ch41

C H A P T E Rz z z z z z z z z z z z z z z z z z z z z z z z z z z41

Diaphyseal Fractures of the ForearmDiaphyseal Fractures of the Forearm

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Jesse B. Jupiter, M.D.James F. Kellam, M.D., F.R.C.S.(C.)

The supporting skeleton and articulations of the upperextremity serve to position its terminal unit, the hand, inspace. In the adult, exacting management of diaphysealfractures of the radius and ulna is necessary to ensureforearm motion. These injuries can even be viewed asintra-articular fractures with the forearm ‘‘joint’’ providingsupination and pronation. Unsatisfactory treatment canlead to loss of motion as well as muscle imbalance anddisability of hand function.44, 85, 124

The inherent difficulties in the management of forearmfractures have long been recognized.8, 35, 62, 106, 134 Withthe exception of Evans,44 most investigators have beenunable to achieve acceptable results in the adult forearmfracture with closed reduction and plaster cast immobili-zation.8, 13 Even in Evans’ series, there was a loss of morethan 50° of forearm rotation in almost 30% of patients.Hughston62 noted an exceptionally high rate of unsatis-factory results in isolated displaced radius (Galeazzi)fractures. Charnley,26 writing in his classic book empha-sizing the nonoperative method of fracture care, recom-mended operative treatment of adult forearm fractures.

Early operative efforts had disappointing outcomes thatwere caused by inadequate methods of internal fixation asmuch as any other factor. Knight and Purvis74 reported ona high rate of nonunion with inadequate plate fixationdespite additional plaster immobilization. Smith andSage133 developed a specific intramedullary nail for theradius and ulna. Their approach required open reductionand an above-elbow cast for 3 months, yet a nonunion rateof almost 7% was observed. Marek83 modified the nailingapproach, developing a square nail and changing theinsertion point in the radius from the styloid to Lister’stubercle. An operative exposure and above-elbow castwere required. Although union was described as 100%, anunsatisfactory functional outcome was observed in 22%.

Perhaps in no other area of the appendicular skeletonhas plate fixation had as dramatic an impact as indiaphyseal fractures of the adult forearm. Burwell andCharnley22 published a landmark paper in 1964 in whichthey reviewed 218 fractures in 150 patients treated with

noncompressing Burns or Sherman plates. Even with thesenow antiquated plates, the authors noted excellent results,provided that the plates were at least 3.5 inches long andhad six or more screws and that fracture comminution didnot exceed 50% of the cortical diameter. Plaster immobi-lization was infrequently used.

The advent of the compression plate originated byDanis in 1947 extended the percentage of predictablefunctional outcome after forearm plating.32 In 1975,Anderson and colleagues3 published their experienceusing the principles of stable fixation put forth by theAssociation for the Study of Internal Fixation (AO/ASIF)and noted union in 97.9% of radius fractures and 96.3% ofulna fractures treated with compression plates. Theirresults have subsequently been duplicated by a number ofother investigators,* thus making compression plating offorearm fractures the standard by which all other treat-ments must be measured.

GOALS OF TREATMENTz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

To ensure maximal functional outcome, the goals oftreatment of forearm fractures should be (1) anatomicreduction of the skeleton, restoring bone length, rotation,and the interosseous space, and (2) secure fixation of theskeleton to enable early soft tissue rehabilitation.

CLASSIFICATION OF DIAPHYSEALFOREARM FRACTURESz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

To be useful, a classification must document a number offactors, including fracture location, fracture pattern, softtissue involvement, and proximal or distal radioulnar joint(DRUJ) involvement.

*See references 53, 56, 59, 77, 87, 98, 105, 114, 115, 120, 145.

1363

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The forearm has been considered by many to be dividedinto thirds for operative considerations (Fig. 41–1). Theproximal third of the radius extends from the radialtuberosity to the beginning of the radial bow. The middlethird includes the radial bow to the point at which thediaphysis begins to straighten. The distal third of theradius extends out to the metaphyseal flare. The ulna, bycontrast, is relatively straight and can be divided intothirds solely on the basis of linear dimensions (see Fig.41–1). Finally, the enveloping and interconnecting softtissues must always be considered in identifying patternsof forearm injury.

To address the need for greater specification in forearmfracture classification, the Comprehensive Classification ofFractures, developed by Muller and colleagues,96 has beenadopted by most investigators (Fig. 41–2). The acceptanceof this system will become increasingly important astrauma centers compare results of treatment protocols.

TREATMENTz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

Nonoperative Indications

In the adult forearm fracture, the primary indication fornonoperative treatment is the isolated ulnar shaft fracturethat has resulted from a direct blow (nightstick fracture)(Fig. 41–3). Even if the fracture is displaced by 25% to50% of the shaft width, the ulna can be stabilizedeffectively with a long arm plaster cast for 8 to 10 weeks orwith a functional fracture brace. The latter has beenreported by Sarmiento and associates121, 122 to maintain

the anatomic position of the bone successfully when acarefully made interosseous mold is used in the brace.

Displacement, particularly shortening, when located inthe distal third of the ulna, can result in deformity of thearticulation of the DRUJ. This possibility must be carefullymonitored for in fractures that are treated nonoperatively.

With nondisplaced radial shaft fractures, nonoperativetreatment may prove successful provided that the anatomicbow of the radius is maintained. The time to healing maybe prolonged because the intact ulna prevents coaptationof the radius fracture.

Operative Treatment

Displaced fractures of the forearm diaphysis are besttreated operatively. This treatment has been most predict-ably accomplished with plate fixation and early functionalrehabilitation. However, despite widespread acceptance ofplate fixation, a number of issues remain in question.These include timing, surgical technique, surgical ap-proaches, fixation techniques, indications for ancillarybone graft, and postoperative management. With theexception of certain isolated ulnar fractures, all displacedfractures of the diaphysis of the radius or ulna (or both) aremanaged by open reduction and internal fixation.

TIMING

Although at one point it was suggested that operativeintervention should be delayed to ensure a higher rate ofunion,133 this is no longer considered necessary. To thecontrary, early operative treatment permits decompres-sion of the fracture hematoma and reduction of the frac-ture fragments, thus minimizing soft tissue trauma.46, 51, 95

Even many open forearm fractures have now been shownto be safely treated by immediate operative treatment (see‘‘Open Fracture’’).25, 36, 64, 90 However, there are somesituations, such as polytrauma or a compromised softtissue envelope, in which surgery is best delayed to alloweither systemic or local conditions to improve.79, 109, 129

SURGICAL TECHNIQUE

Most fractures of the forearm can readily be approachedwith the patient supine and the upper limb abducted ontoa hand table. In this position, however, it is necessary toflex the elbow to gain access to the ulnar shaft. This factorhas encouraged some surgeons to operate with the patientin the prone position. The ulna is approached with theforearm in pronation, and the radius is approached withthe forearm supinated. However, this position may proveuncomfortable with regional block anesthesia and mayincrease the anesthetic risk in a medically compromisedpatient.

The use of a pneumatic tourniquet is advisable in mostcases. The exception is situations in which the soft tissueenvelope is extremely traumatized (see ‘‘Open Fracture’’).Avoidance of tourniquet-induced ischemia aids the sur-geon in assessing the viability of the compromised skeletalmuscle during the surgical approach and debridement.

Proximal third

Proximal/middle

Middle

ULNA RADIUS

Middle/distal

Distal third

FIGURE 41–1. Division of the forearm skeleton into thirds for surgicalclassification.

1364 SECTION IV • Upper Extremity


Full Diagnosis

AA1 Simple fx, ulna, radius intact

.1 oblique

.2 transverse

.3 with dislocation radial head (Monteggia)

A2 Simple fx, radius, ulna intact

.1 oblique

.2 transverse

.3 with dislocation distal radioulnar joint (Galeazzi)

A3 Simple fx, both bones + Q all subgroups

.1 radius, proximal zone

.2 radius, middle zone

.3 radius, distal zone

B

BB1 Wedge fx, ulna, radius intact

.1 intact wedge

.2 fragmented wedge

.3 with dislocation radial head (Monteggia)

B2 Wedge fx, radius, ulna intact

.1 intact wedge

.2 fragmented wedge

.3 with dislocation distal radioulnar joint (Galeazzi)

B3 Wedge fx, one both wedge, other simple or wedge + Q all subgroups

.1 radius, proximal zone simple fx radius .2 radial wedge and simple fx ulna

.3 radial wedge and ulnar wedge

C

CC1 Complex fx, ulna

.1 segmental, radius intact + Q

.2 segmental, radius fractured + Q

.3 irregular + Q

C2 Complex fx, radius

.1 segmental, ulna intact + Q

.2 segmental, ulna fractured + Q

.3 irregular + Q

C3 Complex fx, both bones

.1 segmental

.2 segmental of the one, irregular of the other + Q

.3 irregular

D

FIGURE 41–2. A, Comprehensivefracture (fx) classification types.B, Comprehensive fracture classifica-tion groups and subgroups of simpleextra-articular diaphyseal fractures.C, Comprehensive fracture classifica-tion of groups and subgroups ofwedge-type fracture. D, Comprehen-sive fracture classification of groupsand subgroups of complex forearmdiaphyseal fractures.Illustration continued on following page

1365CHAPTER 41 • Diaphyseal Fractures of the Forearm


When a tourniquet is used, it is best left inflated for 90 to120 minutes at most. The tourniquet should always bereleased before wound closure to ensure control ofbleeding.

SURGICAL APPROACHES

The wide variability of fracture patterns and soft tissuetrauma makes it vital that the surgeon become familiarwith several surgical approaches to the forearm skeleton.27

RadiusTwo general approaches have been advocated for thediaphysis of the radius: the anterior approach as describedby Henry58 and the dorsal approach of Thompson144

(Table 41–1). The anterior approach is extensile, permit-ting ready extension across the elbow or onto the hand;presents a flat surface of the radius distally; and is idealwhen fasciotomies are required. When the proximal radiusis approached anteriorly, however, the surgeon is con-fronted with the major neurovascular structures of theforearm as they fan out anteriorly in front of the elbow.

The dorsal or Thompson approach is advantageous inthat it is essentially subcutaneous for the distal half of itscourse. The proximal radius is readily approached as well,with only the common extensors covering the bone.Furthermore, the plate can be applied along thedorsoradial cortex or ‘‘tension’’ side. The disadvantagesinclude limited access to the anterior surface in the event afasciotomy is required, vulnerability of the posterior inter-

FIGURE 41–3. A, B, Minimally displaced nightstick fracture of the ulna treated effectively witha long arm functional brace. Note the early callus.

Qualifications = Q A3 + B3:1) without dislocation2) with dislocation radial head (Monteggia)3) with dislocation distal radioulnar joint (Galeazzi)

C1.1:1) without dislocation2) with dislocation radial head (Monteggia)

C1.2:1) simple2) wedge C1.3:1) radius intact2) radius simple3) radial wedge C2.1:1) without dislocation2) with dislocation distal radioulnar joint (Galeazzi)

C1.2: 1), 2) idem to C1.2 C2.3:1) ulna intact2) ulna simple3) ulna wedge C3.2:1) bifocal of radius, irregular of ulna2) bifocal of ulna, irregular of radius

General Qualifications: 7) bone loss 8) partial amputation 9) amputation

E

FIGURE 41–2. Continued E, Compre-hensive classification of fracturequalifications.



osseous nerve to injury in the proximal third exposure, andthe fact that it is not truly an extensile approach.

Anterior or Henry Approach. In the anterior ap-proach, the patient is positioned supine with the armabducted and forearm supinated. To approach the proxi-mal radius, an incision is made starting at the lateralbicipital sulcus, extending across the elbow flexion crease,and distal to the middle forearm. The brachioradialismuscle is identified, and the fascia along the medial borderis incised (Fig. 41–4A). The lateral cutaneous nerve of theforearm is protected. The brachioradialis is retractedlaterally, and the biceps and brachialis tendons areidentified and retracted medially. The lacertus fibrosusmust be divided. The radial nerve can be visualized at thisjuncture. The branches of the nerve can be identified, withthe superficial sensory branch tracking over the supinatorand passing distally into the forearm and the posteriorinterosseous nerve entering the supinator muscle (see Fig.41–4B). With the forearm maximally supinated, thesupinator muscle is dissected off the proximal radius whilethe posterior interosseous nerve is protected within thetwo layers of the muscle. With the supinator detached, thebrachioradialis and extensor carpi radialis longus andbrevis can be mobilized radially to identify much of theradial shaft (see Fig. 41–4C).

For more distal extension, the incision is carried

distally 1 fingerbreadth lateral to the edge of the biceps tothe radial styloid. The fascia is split longitudinally alongthe ulnar border of the brachioradialis. This muscle, aswell as the remainder of the mobile wad, can be takenradially. On the undersurface of the brachioradialis can beseen the superficial branch of the radial nerve. The radialartery can also be identified at this point, lying on top ofthe flexor digitorum superficialis and across the pronatorteres. The radius can be pronated, directing the surgeonto complete access to the dorsoradial surface (see Fig.41–4C). If dissection must extend distally to the carpaltunnel, the palmaris longus serves as a landmark in theidentification of the median nerve, which lies betweenit and the flexor carpi radialis. The palmaris longus andthe median nerve can be retracted radially, with thesuperficial and deep flexors taken ulnarly. Doing soreveals the pronator quadratus, which is elevated off theradius from its radial side. Complete access to the ra-dius is gained from the distal articular margin into theforearm.

Closure of the anterior approach is straightforward. Theonly muscles that ordinarily require reattachment are thesupinator proximally and the pronator quadratus distally;the remainder fall into place. The deep fascia is neverclosed. The subcutaneous tissue and skin are closed over asuction drain (Fig. 41–5A to H).

A B C

FIGURE 41–4. Anterior surgical approach to the radius. A, The surgical incision starts at the lateral bicipital sulcus, extends across the elbow flexioncrease, and passes distally along the medial border of the brachioradialis muscle. B, With the forearm maximally supinated, the supinator muscle isdissected off the proximal radius. The posterior interosseous nerve is protected within the two layers of the muscle. C, With the supinator detached,the brachioradialis and radial wrist extensors are readily mobilized to expose much of the radial diaphysis.

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Surgical Approaches to the Radius

Approach Advantages Disadvantages Recommendation

Anterior (Henry) Extensile; allows fasciotomy Proximity of neurovascular structures Proximal third, distal fracturesPosterior (Thompson) Easy; plate on tension side Not extensile Middle third fractures

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FIGURE 41–5. A–H, A 60-year-old woman with a proximal third radius fracture associated with dislocation of the radiocapitellar joint. A andB, The anteroposterior and lateral radiographs of the fracture-dislocation. C, The fracture and elbow were exposed through an anterior surgicalapproach. D, Stable plate fixation with a limited contact dynamic compression plate on the radius. E–H, Excellent functional result.



Dorsolateral or Thompson Approach. The dorsolat-eral approach is best suited to fractures of the proximaland middle thirds of the radius. The patient is positionedsupine with the shoulder abducted and the arm resting ona hand table. The incision extends from the lateralepicondyle of the humerus along the dorsal border of themobile wad of Henry (the extensor carpi radialis brevisand longus and brachioradialis muscles) down to theradial styloid. The length of incision is determined solelyby the fracture. The fascia between the digital extensorsand mobile wad is split. This interval is sometimes moreapparent distally where the outcropping muscles of thethumb cross over the radius. Often a fibrous band can beidentified between the extensor carpi radialis brevis andextensor digitorum communis. This seam is developedproximally in the direction of the lateral epicondyle toexpose the supinator in the proximal third of the forearm(Fig. 41–6A).

At this point, the posterior interosseous nerve haspierced the supinator anteriorly and is running at rightangles to the muscle’s fibers. The nerve can be identified byseparating the fibers of the supinator at a level approxi-mately 3 fingerbreadths distal to the radial head (see Fig.41–6B). The radius is next supinated to identify theinsertion of the supinator muscle, which is elevated offthe radius. The posterior interosseous nerve has entered

the muscle more proximally and is protected as the muscleis elevated. Ready access has now been gained to theproximal and middle thirds of the radius.

To expose the distal third, the surgeon must identify theexact location of the superficial radial nerve as it passesbetween the brachioradialis and digital extensors. Theoutcropping muscles of the thumb cross obliquely over theradius at this level. These are readily elevated to permit aplate to be placed beneath them. The remainder of theradius distally is virtually subcutaneous.

Wound closure with the dorsal approach can beaccomplished through closure of only the subcutaneoustissue and skin over a suction drain.

UlnaThe ulna lies in a subcutaneous position throughout itslength in the forearm. The only structure of significancethat crosses the ulna is the dorsal cutaneous branch of theulnar nerve, which passes onto the dorsal surface of theflexor carpi ulnaris muscle approximately 6 to 8 cmproximal to the ulnar styloid. Consequently, when anincision is made along the distal third of the ulna, caremust be taken to identify and protect this nerve.

To approach the ulnar shaft, an incision is made paralleland just slightly dorsal or volar to its palpable crest. Theextensors are detached from the dorsal crest of the ulna. A

A B

FIGURE 41–6. Dorsolateral approachto the radius. A, The surgical ap-proach extends between the extensorcarpi radialis brevis and the extensordigitorum communis, exposing thesupinator muscle in the proximalthird of the forearm. B, The supinatormuscle is elevated off the radius,providing access to the proximal andmiddle thirds of the radius.



plate can be applied on either the flexor or extensorsurface, depending on the fracture configuration and thepreoperative plan. This incision can be extended proxi-mally to expose the olecranon or distal humerus. The ulnarnerve at this juncture must be identified and protected(Fig. 41–7).

REDUCTION TECHNIQUES

The forearm is a two-bone structure; reduction andfixation of one bone present significant difficulty inobtaining reduction of the other bone. Consequently, it isadvisable to expose both fractures and reduce the lesscomminuted fracture first, holding it provisionally with aplate and two clamps. Doing so establishes length andfacilitates reduction of the second fracture. Provisionalfixation is applied to the second bone, and radiographs areobtained. When exposing an isolated diaphyseal fracture,assessment of the proximal and distal articulations ismandatory.

Alternatively, comminuted fractures can be reduced bythe techniques of indirect reduction, whereby longitudi-nal traction is applied to the bone using either asmall distractor (Fig. 41–8) or the plate itself 84 (Fig.41–9A to H).

The fracture reduction can be controlled in a number ofways. The simplest way is to visualize the interdigitation ofthe fracture line and the contour of the diaphysis.Visualization may not be easy with an extremely commi-nuted fracture. In this instance, after provisional fixation ofboth fractures, supination and pronation of the forearm are

tested. If full forearm rotation has been restored, thereduction should be considered acceptable and a func-tional result can be anticipated. If forearm rotation is notcomplete, the fracture must be reduced again and rotationrechecked. Radiographic control of the reduction ismandatory.

Plate ApplicationThe plate that has gained widespread acceptance is the3.5-mm dynamic compression (DC) plate. In most cases, aplate of adequate length, applied with appropriate tech-nique, is of sufficient strength to support functionalloading while the fracture heals. At least eight corticesabove and below the fracture are usually required, exceptin the case of a pure transverse fracture, which is effectivelyheld with six cortices on each side (Fig. 41–10). In cases ofcomminution, 10- or 12-hole plates are recommended(Fig. 41–11).

The development of indirect reduction techniques (byMast and co-workers84) and a more ‘‘biologic’’ approach toplate fixation of forearm fractures have been enhanced bynewer plate designs, such as the limited contact DC plate.*This plate features a structured undersurface, improvingthe local blood supply under the plate; even stiffness;longitudinal undercut screw holes, allowing 40° of tiltingof screws in the long axis of the plate; uniform spacing ofscrew holes, permitting easy shifting and exchanging ofplates of different lengths; symmetric plate holes, allowingmore versatility in handling complex fracture patterns; anda more trapezoidal shape (Fig. 41–12).

What has become evident is that the blood supply tothe diaphyseal skeleton is very sensitive to the externalcontact of standard compression plates. As part of thestability of plate fixation is derived from friction betweenthe plate and underlying bone, this continued contactresults in areas of necrosis in the cortex under the plate.These observations have led not only to implants with lesssurface contact with the underlying bone but also to newerdesigns in which the screws lock into the plate, thuscreating an internal ‘‘splint.’’ With the development ofthese implants, which have reduced the area of platecontact to small points isolated from each other, it wasrecognized that by fixing the screw heads within the plate,the length of the screws could be reduced to unicorticalfixation (Fig. 41–13A to D). It is quite likely that thestandard plate used in the near future will combine bothlocked screws and bicortical fully threaded standardscrews.118

*Synthes, Ltd., Paoli, PA.FIGURE 41–8. A comminuted fracture of the proximal ulna is reduced bythe technique of indirect reduction using a small distractor.

FIGURE 41–7. The surgical approach tothe ulnar diaphysis is made parallel andjust dorsal or volar to the palpable crestof the shaft.



FIGURE 41–9. A–H, A comminuted distal third forearm fracture caused by an accidental gunshot in a 31-year-old male.A, B, Anteroposterior and lateral radiographs of the comminuted fractures. C, D, A bridge plate was applied on the radius usinga small distractor to reduce the fracture and restore length and small plates applied to the ulna. E–H, Excellent function wasachieved, as the stability permitted early motion.



FIGURE 41–10. A 32-year-old construction worker sustained a transverse fracture of the distal third of both the radius and the ulna of his right(dominant) limb. A, B, Transverse fractures of both the radius and the ulna at the junction of the middle to distal third of the forearm seen inanteroposterior and lateral radiographs. C, D, The fractures were each stabilized with six-hole 3.5-mm dynamic compression plates with an excellentfunctional outcome. E, Schematic of the internal fixation.



Whenever possible, an interfragmentary screw isadded, either through the plate or in conjunction with theimplant (Fig. 41–14). In pure transverse fractures, thisaddition is not possible. In fractures with an obliqueconfiguration, the plate is precontoured to sit slightly(1 mm) off the shaft over the fracture (Fig. 41–15A). Thefracture is reduced, and the plate is applied by placing onescrew in the fragment that has its obliquity facing awayfrom the plate (see Fig. 41–15B). This allows the fragment,with its spike directly under the plate, to be pulled into the

plate and fracture when compression is applied by theinsertion of the load screw in the other fragment (see Fig.41–15C). After this, a screw is placed as an interfragmen-tary lag screw through the plate and across the obliquefracture line (see Fig. 41–15D and E).

Spiral fractures are optimally fixed with the use ofinterfragmentary screw fixation over the length of thespiral. These screws serve as the primary means ofachieving compression of the fracture. A plate is thenapplied as a neutralization plate, spanning the fracture

FIGURE 41–11. Complex ulnar fracture including a large wedge fragment and a moreproximal comminuted olecranon fracture. A, Lateral radiograph. B, C, Anteroposterior andlateral radiographs revealing stable internal fixation of the ulnar diaphysis with a 10-hole3.5-mm dynamic compression plate neutralizing an interfragmentary lag screw, as well asa combination of interfragmentary screw and tension band fixation of the olecranonfracture. D, Schematic of the fixation.



lines. The plate should be long enough to have screws inat least six cortices of cortical bone on either side of thefracture (see Fig. 41–14).

The management of comminuted fractures is moredifficult.31 The first priority is to preserve the soft tissueattachments to the comminuted fragments. The approachto the skeleton should be extraperiosteal except at thefracture site. In the badly comminuted fracture, the sur-geon should avoid attempting to reduce all the fragmentsand instead should use the plate to maintain length andalignment; the plate in this case functions as a bridge plate(see Fig. 41–9). The more extensive the comminution, thegreater the length of plate required to provide stablefracture fixation. The use of a distractor can proveinvaluable in gaining length without extensive stripping ofthe bone fragments84 (Fig. 41–16). Cancellous bone

grafting should be performed at this time. As a rule, if theloss of cortical contact opposite the plate is greater thanone third or if absolute stability cannot be ensured,cancellous bone grafting is indicated.

Segmental fractures can prove problematic.31, 130 Twoplates can be used if one plate is not long enough. Whenapplying two plates to the bone, one should be at a rightangle to the other (Fig. 41–17). The ulna, being a straightbone, is more amenable to intramedullary nailing tostabilize a segmental fracture.

The ulnar plate is most easily applied to the flat medialborder, whereas the location of the plate on the radiusdepends to a large degree on the surgical approach. Forfractures of the proximal and middle thirds, the radialplate is ordinarily applied on the anterior or dorsolateralsurface. The flat anterior surface of the distal radius is thepreferred surface for fractures of the middle or distal third.

INDICATIONS FOR ANCILLARY BONE GRAFT

As a rule, cancellous bone grafting is recommendedwhenever comminution or bone loss has prevented ananatomic reduction of the fracture fragments. The recom-mendation of Anderson and colleagues3 to use bone graftsif more than one third of the diaphyseal cortex is deficienthas become widely accepted. In fact, the use of cancellousgrafts in comminuted fractures has resulted in union ratescomparable to those for closed, noncomminuted frac-tures.25

The anterior iliac crest is an excellent source for graft,although the distal radius or olecranon can provideadequate cancellous graft for most fractures. Great caremust be taken to avoid placing graft across the interosse-ous space, especially with fractures of both forearm boneslocated at the same level, in order to prevent developmentof a synostosis.

FIGURE 41–13. A–D, A complex forearm fracture in a 38-year-old man was treated with point contact plates with unicorticalscrews. A, The initial fracture. B, Immediate postoperative radiographs. Note that no attempt was made to secure fixation of thecomminuted fragment of the radius. C, Radiograph at 6 weeks. D, Radiograph at 4 months. Note the incorporation of thebutterfly fragment.

FIGURE 41–12. The limited contact dynamic compression plate is aversatile plate that is ideally suited for forearm fracture or nonunionfixation. Here it is applied for a proximal ulna nonunion.



FIGURE 41–14. Spiral fracture of the radiustreated with multiple interfragmentary lagscrews and a plate. A, B, Anteroposterior (AP)and lateral radiographs demonstrating a spiralfracture of the radius and a transverse fractureof the ulnar diaphysis. C, D, AP and lateralradiographs revealing multiple interfragmen-tary screws providing compression across thespinal fracture. These screws are protected witha 3.5-mm dynamic compression (DC) plate. Asix-hole DC plate securely stabilizes the trans-verse ulnar diaphysis fracture. E, Schematicdemonstrating interfragmentary lag screwsplaced across the spiral fracture with a neutral-ization plate applied.



In the setting of high-energy trauma or gunshotwounds, bone loss may be significant.29, 40, 54, 64, 79 Eitheracutely or after soft tissues have stabilized, a plate can beapplied to ensure skeletal length and rotation and tomaintain the interosseous space. In 7 to 10 days acancellous graft can be used to span the defect. Rapidincorporation usually ensues, given the well-vascularizedenvironment in the forearm (Fig. 41–18).

WOUND CLOSURE

At the completion of internal fixation, the tourniquet isdeflated and hemostasis ensured. Wounds should never beclosed under undue tension. Rather, it is advisable to leavethe wound open and return to the operating room in 48 to72 hours for either delayed closure or split-thickness skingrafting. In the interim, the wounds are covered with moistsaline dressings.

With extensive soft tissue loss, flap coverage may berequired.36, 64 In our experience, the open forearmfractures are treated with internal rather than externalfixation because this best ensures not only union but alsomaintenance of the functional anatomy.

POSTOPERATIVE MANAGEMENT

Closed, diaphyseal fractures treated with plate fixation areusually supported with a resting forearm plaster splint forthe patient’s comfort. Active digital and elbow motion isencouraged from the onset. Forearm rotation can beinitiated after the patient is comfortable and woundhealing is ensured, usually within 3 to 5 days after surgery.If any question exists regarding the stability of the internalfixation or the patient’s reliability, external functionalbracing should be instituted in a manner such as thatadvocated by Sarmiento and associates121 (see Fig. 41–3Aand B). This bracing provides excellent support of theforearm skeleton through a careful interosseous moldcreated in the splint, yet permits functional use of theextremity.

In general, forearm fractures treated with plate fixationheal within 3 to 4 months. During this period, the patientshould be permitted to use the extremity for activities ofdaily living, avoiding only heavy lifting and sports. Afterradiographic union has occurred, the patient may resumea normal lifestyle. Radiographic findings of callus, resorp-tion at the fracture site, or implant loosening should alertthe treating physician to the possibility of instability of theinternal fixation.

OPEN FRACTUREz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

The enhanced functional results achieved by anatomicskeletal restoration of forearm fractures have extended theapplication of plate fixation to the management of mostopen forearm fractures. Clinical studies by Moed andco-workers90 and Chapman and colleagues25 have docu-mented a low rate of late infection: 1 of 79 fractures in 50patients and 2 of 129 fractures in 87 patients, respectively.The results of these studies and the experience of manyother centers have shown that infection and nonunionafter internal fixation of open forearm fractures areuncommon.*

The management of the open fracture demands metic-ulous attention to detail in regard to both the soft tissueand the skeleton. Cultures are obtained before debride-ment and are followed by broad-spectrum antibiotics and

*See references 22, 29, 35, 36, 39, 53, 58, 64, 78, 79.

A

B

C

D

E

FIGURE 41–15. Schematic representation of the technique of applying adynamic compression plate to an oblique forearm shaft fracture. A, Theplate is precontoured to sit 1 mm off the shaft over the fracture site. Thefracture is reduced, the plate is held with a clamp, and a screw is appliedin a neutral mode in the fragment, which has its obliquity facing awayfrom the plate. The gliding hole for an interfragmentary lag screw throughthe plate can next be drilled with a 3.5-mm drill bit. B, A screw is nextapplied in the load or compression position in the opposite fragment,which will allow this fragment to be pulled into the plate whencompression is applied. C, The interfragmentary lag screw is then placedthrough the plate by drilling the far cortex with a 2.5-mm drill bit,tapping it with a 3.5-mm tap. D, A screw of appropriate length is placed.E, The remainder of the screws are applied through the plate.



FIGURE 41–16. An open comminuted both-bone forearm fracture that occurred in a 27-year-old physician. A, Anteroposterior radiograph demonstratinga comminuted ulnar and radial fracture. B, A minidistractor was applied to the ulnar shaft to distract the major fragments while the smaller fragmentswere teased into place. C, Schematic of the distractor in place. D, The fragments were fixed securely with interfragmentary lag screws, and eight-holeDC plates were applied to both ulnar and radial fractures. E, Schematic of the plates in position.

Illustration continued on following page



appropriate tetanus prophylaxis. A tourniquet is appliedbut not necessarily inflated in those wounds with extensiveskeletal muscle trauma. Mechanical debridement, lavage,and direct debridement of the fracture ends throughextensile exposures form the foundations of wound care.All devascularized tissue, including loose fragments ofbone, should be excised. Anatomic reduction of the

fractures is followed by plate fixation, with placement ofthe plates under viable soft tissue coverage wheneverpossible. The surgically created wounds can be closed,leaving the traumatic wounds open. Antibiotics are usuallycontinued for 2 days postoperatively (Fig. 41–19).

Depending to some degree on the extent of the wound,the nature of the contamination, and the associatedinjuries, a second look is recommended at 48 to 72 hoursafter operation. At that point, definitive wound closure canbe considered. Delayed primary closure or split-thicknessskin grafting can be done in most Gustilo grade 1 or 2wounds. In wounds with extensive soft tissue loss orexposed plates, remote pedicled or microvascular flaps arerequired (see Chapter 15). At the time of definitive woundclosure, cancellous iliac crest graft should be consideredfor fractures with bone loss or comminution opposite theplate.25, 54, 90

For patients with extensive soft tissue loss, extremecontamination, or polytrauma, there may be occasionswhen internal fixation should be delayed.79, 81, 127, 131 Theapplication of external fixation or skeletal traction througha metacarpal pin helps to maintain skeletal length andalignment and soft tissue length until the patient isreturned to the operating room for a repeated wounddebridement. At that point, a judgment can be made toconvert the internal fixation if the wound appears clean(Fig. 41–20). The combination of rigid skeletal fixation,meticulous soft tissue care, early wound closure, andliberal use of cancellous bone grafts not only reduces theincidence of complications with these severe injuries butalso maximizes functional recovery.54, 64, 78, 90

SPECIFIC LESIONSz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

Distal Third

Fractures involving the distal third of the forearm aredifficult to treat. Situated at the junction of the diaphysis

FIGURE 41–17. A segmental open grade III fracture was treated byindirect reduction and two dynamic compression plates with restorationof length and skeletal alignment. Note the interosseous synostosis.

FIGURE 41–16. Continued F, G, Normal function resulted.



and metaphysis, these fractures are unstable and offer alimited zone in which secure fixation can be achieved withplates and screws.

A particularly troublesome fracture is the short obliquefracture of the radius (Fig. 41–21). Often comminuted, itis inherently unstable and not infrequently associated withdisruption of the DRUJ. It is viewed by some as just ametaphyseal fracture, and so external skeletal fixationspanning the fracture into pins in the metacarpals has beenadvocated. With this technique, the fixation must remainat least 8 weeks to offset the likelihood of settling ordisplacement (Fig. 41–22), which is even more likely if thefracture is comminuted. It is our preference to advise openreduction and internal fixation with a plate acting as abuttress plate (Fig. 41–23). The management of associatedDRUJ disruption is identical to that outlined with theGaleazzi fracture.45

Fractures of the ulnar shaft at this level can also lead tofunctional limitations if allowed to shorten or angulate,thereby altering the mechanics of the DRUJ.

Galeazzi Fracture

Isolated fractures of the distal third of the radius can provetroublesome. Commonly referred to as the Galeazzifracture,48 they have also been called the reverse Mon-teggia fracture,147 Piedmont,62 or Darrach-Hughston-Milch123 fracture. Whatever the eponym, the distinguish-

ing feature of the fracture is the associated subluxation ordislocation of the DRUJ.

The Galeazzi fracture is uncommon, with an incidencevarying from 3%153 to 6%48, 92, 121 of all forearm fractures.Although it is commonly thought to result from an axialload on a hyperpronated forearm,88, 119, 128, 136, 148, 153 themechanism has never been reproduced in laboratorymodels.47, 61, 93 It is more common in males,35, 88, 92 andits clinical features include pain and deformity at the DRUJin association with a fracture of the radial shaft, mostoften at the juncture of the middle and distal thirds. TheDRUJ disruption has also been observed to occur withisolated proximal or middle third fractures of the ra-dius.37, 39, 67, 73, 75, 88, 99, 105, 106 Because there may besubstantial soft tissue swelling, the diagnosis must beconfirmed radiographically. The radius fracture commonlyhas a short, oblique pattern, often angulated dorsally onthe lateral view and shortened on the anteroposteriorradiograph (Fig. 41–24).

The following radiographic findings suggest traumaticdisruption of the DRUJ in the presence of an isolatedfracture of the radial diaphysis2, 21, 92:

1. Fracture of the ulnar styloid at its base2. Widening of the DRUJ space as seen on the anteropos-

terior radiograph3. Dislocation of the radius relative to the ulna seen on a

true lateral radiograph4. Shortening of the radius beyond 5 mm relative to the

distal ulna

FIGURE 41–18. A 28-year-old man sustained a high-energy injury to his right forearm with extensive skeletal and soft tissue loss. After extensivedebridement, the ulna was stabilized with a six-hole dynamic compression plate. A groin flap was elevated and inset to cover the soft tissue defect.Ten days later, the radius was brought to length with a distractor, and a strut plate was applied; the defect was filled with cancellous iliac crest graft.Anteroposterior (A) and lateral (B) radiographs 4 weeks after operation demonstrate early incorporation of the cancellous graft. C, Schematicillustration of the internal fixation.



FIGURE 41–19. A 60-year-old laborer had his right (dominant) arm crushed in a press. A, Radiograph revealing segmental fractures of the radius andulna, both of which were open. B, Extensive debridement and forearm decompression were achieved through an anterior approach. Anteroposterior(C) and lateral (D) radiographs reveal segmental plating of the fractures. Excellent function resulted.



TREATMENT

It is generally recognized that a Galeazzi fracture is besttreated operatively. Campbell noted this in 1941, termingthe Galeazzi fracture ‘‘a fracture of necessity.’’140 Thedifficulties with nonoperative treatment were subsequentlyconfirmed in 1957 by Hughston,62 who identified unsat-isfactory results in 35 (92%) of 38 cases treated by closedreduction and plaster immobilization. He identified severaldeforming forces that are not adequately controlled byplaster. These include the muscle pull of the brachioradi-alis, pronator quadratus, and thumb extensors and theweight of the hand. Although his criteria for a satisfactoryresult were strict (comprising union, anatomic alignment,no loss of length, no subluxation of the DRUJ, and nolimitation of forearm rotation), succeeding clinical studieshave supported his observations.75, 88, 92, 126, 153

The distal third of the radius is readily approachedthrough the anterior (Henry) exposure. Stable internalfixation is most reliably achieved through compressionplate fixation with a minimum of five and preferably sixscrews. Medullary nails or smaller plates may not controlthe deforming forces and have been associated withdelayed union and nonunion.35, 37, 139

After the anatomic reduction has been secured and the

plate has been provisionally applied with two screws,radiographs are obtained in both the anteroposterior andtrue lateral planes to control the DRUJ. If reduction hasbeen achieved, stability is tested clinically with rotation ofthe forearm (Fig. 41–25). If the reduction is stablethroughout full forearm rotation, there is no need forpostoperative immobilization and early functional rehabil-itation.

If reduction of the DRUJ can be achieved but provesunstable with forearm rotation, two options are available.In cases in which there is an associated fracture of the ulnastyloid at its base, open reduction and fixation of thestyloid with Kirschner wires or a small screw caneffectively stabilize the DRUJ in some cases88 (Fig. 41–26).If the reduction is stable clinically, the forearm should beimmobilized in supination by an above-elbow cast bracefor 4 to 6 weeks to allow soft tissue healing. If no styloidfracture is present, the distal ulna can be transfixed to theradius with one or two 0.062-inch Kirschner wires left for4 weeks. The forearm should also be immobilized insupination by an above-elbow cast brace during this time(Fig. 41–27).

In the unlikely event that the DRUJ cannot be reduced,a soft tissue block should be suspected.12, 24 The DRUJ canbe approached through a dorsal incision and the source ofthe block identified and removed. In most reported cases,the extensor carpi ulnaris tendon has been the cause of theirreducible DRUJ (see Fig. 41–19B). Instability of theDRUJ may also result from failure to recognize the injury,in part because of inadequate radiographs taken postop-eratively or intraoperatively.

COMPLICATIONS

Complications of the Galeazzi fracture are not uncommon;Moore and co-workers92 reported a 39% incidence in 36patients. The complications include nonunion, malunion,infection, instability of the DRUJ, refracture after plateremoval, and nerve injury associated with the operativetreatment. Nonunion or malunion is most commonlyreported in association with the use of plaster casts andinadequate internal fixation.92, 123, 139

The radial nerve is the nerve most frequently injured. InMoore’s series, six dorsal sensory nerves and one posteriorinterosseous nerve were injured.92 Of the six dorsalsensory nerve injuries, three occurred with an anteriorapproach and three with a dorsal approach. In four of sixcases, the nerve was not identified at the time of surgery.

Monteggia Lesion

Fracture of the proximal ulna with a dislocation of theradial head bears the eponym of Monteggia, who firstdescribed this association in Milan in 1814.91 Bado6, 7

coined the term Monteggia lesion to encompass a number oftraumatic lesions having in common disruption of theradiohumeroulnar joint in conjunction with a fracture ofthe ulna at any level.

Although much has been published regarding thevarious presentations, treatment options, and complica-tions, the Monteggia lesion remains a relatively uncommon

FIGURE 41–20. A heavily contaminated open forearm fracture thatoccurred in a horse stable and was treated with extensive debridementand temporary skeletal traction with a pin placed through the second andthird metacarpals.



FIGURE 41–21. A short oblique fracture of the distal radius in a 56-year-old man. The fracture was initially treated with a cast. However, a follow-upradiograph (A) revealed an unsatisfactory alignment. Anteroposterior (B) and lateral (C) radiographs 1 year after plate fixation with a 4.5-mm dynamiccompression plate. Full function resulted.

FIGURE 41–22. A comminuted frac-ture of the distal radius and ulna in a50-year-old woman. A, The fracturewas initially treated with skeletal fixa-tion with the pins placed in theproximal radius and metacarpals. B,The ulnar fracture was stabilized witha five-hole dynamic compressionplate, but the radius was maintainedin the external fixator. Settling oc-curred at the fracture site with disrup-tion of distal radioulnar joint function.



injury, its incidence varying between 1% and 2% of allforearm fractures.20, 22, 23, 105, 106, 123 Problems arise inunderstanding of these lesions in part because fewsurgeons have a wide experience. The literature can also bemisleading because a number of series combine adult andpediatric injuries.

It has become acceptable to categorize Monteggiafractures in terms of the direction of the dislocation of thehead of the radius: anterior, posterior, or lateral. The ulnarfracture has characteristically been located at the junctionof the proximal and middle thirds, although it is notunusual for it to occur proximal or distal to this. The apexof angulation of the ulnar fracture is in the same direc-tion as the displacement of the radial head (Fig. 41–28).Bado6 expanded the categories to include a fourth group:anterior dislocation of the radial head with a fracture ofboth the ulna and the radius at the proximal third of theforearm.

The type I anterior lesion was long thought to be theresult of a direct blow to the posterior aspect of theforearm, which fractures the ulna and forces the radialhead anteriorly.132, 135 However, Evans43 was able to createthis lesion in cadavers with a hyperpronation force on theforearm with the humerus held fixed in a vise. Hepostulated that this injury was instead the result of a fall on

the outstretched hand with the forearm fixed in maximalpronation. Rotation of the torso on this fixed, pronatedforearm results in fracture of the ulna; the radius is forcedinto hyperpronation and is levered anteriorly by theforearm of the fractured ulna.

The anterior dislocation (Bado type I) has beenconsidered the most common type, constituting as muchas 60% to 80% of all Monteggia lesions in someseries15, 135 (see Fig. 41–28A). The posterior and lateraldislocations have been considered to be less common.However, because these series tend to combine both adultand pediatric injuries, the published incidences may notapply universally in adult trauma centers.110

In series of Penrose101 and of Pavel and associates,100

the posterior presentation proved more common than hadbeen previously recognized (see Fig. 41–28B). The inves-tigators identified three distinct components of this injury:(1) a comminuted fracture of the proximal ulna near thecoronoid, frequently including a triangular or quadrangu-lar fragment; (2) posterior dislocation of the proximalradius; and (3) a triangular chip fracture of the anterioraspect of the radial head, resulting from a shearing injuryagainst the capitellum (Fig. 41–29A and B). Penrose101

believed that this lesion more closely resembled a variationof a posterior dislocation of the elbow, except that in this

FIGURE 41–23. A 32-year-old womanwith multiple injuries had this shortoblique radius fracture treated in asplint for 6 weeks. A, Anteroposte-rior radiograph demonstrating a shortoblique distal radius fracture withshortening and disruption of the distalradioulnar joint. B, At surgery, theextensor carpi ulnaris was found inter-posed between the ulnar head and thedistal radius. C and D, The fracturewas taken down, and the bone frag-ments were lengthened and securedwith a 4.5-mm T plate. Residualdisruption of the distal radioulnarjoint remained, limiting the forearmrotation to 30% of normal.



case the ligamentous attachments of the elbow provestronger than the ulnar shaft. To prove this theory, heplaced cadaver humeri on a rigid support with the elbowat 60° of flexion and the forearm in moderate pronation. Adirect blow was given across the wrist, resulting inposterior dislocation of the elbow. When the upperanterior surface of the ulna was notched, a similar forceconsistently produced the posterior Monteggia lesion he

observed clinically. Unlike the anterior Monteggia lesion,which occurs frequently in the pediatric age group, thislesion is more likely to be seen in a middle-aged adult andtypically results from a fall on the outstretched hand withthe elbow flexed approximately 60° and the forearmpronated about 30°. At the Massachusetts General Hospi-tal from 1981 to 1988, 20 adult Monteggia fractures weretreated surgically; 14 were this posterior variant.69

FIGURE 41–24. A 20-year-old laborer fell 20 feet from a scaffolding, sustaining an openGaleazzi fracture. Anteroposterior (A) and lateral (B) radiographs reveal a grossdisruption of the distal radioulnar joint and a short oblique fracture of the radius at thejunction of the middle and distal thirds. C, D, After wound debridement, the radiuswas stabilized with a six-hole 3.5-mm dynamic compression plate with one screw usedthrough the plate as an interfragmentary lag screw across the oblique fracture. Thedistal radioulnar joint proved stable when the radius was reduced.



The third type of Monteggia fracture, that with a lateraldisplacement of the radius, has been identified in bothpediatric and adult patients. It has been attributed to aprimary adduction force103 or a force of both angulationand rotation.97 This lesion has been associated with radialnerve trauma.136 The clinical presentation with all Mon-teggia lesions is a painful elbow that resists attempts at

elbow flexion, extension, or forearm rotation. The neu-rovascular status must be evaluated; associated posteriorinterosseous, anterior interosseous, and ulnar nerve lesionshave all been reported.42, 63, 69, 80, 128, 138

The Monteggia lesion may be misdiagnosed on theinitial examination.111 Whereas the ulnar fracture isreadily apparent, the radial dislocation can be overlooked.Several factors account for this.52 The injury is uncommonand therefore is not always suspected. With associated softtissue swelling or deformity about the elbow, the positionof the radial head can be difficult to assess. In addition, theradial head may have been reduced when the ulna fracturewas splinted. The radiographs may not be adequate if theyare centered on the ulna fracture and miss the elbow.

In the presence of an isolated forearm diaphysealfracture, the clinician must always anticipate the possibil-ity of injury to the other bone. A line drawn through theradial shaft and head should touch the capitellum in anyposition of flexion or extension of the elbow if the radialhead is correctly located.86

Closed treatment remains standard for most pediatricfractures. In the adult displaced Monteggia lesion, opera-tive reduction and stable fixation are mandatory. The ulnarfracture must be anatomically reduced and securelystabilized in order to ensure accurate repositioning of theradial head. In most instances, this is best accomplishedwith a plate, although excellent results have sometimesbeen observed with intramedullary rods.

After operative fixation has been achieved, the surgeonmust ensure the stability of the radial head by fully flexingand extending the elbow and rotating the forearm,preferably under image intensification. Instability of theradial head or incomplete reduction usually suggests amalreduction of the ulnar fracture,123 especially with aposterior lesion. A comminuted metaphyseal ulnar frac-ture, unless rigidly secured, tends to flex at the fracturesite, levering the radial head posteriorly. In these fractures,a plate applied on the dorsal surface of the ulna betterensures an anatomic reduction and functions mechanicallyas a tension band (Fig. 41–30).

FIGURE 41–26. A Galeazzi fracture associated with continued instabilityof the distal radioulnar joint despite anatomic reduction and internalfixation of the radius. When fixation of the large styloid fragment wasachieved, the joint proved stable.

OPEN REDUCTION, STABLE FIXATION OF THE RADIUS

Reduce DRUJ

Reduced and stable Reduced but unstable Irreducible

Open DRUJ(look for

soft tissueinterposition)

Protective splintEarly motion

Largeulnar styloid

fragment

Noulnar styloid

fragment

ORIF ulnar styloidImmobilize in supination

4–6 weeks

Pin ulna to radiusImmobilize in supination

4–6 weeks

FIGURE 41–25. Treatment algorithm for Galeazzi fractures. Abbreviations: DRUJ, distal radioulnar joint; ORIF, open reduction and internal fixation.



If the radial head cannot be relocated despite ananatomic reduction of the ulna (<10% of cases), theincision should be extended as a Boyd-Thompson ap-proach, reflecting the anconeus, extensor carpi ulnaris,and supinator muscles from the ulna and exposing theradiocapitellar joint.16 Soft tissue interposition is likely tobe the source of the inability to reduce the radial head; itcan involve the joint capsule, the annular ligament, or, insome instances, the posterior interosseous nerve.

Boyd and Boals15 described a procedure to stabilize theradial head by reconstructing a new annular ligamentusing a strip of forearm fascia elevated from distal toproximal. Our experience and that of others106 has beenthat this is rarely, if ever, necessary and is fraught with thepossibility of residual scarring and loss of forearm rotation.

In a radial head fracture, the fracture fragment may alsoserve to block reduction or elbow motion. A large, singlefragment is best fixed internally, whereas a smallerfragment should be excised. A comminuted radial headrepresents one of the indications for a radial headarthroplasty.112

Complications of Monteggia lesions are many and canbe disabling.89 They include loss of motion, malunion,nonunion, and nerve palsy, which most often involves theposterior interosseous nerve. The prognosis is good, withrecovery beginning within 6 to 8 weeks after injury.63 If

there is no evidence of nerve function by that time,exploration is advisable. Tardy radial nerve palsy has beenreported with long-standing radial head dislocation andhas responded well to nerve exploration and radial headexcision.4, 80

Malunion can follow failure to diagnose the radial headdislocation, inadequate reduction of the ulnar fracture, orunstable internal fixation. When it is recognized, consid-eration can be given to osteotomy of the ulna and platefixation. In long-standing deformities, radial head resec-tion may be necessary.

Nonunion of the ulnar fracture almost always reflectsinadequate skeletal fixation. In the absence of infection,union is readily achieved with a plate applied on the dorsal(tension) surface and, in some instances, supplemented byan iliac crest bone graft (Fig. 41–31).

COMPLICATIONSz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

Plate Removal and Refracture

Concerns regarding stress protection of the bone under aplate, stress concentration at the end of the plate, and thepatient’s discomfort have led many to recommend removal

FIGURE 41–27. A, Despite stable fixation of the radius fracture, the distal ulna remained unstable even with the forearm supinated. B, Therefore, the ulnawas stabilized to the distal radius with two Kirschner wires for 4 weeks.



of forearm plates. The actual incidence of a fractureoccurring beyond a plate is unknown, but it does pose aproblem to the athlete involved in contact sports.

Plate removal, however, is not without complications.11

The frequency of refracture after forearm plate removal hasbeen reported to be less than 4% in some series25, 35, 76

and as high as 25% in others.34, 55 The basis for this widevariation of incidence is better understood when thenumber of factors that contribute to refracture is analyzed.Premature plate removal (<1 year after injury), delayedunion or nonunion, and inadequate technique wereidentified by Deluca and colleagues34 and by Hidaka andGustilo60 as causes of refracture.

Bone loss under a plate was long thought to be inducedby a mechanical unloading of the bone (stress protection)

by the implant. It has now been demonstrated by Perrenand co-workers102 that the initial porosis observed undera plate is the result of local circulatory disturbance andnecrosis followed by bone remodeling. According to theseobservations, plate removal should be considered onlyafter the remodeling is complete and the cortex under theplate has returned to a near-normal condition. Rosson andassociates116, 117 have suggested that remodeling under aplate requires 18 to 21 months after application.

Given these observations, it has become our policy notto recommend routine removal of the plates. If plates are tobe removed, there should be radiographic evidence ofcortical remodeling under the plate, which often requires2 years from the time of plating. For the high-demandathlete, if a decision is reached to remove the plate, it

A

C

B

D

FIGURE 41–28. The classification of Monteggia lesions by Bado. A, Type I: Anterior angulation of the ulnar fracture and anterior dislocation ofthe radial head. B, Type II: Posterior angulation of the ulnar fracture and posterior dislocation of the radial head. C, Type III: Fracture of theproximal ulna metaphysis and lateral dislocation of the radial head. D, Type IV: Anterior dislocation of the radial head and fracture of the radialand ulnar shafts.



should be done only after cortical bone remodeling isevident radiographically. After plate removal, the forearmshould be protected with a functional forearm brace for6 weeks, and return to activity should occur 3 to 4 monthsafter plate removal.113

If pain is the reason for plate removal, the surgeon mustidentify whether the pain is at the site of the originalfracture. Should this be the case, adequate imaging,including radiographs and tomographs, should be ob-tained to define the status of fracture healing.

Synostosis

Cross union between the forearm bones, first describedby Gross in 1864,55 has subsequently been identifiedin conjunction with almost every form of forearmtrauma.14, 119, 149, 150 Although it is more common withfractures of the middle and proximal thirds, the distalforearm is not entirely spared this troublesome complica-tion (Fig. 41–32).

The true incidence of cross union secondary to forearmfractures is difficult to determine accurately because not allreported series address this issue. Vince and Miller149

reviewed 2381 reported forearm fractures in the literatureand identified a combined incidence of approximately 2%.

The incidence may be higher with Monteggia fractures,particularly those involving both forearm bones along withdislocations of the radial head.17, 145

A number of etiologic factors have been implicatedin the formation of cross unions, but the most likelycauses include high-energy trauma with open frac-tures,5, 19, 82, 104 infection,23 multiple trauma with headinjuries,49, 149 and delayed (i.e., by several weeks) internalfixation.10, 41, 134, 149 Less common factors are nonana-tomic reduction with narrowing of the interosseous space,onlay bone grafting, and the use of screws that are too longand cross the interosseous membrane.14, 28, 74

Although there have been no studies specificallyidentifying measures to prevent synostosis, it wouldappear that both open and closed fractures that are treatedearly with stable internal fixation and mobilized in theearly postoperative period have little risk of developingcross union.53, 57, 59

The loss of forearm rotation caused by post-traumaticradioulnar synostosis substantially impairs the function ofthe entire upper limb. In the past, unpredictable resultsafter operative excision led to recommendations to useinterposed materials after excision of the synostosis. Thematerial recommended included muscle, silicone rubbersheets, and fat grafts.125 Experience with low-dose radia-tion to prevent heterotopic ossification after reconstructivesurgical procedures about the hip has led to similar

FIGURE 41–29. A, Schematic of a posterior Monteggia lesion. The featuresof this fracture-dislocation include (1) comminuted fracture of the proximalulna near the coronoid, (2) posterior dislocation of the proximal radius,and (3) triangular chip fracture of the radial head resulting from shearingagainst the capitellum. B, Lateral radiograph of a posterior Monteggia lesionin a 36-year-old man.



applications after synostosis resection in the forearm withfavorable results.1, 30

Although excision of the synostosis in the distal ormiddle forearm has been well accepted, in the past therewas pessimism about the operative approach in theproximal third of the forearm. One of us (JBJ) reported onfavorable results of resection of proximal radioulnarsynostosis in 18 limbs of 17 consecutive patients.71 Theresection was performed on average 19 months afterinjury, although eight patients had their surgery less than12 months after injury. It has become evident thatsuccessful treatment can be achieved as early as 6 monthsafter injury combined with adjuvant postexcision radia-tion. In this group of 17 patients, recurrence was noted inonly 1 patient who had an associated closed headinjury. The average forearm rotation in the other 17 limbswas 139°. No neurovascular problems were noted(Fig. 41–33).

Neurovascular Injury

Most major vascular injuries associated with forearmfracture involve a single arterial laceration and do notthreaten the viability of the hand. Some studies havesuggested that repair of the damaged vessel in thissituation may not be worthwhile because thrombosis mayresult from backflow from the patent artery.66, 68

Median, ulnar, and radial nerve palsies have beenreported in association with forearm fractures.63, 94, 138

One of the most common nerve injuries is a posteriorinterosseous nerve palsy in association with a Monteggiafracture-dislocation.63, 136, 138 Nerve palsy associated withforearm fracture usually represents a neurapraxic injurycaused by nerve contusion or traction and remits sponta-neously. Rarely, a nerve becomes trapped in the fracturesite or is even transected by a sharp fracture fragment.94 Ingeneral, early nerve exploration in the management of a

FIGURE 41–30. A 44-year-old man had a posterior Monteggia lesion treated with a plate applied to the lateral surface of the ulna. Incomplete reductionof the radial head was noted. A, Lateral radiograph showing inadequate skeletal fixation with the plate. Note the persistent posterior subluxation of thefractured radial head. B, The fracture displaced with the inadequate fixation. Anteroposterior (C) and lateral (D) radiographs 5 months after revisionsurgery including placement of a 12-hole 3.5-mm dynamic compression plate on the tension side and radial head resection.



fracture-associated nerve deficit is not indicated unlessthere is a change in the neurologic examination afterreduction, there is an associated vascular injury or openwound, or the fracture is irreducible.128 Most forearmfractures are treated operatively, and a nerve explorationcan usually be performed without considerable additionalsurgical trauma.

Most neural injuries, even those associated withhigh-velocity bullet wounds, recover spontaneously.40, 68,

78, 128, 131 Nerve exploration can be carried out during theinitial irrigation and debridement. Even with early explo-ration, however, the extent of nerve damage can bedifficult to determine. In the case of complete nervetransection, the nerve ends can be sutured to adjacent softtissue to prevent retraction. Delayed repair is performedafter the wound is cleaned and adequately debrided.

Complex combined neurovascular injury is but one ofthe adverse sequelae of severe mangling upper extremity

trauma. The approach to vascular injuries is modifiedsomewhat by the presence of an associated nerve lesionbecause there is some evidence to suggest that recovery ofnerve function is improved by optimization of bloodflow.68, 79 Hand viability may be maintained even if bothradial and ulnar arteries have been damaged because, inaddition to the dual major arterial supply to the forearm,there are a number of longitudinally oriented collateralvessels in the upper extremity.66 If both major arteries aredamaged in the presence of associated nerve injury, it isrecommended that both be repaired, regardless of theapparent vascular status of the hand, in order to optimizenerve recovery. If one major supplier remains intact andprovides adequate perfusion to the entire hand (asdetermined by a timed Allen test), the damaged arteryneed not be repaired.

Vascular repair should follow fracture stabilization iffeasible (often by temporary means such as external

FIGURE 41–31. A–F, A 67-year-old schoolteacher with a nonunion of the ulna after operative treatment for a posterior Monteggia variant. A, B, Tworadiographic views of the unstable nonunion. C, Following plate removal and debridement of the synovial nonunion, a malleable template is appliedfor guidance in contouring the plate.



fixation) in order to provide protection of the repaired ves-sel. After revascularization, compartment pressures shouldbe checked and fasciotomies performed as indicated.50

In many cases, patients with severe mangling upperextremity injury may best be served by early amputation.However, upper extremity prosthetics provide a poorsubstitute for upper extremity function, and most reason-able attempts at limb salvage are worthwhile.68, 79 Inaddition to the judgment of the treating surgeon (based onhistory, examination, radiologic studies, and operativeexploration), consideration of the mangled extremity scoreis useful in determining the appropriateness of primaryamputation.

Operative treatment of forearm fractures exposes thepatient to the risk of iatrogenic nerve injury. A neurapraxicsuperficial radial nerve palsy can occur because this nerve

is retracted laterally along with the brachioradialis whenthe proximal radius is approached. Rarely, the nerve, andsometimes the nearby radial artery, is damaged during theapproach. This damage can be avoided by routinelyvisualizing and protecting these structures. Central to boththe anterior (Henry) and dorsal (Thompson) approaches tothe radius is protection of the posterior interosseous nerve.This nerve enters through the supinator muscle; unless itis protected by maximal supination of the forearm duringsubperiosteal elevation of the supinator muscle (with thevolar approach) or direct visualization during the dorsalapproach, it is at risk of being damaged.

Treatment of chronic regional pain syndrome (reflexsympathetic dystrophy) has focused on early, aggressivetherapy and interruption of the abnormal sympatheticactivity by direct block or systemic pharmacologic means.

FIGURE 41–32. A–D, A distal third post-traumatic radio-ulnar synostosis after open reduction and internalfixation of an unstable ulnar fracture. A, The synostosisis easily visualized. B, Radiograph after plate removaland excision of the synostosis. C, D, Excellent forearmrotation.



Nerve blocks, such as a stellate ganglion block forsympathetic maintained pain of the upper extremity, canprovide excellent short-term relief, allowing aggressivetherapy and possibly facilitating recovery. Pharmacologictherapy (with alpha-adrenergic blockers such as phenoxy-benzamine) can be effective but is associated withundesirable side effects.

Yet, experience has demonstrated that if the sympa-thetic maintained pain is associated with a definable nervelesion, an operative approach consisting of a combinationof repair, reconstruction or lysis (or both) of the involvednerve, and rotation of a local muscle flap intended toenhance the blood supply to the area of injury andminimize scarring can be efficacious.65

FIGURE 41–33. A–G, Post-traumatic proximal radioulnar synostosis following complex forearm fracture. A, Anteroposterior radiograph demonstrates theextensive synostosis extending from the radial neck to beyond the radial tuberosity. B, C, Radiographs after resection of the incongruous radial head andproximal radioulnar synostosis. D–G, Excellent function.



Infection

At one time there was concern regarding the risk ofintroducing infection in conjunction with operative treat-ment of a forearm fracture. However, with currentoperative techniques and implants (including periopera-tive antibiotic prophylaxis), infection after operative treat-ment of closed fractures is uncommon.3, 25, 87 Further-more, reports have cited an acceptably low rate of infectionin open forearm fractures treated by immediate plate-and-screw fixation (0% to 3%).25, 36, 64, 78, 90 Adequate de-bridement and copious irrigation are requisite with thisapproach and should be repeated frequently until a clean,

healthy soft tissue bed is achieved. Surgical wounds areclosed primarily and traumatic wounds by delayedprimary closure after adequate wound definition by serialdebridement (Fig. 41–34).

If infection occurs, its eradication does not necessarilydepend on implant removal. As long as bone fragmentsand soft tissues are well vascularized, stable internalfixation facilitates wound care and helps maintain length,alignment, range of motion, and overall function withouthindering treatment of the infection. After successfuleradication of the infection (with organism-specific antibi-otics and local wound care), the wound can be irrigatedand closed.

FIGURE 41–34. A–F, An infected, loose plate and screws on an ulnarfracture in a 26-year-old man. A, B, Radiographs of the infected, looseplate. C, D, Following debridement, an external fixator was used. E, Acancellous graft was applied. F, Excellent union and full function at 3months.



Infection and Bone Defect

On occasion, sequential debridement of an uninfectedforearm fracture results in a bone defect. When the defect isassociated with a poorly vascularized, contracted, andunstable soft tissue envelope, the bone reconstruction canprove more complicated. Operative approaches basedupon nonvascularized autogenous or allogeneic bone graft-ing may not be applicable because their use is dependentupon the surrounding soft tissue to revascularize thetransplanted bone graft.72 Prior infection is also a threat.137

We have found, however, in certain situations in whichthe overlying soft tissue envelope is well vascularized thatsubstantial defects up to 6 cm can be reconstructed usingthe technique described by Weber and Brunner151 of the‘‘wave plate’’ and autogenous iliac crest cancellous auto-graft. The wave plate is constructed using a standard platethat is contoured to sit off the bone just proximal and distalto the site of the defect (Fig. 41–35). Use of a smalldistractor helps to minimize additional soft tissue dissec-tion and devascularization. This plate concept is consistentwith the overall emphasis on biologic internal fixation. Thecontour of the wave plate serves not only to optimize thevascularity of the underlying bone but also to distributethe cyclic forces across a broader one on the plate,reducing the risk of plate failure.108 The space created bythe contour also permits greater access of the autogenousgraft to revascularization from the surrounding soft tissue.

Another alternative in the reconstruction of compositeskeletal and soft tissue defects after radical debridementsfor infected fractures is that of the vascularized fibular grafttaken either with overlying muscle alone or as a compositeosteoseptocutaneous autograft.72, 152 This approach en-ables, in a single operative procedure, the reconstruction ofa diaphyseal segment of bone with similar dimensions ofthe radius or ulna along with a vascularized soft tissueenvelope (Fig. 41–36). Jupiter and co-workers reported onnine patients treated for composite defects with an averagelength of fibular transplant of 7.9 cm and average size ofassociated fasciocutaneous component 11.8 by 5.9 cm. Atan average follow-up of 24 months, all but one of thepatients had radiographic evidence of bone union at bothjunctions. No patient had symptoms referable to the donorleg, and six returned to their preinjury occupation.

The distraction-histogenesis method developed byIlizarov provides an alternative for the reconstruction ofcomposite skeletal and soft tissue defects; however, thisapproach is complex, lengthy, and associated with numer-ous complications.143 This technique can be used torealign and lengthen soft tissue contracture before autog-enous bone grafting (Fig. 41–37).

Nonunion

In the past, closed treatment of both-bone forearmfractures in adults was associated with a substantial rate ofnonunion.13, 18 Nonunion was associated with poor re-ductions in which minimal apposition of the fracturefragments was obtained and held. Therefore, open reduc-tion with or without internal fixation has been advocatedfor inadequate or unstable reductions.

Early attempts at internal fixation (including sutures,wires, screws, small plates, and intramedullary wires orpins) provided minimal fracture stabilization, and pro-longed cast immobilization was required.74 All of thedisadvantages of operative treatment, including additionalsoft tissue trauma, devascularization of fracture fragments,and the risks of infection and iatrogenic neurovascularinjury, were added to the problems of prolonged immobi-lization. Among forearm fractures undergoing operativetreatment (i.e., fractures irreducible by closed means), therate of nonunion remained high, and functional outcomeswere dismal.33, 74

In 1957, Smith and Sage133 published the disappoint-ing results of early attempts at intramedullary fixation offorearm fractures with a variety of pins and nails. Use ofKirschner wires, associated soft tissue injury, and delayedtreatment were all associated with an increased risk ofnonunion. Caden23 recorded similarly poor results withRush pin fixation.

After studying cadaver radii, Sage119 introduced a nailwith proximal and distal angulations and a triangular crosssection in an attempt to improve restoration of radial bowand rotational stability. Complications included nail pro-trusion, splitting of the cortex, rupture of the extensorpollicis longus tendon, synostosis, and radial nerve palsy;11.1% of fractures failed to unite within 6 months, inmany cases because of technical errors and complications.Marek83 reported 100% union with the use of a squarenail; however, he defined union clinically, had a very shortfollow-up in many cases, and described many fractures asrequiring well over 6 months to heal. Despite continuedinterest in intramedullary nailing and the periodic intro-duction of new nail designs, it remains a technicallydemanding procedure, prone to difficulties and complica-tions.57

Improvements in plate-and-screw fixation have al-most eliminated nonunion in forearm fractures. Initialimprovements were noted with the use of larger platessuch as the Eggers slotted plates.9, 38 In 1964, Burwelland Charnley22 noted that nonunion was far less com-mon when plates 3.5 inches in length were used. Withthe addition of interfragmentary compression by theAO/ASIF group,96 the only problem fractures remain-ing were those with substantial bone loss or com-minution.3, 25, 29, 35, 53, 98, 120, 142 Primary bone grafting ofsuch fractures has further reduced the risk of non-union.3, 25 Also of note, Chapman and colleagues25 foundthat the use of 3.5-mm DC plates did not increase therate of nonunion over that seen with traditional 4.5-mmplates.

The current rate of nonunion is less than 2% when theproper technique is utilized in compliant patients.25

Nonunions are ascribed to technical errors such as the useof plates of inadequate size (e.g., semitubular plates) orlength, inadequate reduction, and failure to use bonegrafting for comminuted and open fractures.70, 77, 139

One of us (JBJ) reviewed an experience of 44 consecu-tive nonunions of diaphyseal forearm fractures treated overa 15-year period. Twenty-four involved the radius alone,11 the ulna, and 9 both bones. The average age of thepatients was 38 years. Thirty-four fractures were the resultof high-energy trauma, with 24 associated with open



FIGURE 41–35. A–F, A 47-year-old man had an open forearm fracture that became infected and required extensive bone grafting and realignment.A, The radiograph at 4 weeks after debridement and external fixation. B, The patient was referred at 10 weeks after injury with loss of length.C, Intraoperative distraction allowed realignment and control over adequate plate length for a wave plate. D, The wave plate applied with a cancellousbone graft bridging the gap. E and F, Radiographs at 4 months reveal complete incorporation of the cancellous graft. Excellent forearm rotation wasgained.



wounds. The main complaint of the patients was severefunctional disability. Twenty patients had associated infec-tion. All nonunions healed after operative treatmentscomprising stable internal fixation and autogenous cancel-lous bone grafting in all but two hypertrophic nonunions.Forearm rotation averaged 60 to 70° of supination and 60to 70° of pronation. All patients noted improved function(Fig. 41–38).

Malunion

With the success of modern plate-and-screw fixation offorearm fractures, malunion has proved to be one of themost important determinants of functional outcome.107

Historically, a good reduction was regarded as one inwhich apposition of the fracture fragments of both boneswithout visually obvious deformity had been achieved.

FIGURE 41–36. A–G, A complex infected nonunion of the radius in a 37-year-old man. A, The clinical appearance of the wound.B, Debridement led to a 7-cm defect of the radius. C, A vascularized fibula with overlying skin was harvested. D, E, Radiographs of the graftin place. F, G, Excellent function with little donor site morbidity.



Substantial angulation and rotation of fragments werecommonplace. Limitation of supination and pronationresulted from impingement between the malunited radiusand ulna, rotational malunion, cross union, and narrowingand contracture of the interosseous membrane in additionto the stiffness resulting from prolonged immobilization146

(Fig. 41–39).The problem of rotational malunion was emphasized

by Evans,44 who noted that inadequate or unstablerotational reduction was a source of severe limitationof supination or pronation, or both. In severe angu-lar malunion, especially when the apices of angularmalunion are convergent, radioulnar impingement mayoccur. Subsequent studies of the effect of angular de-formity on pronation and supination in cadaver fore-arms (performed by advocates of closed treatment) dem-onstrated progressive loss of forearm rotation with in-creasing angular deformity.85, 141 The authors concludedthat limitation of rotational movement is acceptable(<20%) in closed reductions with 10° or less of com-bined deformity of the radius and ulna; this representsessentially a near-perfect reduction and is very difficult toachieve.

The importance of restoring the normal anatomic radialbow was emphasized by advocates of closed treatment andintramedullary nailing of forearm fractures.119 Schemitschand Richards,124 reporting on the effect of malunion afterplate-and-screw fixation, demonstrated an important rela-tion between restoration of the normal magnitude andlocation of the maximal radial bow and functionaloutcome (Fig. 41–40).

The effects of prolonged immobilization on limitationof forearm motion were minimized in their study by theuse of modern plate fixation in all patients and earlypostoperative mobilization in most. Accounting for theeffects of associated soft tissue injury, ipsilateral fracture, orcomplications in forearm rotation, they demonstrated thatfailure to restore the location and magnitude of the radialbow to within 4% to 5% of that of the normal arm wasassociated with a greater than 20% loss of forearmrotation. Grip strength was also reduced with malunitedfractures. They suggested that attention to restoration ofthe radial bow (including comparison with the uninjuredforearm in difficult cases) and appropriate contouring ofthe plate should help to maximize functional outcomes(Fig. 41–41).

FIGURE 41–37. A–D, A complex reconstructive problem in a 32-year-old woman involving bone loss, severe deformity, and disruption of the distalradioulnar joint after fracture and infection as a child. A, The severe deformity is apparent on the anteroposterior radiograph. B, Ilizarov techniqueswere used to gain length and alignment. The distal ulnar was resected. C, D, A wave plate and autogenous bone graft were successful in achievingreconstruction of the radius.



FIGURE 41–38. A–H, A painful nonunion in a 75-year-old active woman who had two prior surgical attempts at fracture union. A, B, Anteroposterior andlateral radiographs of the ununited radius and ulna. Note the severe disruption of the distal radioulnar joint. C, D, Union of the radius was achieved withtwo orthogonally placed 2.7-mm condylar plates. The distal ulna was used as the source of an autogenous bone graft. E–H, Excellent function resulted.



FIGURE 41–39. A–H, A malunited Galeazzi fracture 4 months after injury in a 29-year-old woman. A, The anteroposteriorradiograph of the skeletal deformity. Note the disrupted distal radioulnar joint. B, The original fracture line wasre-created with an osteotome. C, D, A distractor was used to regain length and a limited contact dynamic compressionplate applied. The proximal distractor pin is still present (intraoperative radiograph). E–H, Full function was restored.



ASSESSMENT OF OUTCOMEz z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

Normal function and skeletal union are the goals oftreatment of adult forearm fractures. Therefore, anyassessment of outcome must address these criteria as wellas associated complications. The assessment criteria ofAnderson and colleagues3 continue to provide a reliablemeans of identifying outcome and allow a more accuratecomparison of the results of different studies (Table 41–2).

In their series of 330 acute fractures in 244 patients,Anderson and colleagues3 recorded 85% satisfactory orexcellent results. Union rates were 97.9% within anaverage of 7.4 weeks for radial fractures and 96.3% within7.3 weeks for ulnar fractures. Infection occurred in 2.9%of cases and nonunion in 2.9%. In this series, 4.5-mm DCplates were used for the most part.

In a later series using the same grading system,Chapman and colleagues25 evaluated 129 diaphyseal

FIGURE 41–41. A–G, A complex malunion of the radius in a 62-year-old man with Paget’s disease following several fractures. A, The presenting lateralradiograph of the severe deformity. B, The clinical appearance. C, A bone model was made from computed tomographic scans and used for preoperativeplanning. D, The deformity was corrected through a single oblique cut. E, A contoured plate is applied. F, G, Radiographs of the corrected deformity.

a

xy

Maximum radial bow = a (mm)

Location of maximum radial bow = x/y � 100

FIGURE 41–40. The technique of Schemitsch and Richards for measuringthe amount and location of the maximal radial bow. The amount isdetermined by drawing a line from the bicipital tuberosity to the mostulnar aspect of the radius at the wrist. A perpendicular line is drawn fromthis line to the radius at the point of maximal radial bow, and the distanceis measured in millimeters. The location of the maximal radial bow isdetermined by dividing the distance from the bicipital tuberosity to thepoint of maximal bow by the length of the entire line. The value isexpressed as a percentage.



forearm fractures. They used primarily 3.5-mm DC plates;union was recorded in 98% of fractures, and 92% ofpatients achieved a satisfactory or excellent result. Infec-tion was found in 2.3% of cases.

In other reports on the higher rates of complicationsassociated with plate fixation of forearm fractures,34, 139

the authors emphasized that the source of most complica-tions is lack of attention to detail, errors in judgment, orerrors in technique.

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TABLE 41–2z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z

Outcome Evaluation Scale

Rating Outcome

Excellent Union with <10° loss of elbow or wrist flexionor extension and <25% loss of forearmrotation

Satisfactory Union with <20° loss of elbow or wrist flexionor extension and <50% loss of forearmrotation

Unsatisfactory Union with >30° loss of elbow or wrist flexionor extension and >50% loss of forearmrotation

Failure Malunion, nonunion, or unresolved chronicosteomyelitis

z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z z zSource: Anderson, L.D., et al. J Bone Joint Surg Am 57:287, 1975.



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