Introduction and Management of forearm shaft fractures in Adults.

1. Forearm Diaphysial fractures
of Adults
By. Dr. W.G.P. Kanchana
Registrar Surgery
Teaching Hospital Peradeniya

2. Content
• Introduction
• Epidemiology
• Mechanism
• Classification
• Assessment of the forearm
• Anatomy of forearm
• Management
• Outcomes / Complications

3. Introduction
• The forearm plays an important role in positioning of the hand
in space by flexion and extension of the elbow and wrist as
well as pronation and supination through the proximal and
distal radioulnar joints.

4. Introduction
• Ulnar shaft fractures are defined as those
occurring between the distal aspect of the coronoid proximally
and the ulnar neck distally.
• Radial shaft fractures are defined as those occurring between
the radial neck proximally and the junction of the metaphysis
and diaphysis distally, approximately 3 cm proximal to the distal
articular surface.

5. Epidemiology
• Termed frequent a fracture. (Incidence 10 times less than distal radial
#s.)
• Overall incidence – 1.4 / 10,000.
• Male predominance.
• Half of all forearm shaft fractures occur in males within the ages of 15
and 39 years.
• US high school athletes the incidence of forearm fractures is 4 per
10,000 athlete exposures.
• Motor vehicle accidents account for an important fraction of forearm
shaft fractures.

6. Mechanism
• Majority of forearm shaft fractures occur in young males with good
bone stock.
• Frequently occur in the setting of high-energy trauma such as motor
vehicle accidents or sports injuries.
• Direct
• Defense Injuries / Nightstick fractures (isolated Ulnar # commonly)
• Gunshot Injuries

7. Mechanism
Direct Blow causing
Nightstick Fracture

8. Mechanism
• Indirect
• Bending Force.
• Torsional Forces with axial loading.
Both bone # at the same bone
segment due to a bending
force.

9. Mechanism
Monteggia # - bending forces can result
in Monteggia fracture dislocation,
in which the proximal ulna is fractured
and the proximal radioulnar joints
(PRUJs) dislocate in the direction of the
ulnar deformity.

10. Mechanism
Both bone # at different
levels due to torsional
force with axial loading.

11. Mechanism
Fall with Hyper-pronated
forearm and wrist extension
can cause Both bone #s at
different levels or Galeazzi #

12. Classification
• In most instances forearm shaft fractures are classified according to
location (proximal, middle, and distal third) or fracture comminution.
• Open fractures are classified according to Gustilo’s classification.
• Monteggia and Galeazzi fractures have their own subclassifications.

13. AO/OTA Classification

14. Monteggia #
• Proximal radial dislocation and a fracture of the ulna.
They are classified according to Bado based on
the direction of the apex of the ulnar fracture and
the direction of the proximal radial dislocation.

15. Monteggia #
• Understanding the deformity of the ulna and the direction of
dislocation of the radial head is important for fracture
reduction.
• In most instances, reduction of the ulnar fracture
leads to reduction of the radial head.
• type 1 fractures are considered the most frequent type in children.

16. Monteggia # - Subclassification of Type II
• 2A: Very proximal ulna fracture through the coronoid
• 2B: Fracture at the junction of the proximal metaphysis and
diaphysis of the ulna
• 2C: Diaphyseal ulnar fracture
• 2D: Complex fracture involving the ulna from the olecranon
into the diaphysis

17. Galleazzi #
• Fracture of the radial shaft with dislocation of the distal radioulnar
joint.
• Sub-classified according to the distance of the radial fracture from the
articular surface.
• Type I – # within 7.5cm from distal articulation surface.
• Type II - # > 7.5cm from distal articulation surface.
• Simple – DRUJ reduced after Radial Alignment.
• Complex – DRUJ Irreducible after Radial Alignment.

18. Essex-Lopresti lesion
• An Essex-Lopresti lesion is a proximal radial shaft or radial
head fracture.
• Proximal migration of the radius tears the interosseous membrane
and causes disruption of the DRUJ.

19. Assessment of Patient
• ATLS Approach.
• Assessment of Vascular / Nerve injuries and documentation.
• Radiological Investigations,
• Forearm AP / Lateral – From Elbow to Wrist
• PA view of the forearm is taken with the elbow in 90 degrees of flexion, the
shoulder abducted, and the forearm in neutral rotation.
• Standard lateral radiograph is taken with the elbow flexed to 90 degrees and
the forearm in neutral rotation.

20. Associated Injuries
• One-third of forearm shaft fractures treated surgically occur as isolated
injuries.
• Remaining fractures occur in the presence of at least one additional injury.
• Upper extremity injuries occur in up to 26% of forearm fractures and
include,
• humeral shaft fractures, proximal humerus fractures, elbow dislocation,
wrist injuries, glenoid fractures, and contralateral forearm fractures.
• Distal biceps ruptures have been reported as well as traumatic rotator cuff
tears.
• Radial head fractures may present at the same time as diaphyseal forearm
fractures.

21. Anatomy of forearm

22. Anatomy of forearm

23. Anatomy of forearm - TFCC
• The TFCC serves as the medial continuation of the distal articular
surface of the radius as well as a static stabilizer of the distal
radioulnar joint.
• It consists of an articular disc
• the dorsal radioulnar ligament (DRUL)
• palmar radioulnar ligament (PRUL)
• the meniscus homologue
• the ulnar collateral ligament
• sheath of the

24. Anatomy of forearm - TFCC

25. Anatomy of forearm

26. Anatomy of forearm

27. Anatomy of forearm

28. Anatomy of forearm

29. Anatomy of forearm

30. Anatomy of forearm

31. Management
• Goals of treatment
• Obtain adequate reduction
• Achieve and maintain fracture reduction
while
• Preserving biology
and allowing
• Early range of motion.
• Anatomical Reduction is important to restore the ROM of forearm
functional joint.

32. Non-Operative Treatment
• Mainly limited to isolated fractures affecting the distal two-thirds
of the ulna
• With less than 50% of displacement.
• Less than 10 degrees of angulation.
• >50% of displacement associated with interosseous membrane damage
leading to instability.
• In the largest study on functional bracing of isolated ulnar shaft fractures,
Sarmiento et al. reported 96.5% of good and excellent results and
a healing rate of 99%.

33. Operative Treatment
• Several approaches may be used to fix shaft fractures of the
forearm:
1. Ulna—entire diaphysis: A straight incision is made along the subcutaneous
border. The plate is placed on the posterolateral (extensor) or anterior
(flexor) aspect of the bone.
2. Radius—entire diaphysis: The anterior approach according to Henry is
used. The plate is placed on the anterior(flexor) aspect of the radius.
3. Radius—middle third of the diaphysis: The posterolateral approach is used
with the plate on the posterior (extensor) aspect of the radius.

34. Surgical Approach - Ulnar

35. Surgical Approach - Radius

36. Operative Treatment
• No significant difference in outcome using DCP
vs LCP
• It is mandatory to fix a simple fracture with
interfragmentary compression providing
absolute stability.
• If the fracture pattern is amenable, a lag screw
can be placed first to hold the shaft fragments
together.
• Clinical experience have proven the plate 3.5 to
be the ideal size for forearm bones.

37. Outcomes / Complications
• Pain
• Infection (Superficial / Deep / OM)
• ROM
• Delayed Union
• Non Union
• Patient-specific outcomes measures using questionnaires,
DASH is a standardized questionnaire that assesses upper extremity function based on pain
symptoms and physical, emotional, and social domains. (DASH - Disability of the Arm, Shoulder and
Hand)

38. Thank You!!