgeons ability to place the screws for fragment fixation.
The concept of the PC-Fix places maximum emphasis on the preservation of bone vascularity and the degree of stability of fixation is considered less important. However, a prospective clinical study by Leung and Chow (65) comparing union rates and functional outcome of the PC-Fix with the LC-DCP concluded that the two implants are equally effective for treatment of fractures of the radius and ulna diaphyses, despite their fundamental differences. Clinically the PC-Fix provides no advantage over the conventional LC-DCP, but it does require the surgeon to accept a different concept of plate fixation (72). It is however a step in the evolutionary process of improving the biomechanical and biological properties of fracture fixation. Information gained during the development and use of the PC-Fix led to the development of the locking compression plate (LCP). We believe that the investigation of Anderson et al (42) using conventional devices has set the standard whereby new devices must be measured and we believe that until other fixation devices prove to be superior, the 3.5 LC-DCP remains the gold standard for internal fixation of forearm fractures.
FIGURE 27-17 Postoperative x-ray of a fracture treated with a PC-Fix plate illustrates the parallel orientation of the unicortical screws.
Table 27-6 Guideline for Strategic Planning
Aim?
  • Anatomic reduction of all fragments or anatomic alignment of the shaft (length, axial alignment, and rotation)? With or without anatomic reduction of all fragments?
Position of the patient?
Tourniquet?
Approach?
How and when to treat associated ligamentous injuries.
Which side first? Ulna or radius?
Technique of reduction and alternatives?
  • Direct or indirect?
  • Distractor?
How and when to check adequacy of reduction.
  • Image intensifier?
  • X-ray?
Wound closure.
  • Will it be possible? Swelling, compartment syndrome?
  • What to do if closure is not possible?
  • How to avoid exposure of the implant?
Required personnel, infrastructure, instruments, and implants? Availability?
FIGURE 27-18 Reduction technique sequence. A. A pre-bent plate is approximately mounted on the proximal fragment to prepare for indirect reduction. B. The fragments are gently reduced with minimal manipulation of the main fragments and no manipulation of the accessory fragments and temporarily fixed to the plate with a clamp. C. Adequate alignment is obtained. D. Compression is applied between the main fragments by the use of a clamp or a tensioning device.
FIGURE 27-19 Osteosynthesis using an 8-hole low contact-dynamic compression plate (LC-DCP) with two screws on each side of the fracture.
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Pearls and Pitfalls
Pearls
There is a high incidence of associated musculoskeletal injury.
Tense swelling in the forearm suggests compartment syndrome.
In type II Monteggia fracture dislocations, an anterior triangular or quadrilateral anterior fragment must be looked for on x-rays.
It is important to have a good treatment algorithm.
The results of using the 3.5-mm LC-DCP have not been bettered by more modern plates.
Pitfalls
Subluxation of dislocation of the DRUJ may develop slowly.
Failure to restore the radial bow will restrict forearm rotation.
Intramedullary nailing frequently does not restore the radial bow.
In initially undisplaced fractures, nonoperative management can be associated with poor results.
Minimally invasive techniques are not recommended.
Early plate removal may cause refracture.
Narrowing of the interosseous space may cause radio-ulnar synostosis.
COMPLICATIONS
Compartment Syndrome
Compartment syndrome is an important complication (77). There are a number of initiating factors. One pathway is tissue hypoxia followed by swelling which further reduces the perfusion pressure at the capillary level, eventually leading to ischemic muscle and myonecrosis. Another more common pathway is direct or indirect muscle damage leading to muscle swelling followed by increased intracompartmental pressure, the pressure rising more quickly if the injury was not severe enough to tear the fascial compartments. Again, increased intracompartmental pressure will lead to reduced capillary blood flow, muscle ischemia, and myonecrosis. As the capillary blood flow will cease at a pressure much lower than the arterial blood flow, palpation of the pulses and the use of laser Doppler will not diagnose an impending compartment syndrome and will only diagnose the established compartment syndrome after it is too late to treat it successfully (21). The most useful clinical sign of acute compartment syndrome is increased pain, which can be tested by passively stretching the fingers in a flexor compartment syndrome or extending the fingers in an extensor compartment syndrome. Compartment syndromes are more common in young men, in patients with low-energy minimally displaced fractures, and in patients with bleeding disorders or who are anticoagulated (78). Further information on compartment syndrome is contained in Chapter 13.
The forearm is the most common site for compartment syndrome in the upper extremity. The three compartments of the forearm include the anterior (or flexor compartment), the posterior (or extensor compartment), and the mobile wad (including
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brachioradialis and extensor carpi radialis longus and brevis). Flexor digitorum profundus and flexor pollicis longus are the most severely affected muscles because of their deep location.
Initial management consists of removal of occlusive dressings with splitting or removal of a cast. If the symptoms do not resolve rapidly, fasciotomy is indicated. Fasciotomy of the forearm is performed through volar and/or dorsal approaches. The carpal tunnel should be included.
Malunion
As has already been discussed, exact anatomical realignment is crucial to restore forearm function. There is limited literature available on the treatment and outcome of corrected osteotomies after forearm fracture malunion. Trousdale and Linscheid (79) reported on a consecutive series of 27 corrective osteotomies undertaken an average of 73 months after fracture. In 20 patients the indication for surgery was functional loss of forearm rotation with an average arc of prosupination of 72 degrees ranging from 20 degrees to 120 degrees. Nine of these patients underwent the procedure within 12 months of the initial injury and 11 were treated later. The patients who were managed within the first 12 months regained an average of 79 degrees of forearm rotation, while those managed after the first 12 months regained only an average of 30 degrees. It seems therefore that early correction yields better results than late correction if osteotomy is required.
Nonunion
In general, fracture nonunion results from unstable fixation or a compromised blood supply secondary to the severity of the injury or poor surgical technique. As nonoperative management has only limited control of the fracture fragments and stability during healing, it is not surprising that it is associated with substantial rates of nonunion (39,80). Smith and Sage (54) published the results of early attempts at intramedullary fixation of forearm fractures. The use of Kirschner wires introduced with an open technique was associated with an increased risk of nonunion and the results were disappointing.
With the advent of plate osteosynthesis nonunions have been almost eliminated. Following the guidelines of the AO/ASIF group (61) who have promoted the concept of interfragmentary compression, the only fractures that are still associated with a high rate of nonunion are those with substantial bone loss or comminution (42,44,63,81). Although routine bone grafting is not advocated now as there is no evidence that bone grafted fractures have a higher union rate than nonbone grafted fractures (42,62), it is reasonable to bone graft fractures associated with bone loss and devitalized bone fragments. This has helped reduce the rate of nonunion.
In their series of 258 patients treated with compression plating Anderson et al (42) had nonunion rates of 2% to 3%. Chapman et al (44) stated that the nonunion rate should be less than 2% if the proper technique is used in compliant patients. With the exception of severely comminuted or open fractures associated with substantial bone loss and/or significantly traumatized soft tissues, nonunions are usually ascribed to technical errors nowadays. If a correct approach and proper soft tissue handling is employed, the rate of nonunion using compression plate osteosynthesis should be low. If it does occur, re-osteosynthesis with iliac crest cancellous bone grafting is recommended. Figure 27-20 shows an example of a nonunion that healed after re-osteosynthesis with cancellous bone grafting. Nonunion is discussed further in Chapters 8 and 18.
Infection
Nowadays infection after operative treatment of closed fractures is rare if proper surgical technique is employed. The reduction in infection rates has been mainly attributed to improved operative technique, implant development, and peri-operative antibiotic prophylaxis (42,44,82). If infection does occur, surgical treatment with an adequate debridement is recommended. Implant removal should not be undertaken, as in our experience eradication of the infection does not require plate removal and instead requires well-vascularised bone and soft tissues with stable internal fixation. We believe that fracture stability is important and therefore advocate aggressive surgical treatment combined with appropriate antibiotic treatment depending on the bacteria involved in the infection.
Infection rates between 0% to 3% have also been reported for open fractures treated immediately by open reduction and plate fixation (44,83,84,85). In these fractures, a thorough debridement is crucial for successful treatment. It should be carried out as an emergency procedure on the day of admission with flap reconstruction being performed if required (76). If this approach is employed, the infection rate is minimized; but if infection does occur, it requires an aggressive surgical approach with resection of all infected and devitalized soft tissues and reconstruction of any bone defects and flap cover as required. Infection is discussed further in Chapter 18.
Plate Removal and Refracture
Plate removal is not without complications (86). In addition to the operative complications of infection, hematoma or neurovascular damage, refracture after plate removal is not uncommon. The literature reports refracture rates from as low as 4% (44,63,87) up to 25% (88). Deluca et al (88) and Hidaka and Gustilo (89) have identified that an inadequate technique, delayed union or nonunion, and plate removal less than 1 year after injury are the most important causes of refracture (Table 27-7). Refracture has also been linked to local osteoporosis visible as a radiolucency under the plate. This was initially thought
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to be due to stress protection following application of the plate (88,90), but it has been demonstrated that the initial osteoporosis is the result of impaired local blood supply to the cortical bone under the plate. If plate removal is to be undertaken, it is therefore clear that the bone should be allowed to remodel before the plate is removed. It has been suggested that remodeling takes up to 21 months to complete (91,92). We do not advocate routine plate removal in the asymptomatic patient.
Table 27-7 Risk Factors for Refracture
Inadequate technique
Delayed union/nonunion
Premature plate removal (<1 year after injury)
FIGURE 27-20 A. The fracture of the radius shows no union 3 months after surgery, while on the ulna callus formation is visible. B. After another 1.5 months, the fracture still showed no signs of healing. C. Re-osteosynthesis was performed by using a longer plate and compression together with cancellous bone grafting. D. Follow-up 2 months after revision surgery shows callus formation at the fracture site.
Radio-Ulnar Synostosis
Radio-ulnar synostosis, or crossed union between the radius and ulnar (Fig. 27-21), is rarely reported either because it rarely occurs or because it is an issue that is not addressed. However, it is an important problem as it may severely impair forearm function by limiting the rotational amplitude. In a review of 2,381 forearm fractures, an incidence of about 2% was reported (93); and it is suggested that the incidence is higher in type IV Monteggia fractures involving both bones of the forearm together with a radial head dislocation. Another study reported an incidence of 6.6% in a series of 167 patients, more than half of which were fractures of both bones of the forearm (94). In patients with co-existing head trauma, the incidence of radio-ulnar synostosis has been reported as high as 18% in a mixed group of nonoperative and operatively treated patients (95).
The most important risk factors for the development of radio-ulnar synostosis are summarized in Table 27-8 and include high-energy trauma open fractures (96,97), infection, head injuries (93,95), and where internal fixation is delayed by several weeks (93,94). Surgical factors include narrowing of the interosseous space by imperfect reduction, bone grafting, and overlong screws that transgress the interosseous space or may impinge in the proximal third of the forearm (38,98).
Restoration of forearm rotation after radio-ulnar synostosis has occurred involves surgical excision with interposition of silicone rubber, muscle, or fat grafts. The results of surgical excision in combination with these procedures are unfortunately not very encouraging with an average rotation of 55 degrees with a mean follow-up of 40 months (99). Combining surgical resection with low-dose radiation has yielded better results (100). Restoration of forearm rotation in the presence of a proximal-third synostosis is difficult because of a subsequent loss of rotational amplitude after the surgical procedure due to heterotopic ossification or scarring. Jupiter and Ring (101) reported on a series of 18 forearms in 17 patients. Using surgical resection with adjuvant radiotherapy an average forearm rotation of 139° was reported in patients who underwent surgery as early as 6 months after the injury. Recently Kamineni et al (102) published the results of a series of seven patients
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with radio-ulnar synostosis who were treated by resection of a 1-cm section of the proximal radius distal to the synostosis. Initially the seven patients started with a mean fixed pronation of 5 degrees, but at an average follow-up of 80 months the mean forearm rotation was 98 degrees.
FIGURE 27-21 A radio-ulnar synostosis.
Table 27-8 Risk Factors for Radio-Ulnar Synostosis
General
  • Open fractures
  • Infection
  • Multiply-injured patients with head trauma
  • Delayed internal fixation
Surgical (less common)
  • Narrowing the interosseous space by nonanatomic reduction
  • Use of too long screws
  • Bone grafting
We believe that the use of a nontraumatic surgical technique and rehabilitation with early mobilization should prevent the development of radio-ulnar synostosis. However, if it occurs, there are surgical treatment options which provide an improvement in forearm rotation.
Neurovascular Complications
A number of neurovascular complications are iatrogenic and are caused either by the surgery, the use of a tourniquet, or positioning the patient on the table incorrectly. If an anterior Henry approach is used, the superficial radial nerve and the radial artery need to be protected and care has to be taken not to over-retract the nerve thereby causing a neuropraxia. The posterior interosseous nerve is at risk in both the anterior and dorsolateral Thompson approach and care must be taken when the supinator muscle is elevated subperiosteally, as the posterior interosseous nerve runs in this muscle and exits in the arcade of Frohse.
CONTROVERSIES AND FUTURE DIRECTIONS
Surgeons always seek to treat their patients better. Ideally it would be desirable to obtain a higher union rate, avoid any malalignment, and consistently obtain full function following treatment. These goals were largely addressed in the second half of the last century, and in expert hands good results should be obtained.
If results are poor, it is usually due to factors that are difficult to control, such as bone and soft tissue devascularization, contamination, and an impaired immune response. It is therefore unlikely that developing new implants is going to materially improve existing results.
Future developments should therefore perhaps focus on
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other aspects, such as the type of surgery and the precise operative technique that is used. Theoretically it might be desirable to develop minimally invasive treatment techniques providing the injured patient with a less painful and more efficient method of restoring function quickly. As has already been pointed out, this is difficult if plate fixation is used and would seem to indicate that the future might lie with intramedullary nailing. Unfortunately the use of intramedullary nailing in the forearm is not as atraumatic as it would initially appear. Restoration of the normal bow of the radius and the shape of the ulna is not consistently achieved and rotational stability is poor particularly in AO (OTA) type B and type C fractures. It is certainly possible that even with improved intramedullary nails, minimally invasive surgery might be achieved at the expense of functional outcome. Minimally invasive osteosynthesis aims at minimizing damage to all soft tissues including those that immediately surround the bone, but it is unlikely that percutaneous plating is going to be as successful in forearm fractures as in other fractures because of the local anatomy. However, it is possible that improving reduction techniques will help to facilitate the surgery and may prove to be more beneficial than merely inventing new implants and plant introduction techniques (103).
ACKNOWLEDGMENT
The authors would like to acknowledge and thank Dr. Norman Espinosa for the illustrations he provided for our chapter.
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