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7/29/2019 Fracturas diafisarias de cúbito y radio en adultos
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Diaphyseal Fractures of the Radius and Ulna in Adults
Joshua P. Moss, MD*, Donald K. Bynum, MDDepartment 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 ana-
tomic relationships of the proximal and distal
radioulnar joints as well as the interosseous space
is critical to preserving function. This article pro-
vides an overview of the management of diaphy-
seal 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 tuberos-
ity 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 fore-
arm 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. In-
adequate internal fixation techniques were often
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 theradius 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 both-
bone forearm fractures. Despite excellent func-
tional 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 com-
pression plating techniques than the treatment of
any other skeletal injury. Anderson and col-
leagues [7] published a paper in 1975 touting the
benefits of the AO/ASIF technique in treating di-
aphyseal forearm fractures. They noted roughly97% union in all fractures, results that have
* Corresponding author.E-mail address: [email protected] (J.P. Moss).
0749-0712/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.hcl.2007.03.002 hand.theclinics.com
Hand Clin 23 (2007) 143–151
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been duplicated in multiple publications. Internal
fixation with compression plating has since been
accepted as the gold standard treatment for diaph-
yseal 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 accompa-
nied 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 arenot overlooked during the period of acute pre-
sentation. Orthogonal radiographic views of the
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 todecrease gross contamination, and then dressed
with a sterile dressing while awaiting definitive
treatment. Any gross deformity should prompt
a provisional closed reduction, followed by appli-
cation 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. 1. Technique for shooting the tuberosity view.
Fig. 2. Typical contours of the bicipital tuberosity with
varying degrees of forearm rotation.
Fig. 3. Onlay graft technique used by Knight and
Purvis.
Fig. 4. Double plating technique used by Sargent and
Teipner.
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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 theradius. There are few indications for closed treat-
ment of both-bone forearm fractures in adults.
Only for a critically injured patient or a patient
with severe medical comorbidities such that oper-
ative 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. Forearmsupination and pronation are important compo-
nents 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 volarforearm 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 fulllength of the ulna, surgical access to that bone is
relatively simple. The only neurovascular structure
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 distanceof 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 enve-
lope and closely associated neurovascular struc-
tures, is more difficult to approach at all levels, but
particularly the proximal third. One of two work-horse 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 volarand 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 iden-
tified 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 eleva-
tion of the supinator from its insertion to protectthe 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 inter-
val between the radial outcropper muscles and the
brachioradialis is bluntly developed. The superfi-
cial radial nerve must be identified and protected
as it passes through this interval.Thevolar Henry approach to theradius is a truly
extensile approach. The incision passes from the
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lateral bicipital sulcus distally toward the radialstyloid. 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 de-
veloped, the radial nerve and its branches are
identified. As with the Thompson approach, the
radius is then maximally supinated to allow eleva-tion 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 teresshould 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 middleand 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. 5. Anatomy of the dorsal cutaneous branch with exposure of the ulna. (From Doyle JR, Botte MJ. Surgical anat-
omy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 476; with permission.)
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 insertionto allow complete volar bony access
(Figs. 7 and 8).
Once adequate bony exposure has been ob-
tained, the fractures must be reduced. Given the
proximal and distal linkage of the two forearmbones, 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
both bones are significantly comminuted, indirect
reduction by traction and manipulation may be
performed and then maintained by a fracture dis-
tractor or provisional plate application. Once pro-
visional fixation is applied, forearm rotation range
of motion should be assessed to confirm anatomicalignment. 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. Sur-
gical anatomy of the hand and upper extremity. Philadelphia; Lippincott Williams and Wilkins. p. 439; with permission.)
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(LCDC) plates should be used whenever possible.
These plates are generally considered to be, in
most cases, of sufficient strength to allow func-
tional 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 frac-
ture with plates of varying lengths. They notedthat as the ratio of fracture working length to
plate length increases, stability diminishes (Fig. 9).
If possible, an interfragmentary screw shouldbe 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 de-
velopment and implementation of locked intra-medullary 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 frac-
tures treated with the ForeSight system (Fig. 10).
Indications for intramedullary nail fixation of
diaphyseal forearm fractures include poor soft-
tissue integrity, segmental fractures, multiple in-
juries, and severe osteopenia. Contraindications
include active infection, medullary canal smaller
than 3 mm, and open physes. This technique canbe technically difficult, as the anatomic bow of the
radius and the serpentine shape of the ulna can
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.)
Fig. 9. (B – C ) Four cortices of fixation on either side of
the (A) fracture, as performed by Lindvall and Sagi.
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require a pre-bend to be applied to the nails before
insertion. Also, the closed reduction can be diffi-
cult 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. Split-
thickness skin grafting or delayed closure is prefer-
able 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 encour-
aged during this period. Wrist and forearm motionwith 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 compli-
cation rate associated with the removal of forearmhardware. Complications include refracture and
neurovascular injury. Mih and colleagues [14]
reported an 11% refracture rate following re-
moval 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 sur-
gery. 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 re-
moval 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 1year 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.
ComplicationsComplications of open treatment for both-
bone forearm fractures include nonunion,
Fig. 10. (A) Comminuted both-bone forearm fracture (B) treated with locked intramedullary nail fixation.
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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 fracturesand 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 diaphy-seal 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 rota-
tion were the factors most often associated with
the inability to return to the same work following
injury. Combined angular malalignment of the ra-
dius and ulna of less than 40 degrees limited lossof forearm rotation such that patients usually re-
turned to the same occupation. Malunion is
avoidable if an anatomic reduction is maintained
with rigid internal fixation. Checking intraopera-
tive forearm range of motion can help prevent a re-
duction that decreases the interosseous space,
reducing motion. Malunion can also affect the ar-
ticulation of the proximal and/or distal radioulnar
joints resulting in pain and eventually arthrosis.
Corrective osteotomy may be indicated in the set-
ting of significant loss of motion or proximal/dis-
tal 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. Intra-
medullary rod fixation is an emerging technology.
Surgical exposure of the radius may be accom-
plished through either volar or dorsolateral ap-
proaches. 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
[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.
Fig. 11. Radial fracture following removal of hardware.
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
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