9 Fractures of the Radius and Ulna 137 9 Fractures of the Radius and Ulna M. Tile (1957), reporting 92% unsatisfactory functional 9.1 results in the treatment of 41 isolated, displaced Introduction radial shaft fractures (Galeazzi type). Therefore, even Charnley (1961), in his classic treatise Closed Treat- Fractures of the forearm present unique manage- ment of Common Fractures, strongly recommended ment problems. In these particular diaphyseal frac- operative treatment of forearm fractures. tures, perhaps more than any others, the combination of anatomical reduction and skeletal stability with mobility of the extremity is necessary to produce excellent functional results. Of all diaphysial frac- 9.2.2 tures, only the forearm requires anatomical reduc- Open Treatment tion and stable internal fixation, in order to main- tain full function of the hand. The ASIF system of Early attempts at enhancing the functional results stable internal fixation is admirably suited to this by open reduction and internal fixation did little to end; therefore, it is not surprising that the use of this improve the situation, but they represented pioneer- system in diaphyseal fractures of the radius and ulna ing efforts. Unstable fixation with inadequate and has revolutionized their management and improved poorly applied plates required long-term plaster the end results. immobilization, again compromising the final results. Despite the necessary cast immobilization, which resulted in some stiffness of the injured extremity, the nonunion rate remained significantly high. This was particularly evident in the report of Knight and 9.2 Purvis (1949). Natural History Smith and Sage (1957) attempted to change this outlook by the development of specialized intramed- ullary devices, with improved results, but their non- 9.2.1 union rate was unacceptably high. Intramedullary Closed Treatment devices cannot restore the most important rotatory stability to the injured forearm. Also, they tend to For many years, surgeons have grappled with the dif- straighten the normal dorsoradial bow of the radius ficulty of restoring early function to the fractured and are therefore not well suited to the radius; how- forearm. Early authors recommended closed reduc- ever, locked intramedullary nails have been devel- tion followed by lengthy plaster immobilization, but oped (De Pedro et al. 1992). the deficiencies of this method were soon recognized. Malunion and nonunion were frequent complications with resultant poor functional results. Böhler (1936) recognized that to maintain skel- 9.2.3 etal length, continuous traction was often required. AO/ASIF Techniques He recommended Kirschner wires inserted above and below the fracture and held by a plaster cast to Major improvements in the results of this injury achieve this goal; however, the results were not sig- awaited the development of advanced techniques. nificantly improved. Perhaps the most severe indict- Danis (1947) is generally credited with initiat- ment of the closed method was made by Hughston ing the era of compression plates. The introduc- 9.2 Natural History SCHA_09-Schatzker.indd 137 16.04.2005 17:38:49 Uhr 138 M. Tile tion of AO implants and the strict adherence to or distal radioulnar joint and will reestablish length AO principles have changed the outlook dramati- to the muscles controlling that most beautiful tactile cally. Stable internal fixation using these proven instrument of the body, the hand; and (b) restora- techniques has eliminated most external casts and tion of rotational alignment is essential for normal splints; this, in turn, has led to markedly improved pronation–supination function of the forearm. The functional results for the patient, depending on the restoration of the normal dorsoradial bow of the degree of soft tissue injury. Malunion should be radius is essential to maintain this rotatory func- eliminated with use of the proper technique and tion – again, difficult to achieve with intramedullary nonunion should almost disappear, further enhanc- devices. Therefore, intramedullary devices are not ing the results. Most recent surveys have indicated suited for the treatment of forearm fractures, espe- a nonunion rate of less than 5%. Even if nonunion cially the radius. If locked intramedullary devices are does develop, the final result should not be com- used in the ulna, it is essential that ulnar length and promised, since these patients, free of all external rotation are anatomical. casts and splints, can maintain full function of the The principle of anatomical reduction in forearm extremity during this period. fractures must be upheld in this era of biological Lack of recognition of the important biological reduction. While it is important to maintain bone and biomechanical principles of modern techniques viability by improved techniques, in the forearm it is of internal fixation is the most common cause of fail- more important to achieve anatomical reduction. ure. In our first 60 consecutive cases in which this Anatomical reduction and stable internal fixation method was used prior to obtaining the sophisti- with plates will reduce pain and allow early soft tissue cated skills later possessed, we achieved 90% excel- rehabilitation, without the use of external splints or lent functional results (Tile and Petrie 1969). All our casts. Rapid restoration of both hand and forearm failures were technical, as were those of Anderson et function is assured by the use of plates, either as a al. (1975), who achieved union rates of 97.9% for the tension band, axially compressing the fracture, or radius and 96.3% for the ulna, with excellent func- as a neutralization plate with prior interfragmental tional results. These results and those of others are compression. a far cry from those reported only a decade earlier, In summary, the forearm fracture, whether of one when the usual scenario for the fractured forearm was or both bones, more than any other diaphyseal frac- an open reduction with imperfect fixation, requiring ture in the body, requires open anatomical reduction the use of a plaster cast for a minimum of 8–12 weeks. with stable fixation, preferably with plates, for opti- Even then, a nonunion rate for one or the other bone mal functional results. of 20% or more was expected. More recent reports have continued to show excellent functional results with anatomical reduc- 9.3.2 tion, stable fixation with plates, and early motion Indications for Surgery (Chapman et al. 1989; Schemitsch and Richards 1992; Duncan et al. 1992). As stressed in other chapters in this book, the indi- cations for surgery in this type of fracture depend on knowledge of the natural history of the fracture combined with an assessment of its personality. The natural history of the forearm fracture, under almost 9.3 all circumstances, is so uncertain when treated by Management means other than anatomical open reduction, stable fixation with plates, and early motion of the extrem- ity that this treatment alone can be recommended in 9.3.1 almost all of the cases described below. Principles 9.3.2.1 To achieve excellent results, anatomical reduction Fractures of Both Bones and stable fixation are required. The forearm frac- ture requires anatomical reduction for the following For reasons previously discussed, displaced fractures reasons: (a) restoration of normal radial and ulnar of both radius and ulna should be treated by open length will prevent subluxation of either the proximal reduction, stable internal fixation, and early motion. 9.2 Natural History SCHA_09-Schatzker.indd 138 16.04.2005 17:38:50 Uhr 9 Fractures of the Radius and Ulna 139 9.3.2.2 Isolated Fracture of the Ulna Fracture of One Bone The management of this fracture, usually caused by a Fractures of the Shaft of the Radius or the Ulna direct blow and not associated with a proximal radial with Radioulnar Subluxation head dislocation, has been a subject of controversy. Even (Galeazzi or Monteggia Fractures) with minimal displacement and prolonged immobiliza- tion in a plaster cast, union may be delayed (Fig. 9.1). Displaced single-bone fractures of the radius or Proximal ulnar fractures are the most dangerous, as ulna, if treated nonoperatively, have a notoriously they are subjected to a greater torque and may bow. poor outcome. Displacement at the fracture site is Therefore, to obviate these problems, surgery may be always accompanied by displacement at the cor- indicated for this seemingly innocuous fracture. responding radioulnar joint, whether proximal or Reports by Sarmiento et al. (1975) Goel et al. (1991), distal. Reduction must be absolutely anatomical or Gebuhr et al. (1992), and others dispute this, indicating subluxation of that radioulnar joint will remain, universally good functional results with a simple below- with significant functional loss. Therefore, the elbow splint. We feel that most of these fractures, if rela- displaced fracture of the radial shaft with distal tively undisplaced, may be treated with casts or splints radioulnar subluxation (Galeazzi fracture; see with the expectation of a good result (Fig. 9.2). However, Fig. 9.11b–e) and the displaced fracture of the in certain instances, open reduction and internal fixation ulnar shaft with proximal radioulnar subluxation may be preferable to prolonged splinting for the patient. (Monteggia fracture) constitute absolute indica- In these cases, the patient should share in the decision- tions for surgery. making process, after being informed of the advantages and disadvantages of each method (Fig. 9.3). ab c Fig. 9.1a–c. Isolated fracture of the ulna – nonoperative management. a Anteroposterior and lateral radiographs of an isolated fracture of the ulna caused by a direct blow. No injury to the elbow or wrist is apparent. b,c After 24 weeks of immobilization in plaster, the radiograph shows nonunion requiring internal fi xation 9.3 Management SCHA_09-Schatzker.indd 139 16.04.2005 17:38:51 Uhr 140 M. Tile abcd Fig. 9.2. a,b Anteroposterior and lateral radiographs of a 45-year-old man with an isolated undisplaced fracture of the ulna.