David M. Kalainov and Charles Carroll IV

Indications

1. Radial shaft fracture with angulation greater than 10 degrees, malrotation, or disturbance of the normal radial bow

2. Ulnar shaft fracture with angulation greater than 10 degrees, malrotation, displacement greater than 50%, or shortening with distal radio-ulnar joint incongruency

3. Both-bones forearm fracture

4. Monteggia fracture

5. Galeazzi fracture

6. Open fracture

7. Segmental or comminuted fracture (relative)

8. Concomitant soft-tissue injury requiring frequent wound care (e.g., burn)

9. Compartment syndrome

Contraindications

1. Nondisplaced radial shaft fracture

2. Minimally displaced ulnar shaft fracture (“nightstick” fracture)

3. Severe coexisting medical illness

4. Childhood injury (relative). In general, a greater degree of initial displacement can be accepted in children given their potential for remodeling during growth and high incidence of satisfactory functional outcomes with nonoperative treatment.

Preoperative Preparation

1. Standard AP and lateral radiographs of the injured forearm, elbow, and wrist

2. Comparative views of the contralateral forearm and wrist may be helpful.

3. Determine the radiographic characteristics of the fracture.

a. One or both bones

b. Shaft location—proximal, middle, or distal third

c. Pattern of injury—transverse, oblique, spiral, comminuted, segmental, bone loss

d. Degree and direction of displacement

4. Document the neurovascular status and evaluate the extremity for associated trauma (e.g., radial head dislocation, distal radio-ulnar joint instability).

5. Assess for elevated forearm compartment pressures.

6. Plan the surgical approach: anterior, posterior, ulnar.

7. Discuss with the patient the common potential complications associated with operative treatment of forearm fractures.

Special Instruments, Position, and Anesthesia

1. Supine position with a hand table extension

2. Regional or general anesthesia

4. If autogenous bone grafting is anticipated, prepare the anterior iliac crest.

5. Standard or minifluoroscopy unit

6. Consider low-power loop magnification (2.5×).

7. Basic hand tray and routine orthopaedic instruments (tissue scissors, retractors, fracture reduction clamps, dental probe, periosteal elevator, Freer elevator, currettes, osteotomes, mallet)

8. Internal fixation set with 3.5-mm screws and plates (dynamic compression plates, angled plates, T-plates); smaller 2.7-mm plates are useful for proximal radial and distal ulnar shaft fractures.

9. Availability of an external fixation device

Tips and Pearls

1. Administer intravenous antibiotics prior to tourniquet inflation. Avoid use of a tourniquet with extremely traumatized soft tissues or in the setting of a compartment syndrome.

2. Select the appropriate surgical exposure.

a. Anterior approach (Henry)—preferred for fractures involving the distal third of the radial diaphysis (or any radial shaft fracture associated with elevated compartment pressures).

b. Posterior approach (Thompson)—preferred for fractures involving the proximal and middle thirds of the radial diaphysis.

c. Ulnar approach—applicable to all ulnar shaft fractures; additional incisions may be required for volar and dorsal fasciotomies.

3. Stabilize the fracture with a 3.5-mm dynamic compression plate(s).

a. Allow for six to eight cortices of screw purchase both above and below the fracture line.

b. Consider lag screw fixation either through the plate or separate from the plate for increased strength.

c. A segmental radial or ulnar shaft fracture may necessitate two plates if the length of one plate is insufficient to bridge the fracture. Position the plates 90 degrees apart.

d. When addressing a both bones injury, obtain provisional plate fixation with clamps to assess forearm rotation. If there is loss of normal supination or pronation, adjust the reduction before securing the plates with screws.

4. Bone graft areas of extensive comminution and bone loss.

5. Confirm reduction and stability of the distal radio-ulnar and proximal radio-capitellar joints after plate fixation. Be prepared to address residual problems at these sites.

6. Consider intramedullary nailing as an alternative method of stabilizing segmental forearm fractures in adults. This technique is particularly useful when addressing unstable diaphyseal fractures in children.

7. Apply an external fixator if early internal fixation is deemed inappropriate (e.g., significant soft-tissue destruction, wound contamination, poly trauma). Conversion to plate fixation at a later date is recommended.

What To Avoid

1. Do not expose the proximal third of the radius without protecting the posterior interosseous nerve.

2. Avoid injury to the dorsal cutaneous branch of the ulnar nerve when exposing the ulnar shaft distally. The nerve branches approximately 6 cm proximal to the ulnar head.

3. Avoid injury to the lateral antebrachial cutaneous and dorsoradial sensory nerves when approaching the radius anteriorly. The lateral antebrachial cutaneous nerve emerges from between the biceps tendon and brachialis proximally and courses down the volar-radial side of the forearm subcutaneously. The dorsoradial sensory nerve lies under cover of the brachioradialis in the proximal two thirds of the forearm and penetrates the fascial interval between the brachioradialis and extensor carpi radialis longus tendons distally.

4. Refrain from overzealous retraction of neurovascular structures.

5. Avoid excessive soft-tissue dissection, particularly with comminuted fractures.

7. Do not close forearm fascia and avoid reapproximating wound edges under undue tension.

Postoperative Care Issues