The hand plays a critical role in our interaction with the environment and provides us with the ability to interact with objects in space physically. The forearm provides the bony structure and muscular origins that allow the hand to operate in many orientations. The two bones of the forearm function to allow flexion and extension at the elbow as well as at the wrist via diarthrodial joints.
The radius and ulna exist in a delicate anatomical balance that allows for pronation and supination of the hand in a 180-degree arc of motion. The anatomical bow of the radius allows for rotation around a fixed ulna, and its structure is critical for this motion. Any disruption in the anatomy of the forearm can lead to a significant loss of the normal range of motion that allows for motions as complex as a golf swing or as simple as turning the page in a book. The proximal ulna articulates with both the distal humerus, forming the ulnohumeral joint and the proximal radius, forming the proximal radioulnar joint.
Multiple ligamentous structures stabilize the proximal radioulnar joint, and these ligaments are dynamic throughout forearm motion. The stability of this joint is critical to the overall stability of the elbow. Similarly, the distal radioulnar joint integrity is equally as crucial to the stability of the wrist. An interosseous membrane joins the radius and ulnar diaphysis and is susceptible to injury during fractures of the forearm. This article will focus on simultaneous diaphysial fractures of the radius and ulna in the adult, often referred to as ‘both bone’ forearm fractures. Both bone fractures are traditionally seen in the pediatric population but are also common in the skeletally mature individual.
Both bone forearm fractures are the result of high energy trauma in young individuals with age-appropriate bone quality. In adults, the common mechanisms that result in both bone fractures are motor vehicle accidents, athletic injuries, and falls from height. Both bone forearm fractures that result from low energy trauma, such as a fall from standing height, are typically only seen in individuals with impaired bone quality.
Despite the commonality of radius and ulnar shaft fractures, studies that define the epidemiology are scarce. It appears that there is bimodal age distribution with peaks before age 40 and after age 60. Men have similar rates of both bone fractures compared to women early in life. However, women experience a higher proportion of fractures after the age of 60. High school athletes and active individuals have also been shown to be at-risk populations.
The most common cause is trauma, typically from an axial load on an outstretched hand or a direct blow to the forearm. In the elderly, forearm fractures are often the result of poor bone quality secondary to osteoporosis. Less commonly, both bone forearm fractures can be an insufficiency fracture due to cancer or other pathologic bone disorders.
Patients generally present with forearm pain after a high energy mechanism of injury. As with any trauma, the priority is to rule out any life-threatening injuries first. Begin by following the trauma life support protocol, including primary and secondary surveys. Both bone forearm fractures often present with a visible deformity and have significant potential for open fractures. Thus, a thorough examination of the skin surrounding the fracture site should be performed.
Open fractures should be treated with prompt antibiotics, irrigation, and a tetanus booster if needed. The appropriate timing to debridement and closure is a debated topic in the literature. A thorough neurovascular examination of the entire extremity should be performed. The anterior interosseous nerve (AIN), posterior interosseous nerve (PIN), and ulnar nerve distributions should be assessed for motor and sensory deficits. Motor function testing of the AIN can be performed by having the patient perform the ‘a-okay’ sign, the PIN with a ‘thumbs-up,’ and the ulnar nerve with the crossing of the fingers. The radial and ulnar arteries should also be assessed with the use of Doppler if needed. Capillary refill to all digits should be assessed, monitored, and appropriately documented.
While uncommon, concomitant injuries to the distal radioulnar joint should always be assessed by physical examination and radiographic parameters. The volar and dorsal compartments of the forearm must always be assessed in the setting of an acute both bone forearm fracture. An analysis of the national trauma database that included over 300,000 adults indicated that 1.22% of forearm fractures required fasciotomy for suspected or confirmed compartment syndrome. Compartment syndrome can also occur in the setting of open fractures. Multiple studies on acute compartment syndrome of the forearm have demonstrated the presence of compartment syndrome in the setting of an open fracture.
Orthogonal radiographs of the forearm should be obtained during the evaluation of both bone forearm fractures. Standard radiographs should include an AP (anterior-posterior) and lateral views of the forearm. Oblique views of the forearm, as well as imaging of the wrist and elbow, should be considered as needed. CT scan is rarely needed in the setting of both bone forearm fractures but can be useful for complex fractures or if there is a concern for intraarticular involvement.
Non-operative treatment of both bone forearm fractures in the pediatric population is common and typically results in a good to excellent outcome. However, non-operative treatment of adult forearm fractures is very rarely indicated, and the comparison of non-operative to operative treatment in the literature is scarce. Isolated radial shaft fractures usually require surgical fixation to maintain adequate anatomic alignment and rotation.
Isolated minimal or nondisplaced ulnar shaft fractures can be treated nonoperatively with casting or functional bracing and close followup and serial examinations. Because most both bone forearm fractures require surgery, initial reduction and immobilization should be performed with the goal of best preparing the patient for surgery.
For significantly displaced fracture, procedural sedation can be utilized to reduce the fracture and apply a splint properly. Open fractures should be reduced, thoroughly irrigated, and antibiotics started as soon as possible. Standard immobilization is achieved using a sugar-tong splint with the forearm in neutral rotation, and the elbow flexed to 90 degrees. Surgical treatment options include open reduction internal fixation (ORIF) and intramedullary nailing. Shorter intraoperative times and decreased scarring are observed benefits following fixation with intramedullary nailing. However, achieving rotational stability as well as restoration of the radial bow is difficult with the use of intramedullary nailing. ORIF with plate and screw construct is generally accepted as the gold standard for treatment. Comparison of ORIF and intramedullary nailing has been inconclusive.
Some studies suggest that a hybrid fixation method of plate fixation of radius and intramedullary nailing of the ulna is a better approach as it shows good stability, fewer complications, and good clinical outcomes. The type of plate and screw construct is typically dictated by the fracture pattern. For oblique or transverse fractures, compression plating is often utilized to achieve compression at the fracture site and promote primary bone healing. In the setting of long oblique or spiral fracture patterns, interfragmentary screws are utilized to provide compression at the fracture site, and a spanning plate is applied for neutralization.
Finally, bridge plating techniques are utilized for fractures with significant comminution, and when interfragmentary compression is unattainable. The goal of any fixation method is to achieve anatomic length, alignment, and rotation across the fracture site. Bone grafting is often utilized if segmental defects are present. However, its effect with regards to fracture union is debated. Open fractures are classified using the Gustilo-Anderson classification system. Prompt administration of antibiotics is critical in the management of open fractures. Irrigation and debridement at the time of fixation are indicated for all open fractures. The amount of soft tissue damage may dictate the type of fixation method chosen. For example, Gustilo-Anderson IIIB open fractures with large soft tissue defects may require temporary external fixation prior to definitive fixation and skin coverage.
The diagnosis of both bone forearm fractures is relatively straightforward with appropriate imaging. Associated injuries can often be ruled out with imaging of the elbow and wrist, as well as a thorough secondary assessment. Galeazzi and Monteggia fractures should be ruled out with any both bone forearm fracture. A Galeazzi fracture is described as a distal one-third radial shaft fracture with associated injury to the distal radioulnar joint. A Monteggia fracture is described as a fracture of the proximal one-third of the ulnar shaft with associated dislocation of the radial head. These fracture patterns are more often seen in the pediatric population. Treatment of these fracture variants differs from that of both bone forearm fractures.
Treatment planning in both bone forearm fractures depends on many factors. Some of these factors include affected bones, mechanism of the injury, fracture pattern, soft tissue status, demographics, degree of initial displacement, etc. The outcome of treatment also depends on the above factors, as well as the accuracy of the reduction with regard to angulation, length, and rotation of the reduced fractures. The surgical approach for ORIF of both bone forearm fractures is fairly universal. The ulnar shaft fracture is approached through a direct ulnar approach at the interval between the flexor carpi ulnaris and the extensor carpi ulnaris. The plate can be placed either dorsal or volar on the ulnar shaft. Care should be taken not to place the plate directly ulnar to avoid post-operative hardware irritation and prominence. The radial shaft fracture is approached via the standard volar Henry approach. The approach varies based on the level of fracture (distal, middle, and proximal thirds).
Prognosis after both bone forearm fracture is generally very good. Studies have shown very high rates of union in two months following operative fixation. Range of motion exercises of the wrist and elbow are encouraged early following operative fixation, often within one week. Mild decreases in grip strength and range of motion have been observed; however, rates of disability are low.
Acute compartment syndrome is a devastating complication of both bone forearm fractures treated with or without surgery. If compartment syndrome is confirmed or suspected, emergent fasciotomy should be performed. Complications following the surgical intervention of both bone forearm fractures include infection, bleeding, non-union, malunion, cross-union, and neurovascular injury. These are minimized by routine surgical safety measures, including medically optimizing the patient prior to surgery, using standard approaches, and administering antibiotics perioperatively. The use of bone-grafting for significantly comminuted or segmental fractures may decrease the risk of non-union. The risk of radioulnar synostosis has been associated with a single incision approach. Inadequately treatment and/or reduction of both bone forearm fractures can lead to a significant loss of motion and function. Malunion particularly limits the pronation-supination movements. Hardware may become bothersome and necessitate removal. There is an increased risk of refracture after plate and screw removal. Initial characteristics of the fracture, early removal, lack of bracing after hardware removal, and characteristics of the plate all appear to influence the risk of refracture. Disruption of the proximal or distal radioulnar joints, as well as the radiocapitellar joint, should be appropriately evaluated for and treated as there are unique complications with these injuries.
Following fixation of radius and ulna shaft fractures, the patient should be placed into a splint that immobilizes the elbow and forearm on the affected extremity. The fingers and thumb should be left free to encourage range of motion and to prevent stiffness. Typically, the patient can begin range of motion exercises of the elbow and forearm 5 to 7 days post-surgery. The patient should be routinely followed postoperatively until the soft tissues have healed, and bone union has been confirmed radiographically. This usually occurs around 2 to 3 months post-surgery. Once bone union has been confirmed, the patient can resume most activities using the affected limb.
Routine safety precautions in high-velocity situations should be implemented, such as wearing a seatbelt while driving a car. Once the injury is sustained, patients should present to a trauma center promptly for evaluation. Patients who sustain both bone forearm fractures should be educated on the typical clinical course as well as the most common complications. The signs and symptoms of compartment syndrome should be discussed in detail. Often patients will be immobilized in a splint and given follow up for an orthopedic surgery clinic. Splint care instructions should be provided, and the importance of follow up should be stressed. Modifiable risk factors for complications should be addressed at the initial visit, including the cessation of tobacco if applicable. The patient should not be allowed to bear weight on the affected extremity.
Appropriate initial management can make a significant difference in the longterm outcomes for patients who suffer from these fractures. Antibiotics should be administered for open fractures as quickly as possible, and a thorough neurovascular and soft tissue assessment should be completed. If compartment syndrome is suspected, surgical consultation should be made immediately. An urgent closed reduction should then be performed, and medical clearance for surgery should be obtained when indicated. The importance of follow-up should be stressed, and detailed follow-up information should be provided to the patient.
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