Radius and Ulna Fracture Treatment Options

Radius, extraarticular, avulsion of
bicipital tuberosity
1. Nonoperative
• Main indications
• Patients who tolerate 40% loss of
supination strength. Nondisplaced
fractures.
• Note: Nonoperative treatment is generally
only indicated if functional forearm
rotation can be demonstrated with or
without anesthetic injection.
• Contraindication
• Fragment of bone restricting forearm
rotation
• Infirm or dependent person
• Polytrauma
• Advantages
• Avoid the risks of surgery.
• Disadvantages
• Weaker supination
2. Biceps reinsertion
• Displaced fracture and desire for optimal
supination strength
• Contraindications
• Infirm or inactive patient
• Poor soft-tissue condition
• Advantages
• Stronger supination
• Disadvantages
• Risk of radial nerve injury
• Risk of radioulnar synostosis

Radius, extraarticular, simple
1. Nonoperative
• Non- or minimally displaced stable fracture
• Note: Nonoperative treatment is generally
only indicated if functional forearm rotation
can be demonstrated with or without
anesthetic injection.
• Part of a more complex injury with elbow or
forearm instability
• Polytrauma
• Advantages
• Avoid operative risks
• Disadvantages
• Very slight chance of symptomatic radial
neck nonunion
2. Compression with T-plate and screws
• Displaced transverse fracture
• Further indications
• Displaced fracture that is either part of a
complex injury with elbow or forearm
instability, or with restriction of forearm rotation
• Elbow and forearm stable and mobile
• Advantages
• Healing of native radial head in more
anatomical position
• Disadvantages
• Risk of prominent or errant implants
• Risk of nonunion
• Risk of radial nerve injury

Radius, extraarticular, multifragmentary
1. Nonoperative
• Well aligned elbow and likely to remain so
• Note: Nonoperative treatment is generally only indicated if
functional forearm rotation can be demonstrated with or
without anesthetic injection.
• Elbow subluxation or dislocation
• Deformity likely to restrict forearm rotation
• Polytrauma
• Advantages
• Avoids surgical risks of neurovascular injury
• Fragmented radial neck fractures extending to the bicipital
tuberosity are difficult to stabilize adequately
• Disadvantages
• Risk of elbow subluxation, elbow stiffness, and hindrance of
forearm rotation
2. Radial head arthroplasty
• Irreparable radial head and neck
• In setting of fracture dislocations with instability or residual
subluxation
• Advantages
• Allows for early motion
• Disadvantages
• Early loosening of the prosthesis
• Risk of elbow stiffness (prosthesis too large)
• Risk of unstable elbow (prosthesis too small)
3. Bridge plate
• Displaced or unstable fracture when stable fixation
is possible
• Fragmented fracture associated with elbow
dislocation
• Restriction of forearm rotation
• No associated ligament injury (consider
nonoperative treatment or resection of radial head)
• Advantages
• Stabilizes elbow and forearm
• Retains native radial head
• Disadvantages
• Risk of radial nerve injury and implant prominence
and restriction of forearm rotation
• Technically demanding

Radius, partial articular
1. Nonoperative
• Non- or minimally displaced fractures with no
restriction of forearm rotation
• Note: Nonoperative treatment is generally only
indicated if functional forearm rotation can be
demonstrated with or without anesthetic injection.
• Presence of elbow or forearm subluxation
• Polytrauma
• Advantages
• Allows immediate motion and stretching exercises to
avoid elbow stiffness
• Disadvantages
• Malunion of the radial head restricting forearm
rotation and elbow subluxation can be difficult to
salvage later.
2. Lag screw
• Simple displaced fractures
• Multifragmentary fracture
• Advantages
• Anatomical reduction
• Good interfragmentary compression
• Disadvantages
• Risk of joint penetration
• Risk of additional fracture
3. Radial head excision
• Isolated unreconstructable radial head fracture with stable elbow but
limited forearm rotation. Intact interosseous membrane and distal
radioulnar joint (DRUJ).
• Simple fracture
• Associated coronoid fracture (>50%)
• DRUJ injury
• Advantages
• Fast procedure
• Good functional recovery
• Inexpensive and easy technique
• Disadvantages
• Risk of missed Essex-Lopresti injury
• Risk of unstable elbow after wrong diagnosis
• Risk of late proximal migration of the radius
• Inability to reconstruct radial head fracture so that it provides sufficient
stability for elbow joint. Interosseous membrane injury (Essex-Lopresti
injury).
• Unreconstructable radial head fracture associated with an unstable
fracture of the coronoid process
• After radial head excision with evidence of medial collateral ligament
insufficiency or ulnohumeral instability
• Unreconstructable radial head fracture with acute distal radioulnar joint
injury (Essex-Lopresti injury)
• Simple fracture
• Reconstructable multifragmentary fracture
• Stable elbow
• Advantages
• Fast procedure
• Stable elbow
• Disadvantages

Radius, complete articular
1. Nonoperative
• Undisplaced or minimally displaced fractures with
acceptable supination and pronation range.
Immobilization desired.
• Note: Nonoperative treatment is generally only
indicated if functional forearm rotation can be
demonstrated with or without anesthetic injection.
• Presence of elbow or forearm subluxation
• Polytrauma
• Advantages
• Allows immediate motion and stretching exercises to
avoid elbow stiffness
• Disadvantages
• Malunion of the radial head restricting forearm
rotation and elbow subluxation can be difficult to
salvage later.
2. Plate and screws
• After elevation of an impacted fracture
• Advantages
• Fracture compression
• Rotational control of the radial head
• Disadvantages
• Risk of malpositioning of the plate outside the “safe
zone”, beyond which the plate may block rotation of
the radius, by impinging on the proximal radioulnar
joint
• Risk to the posterior interosseous nerve
3. Radial head excision
• Isolated unreconstructable radial head fracture with stable elbow but
limited forearm rotation. Intact interosseous membrane and distal
radioulnar joint (DRUJ).
• Simple fracture
• Associated coronoid fracture (>50%)
• DRUJ injury
• Advantages
• Fast procedure
• Inexpensive and easy technique
• Disadvantages
• Risk of missed Essex-Lopresti injury
• Risk of unstable elbow after wrong diagnosis
• Risk of late proximal migration of the radius
• Inability to reconstruct radial head fracture so that it provides sufficient
stability for elbow joint
• Indications
• Unreconstructable radial head fracture associated with an unstable
fracture of the coronoid process
• After radial head excision with evidence of medial collateral ligament
insufficiency or ulnohumeral instability
• Unreconstructable radial head fracture associated with interosseous
membrane injury and distal radioulnar joint subluxation (Essex-Lopresti
injury)
• Simple fracture
• Stable elbow
• Advantages
• Fast procedure
• Stable elbow
• Disadvantages

Ulna, extraarticular, avulsion of
triceps insertion
1. Nonoperative
• Minimal displacement (< 2 mm). Active elbow
extension. Immobilization unnecessary.
• Partial triceps avulsion with good residual extension
strength
• Infirm, less active patients that can function without
elbow extension strength (eg demented persons
dependent on others for basic tasks such as
bathing and eating)
• Preference for strong elbow extension
• Polytrauma
• Advantages
• Avoid medical and surgical risks
• Disadvantages
• Difficult to reconstruct later if unsatisfied with elbow
extension strength
2. Tricepts reinsertion
• Triceps avulsion with unacceptable weakness
• Displacement of more than 2 mm
• Infirm patient (high anesthetic risk)
• Infected or abraded skin. Let the skin heal first
• Functionally low demand patient
• Advantages
• Restoration of extensor mechanism / optimal elbow
extension strength
• Disadvantages
• Potential for prominent suture or wire
• Operative complications (anesthesia, infection, skin
necrosis)

Ulna, extraarticular, simple
1. Nonoperative
• Minimally displaced, stable fracture
• Infirm and inactive patient
• Polytrauma
• Advantages
• Disadvantages
• Displacement or nonunion can be problematic
2. Temporary external fixation
• Significant soft-tissue injury or contamination
• Infection
• Polytraumatized patients (damage control)
• Instability that cannot be controlled with splint or
cast
• Advantages
• Quick procedure
• Easy to perform
• No additional damage to already injured tissue
• Stabilizes the fracture for soft-tissue healing
• Disadvantages
• Temporary procedure
• Pin-track complications
• Iatrogenic nerve injury
3. Compression plate
• Displaced transverse fracture
• Infected or abraded skin. Let the skin heal first
• Advantages
• Stable fixation
• Early motion and function
• Disadvantages
• Prominent implant
• Risks of infection, loosening of fixation, medical problems
associated with anesthesia
4. Compression plate and lag screw
• Oblique fracture suitable for compression with both lag screw
and plate
• Infected or abraded skin (let the skin heal first)
• Advantages
• Stable fixation
• Early motion and function
• Disadvantages
• Prominent implant
• Risks of infection, loosening of fixation, medical problems
associated with anesthesia

Ulna, extraarticular, multifragmentary
1. Nonoperative
• Nondisplaced, stable fracture
• Infirm, less active patients that can function with
less elbow extension strength (eg demented
persons dependent on others for basic tasks such
as bathing and eating)
• Polytrauma
• Advantages
• Disadvantages
• Difficult to reconstruct later if unsatisfied with elbow
extension strength
• Risk of malunion
• Significant soft-tissue injury or contamination
• Infection
• Major bone loss
• Instability that cannot be controlled with splint or
cast
• Advantages
• Quick procedure
• Easy to perform
• Disadvantages
3. Bridge plate
• Unstable, displaced fracture
• Instability of radiocapitellar or proximal radioulnar
joint
• Severe contamination or tissue loss
• Advantages
• Restoration of alignment
• Ability to move and exercise the arm

Ulna, articular, olecranon
1. Nonoperative
• Undisplaced fractures
• Displaced fractures in infirm, dependent individuals (eg
demented persons dependent on others for basic tasks
such as bathing and eating)
• Polytrauma
• Advantages
• Disadvantages
• Risk of displacement which is difficult to reconstruct later if
unsatisfied with elbow extension strength
• Extensive soft-tissue damage
• Infection or severe contamination
• Major bone loss
• Joint instability
• Advantages
• Quick procedure
• Easy to perform
• Disadvantages
3. Tension band wiring
• Transverse simple fracture of the olecranon
• Fragmentation of the articular surface
• Fracture dislocation
• Advantages
• Inexpensive implant
• Disadvantages
• Risk of joint penetration with K-wires
• Risk of backing-out of K-wires and implant prominence
• Risk of fragmentation in osteoporotic bone
• Fatigue failure of the tension band
4. Bridge plate
• Multifragmentary fractures
• Infirm and dependent patients
• Severe skin problems or infection
• Advantages
• Restoration of anatomy and function
• Disadvantages
• Medical and surgical risks
5. Lag screw with neutralization plate
• Oblique simple fracture of the olecranon
• Multifragmentary fracture
• Simple transverse fracture
• Advantages
• Stable fixation
• Functional motion
• Disadvantages
• Symptomatic prominent hardware

Ulna, articular, coronoid
1. Nonoperative
• Well aligned joint on 3DCT and reliability patient
• Infirm, dependent patient
• Polytrauma
• Open fracture
• Advantages
• Disadvantages
• Residual subluxation can cause arthritis and may
not be possible to successfully treat weeks or
months later.
2. Repair of coronoid fracture
• Coronoid fracture with elbow subluxation
• Small coronoid fracture in unquestionably stable
elbow
• Infirm and dependent patient
• Advantages
• Prevents joint subluxation
• Disadvantages
• Risk of nerve injury
• Major bone loss
• Advantages
• Quick procedure
• Easy to perform
• Disadvantages

Ulna, complete articular
1. Nonoperative
• Well aligned joint on 3DCT and reliability patient
• Infirm, dependent patient
• Open fracture
• Polytrauma
• Advantages
• Disadvantages
• Residual subluxation can cause arthritis and may not be
possible to successfully treat weeks or months later.
2. Bridge plate
• Bridge plating is required to maintain anatomic articular
congruence
• Excessive fragmentation of triceps insertion preventing
proximal fixation
• Soft-tissue compromise
• Disadvantage
• Major bone loss
• Advantages
• Quick procedure
• Easy to perform
• Disadvantages

Terrible triad
1. Open reduction internal fixation
• Posterior dislocation with fractures of
the radial head and coronoid and
residual subluxation or recurrent
dislocation after reduction
• Advantages
• Ensures the elbow remains located
during functional after treatment
2. Hinged external fixation following ORIF
• Residual subluxation or repeat dislocation
after open repair
• Advantages
• Holds elbow reduced during early healing
and mobilization
• Disadvantages
• Places nerves at risk
• Cumbersome
• Pin-track infections

Anterior fracture dislocation
• Most anterior transolecranon fracture-
dislocations benefit from plate and
screw fixation
• Perhaps a delay for extensive
contamination or wound issues
• Advantages
• Restores stability and alignment
• Disadvantages
• Prominent plate on elbow
2. Hinged external fixation following
ORIF
• ORIF does not provide sufficient elbow
stability
• Advantages
• Holds elbow aligned while early
healing is established
• Disadvantages
• Cumbersome

Posterior fracture dislocation
• Most posterior olecranon fracture
dislocations benefit from plate and
screw fixation
• Soft tissue severely compromised
• Advantages
• Restores stability and alignment
• Disadvantages
• Prominent plate on elbow
2. Hinged external fixation following
ORIF
• ORIF does not provide sufficient elbow
stability
• Advantages
• Holds elbow aligned while early
healing is established
• Disadvantages
• Cumbersome

Varus posteromedial rotational instability
• Anteromedial coronoid facet fracture and
lateral collateral ligament avulsion or
olecranon fracture with subluxation of the
elbow
• Disadvantages
• Small coronoid fracture with joint aligned
• No crepitation with elbow motion when the
shoulder is abducted
• Advantages
• A buttress plate is the best way to secure
these shearing fractures
• Disadvantages
• The ulnar nerve is at risk
• The exposure is unfamiliar and can be
difficult
2. Hinged external fixation following ORIF
• Comminuted coronoid fracture that needs
protection or when coronoid repair does not
provide sufficient elbow stability
• Advantages
• Holds elbow aligned while early healing is
established
• Disadvantages
• Cumbersome

Oblique simple fracture of the ulna
1. Nonoperative treatment
• Minimally displaced fractures
• Minimally displaced fractures may be treated
nonoperatively, usually with a long-arm cast,
followed by a brace.
2. External fixation
• A means of temporary fixation for severely open
fractures
• External fixation can be indicated in severely open
fractures as a means of temporary fixation (with a
view to later conversion to internal fixation).
• ORIF - Lag screw and
plate fixation
• Treatment of choice
• The treatment of choice
for displaced forearm
shaft fractures is ORIF
with absolute stability.
This is achieved using a
compression plate with
or without lag screw.

Transverse simple fracture of the ulna
• A means of temporary fixation for severely
open fractures
• External fixation can be indicated in severely
open fractures as a means of temporary
fixation (with a view to later conversion to
internal fixation).
3. ORIF - Compression plating
• The treatment of choice for displaced
forearm shaft fractures is ORIF with
absolute stability. This is achieved using a
compression plate.

Simple fracture of the ulna, with dislocation of
proximal radioulnar joint (Monteggia)
• Surgical treatment not possible
• This is only indicated when surgical
fracture treatment is impossible. A
good functional result is unlikely.
• A means of temporary fixation for
severely open fractures
• External fixation can be indicated in
severely open fractures as means of
temporary fixation (with a view to later
conversion to internal fixation).
3. ORIF - Plating
• In Monteggia fracture-dislocations,
anatomical reduction and stable
fixation of the ulna and stable
reduction of the radial head are only
likely to be achieved by plating. These
fractures therefore present strong
indications for plating.

Oblique simple fracture of the radius
open fractures
internal fixation).
3. ORIF - Lag screw and plate fixation
compression plate with or without lag screw.

Transverse simple fracture of the radius
fractures
fractures as a means of temporary fixation (with a
view to later conversion to internal fixation).
• The treatment of choice for displaced forearm shaft
fractures is ORIF with absolute stability. This is
achieved using a compression plate.
4. MIO - Minimally invasive compression plating
• Transverse distal third radial shaft fractures
• The minimally invasive ("limited open") technique is
only applicable in the forearm for transverse distal
third radial shaft fractures. This technique requires
considerable surgical experience. The fractures
best suited for this technique are those with a dorsal
displacement of the distal fragment in the lateral
view, with only minimal displacement in the AP view.
• Fractures especially suitable are at the level of the
abductor pollicis longus muscle belly.
• Oblique distal radial shaft fractures are not suitable
because indirect anatomical reduction and
interfragmentary compression are difficult to
achieve with this technique.
• The advantage of the minimally invasive technique
is the preservation of a skin bridge in the region of
the abductor pollicis longus muscle.

Simple fracture of the radius, with dislocation of distal radioulnar
joint (Galeazzi)
• Surgical treatment not possible
• This is only indicated when surgical
fracture treatment is impossible. A
good functional result is unlikely.
3. ORIF - Plating
• In Galeazzi fracture-dislocations,
fixation of the radius and stable
reduction of the ulnar head are only
likely to be achieved by plating. These
fractures therefore present strong
indications for plating.

Simple fracture of the radius and the ulna
nonoperatively with a long-arm cast,
possibly followed by bracing, including the
proximal and distal joints. Frequent
radiological monitoring of the fractures is
advised to check for secondary
displacement.
open fractures
open fractures as means of temporary
internal fixation).
3. ORIF - Compression Plating

Wedge fracture of the ulna with no dislocation
• Nonoperative treatment
• Minimally displaced fractures may be
treated nonoperatively, e.g., with a
brace.
• External fixation
• ORIF - Compression Plating
absolute stability. This is achieved
using a compression plate with or
without lag screw.

Wedge fracture of the ulna, with dislocation of
proximal radioulnar joint (Monteggia)
• External fixation can be indicated
in severely open fractures as
means of temporary fixation (with
a view to later conversion to
internal fixation).
• In Monteggia fracture-dislocations,
fixation are mandatory. This can
only be achieved by surgical
means

Wedge fracture of the radius with no dislocation
nonoperatively, e.g., with a long-arm cast
open fractures
open fractures as means of temporary
internal fixation).

Wedge fracture of the radius, with dislocation of distal
radioulnar joint (Galeazzi)
• External fixation can be indicated
in severely open fractures as
means of temporary fixation (with
a view to later conversion to
internal fixation).
• In Galeazzi fracture-dislocations,
fixation are mandatory. This is
best achieved by compression
plating.

Wedge fracture of one bone, with a simple or wedge
fracture of the other
• May be an option in compromised patients
• Minimally displaced fractures in
compromised individuals may be treated
nonoperatively with a long-arm cast,
possibly followed by bracing, including the
proximal and distal joints. Frequent
radiological monitoring of the fractures is
advised to check for secondary
displacement.
open fractures
internal fixation).

Multifragmentary ulnar fracture with non-
multifragmentary radial fracture
• Severely injured polytrauma patients; patients who
are medically unfit for surgery
• In severely injured polytrauma patients, definitive
fixation of such injuries is delayed until physiological
stabilization has been achieved. In the interim, the
forearm and elbow should be placed in a well-
padded splint. Neurovascular and muscle
compartment status, and soft-tissue conditions
should be closely monitored.
• Nonoperative treatment may be necessary in
patients who are medically unfit for surgery.
• The outcome of nonoperative treatment of both
bone fractures is likely to be suboptimal.
fractures
fractures. A monolateral frame configuration can be
used on the ulna as a temporary means of
treatment in the presence of compromised soft
tissues. Alternatively, in experienced hands, ring
fixators of the Ilizarov type can be used for the
definitive fixation of these injuries; this requires a
high level of expertise in this field. This method will
not be considered in any further detail.
3. ORIF - Plating of one or both bones
• The preferred treatment of the simple fractures of
the radius in these injury configurations is
compression plating (with or without lag screw),
leading to absolute stability and direct bone healing.
• The preferred treatment of the segmental fractures
of the ulna is compression plating leading to
anatomical restoration of length, rotational
alignment, and absolute stability. The blood supply
of the intermediate fragment must be meticulously
preserved throughout.
• In certain circumstances, compression plating of the
ulna may not be achievable and other management
options should be considered.
• Some segmental fractures cannot be treated by
compression plating for technical reasons and
occasionally, bridge plating of the ulna is indicated;
in such circumstances, the blood supply of the
intermediate fragment must be meticulously
preserved.
• Anatomical reduction cannot be achieved in
fragmentary segmental fractures of the ulna, but
maintaining relative stability using bridge plating is
widely accepted. Either a conventional plate, or a
locked plate, can be used if the principles of
minimizing soft-tissue stripping and achieving both
length and alignment are respected.

Multifragmentary radial fracture with non-
multifragmentary ulnar fracture
• Severely injured polytrauma patients
fixation of such injuries is delayed until physiological
stabilization has been achieved. In the interim, the
forearm and elbow should be placed in a well-
padded splint. Neurovascular and muscle
compartment status, and soft-tissue conditions
should be closely monitored.
bones fractures is likely to be suboptimal.
fractures
used on the radius as a temporary means of
treatment, in the presence of compromised soft
tissues. Alternatively, in experienced hands, ring
fixators of the Ilizarov type can be used for the
definitive management of these injuries; this
requires a high level of expertise in this field. This
method will not be considered in any further detail.
3. ORIF - Plating of one or both bones
• The preferred treatment of simple fractures of the
ulna is compression plating (with or without lag
screw) leading to absolute stability and direct bone
healing.
• The preferred treatment of segmental fractures of
the radius is compression plating (with or without
lag screw) leading to anatomical restoration of
length and radial curvature, rotational alignment,
and absolute stability. The blood supply of the
intermediate fragment must be meticulously
preserved throughout.
• In certain circumstances, compression plating of the
radius may not be achievable and other
management options should be considered.
• Some segmental fractures cannot be treated by
compression plating for technical reasons and
occasionally, bridge plating of the radius is
indicated; in such circumstances, the blood supply
of the intermediate fragment must be meticulously
preserved.
fragmentary segmental fractures, but maintaining
relative stability using bridge plating is widely
accepted. Either conventional, or locked (if
available), plates can be used if the principles of
minimizing stripping, and restoring both length and
alignment are respected.

Multifragmentary, intact segmental
fracture of both bones
• Severely injured polytrauma
patients
• In severely injured polytrauma
patients, definitive fixation of such
injuries is delayed until
physiological stabilization has
been achieved. In the interim, the
forearm and elbow should be
placed in a well-padded splint.
Neurovascular and muscle
compartment status, and soft-
tissue conditions should be
closely monitored.
• Nonoperative treatment may be
necessary in patients who are
medically unfit for surgery.
• The outcome of nonoperative
treatment of both bones fractures
is highly likely to be suboptimal.
• Anatomical reduction can be achieved in segmental
fractures provided the soft-tissue condition permits
open procedures. Either conventional, or locked, plates
can be used, if the principles of minimizing soft-tissue
stripping and achieving both length and alignment are
respected.
fractures
used on one or both bones, as a temporary means of
treatment for these high energy fractures associated
with compromised soft tissues. Alternatively, in
experienced hands, ring fixators of the Ilizarov type can
be used for the definitive fixation of these injuries; this
requires a high level of expertise in this field. This
method will not be considered here in any further
detail.
•

Multifragmentary, intact segmental fracture of one
bone, fragmentary of the other
• In severely injured polytrauma patients,
definitive fixation is delayed until
physiological stabilization has been
achieved. In the interim, the forearm and
elbow should be placed in a well-padded
splint. Neurovascular and muscle
compartment status, and soft-tissue
conditions should be closely monitored.
• Nonoperative treatment may be necessary
in patients who are medically unfit for
surgery.
• The outcome of nonoperative treatment of
both bones fractures is usually suboptimal.
2. Intramedullary nailing
• Irregular fractures with severe soft-tissue
injury (see discussion)
• Nailing is the preferred option only in
pediatric fractures.
3. ORIF - Plating
• Anatomical reduction and absolute stability
can be achieved in the segmental fractures
using compression plating. For fragmentary
segmental fractures, bridge plating is used.
The condition of the soft-tissue injury may
preclude plating techniques.
• Either conventional plates, or locked plates,
can be used, if the principles of minimizing
soft-tissue stripping and achieving both
length and alignment are respected
• 4. External fixation
open fractures
open fractures. A monolateral frame
configuration can be used on one or both
bones, as a temporary means of treatment
for these high energy fractures associated
with compromised soft tissues. Alternatively,
in experienced hands, ring fixators of the
Ilizarov type can be used for the definitive
fixation of these injuries; this requires a high
level of expertise in this field. This method
will not be considered here in any further
detail

Multifragmentary, fragmentary
segmental fracture of both bones
fixation is delayed until physiological stabilization
has been achieved. In the interim, the forearm and
elbow should be placed in a well-padded splint.
Neurovascular and muscle compartment status,
and soft-tissue conditions should be closely
monitored.
bones fractures will be suboptimal.
2. Intramedullary nailing
• Treatment option in the presence of severe soft-
tissue injury
• Intramedullary nailing is not widely used in adult
forearm shaft fractures, due to difficulty in achieving
anatomical reduction and rotational stability. In
fragmentary segmental fractures of both bones,
however, there may be an indication for nailing
since, in these fractures, anatomical reduction is
impossible, and absolute stability cannot be
achieved
3. ORIF - Bridge plating
• Treatment of choice in the absence of severe soft-
tissue injury
fragmentary segmental fractures of both bones, but
maintaining relative stability using bridge plating is
widely accepted. Either conventional plates, or
locked plates, can be used, if the principles of
minimizing soft-tissue stripping and achieving both
length and alignment are respected.
fractures
used on one or both bones, as a temporary means
of treatment for these high energy fractures
associated with compromised soft tissues.
Alternatively, in experienced hands, ring fixators of
the Ilizarov type can be used for the definitive
fixation of these injuries; this requires a high level of
expertise in this field. This method will not be
considered here in any further detail.

Extraarticular fracture of the
ulnar styloid process
1. Nonoperative treatment - Cast
• Stable wrist and DRU joint
• Indications
• Undisplaced
• Simple (noncomminuted)
• Stable distal radioulnar joint
• Low-demand patient
• Unstable distal radioulnar joint
• Disadvantage
• Increased risk of long-term mobility loss
2. ORIF - Tension band wire
• Unstable, small fragment
• Indications
• Small fragment of the ulnar styloid
• Widely displaced fracture
• Unstable fracture
• Comminuted fracture (relative indication)
• Unstable DRU joint
Contraindications
• Local soft-tissue injuries
• Poor condition of overlying soft-tissue envelope
• Patient not fit for surgery
• Advantages
• Early mobilization
• Healing in anatomical position
• Disadvantage
• Can cause irritation; the tension band wire may
need to be removed
3. ORIF - Lag screw
• Unstable, large fragment
• Indications
• Large-fragment ulnar styloid fractures
• Widely displaced fracture
• Unstable distal radio ulnar joint
• Local soft-tissue injuries
• Advantages
• No local irritation (compared to tension band)
• Disadvantage

Extraarticular simple
fracture of the ulna
• Stable, undisplaced: reducible, transverse fracture
• Indications
• Stable fracture
• Undisplaced
• Simple (noncomminuted)
• Stable DRU joint
• Unstable distal radioulnar joint
• Disadvantage
2. ORIF - Lag screw and protection plate
• Indications
• Oblique or spiral fracture
• Locking plate preferable for short distal fragments
• Displaced fracture
• Irreducible fracture
• Advantages
• Disadvantages
• Subcutaneous plate may cause irritation
• Screws may cut out, particularly in osteoporotic bone
3. ORIF - Compression plate
• Transverse, or short oblique fracture
• Indications
• Transverse or short oblique fracture
• Locking plate preferable for short distal fragments
• Advantages
• Disadvantages
• Subcutaneous plate may cause irritation
• Screws may cut out, particularly in osteoporotic bone

Extraarticular multifragmentary
fracture of the ulna
• Unfit or low-demand patient
• Indication
• Stable DRU joint
• Poor state of soft tissues
• Disadvantage
2. ORIF - Bridge plate
• All ulnar multifragmentary extraarticular fractures,
where possible
• Advantages
• Note: For multifragmentary fractures of the neck of
the ulna, consideration may have to be given to the
use of a mini condylar plate.
3. ORIF - Hook plate
• All ulnar multifragmentary extraarticular fractures,
where possible
• Advantages
• Better control of smaller distal fragments than with
conventional plate
• Note: For multifragmentary fractures of the neck of
the ulna, consideration may have to be given to the
use of a mini condylar plate.

Extraarticular undisplaced
fracture of the radius
• Almost all radial extraarticular simple fractures with
no displacement/tilt
• Indication
• Indicated for patients with no associated injuries
2. ORIF - Palmar plate
• Severe shortening, late collapse, associated
neurovascular injury
• If the bone is significantly osteoporotic there is an
increased risk of early shortening or late collapse.
• Indications
• Shortening of the radial metaphysis, with relative
ulnar overlength
• Late collapse
• Associated neurovascular injury
• Unstable injury
• Advantages
• Anatomical restoration of radial length
• Minimal risk of redisplacement
• Early motion
• Disadvantage
• Cost
3. Joint-spanning external fixation (temporary or definitive)
• Temporary stabilization in polytrauma, unfit patient, insufficient
hold in a cast, patient not suitable for ORIF
• Indications
• Temporary stabilization in polytrauma
• Redisplacement in cast
• Open fracture
• Local soft-tissues compromised for plating
• Poor state of local soft tissues increasing risk of pin track
infection
• Advantages
• Reduced risk of infection at the fracture site compared to open
technique
• Lower risk in cases of significant local soft-tissue injury
• Restoration of extraarticular anatomy
• Loss of position unlikely
• Straightforward technique
• Less invasive than ORIF
• Disadvantages
• Radial sensory nerve injury
• Risk of loss of radial length
• Risk of injury to extensor tendon
• Stiffness, especially with over distraction
• Risk of complex regional pain syndrome (type I) (CRPS-I)
• Pin-track infection
• Risk of redisplacement after removal

Extraarticular fracture of the radius
with dorsal displacement or tilt
• Reducible fracture in absence of dorsal comminution
• The outcome of nonoperative treatment depends on the ability
to achieve and maintain good reduction.
• Indications
• Reducible fracture
• Stable after reduction
• Simple (non-comminuted) fractures
• Unsuccessful closed reduction
• Neurovascular compromise
• Advantages
• No surgical risk
• Low cost
• Minimal infrastructure required
• Local or regional anesthesia
• Disadvantages
• Potential loss of reduction
• Frequent radiological follow-up necessary to detect loss of
reduction
• Stiffness due to immobilization
• General disadvantages of casting
2. Closed reduction - K-wires and cast/external fixator
• Unstable fractures, loss of reduction
• Indications
• Redisplacement following reduction
• Unstable fractures
• Poor state of local soft tissues
• Significant comminution
• Unstable fracture, dorsal comminution, associated
neurovascular injury
• There are many implants now available, most with locking
screws, which give better hold in osteoporotic bone.
• Indications
• Dorsal comminution
• Irreducible displacement
• Redisplacement after closed reduction
• High-demand patients
• Delayed presentation
• Advantages
• Anatomical restoration
• Minimal risk of redisplacement
• Early return of function
• Less need for implant removal
• Less radiological and clinical need for monitoring: May balance
costs of implants
• Disadvantages
• Cost
• Risk of nerve injury
• Potential tendon irritation
• Possible need for later implant removal

Extraarticular fracture of the radius
with volar displacement or tilt
• Reducible fracture in absence of palmar comminution
• The outcome of nonoperative treatment depends on the ability
to achieve and maintain good reduction.
• Indications
• Simple (non-comminuted) fractures
• Minimal displacement or stable after closed reduction
• No shortening
• Unsuccessful closed reduction
• Indications
• Temporary stabilization in polytrauma/ unfit patient
• Open fracture
infection
• Indications
• Unstable fractures
• Loss of reduction in absence of palmar comminution
• Irreducible palmar angulation and shortening
• Significant comminution
• Irreducible, or unstable reduction, associated neurovascular
injury
• There are many implants now available, most with locking
screws, which give better hold in osteoporotic bone.
• Indications
• Irreducible displacement
• Redisplacement after closed reduction
• Delayed presentation
• Irreducible palmar angulation and shortening

Extraarticular wedge or
multifragmentary fracture of the radius
• Low-demand patient; surgery not possible
• Indications
• Acceptable displacement
• Surgery not possible
• Unacceptable displacement or shortening
• Irreducible
• Open fracture
• Indications
• Instability
• Open fracture
• Unacceptable shortening or dorsal inclination
• Extension of fracture into diaphysis
• Axial impaction
infection
• Indications
• Unstable reduction in cast alone
4. ORIF - Palmar bridge plate
• Irreducible, or unstable reduction: associated neurovascular
injury
• Preferably locking plates, as conventional plates require
additional dorsal radial cortical cancellous bone graft.
Dorsal plating has largely been superseded by palmar plating.
• Indications
• Short distal segment
• Active patients
• Open fractures
• Irreducible
• Unacceptable shortening or dorsal inclination, initially or
following other methods
• Extensive metaphyseal comminution
• Early malunion / delayed presentation

Partial articular, sagittal simple radial
fracture, involving scaphoid fossa
• Minimally displaced fracture, low demand patient
• Indications
• Minimally displaced fracture
• Displacement
• Associated intercarpal ligament injury
• Indications
• Instability
• Open fracture
infection
3. ORIF - Radial column plate
• Failed, or unstable reduction
• Indications
• Failure of attempted closed reduction
• Redisplacement after reduction
• Open fractures
• Associated intercarpal ligament injury (scapholunate diastasis)
• Severe swelling
• Indications
• Loss of reduction
• Reducible fractures
• Displacement with significant articular step
• Open fractures
• Intercarpal ligament injury (scapholunate diastasis)
• Osteoporosis
• Significant local skin compromise
5. Closed reduction - Lag screws
• Displaced, reducible, no intercarpal ligament instability
• Indications
• Skin condition contraindicating ORIF
• No significant articular incongruity
• Satisfactory reduction via closed methods
• Osteoporosis

Partial articular, sagittal multifragmentary
radial fracture, involving scaphoid fossa
• Minimally displaced fracture, low-demand patient
• Indications
• Displacement
2. Joint-spanning external fixation (temporary or
definitive)
• Temporary stabilization in polytrauma, unfit patient,
insufficient hold in a cast, patient not suitable for
ORIF
• Indications
• Open fracture
• Insufficient hold in a cast
• Poor state of local soft tissues increasing risk of pin
track infection
3. ORIF - Lag screws/K-wires
• Displaced, irreducible
• The surgeon may prefer to use cannulated screws, if they are
available.
• Indications
• No significant articular incongruity
• Open fractures
• Osteoporosis
4. ORIF - Radial column plate
• Failed, or unstable reduction
• Indications
• Failure of attempted closed reduction
• Open fractures
• Associated intercarpal ligament injury (scapholunate diastasis)
• Severe swelling

Partial articular, sagittal fracture of the
radius, involving the lunate fossa
• Minimally displaced: low-demand patient
• Indications
• Displacement
2. Joint-spanning external fixation (temporary
or definitive)
• Temporary stabilization in polytrauma, unfit
patient, insufficient hold in a cast, patient not
suitable for ORIF
• Indications
• Instability
• Open fracture
• Poor state of local soft tissues increasing
risk of pin track infection
3. ORIF - Dorsal plate
• Failed or unstable articular reduction
• Indications
• Unacceptable displacement
• Failure of less invasive methods
• Instability of distal radioulnar joint
• Open fractures
• Intercarpal ligament injury (especially
scapholunate diastasis)
• Severe swelling

Partial articular, simple fracture of
the radius, involving the dorsal rim
• Indication
• Displacement
• Radiocarpal subluxation
• Open fractures
or definitive)
suitable for ORIF
• Indications
• Unfit patient
• Open fracture
3. ORIF - Dorsal plate
• Almost all radial partial articular, dorsal rim,
simple fractures
• As these are articular injuries, with a high
risk of radiocarpal subluxation, they should
normally be fixed.
• Indications
• Unstable injury
• Articular incongruity
• Severe swelling

Partial articular, fragmentary fracture of
the radius, involving dorsal rim
• Patient not fit for surgery, low demand
patient
• These fractures should only ever be treated
nonoperatively in very low demand or unfit
patients.
• Indications
• Open fractures, if condition of patient
permits surgery
2. ORIF - Dorsoradial double plate
• Almost all radial dorsal rim fractures,
involving the scaphoid fossa
normally be fixed.
or definitive)
suitable for ORIF
• Indications
• Unfit patient
• Open fracture

Partial articular fracture of the
radius, with dorsal dislocation
• Patient not fit for surgery, low demand
patient
• These fractures should only ever be treated
nonoperatively in very low demand or unfit
patients.
• Indications
• Open fractures, if condition of patient
permits surgery
or definitive)
suitable for ORIF
normally be fixed.
• Anatomic reduction may be possible to
achieve through closed manipulation and
insertion of percutaneous K-wires.
• Almost all partial articular fractures which involve a
significant radial styloid fragment.
• As these are articular injuries, with a high risk of
radiocarpal subluxation, they should normally be
fixed.
• Indications
• Identified intercarpal ligament injury
• Identified median nerve compromise (which will
require an additional palmar approach)
4. ORIF - Dorsal double plate
• Almost all partial articular fractures which involve a
significant radial styloid fragment
• As these are articular injuries, with a high risk of
radiocarpal subluxation, they should normally be
fixed.

Partial articular fracture of the
radius, involving the volar rim
• Low-demand patient; surgery
contraindicated
• Indications
• Displacement
• Open fractures
2. Joint-spanning external fixation
(temporary)
suitable for ORIF
normally be fixed.
• Indications
• Poor medical condition of patient
• Congruous reduction of the dislocation
possible
• No more than three sizeable dorsal fracture
fragments
• Osteoporosis
• Almost all Goyrand-Smith II fractures
normally be fixed.

Complete simple articular, simple
metaphyseal radial fracture
• Unfit or low-demand patient, undisplaced fracture
• Indications
• Undisplaced and stable fracture
• low-demand patient
2. Closed reduction - K-wires and cast/external
fixator
• Reducible and large fragments, low demand
patients
• Indications
• Reducible by closed means
• Large fragments
• Osteoporosis
• Residual articular surface depression after closed
reduction
• Significant loss of radial length
• Substantial metaphyseal comminution
• Articular surface depression
• Severe swelling
• Almost all complete articular simple fractures of the
radius
• As these are articular injuries, they should normally
be fixed.
• When a posterior approach is necessary to treat
intercarpal instability
• Optimum hold and stability is probably best
obtained with separate plating of the radial and
intermediate columns. The fixation of the small,
distal fragments is more secure with locking plates,
and additional bone graft is not then necessary.
• Indications
• Dorsally displaced fractures (using indirect
reduction technique for locking plates if required)
• Loss of radial length
• Displaced coronal split in lunate fossa
• Impacted articular fragments and associated carpal
ligament tears
• Small articular fragments
• Persistent displacement following other methods
• Redisplacement
• Active patients

Complete simple articular, fragmented
metaphysis radial fracture
• Indications
• Undisplaced and stable fracture
• Indications
• Open fracture
• Unacceptable shortening or dorsal inclination
• Closed reduction possible
• Reducible and large fragments, low demand patients
• ORIF - Palmar bridge plate
4. Main indications
• Most complete articular fractures with marked metaphyseal
comminution
• Indications
• Impacted fragments
• Persistent or recurrent displacement following other methods
• Carpal instability
• Marked metaphyseal comminution
• Severe swelling
• When a dorsal approach is necessary to treat intercarpal
instability
• Optimum hold and stability is probably best obtained with
separate plating of the radial and intermediate columns. The
fixation of the small, distal fragments is more secure with
locking plates, and additional bone graft is not then necessary.
• Indications
• Dorsally displaced fractures (using indirect reduction technique
for locking plates if required)
• Impacted articular fragments and associated carpal ligament
tears
• Persistent displacement following other methods
• Redisplacement
• Active patients
• Palmar displaced fractures
• Dorsal soft-tissue injury
• Median nerve Compromise
• Poor state of soft tissue
• Severe swelling

Complete multifragmentary
fracture of the radius
• Indications
• Relatively undisplaced and stable fracture
2. ORIF - Palmar bridge plate
• Indications
• Persistent or recurrent displacement following other methods
• Severe swelling
3. ORIF - Dorsoradiopalmar triple plate
• Gross articular injury which can be reconstructed
• Optimum hold and stability is probably best obtained with separate plating of the
radial and intermediate columns. The fixation of the small, distal fragments is more
secure with locking plates, and additional bone graft is not then necessary.
• Indications
• Hyperextended palmar articular fragments
• Irreducible dorsal ulnar fragments
• Impressed articular fragments
• Significant ligament injury of the proximal carpal row
• Complex metaphyseal and/or diaphyseal components
• Open fractures
• Significant closed skin injuries
4. ORIF - Joint-spanning distraction plate
• Severe comminution
• Indications
• Persistent or recurrent displacement following other
methods
• Polytrauma patients
• Severe swelling
• When a posterior approach is necessary to treat
intercarpal instability
• Optimum hold and stability is probably best obtained
with separate plating of the radial and intermediate
columns. The fixation of the small, distal fragments is
more secure with locking plates, and additional bone
graft is not then necessary.
• Indications
• Dorsally displaced fractures (using indirect reduction
technique for locking plates if required)
• Impacted articular fragments and associated carpal
ligament tears
• Complex metaphyseal and/or diaphyseal components
• Open fractures
• Dorsal soft-tissue injury

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