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Diaphyseal Fractures of the Radius and Ulna in Adults
Hand Clin 23 (2007) 143–151
Diaphyseal Fractures of the Radius and Ulna in Adults Joshua P. Moss, MD*, Donald K. Bynum, MD Department of Orthopaedic Surgery, University of North Carolina, CB 7055, 3157 Bioinformatics Building, Chapel Hill, NC 27599-7055, USA
Diaphyseal fractures involving the radius and ulna, so called ‘‘both-bone’’ or ‘‘double-bone’’ forearm fractures are common orthopedic injuries. These injuries can result in significant loss of function if inadequately treated. As the upper extremity serves to position the hand in space, loss of forearm motion and/or muscle imbalance resulting from a poorly treated fracture can be particularly debilitating. Preservation of the anatomic relationships of the proximal and distal radioulnar joints as well as the interosseous space is critical to preserving function. This article provides an overview of the management of diaphyseal fractures of the radius and ulna in adults. History Historically, both-bone forearm fractures, like nearly every other orthopedic injury, were treated with closed manipulation and casting; however, even the best published results of this technique were far from perfect. Evans [1] reported a series of five patients treated with closed reduction and casting. His technique was reliant upon a tuberosity view radiograph of the proximal radius, which revealed the relative pronation or supination of the proximal fracture fragment (Figs. 1 and 2). Reduction was thus performed to match the forearm rotation. His results still revealed more than 50 degrees of loss of forearm rotation in more than 30% of patients. Early efforts with operative techniques resulted in poor outcomes and disappointing results. Inadequate internal fixation techniques were often
* Corresponding author. E-mail address: [email protected] (J.P. Moss).
cited as the main cause of failure. Knight and Purvis [2] reported a high rate of unsatisfactory outcome with early internal fixation techniques involving onlay grafts, intramedullary Kirschener wires, and inadequate plate fixation (Fig. 3). Before the AO (Association for Osteosynthesis) revolution, many different fixation techniques were used for both bone forearm fractures. Smith and Sage [3] developed an intramedullary nail for the forearm, augmenting their fixation with a long-arm cast for 3 months. Still, they reported a nonunion rate of 6.2%. Sargent and Teipner [4] published a series of 29 both-bone forearm fractures treated with double, orthogonal plates on both the radius and ulna (Fig. 4). Their reported union rate was 100%, however their refracture rate following hardware removal was 29%. In a subsequent study, Teipner and Mast [5] compared double plating to single plating using AO techniques. They concluded that double plating offered no advantages while requiring more surgical time, so they abandoned double plating. In 1964, Burwell and Charnley [6] published a case series demonstrating the use of noncompressing plates in a series of 231 bothbone forearm fractures. Despite excellent functional results, their rate of nonunion was 10%. In the mid 1970s, the concepts of internal fixation promoted by AO/ASIF (Association for the Study of Internal Fixation) began to take hold. It is reasonable to conclude that treatment of diaphyseal fractures of the forearm has benefited more from the advances in modern compression plating techniques than the treatment of any other skeletal injury. Anderson and colleagues [7] published a paper in 1975 touting the benefits of the AO/ASIF technique in treating diaphyseal forearm fractures. They noted roughly 97% union in all fractures, results that have
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MOSS & BYNUM
Fig. 1. Technique for shooting the tuberosity view.
been duplicated in multiple publications. Internal fixation with compression plating has since been accepted as the gold standard treatment for diaphyseal both-bone forearm fractures. Patient presentation and initial evaluation Forearm fractures can present as a result of low-energy trauma, such as falls, sporting injuries, and low-velocity gunshot injuries, or high-energy trauma, such as falls from a height, motor vehicle crashes, and high-energy gunshot injuries. Local pain and deformity are the rule, often accompanied by soft-tissue injury corresponding to the energy of the injury. Open fractures are common and can occur even with low-energy injuries given the subcutaneous anatomy of the ulna. Less commonly, patients will present with one or more neurological or vascular deficits. A meticulous history and physical exam are required so that subtle neurovascular deficits are not overlooked during the period of acute presentation. Orthogonal radiographic views of the
Fig. 3. Onlay graft technique used by Knight and Purvis.
forearm, including the elbow and wrist, should be obtained to thoroughly evaluate the location and type of fracture as well as to rule out injuries to the wrist or elbow. Acutely, any open wound should be briefly irrigated with normal saline to decrease gross contamination, and then dressed with a sterile dressing while awaiting definitive treatment. Any gross deformity should prompt a provisional closed reduction, followed by application of a well-padded sugar-tong splint. In the multiply injured patient who may be delayed operative fixation, it is crucial to frequently assess the integrity of the patient’s skin, particularly at the edges of the splint or cast where pressure concentration can quickly lead to skin breakdown and ulceration. Nonoperative management Isolated nondisplaced or minimally displaced (less than 50%) fractures of the ulna can effectively
Fig. 2. Typical contours of the bicipital tuberosity with varying degrees of forearm rotation.
Fig. 4. Double plating technique used by Sargent and Teipner.
DIAPHYSEAL FRACTURES OF THE RADIUS AND ULNA
be treated with immobilization. A long-arm cast or functional fracture brace may be used. Completely nondisplaced fractures of the radius can be treated with 4 to 6 weeks of immobilization in a long-arm cast. However, time to union may be delayed due to the intact ulna preventing coaptation of the radius. There are few indications for closed treatment of both-bone forearm fractures in adults. Only for a critically injured patient or a patient with severe medical comorbidities such that operative risk is prohibitive should closed methods be considered. The literature is clear in concluding that, all things being equal, closed treatment of both-bone forearm fractures leads to higher rates of nonunion, malunion, and crossunion, resulting in a higher rate of poor functional outcomes.
Operative management Fractures involving both bones of the forearm should be treated with anatomic open reduction and rigid internal fixation (ORIF) to restore the forearm axis and allow for early postoperative motion. The purpose of the so-called forearm axis (elbow, forearm, and wrist) is to position the hand in space. To that end, the contributions of elbow and wrist motion are obvious, but many consider the forearm a joint in and of itself. Forearm supination and pronation are important components of the upper extremity’s ability to position the hand. Maintenance of anatomic radial bow and the interosseous space are thus important treatment goals. Dynamic compression plating has been considered the gold standard treatment since the AO/ASIF group released their Manual of Internal Fixation in 1979 [8]. The majority of forearm fractures can be approached with the patient supine and the upper extremity abducted onto a hand table. The volar forearm is easily approached in this position, but approach to the ulna will require elbow flexion. If a dorsal approach is indicated in a supine patient, adducting the arm closer to the body allows more shoulder internal rotation and thus easier access to the dorsal forearm. Prone positioning of the patient allows ready access to the dorsal forearm as well as the subcutaneous border of the ulna. To reduce the incidence of crossunion, the radius and ulna should be approached separately, avoiding exposure of the interosseous space if at all possible. Given the subcutaneous nature of the full length of the ulna, surgical access to that bone is relatively simple. The only neurovascular structure
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in immediate danger during surgical approach to the ulna is the dorsal branch of the ulnar nerve. This nerve is in play during exposure of the distal third of the ulna. Mok and colleagues [9] found that the ulnar nerve exits the deep volar fascia to course dorsally over the ulna at a mean distance of 2.9 cm proximal to the ulnar styloid. Doyle and Botte [10] describe the nerve’s exit from the deep fascia as 5 cm proximal to the proximal edge of the pisiform. Care should be taken when approaching the distal third of the ulna to dissect and preserve this important cutaneous nerve (Fig. 5). The radius, with its surrounding muscular envelope and closely associated neurovascular structures, is more difficult to approach at all levels, but particularly the proximal third. One of two workhorse approaches to the radius are typically used, either the dorsolateral Thompson or volar Henry approach. The Thompson approach is often considered best applied for exposure of the proximal and middle thirds of the radius. One advantage of this exposure is that it allows better reconstitution of the dorsal and radial bows when treating a long oblique or comminuted midshaft fracture. This is because application of a contoured (pre-bent) compression plate to the tension side of the fracture allows compression across both the volar and dorsal cortices. Proximally, the Thompson approach uses the interval between the extensor carpi radialis brevis and the extensor digitorum communis, exposing the supinator muscle in the proximal third of the forearm (Fig. 6). The posterior interosseous nerve can be identified as it runs perpendicular to the fibers of the supinator approximately three finger breadths distal to the radiocapitellar joint. Care is then taken to supinate the radius, allowing safe elevation of the supinator from its insertion to protect the posterior interosseous nerve. This allows exposure of the proximal and middle thirds of the radius. The proximal exposure, however, is not extensile, as further proximal dissection puts the posterior interosseous nerve at risk as it crosses the neck of the radius directly on bone. The distal third of the Thompson approach is relatively subcutaneous. The inter-nervous interval between the radial outcropper muscles and the brachioradialis is bluntly developed. The superficial radial nerve must be identified and protected as it passes through this interval. The volar Henry approach to the radius is a truly extensile approach. The incision passes from the
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Fig. 5. Anatomy of the dorsal cutaneous branch with exposure of the ulna. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 476; with permission.)
lateral bicipital sulcus distally toward the radial styloid. Proximally, this approach exploits the interval between the brachioradialis laterally and the biceps and brachialis tendons medially. The lateral antebrachial cutaneous nerve is identified and protected and the lacertus fibrosus is divided. The recurrent branch of the radial artery courses directly across the field and requires ligation to continue the approach. Once this interval is developed, the radial nerve and its branches are identified. As with the Thompson approach, the radius is then maximally supinated to allow elevation of the supinator from its insertion. This affords protection to the posterior interosseous nerve as it passes deep between the two heads of the supinator. Following elevation of the supinator, the mobile wad is retracted laterally to provide access to the proximal half of the radius. More distally, the radial artery crosses from medial to lateral across the radius, then assuming a course deep to the brachioradialis, adjacent to the superficial radial nerve. The artery should be protected during distal dissection. To access the middle third of the radial shaft, the radial insertion of the pronator teres should be taken down. Pronation of the forearm allows access of the lateral cortex of the middle and
distal radial shaft. For full exposure of the middle and distal volar cortices of the radius, the radial origins of the flexor digitorum superficialis and flexor pollicis longus must be elevated. Finally, the pronator quadratus covers the most distal aspect of
Fig. 6. Surface landmarks for the dorsal approach to the radius. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 473; with permission.)
DIAPHYSEAL FRACTURES OF THE RADIUS AND ULNA
the volar radius. This too must be elevated from its radial insertion to allow complete volar bony access (Figs. 7 and 8). Once adequate bony exposure has been obtained, the fractures must be reduced. Given the proximal and distal linkage of the two forearm bones, reduction of one can make reduction of the other quite difficult. It is generally easiest to reduce the less comminuted of the two bones first, thus establishing length and rotation. Alternatively, if
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both bones are significantly comminuted, indirect reduction by traction and manipulation may be performed and then maintained by a fracture distractor or provisional plate application. Once provisional fixation is applied, forearm rotation range of motion should be assessed to confirm anatomic alignment. Intraoperative fluoroscopic spot views can also be of assistance in confirming reduction. For definitive fixation, dynamic compression (DC) or limited contact dynamic compression
Fig. 7. Anatomy of the radial recurrent artery during volar proximal radial exposure. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 439; with permission.)
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Fig. 9. (B–C) Four cortices of fixation on either side of the (A) fracture, as performed by Lindvall and Sagi.
Fig. 8. Pronated view of the radius following volar Henry exposure. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams & Wilkins. p. 469; with permission.)
(LCDC) plates should be used whenever possible. These plates are generally considered to be, in most cases, of sufficient strength to allow functional loading while bony healing progresses. Depending on the comminution and obliquity of the fracture, most diaphyseal forearm fractures should require six to eight cortices of fixation above and below the fracture. However, Lindvall and Sagi [11] obtained a 97% union rate using four cortices of fixation on either side of the fracture with plates of varying lengths. They noted that as the ratio of fracture working length to plate length increases, stability diminishes (Fig. 9).
If possible, an interfragmentary screw should be added, although this is obviously not possible with transverse fractures. Compression should be performed using standard AO compression plate technique. An alternative technique to compression plating is intramedullary nail fixation. Interference nails have long been considered inferior to compression plating because of their relative lack of rotational control and poor ability to maintain length in comminuted fractures. However, the recent development and implementation of locked intramedullary nail systems provides an effective alternative to plating. Weckbach and colleagues [12] obtained 97.5% union in 40 forearm fractures treated with the ForeSight locked IM nail. Gao and colleagues [13] reported 100% union in 32 fractures treated with the ForeSight system (Fig. 10). Indications for intramedullary nail fixation of diaphyseal forearm fractures include poor softtissue integrity, segmental fractures, multiple injuries, and severe osteopenia. Contraindications include active infection, medullary canal smaller than 3 mm, and open physes. This technique can be technically difficult, as the anatomic bow of the radius and the serpentine shape of the ulna can
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Fig. 10. (A) Comminuted both-bone forearm fracture (B) treated with locked intramedullary nail fixation.
require a pre-bend to be applied to the nails before insertion. Also, the closed reduction can be difficult to obtain before nail insertion. Matching the cortical diameters under fluoroscopic guidance is a useful trick to obtain a more accurate reduction. Once definitive fracture fixation is performed, the tourniquet is released and hemostasis obtained. Forearm fascia should never be closed, and the wounds should not be closed under tension. Splitthickness skin grafting or delayed closure is preferable to wound dehiscence or skin flap necrosis following an excessively tensioned closure. Postoperatively, soft tissues should be rested with a bulky forearm-based splint for 5 to 7 days. Active elbow and digit motion should be encouraged during this period. Wrist and forearm motion with light functional loading (ie, dinner fork) should ensue immediately after the initial wound check clinic visit. This level of function should be maintained until radiographic and clinical signs of union have been observed, usually after 12 to 16 weeks. Hardware removal Routine removal of forearm fracture hardware should not be performed. There is a high complication rate associated with the removal of forearm hardware. Complications include refracture and neurovascular injury. Mih and colleagues [14]
reported an 11% refracture rate following removal of forearm hardware from 62 patients out of an overall cohort of 175 patients treated with ORIF for forearm fractures. Refracture occurred at an average of 6 months from plate removal with none occurring after 9 months following surgery. Sixty-seven percent of the patients still had residual symptoms despite hardware removal. They reported a four times higher complication rate in patients having undergone hardware removal compared with those retaining their plates. Dense scarring can place forearm neurovascular structures at risk during any approach for revision or hardware removal (Figs. 11 and 12). Risk factors for fracture following hardware removal include early plate removal (less than 1 year after index procedure), fracture with initial comminution, and plating with 4.5-mm hardware. The use of 4.5-mm hardware has largely been abandoned in treating both-bone forearm fractures. The larger residual hole size following hardware removal places the patient at a higher risk of postoperative refracture. Compression plates of 3.5 mm have been accepted as the gold standard for the treatment of most forearm fractures. Complications Complications of open treatment for bothbone forearm fractures include nonunion,
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Fig. 11. Radial fracture following removal of hardware.
malunion, infection, and neurovascular injury. Nonunion is rare following treatment of closed fractures of the forearm. Multiple publications have reported union rates of 97% to 100% with anatomic compression plating. Open fractures and fractures that are highly comminuted can
have an increased nonunion rate. Many advise primary autologous bone grafting of forearm fractures with greater than 50% comminution, although both Wei and colleagues [15] and Wright and colleagues [16] found no difference in union rates regardless of whether comminuted diaphyseal forearm fractures are grafted. Matthews and colleagues [17] found, in their cadaveric study, that coronal plane deformity of the radius or ulna of 20 degrees or greater resulted in at least a 30% reduction in forearm rotation. Wilson and colleagues [18] reported that angular malalignment and the related loss of forearm rotation were the factors most often associated with the inability to return to the same work following injury. Combined angular malalignment of the radius and ulna of less than 40 degrees limited loss of forearm rotation such that patients usually returned to the same occupation. Malunion is avoidable if an anatomic reduction is maintained with rigid internal fixation. Checking intraoperative forearm range of motion can help prevent a reduction that decreases the interosseous space, reducing motion. Malunion can also affect the articulation of the proximal and/or distal radioulnar joints resulting in pain and eventually arthrosis. Corrective osteotomy may be indicated in the setting of significant loss of motion or proximal/distal radioulnar joint symptoms.
Summary In summary, both-bone forearm fractures are common injuries in adults. They are routinely treated with anatomic open reduction and internal fixation with dynamic compression plating. Intramedullary rod fixation is an emerging technology. Surgical exposure of the radius may be accomplished through either volar or dorsolateral approaches. The ulna may be easily exposed along its subcutaneous border. Restoration of the radial bow and interosseous space is important to maintain forearm rotation. Hardware removal is associated with a high rate of complication, including refracture and neurovascular injury.
References
Fig. 12. Fracture following removal of 4.5 mm hardware.
[1] Evans EM. Fractures of the radius and ulna. J Bone Joint Surg Br 1951;33(4):548–61. [2] Knight RA, Purvis GD. Fractures of both bones of the forearm in adults. J Bone Joint Surg Am 1949; 31(4):755–64.
DIAPHYSEAL FRACTURES OF THE RADIUS AND ULNA
[3] Sage FP, Smith H. Medullary fixation of forearm fractures. J Bone Joint Surg Am 1957;39(1):91–8. [4] Sargent JP, Teipner WA. Treatment of forearm shaft fractures by double-plating: a preliminary report. J Bone Joint Surg Am 1965;47(8):1475–90. [5] Teipner WA, Mast JW. Internal fixation of forearm diaphyseal fractures: double plating versus single compression (tension band) platingda comparative study. Orthop Clin North Am 1980;11(3):381–91. [6] Burwell HN, Charnley AD. Treatment of forearm fractures in adults with particular reference to plate fixation. J Bone Joint Surg Br 1964;46:404–25. [7] Anderson LD, Sisk D, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975; 57(3):287–97. [8] Muller ME. Manual of internal fixation: techniques recommended by the AO Group. 2nd (expanded and revised) edition. Berlin: Springer-Verlag; 1979. [9] Mok D, Nikolis A, Harris PG. The cutaneous innervation of the dorsal hand: detailed anatomy with clinical implications. J Hand Surg [Am] 2006;31(4): 565–74. [10] Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia: Lippincott Williams and Wilkins; 2003. [11] Lindvall EM, Sagi HC. Selective screw placement in forearm compression plating: results of 75
[12]
[13]
[14]
[15]
[16]
[17]
[18]
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consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture. J Orthop Trauma 2006;20(3):157–62 [discussion: 162–3]. Weckbach A, Blattert TR, Weisser C. Interlocking nailing of forearm fractures. Arch Orthop Trauma Surg 2006;126(5):309–15. Gao H, Luo CF, Zhang CQ, et al. Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients. J Orthop Trauma 2005;19(6): 384–91. Mih AD, Cooney WP, Idler RS, et al. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop Relat Res 1994;299:256–8. Wei SY, Born CT, Abene A, et al. Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46(6):1045–8. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma 1997;11(4):288–94. Matthews LS, Kaufer H, Garver DF, et al. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am 1982;64(1):14–7. Wilson FC, Dirschl DR, Bynum DK. Fractures of the radius and ulna in adults: an analysis of factors affecting outcome. Iowa Orthop J 1997;17:14–9.
Diaphyseal Fractures of the Radius and Ulna in Adults Joshua P. Moss, MD*, Donald K. Bynum, MD Department of Orthopaedic Surgery, University of North Carolina, CB 7055, 3157 Bioinformatics Building, Chapel Hill, NC 27599-7055, USA
Diaphyseal fractures involving the radius and ulna, so called ‘‘both-bone’’ or ‘‘double-bone’’ forearm fractures are common orthopedic injuries. These injuries can result in significant loss of function if inadequately treated. As the upper extremity serves to position the hand in space, loss of forearm motion and/or muscle imbalance resulting from a poorly treated fracture can be particularly debilitating. Preservation of the anatomic relationships of the proximal and distal radioulnar joints as well as the interosseous space is critical to preserving function. This article provides an overview of the management of diaphyseal fractures of the radius and ulna in adults. History Historically, both-bone forearm fractures, like nearly every other orthopedic injury, were treated with closed manipulation and casting; however, even the best published results of this technique were far from perfect. Evans [1] reported a series of five patients treated with closed reduction and casting. His technique was reliant upon a tuberosity view radiograph of the proximal radius, which revealed the relative pronation or supination of the proximal fracture fragment (Figs. 1 and 2). Reduction was thus performed to match the forearm rotation. His results still revealed more than 50 degrees of loss of forearm rotation in more than 30% of patients. Early efforts with operative techniques resulted in poor outcomes and disappointing results. Inadequate internal fixation techniques were often
* Corresponding author. E-mail address: [email protected] (J.P. Moss).
cited as the main cause of failure. Knight and Purvis [2] reported a high rate of unsatisfactory outcome with early internal fixation techniques involving onlay grafts, intramedullary Kirschener wires, and inadequate plate fixation (Fig. 3). Before the AO (Association for Osteosynthesis) revolution, many different fixation techniques were used for both bone forearm fractures. Smith and Sage [3] developed an intramedullary nail for the forearm, augmenting their fixation with a long-arm cast for 3 months. Still, they reported a nonunion rate of 6.2%. Sargent and Teipner [4] published a series of 29 both-bone forearm fractures treated with double, orthogonal plates on both the radius and ulna (Fig. 4). Their reported union rate was 100%, however their refracture rate following hardware removal was 29%. In a subsequent study, Teipner and Mast [5] compared double plating to single plating using AO techniques. They concluded that double plating offered no advantages while requiring more surgical time, so they abandoned double plating. In 1964, Burwell and Charnley [6] published a case series demonstrating the use of noncompressing plates in a series of 231 bothbone forearm fractures. Despite excellent functional results, their rate of nonunion was 10%. In the mid 1970s, the concepts of internal fixation promoted by AO/ASIF (Association for the Study of Internal Fixation) began to take hold. It is reasonable to conclude that treatment of diaphyseal fractures of the forearm has benefited more from the advances in modern compression plating techniques than the treatment of any other skeletal injury. Anderson and colleagues [7] published a paper in 1975 touting the benefits of the AO/ASIF technique in treating diaphyseal forearm fractures. They noted roughly 97% union in all fractures, results that have
0749-0712/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved. doi:10.1016/j.hcl.2007.03.002
hand.theclinics.com
144
MOSS & BYNUM
Fig. 1. Technique for shooting the tuberosity view.
been duplicated in multiple publications. Internal fixation with compression plating has since been accepted as the gold standard treatment for diaphyseal both-bone forearm fractures. Patient presentation and initial evaluation Forearm fractures can present as a result of low-energy trauma, such as falls, sporting injuries, and low-velocity gunshot injuries, or high-energy trauma, such as falls from a height, motor vehicle crashes, and high-energy gunshot injuries. Local pain and deformity are the rule, often accompanied by soft-tissue injury corresponding to the energy of the injury. Open fractures are common and can occur even with low-energy injuries given the subcutaneous anatomy of the ulna. Less commonly, patients will present with one or more neurological or vascular deficits. A meticulous history and physical exam are required so that subtle neurovascular deficits are not overlooked during the period of acute presentation. Orthogonal radiographic views of the
Fig. 3. Onlay graft technique used by Knight and Purvis.
forearm, including the elbow and wrist, should be obtained to thoroughly evaluate the location and type of fracture as well as to rule out injuries to the wrist or elbow. Acutely, any open wound should be briefly irrigated with normal saline to decrease gross contamination, and then dressed with a sterile dressing while awaiting definitive treatment. Any gross deformity should prompt a provisional closed reduction, followed by application of a well-padded sugar-tong splint. In the multiply injured patient who may be delayed operative fixation, it is crucial to frequently assess the integrity of the patient’s skin, particularly at the edges of the splint or cast where pressure concentration can quickly lead to skin breakdown and ulceration. Nonoperative management Isolated nondisplaced or minimally displaced (less than 50%) fractures of the ulna can effectively
Fig. 2. Typical contours of the bicipital tuberosity with varying degrees of forearm rotation.
Fig. 4. Double plating technique used by Sargent and Teipner.
DIAPHYSEAL FRACTURES OF THE RADIUS AND ULNA
be treated with immobilization. A long-arm cast or functional fracture brace may be used. Completely nondisplaced fractures of the radius can be treated with 4 to 6 weeks of immobilization in a long-arm cast. However, time to union may be delayed due to the intact ulna preventing coaptation of the radius. There are few indications for closed treatment of both-bone forearm fractures in adults. Only for a critically injured patient or a patient with severe medical comorbidities such that operative risk is prohibitive should closed methods be considered. The literature is clear in concluding that, all things being equal, closed treatment of both-bone forearm fractures leads to higher rates of nonunion, malunion, and crossunion, resulting in a higher rate of poor functional outcomes.
Operative management Fractures involving both bones of the forearm should be treated with anatomic open reduction and rigid internal fixation (ORIF) to restore the forearm axis and allow for early postoperative motion. The purpose of the so-called forearm axis (elbow, forearm, and wrist) is to position the hand in space. To that end, the contributions of elbow and wrist motion are obvious, but many consider the forearm a joint in and of itself. Forearm supination and pronation are important components of the upper extremity’s ability to position the hand. Maintenance of anatomic radial bow and the interosseous space are thus important treatment goals. Dynamic compression plating has been considered the gold standard treatment since the AO/ASIF group released their Manual of Internal Fixation in 1979 [8]. The majority of forearm fractures can be approached with the patient supine and the upper extremity abducted onto a hand table. The volar forearm is easily approached in this position, but approach to the ulna will require elbow flexion. If a dorsal approach is indicated in a supine patient, adducting the arm closer to the body allows more shoulder internal rotation and thus easier access to the dorsal forearm. Prone positioning of the patient allows ready access to the dorsal forearm as well as the subcutaneous border of the ulna. To reduce the incidence of crossunion, the radius and ulna should be approached separately, avoiding exposure of the interosseous space if at all possible. Given the subcutaneous nature of the full length of the ulna, surgical access to that bone is relatively simple. The only neurovascular structure
145
in immediate danger during surgical approach to the ulna is the dorsal branch of the ulnar nerve. This nerve is in play during exposure of the distal third of the ulna. Mok and colleagues [9] found that the ulnar nerve exits the deep volar fascia to course dorsally over the ulna at a mean distance of 2.9 cm proximal to the ulnar styloid. Doyle and Botte [10] describe the nerve’s exit from the deep fascia as 5 cm proximal to the proximal edge of the pisiform. Care should be taken when approaching the distal third of the ulna to dissect and preserve this important cutaneous nerve (Fig. 5). The radius, with its surrounding muscular envelope and closely associated neurovascular structures, is more difficult to approach at all levels, but particularly the proximal third. One of two workhorse approaches to the radius are typically used, either the dorsolateral Thompson or volar Henry approach. The Thompson approach is often considered best applied for exposure of the proximal and middle thirds of the radius. One advantage of this exposure is that it allows better reconstitution of the dorsal and radial bows when treating a long oblique or comminuted midshaft fracture. This is because application of a contoured (pre-bent) compression plate to the tension side of the fracture allows compression across both the volar and dorsal cortices. Proximally, the Thompson approach uses the interval between the extensor carpi radialis brevis and the extensor digitorum communis, exposing the supinator muscle in the proximal third of the forearm (Fig. 6). The posterior interosseous nerve can be identified as it runs perpendicular to the fibers of the supinator approximately three finger breadths distal to the radiocapitellar joint. Care is then taken to supinate the radius, allowing safe elevation of the supinator from its insertion to protect the posterior interosseous nerve. This allows exposure of the proximal and middle thirds of the radius. The proximal exposure, however, is not extensile, as further proximal dissection puts the posterior interosseous nerve at risk as it crosses the neck of the radius directly on bone. The distal third of the Thompson approach is relatively subcutaneous. The inter-nervous interval between the radial outcropper muscles and the brachioradialis is bluntly developed. The superficial radial nerve must be identified and protected as it passes through this interval. The volar Henry approach to the radius is a truly extensile approach. The incision passes from the
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MOSS & BYNUM
Fig. 5. Anatomy of the dorsal cutaneous branch with exposure of the ulna. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 476; with permission.)
lateral bicipital sulcus distally toward the radial styloid. Proximally, this approach exploits the interval between the brachioradialis laterally and the biceps and brachialis tendons medially. The lateral antebrachial cutaneous nerve is identified and protected and the lacertus fibrosus is divided. The recurrent branch of the radial artery courses directly across the field and requires ligation to continue the approach. Once this interval is developed, the radial nerve and its branches are identified. As with the Thompson approach, the radius is then maximally supinated to allow elevation of the supinator from its insertion. This affords protection to the posterior interosseous nerve as it passes deep between the two heads of the supinator. Following elevation of the supinator, the mobile wad is retracted laterally to provide access to the proximal half of the radius. More distally, the radial artery crosses from medial to lateral across the radius, then assuming a course deep to the brachioradialis, adjacent to the superficial radial nerve. The artery should be protected during distal dissection. To access the middle third of the radial shaft, the radial insertion of the pronator teres should be taken down. Pronation of the forearm allows access of the lateral cortex of the middle and
distal radial shaft. For full exposure of the middle and distal volar cortices of the radius, the radial origins of the flexor digitorum superficialis and flexor pollicis longus must be elevated. Finally, the pronator quadratus covers the most distal aspect of
Fig. 6. Surface landmarks for the dorsal approach to the radius. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 473; with permission.)
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the volar radius. This too must be elevated from its radial insertion to allow complete volar bony access (Figs. 7 and 8). Once adequate bony exposure has been obtained, the fractures must be reduced. Given the proximal and distal linkage of the two forearm bones, reduction of one can make reduction of the other quite difficult. It is generally easiest to reduce the less comminuted of the two bones first, thus establishing length and rotation. Alternatively, if
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both bones are significantly comminuted, indirect reduction by traction and manipulation may be performed and then maintained by a fracture distractor or provisional plate application. Once provisional fixation is applied, forearm rotation range of motion should be assessed to confirm anatomic alignment. Intraoperative fluoroscopic spot views can also be of assistance in confirming reduction. For definitive fixation, dynamic compression (DC) or limited contact dynamic compression
Fig. 7. Anatomy of the radial recurrent artery during volar proximal radial exposure. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 439; with permission.)
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Fig. 9. (B–C) Four cortices of fixation on either side of the (A) fracture, as performed by Lindvall and Sagi.
Fig. 8. Pronated view of the radius following volar Henry exposure. (From Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams & Wilkins. p. 469; with permission.)
(LCDC) plates should be used whenever possible. These plates are generally considered to be, in most cases, of sufficient strength to allow functional loading while bony healing progresses. Depending on the comminution and obliquity of the fracture, most diaphyseal forearm fractures should require six to eight cortices of fixation above and below the fracture. However, Lindvall and Sagi [11] obtained a 97% union rate using four cortices of fixation on either side of the fracture with plates of varying lengths. They noted that as the ratio of fracture working length to plate length increases, stability diminishes (Fig. 9).
If possible, an interfragmentary screw should be added, although this is obviously not possible with transverse fractures. Compression should be performed using standard AO compression plate technique. An alternative technique to compression plating is intramedullary nail fixation. Interference nails have long been considered inferior to compression plating because of their relative lack of rotational control and poor ability to maintain length in comminuted fractures. However, the recent development and implementation of locked intramedullary nail systems provides an effective alternative to plating. Weckbach and colleagues [12] obtained 97.5% union in 40 forearm fractures treated with the ForeSight locked IM nail. Gao and colleagues [13] reported 100% union in 32 fractures treated with the ForeSight system (Fig. 10). Indications for intramedullary nail fixation of diaphyseal forearm fractures include poor softtissue integrity, segmental fractures, multiple injuries, and severe osteopenia. Contraindications include active infection, medullary canal smaller than 3 mm, and open physes. This technique can be technically difficult, as the anatomic bow of the radius and the serpentine shape of the ulna can
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Fig. 10. (A) Comminuted both-bone forearm fracture (B) treated with locked intramedullary nail fixation.
require a pre-bend to be applied to the nails before insertion. Also, the closed reduction can be difficult to obtain before nail insertion. Matching the cortical diameters under fluoroscopic guidance is a useful trick to obtain a more accurate reduction. Once definitive fracture fixation is performed, the tourniquet is released and hemostasis obtained. Forearm fascia should never be closed, and the wounds should not be closed under tension. Splitthickness skin grafting or delayed closure is preferable to wound dehiscence or skin flap necrosis following an excessively tensioned closure. Postoperatively, soft tissues should be rested with a bulky forearm-based splint for 5 to 7 days. Active elbow and digit motion should be encouraged during this period. Wrist and forearm motion with light functional loading (ie, dinner fork) should ensue immediately after the initial wound check clinic visit. This level of function should be maintained until radiographic and clinical signs of union have been observed, usually after 12 to 16 weeks. Hardware removal Routine removal of forearm fracture hardware should not be performed. There is a high complication rate associated with the removal of forearm hardware. Complications include refracture and neurovascular injury. Mih and colleagues [14]
reported an 11% refracture rate following removal of forearm hardware from 62 patients out of an overall cohort of 175 patients treated with ORIF for forearm fractures. Refracture occurred at an average of 6 months from plate removal with none occurring after 9 months following surgery. Sixty-seven percent of the patients still had residual symptoms despite hardware removal. They reported a four times higher complication rate in patients having undergone hardware removal compared with those retaining their plates. Dense scarring can place forearm neurovascular structures at risk during any approach for revision or hardware removal (Figs. 11 and 12). Risk factors for fracture following hardware removal include early plate removal (less than 1 year after index procedure), fracture with initial comminution, and plating with 4.5-mm hardware. The use of 4.5-mm hardware has largely been abandoned in treating both-bone forearm fractures. The larger residual hole size following hardware removal places the patient at a higher risk of postoperative refracture. Compression plates of 3.5 mm have been accepted as the gold standard for the treatment of most forearm fractures. Complications Complications of open treatment for bothbone forearm fractures include nonunion,
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Fig. 11. Radial fracture following removal of hardware.
malunion, infection, and neurovascular injury. Nonunion is rare following treatment of closed fractures of the forearm. Multiple publications have reported union rates of 97% to 100% with anatomic compression plating. Open fractures and fractures that are highly comminuted can
have an increased nonunion rate. Many advise primary autologous bone grafting of forearm fractures with greater than 50% comminution, although both Wei and colleagues [15] and Wright and colleagues [16] found no difference in union rates regardless of whether comminuted diaphyseal forearm fractures are grafted. Matthews and colleagues [17] found, in their cadaveric study, that coronal plane deformity of the radius or ulna of 20 degrees or greater resulted in at least a 30% reduction in forearm rotation. Wilson and colleagues [18] reported that angular malalignment and the related loss of forearm rotation were the factors most often associated with the inability to return to the same work following injury. Combined angular malalignment of the radius and ulna of less than 40 degrees limited loss of forearm rotation such that patients usually returned to the same occupation. Malunion is avoidable if an anatomic reduction is maintained with rigid internal fixation. Checking intraoperative forearm range of motion can help prevent a reduction that decreases the interosseous space, reducing motion. Malunion can also affect the articulation of the proximal and/or distal radioulnar joints resulting in pain and eventually arthrosis. Corrective osteotomy may be indicated in the setting of significant loss of motion or proximal/distal radioulnar joint symptoms.
Summary In summary, both-bone forearm fractures are common injuries in adults. They are routinely treated with anatomic open reduction and internal fixation with dynamic compression plating. Intramedullary rod fixation is an emerging technology. Surgical exposure of the radius may be accomplished through either volar or dorsolateral approaches. The ulna may be easily exposed along its subcutaneous border. Restoration of the radial bow and interosseous space is important to maintain forearm rotation. Hardware removal is associated with a high rate of complication, including refracture and neurovascular injury.
References
Fig. 12. Fracture following removal of 4.5 mm hardware.
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[3] Sage FP, Smith H. Medullary fixation of forearm fractures. J Bone Joint Surg Am 1957;39(1):91–8. [4] Sargent JP, Teipner WA. Treatment of forearm shaft fractures by double-plating: a preliminary report. J Bone Joint Surg Am 1965;47(8):1475–90. [5] Teipner WA, Mast JW. Internal fixation of forearm diaphyseal fractures: double plating versus single compression (tension band) platingda comparative study. Orthop Clin North Am 1980;11(3):381–91. [6] Burwell HN, Charnley AD. Treatment of forearm fractures in adults with particular reference to plate fixation. J Bone Joint Surg Br 1964;46:404–25. [7] Anderson LD, Sisk D, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975; 57(3):287–97. [8] Muller ME. Manual of internal fixation: techniques recommended by the AO Group. 2nd (expanded and revised) edition. Berlin: Springer-Verlag; 1979. [9] Mok D, Nikolis A, Harris PG. The cutaneous innervation of the dorsal hand: detailed anatomy with clinical implications. J Hand Surg [Am] 2006;31(4): 565–74. [10] Doyle JR, Botte MJ. Surgical anatomy of the hand and upper extremity. Philadelphia: Lippincott Williams and Wilkins; 2003. [11] Lindvall EM, Sagi HC. Selective screw placement in forearm compression plating: results of 75
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consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture. J Orthop Trauma 2006;20(3):157–62 [discussion: 162–3]. Weckbach A, Blattert TR, Weisser C. Interlocking nailing of forearm fractures. Arch Orthop Trauma Surg 2006;126(5):309–15. Gao H, Luo CF, Zhang CQ, et al. Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients. J Orthop Trauma 2005;19(6): 384–91. Mih AD, Cooney WP, Idler RS, et al. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop Relat Res 1994;299:256–8. Wei SY, Born CT, Abene A, et al. Diaphyseal forearm fractures treated with and without bone graft. J Trauma 1999;46(6):1045–8. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma 1997;11(4):288–94. Matthews LS, Kaufer H, Garver DF, et al. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am 1982;64(1):14–7. Wilson FC, Dirschl DR, Bynum DK. Fractures of the radius and ulna in adults: an analysis of factors affecting outcome. Iowa Orthop J 1997;17:14–9.