Fractures of the radius and ulna shafts are common injuries that can have varying classifications and treatment approaches. The document discusses: 1) Classification systems for these fractures including the OTA system that categorizes fractures as Types A, B, or C based on fracture pattern and involvement of one or both bones. 2) Specific fracture types like Monteggia and Galeazzi fractures which involve fractures of the ulna or radius with dislocations of the proximal radioulnar joint. 3) Treatment options including nonoperative management for nondisplaced fractures or operative treatment with external fixation, intramedullary nailing, or plate osteosynthesis depending on the fracture. Complications are also reviewed

1. FRACTURES OF THE SHAFTS OF
THE RADIUS AND ULNA
Dr. Mohammad Mahdi Shater
Orthopedic Surgery Resident
Baqiyatallah University of Medical Sciences
‫الرحیم‬ ‫الرحمن‬ ‫اهلل‬ ‫بسم‬
Rockwood and Green's Fractures in Adults

2. Introduction
• Role
• 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.
• Ulnar shaft fractures are defined as those occurring between the distal
aspect of the coronoid proximally and the ulnar neck distally.

3. Epidemiology
• Forearm fx are more common in men than women
because of higher incidence in men of MCA ,falls,sports
participation,…
• The ratio of open fx to closed fx is higher for the foream
than for any other bone except tibia

4. Mechanism of Injury
• Direct blow is the most common.
-road traffic accidents
-fights in which the defender uses the forearm for protection.
• Less frequently may result from falls and sports injuries.

5. Night stick
• direct blows occur in fights in which the defender uses the
forearm for protection a direct blow under these
circumstances may cause an isolated ulnar fracture, often
called a "night stick“ fracture, or a Monteggia fracture
dislocation

7. Signs and Symptoms
• Pain
• Swelling
• Loss of function of the forearm and hand
• Local tenderness
• Deformity
• In closed fractures, a tense swelling and pain on passive
stretch of the forearm may suggest compartment
syndrome.

8. Associated Musculoskeletal Injuries
• Muscle
• Radioulnar joint disruption(Monteggia , Galeazzi)

9. Open Diaphyseal Fractures
• The frequency of open fractures ranges from less than 10% in
isolated radial shaft fractures to 43% of both-bone forearm
fractures

10. Compartment Syndrome
• Swelling ,Pain
• Pain out of proportion with passive extension of the digits is the
most sensitive test to clinically diagnose compartment syndrome
• Compartmental pressures within 30 mm Hg

11. • absolute compartment pressure is an unreliable indicator
of the requirement for fasciotomy and that a pressure
differential of less than 30 mm Hg between the diastolic
blood pressure, and the ompartment pressure indicates
that immediate fasciotomy is required

12. Associated Nonmusculoskeletal Injuries
• Head injury
• Nerve injuries
• Artery disruption
• Abdominal and pelvic trauma

13. Imaging and Other Diagnostic Studies
• Anterior–posterior (AP) and lateral radiographs of the forearm
• Tuberosity view
• Computed tomography (CT)
• Magnetic resonance imaging diagnose injuries to the DRUJ and
associated TFCC
• Ultrasound

15. Forearm fractures
Classification
• What bone(s) is (are) fractured?
• In what location is the fracture (proximal, middle, distal
third)
• What is the fracture pattern (simple transverse, simple
oblique, comminuted)?
• Is there instability at the distal or proximal radioulnar
joint?
• Is the fracture open or closed?
• Is a previous implant present?
• Is a previous deformity present?
• Is the bone stock normal?

16. OTA
Classification
Type A fractures
• are simple fractures of the ulna, radius, or both bones. In Al fractures there is
a simple fracture of the ulna and the radius is intact. In A2 fractures there is a
simple fractures of the radius and the ulna is intact. In both these groups, .1
refers to an oblique fractures, .2 to a transverse fracture, and .3 to a fracture
associated with the dislocation. The A1.3 fracture represents a Monteggia
fracture dislocation and the A2.3 fracture represents a Galeazzi fracture
dislocation.
• In the A3 group, .1 refers to a radial fracture in the proximal third of the bone,
.2 to a radial fracture in the middle third, and .3 to a radial fracture in the
distal third.

17. Type B fractures
• are wedge fractures of either the ulna (Bl), the radius (B2), or both
the radius and ulna (B3). In groups Bl and B2, .1 refers to an
intact wedge, .2 to a fragmented wedge, and .3 to an associated
dislocation with B1.3 fractures being Monteggia fracture
dislocations and B2.3 fractures being Galeazzi fracture
dislocations. In the B3 group, B3.1 fractures have an ulnar wedge
and a simple fracture of the radius, B3.2 fractures have a radial
wedge and a simple fracture of the ulna, and B3.3 fractures have
radial and ulnar wedges

18. Type C fractures
• are complex fractures. Cl fractures are complex fractures of the ulna, C2
fractures involve the radius, and C3 fractures involve both the radius and
ulna. In Cl.l fractures there is a bifocal fracture of the ulna with an intact
radius, in Cl.2 fractures there is a bifocal fracture of the ulna with a radial
fracture, and in Cl.3 fractures the ulnar fracture is irregular. In C2.1 fractures
the radial fracture is bifocal and the ulna is intact. In C2.2 fractures the radial
fracture is bifocal but the ulna is fractured, and in C2.3 fractures the radial
fracture is irregular. In C3.1 fractures both bones show a bifocal fracture and
in C3.2 fractures there is a bifocal fracture of one bone with an irregular
fracture of the other. In the rare C3.3 fracture, both fractures are irregular or
comminuted.

20. Monteggia Fracture
• Fractures between the proximal third of the ulna
accompanied by radial head dx.
• Bado divided Monteggia lesions into four types with the
classification depending on the direction of the radial head

21. Bado classification:
• Type I:
• An ant. Dx. Of the radial head
with associated anterioly
angulated fx. Of the ulnar
shaft

22. • Type II:post. Dx. Radial head
with a poteriorly angulated fx
of ulna

23. • Type III:
• A lateral or anterolateral dx of
the radial head with a fx. Of
ulnar metaphysis

24. • Type IV:
• Ant. Dx of radial head with fx
radius and ulna

25. Galeazzi Fracture
• Dislocation or subluxation of the DRUJ in association with
a solitary fx. of the radius at the junction of the middle and
distal third is called Galeazzi fx.
• Injuries to the DRUj are generally subdivided into stable,
partially unstable (subluxation), and unstable.
• Open reduction and internal fixation of the radius depends
on DRUj stability.

26. • Most authorities indicate that :
• about 60% of Monteggia fracture dislocations are type I
• 15% are type II
• 10% are type III (virtually only occur in children)
• 10% are type IV

27. Anatomy
Forearm fractures can be regarded as articular fractures as
slight deviations in orientation of the radius and ulna will
significantly decrease the forearm's rotation and impair
the positioning and function of the hand.

28. Consist of :
• Ulna : Which is straight
• Radius: Bowed
• Interrosseous membrane occupied the space between
them
• The central band is approx, 3.5 cm wide running
obliquelyfrom proximal origin on the radius to its distal
insertion on the ulna

29. Anatomy
• Radius
• Ulna
• Interosseous Space
• Triangular Fibrocartilage Complex
• Proximal Radioulnar Joint
• Muscles
• Nerves
• Arteries

30. CURRENT TREATMENT OPTIONS
• Nonoperative Treatment
• Operative Treatment
• External fixator
• Intramedullary Nailing
• Plating

32. Surgical Approach
• Ulna
• Radius
• Volar Approach of Henry
• Posterior (Thompson) approach

33. Operative Treatment
External fixator:
• There are only a few indications for the use of external
fixation in forearm fx:
1- Initial management of open fractures of the radius
and ulna associated with extensive soft tissue damage
• 2-Maintaining the length in fx with severe bone loss
2- multiply-injured patient

34. Intramedullary Nailing
• intramedullary nails are not as strong and do not maintain
forearm reduction as well as plate osteosynthesis
• Children vs adult
• Type of Nails
• Indications/Contraindications

35. Plating
• Internal fixation with plates allows excellent control of the
fracture
fragments and therefore permits accurate restoration of the
anatomy, which remains the key principle in treating
forearm
fractures as it preserves maximal forearm function

36. • The plates most widely used for internal fixation of
forearm fractures are the 3.5 (DCP) and the 3.5 limited
contact-dynamic compression plate (LC-DCP)
• In comparison to the DCP, the contact
area between the bone and the LC-OCP is reduced by
about 50%

37. • The concept of limited contact between the plate and the
bone has lead to the development of the point contact-
fixator (PC-Fix) in which the contact area between the
plate and the underlying bone is reduced to two contact
points every 16 mm .Fixation achived between the screws
and the bone, like an external fixator.

38. AUTHORS' PREFERRED TREATMENT
Nonoperative treatment:
-undisplaced fractures
-in patients with significant comorbidities
Operative treatment:
-For the treatment of forearm diaphyseal fractures the best
device is plate osteosynthesis(3.5-mm LC-DCP).

39. Pearls and Pitfalls
Pearls
• There is a high incidence of associated musculoskeletal injury.
• Tense swelling in the forearm suggests compartment syndrome.
• In type II Monteggia fracture dislocations, an anterior triangular or
quadrilateral anterior fragment must be looked for on x-rays.
• The results of using the 3.5-mm LC-DCPhave not been bettered
by more modern plates.

40. Pitfalls
• Subluxation of dislocation of the DRUJ may develop slowly.
• Failure to restore the radial bow will restrict forearm rotation.
• Intramedullary nailing frequently does not restore the radial bow.
• In initially undisplaced fractures, nonoperative management can be
• associated with poor results.
• Minimally invasive techniques are not recommended.
• Early plate removal may cause refracture.
• Narrowing of the interosseous space may cause radio-ulnar synostosis.

41. COMPLICATIONS
• Compartment Syndrome
• Malunion
• Nonunion
• Infection
• Plate Removal and Refracture
• Radio-Ulnar Synostosis
• Nerve palsy(FPL)

42. Compatment syndrome
• One pathway is tissue hypoxia followed by swelling which further
reduces the perfusion pressure at the capillary level, eventually
leading to ischemic muscle and myonecrosis.
• Another more common pathway is direct or indirect muscle
damage leading to muscle swelling followed by increased
intracompartmental pressure
• pressure will lead to reduced capillary blood flow, muscle
ischemia, and myonecrosis

43. • The forearm is the most common site for compartment syndrome
in the upper extremity.
The three compartments of the forearm include the anterior (or flexor
compartment), the posterior
(or extensor compartment), and the mobile wad (including
• brachioradialis and extensor carpi radialis longus and brevis).
• Flexor digitorum profundus and flexor pollicis longus are the most severely
affected muscles because of their deep location.

44. Malunion
• It seems therefore that early correction yields better
results than late correction if osteotomy is required.

45. Nonunion
• In general, fracture nonunion results from unstable
fixation or a compromised blood supply secondary to the
severity of the injury or poor surgical technique.

46. Infection
• If infection does occur, surgical treatment with an
adequate debridement is recommended.
• Implant removal should not be under taken
• appropriate antibiotic treatment depending on the bacteria
involved in the infection.

47. Plate removal
• It has been suggested that remodeling takes up to 12-18
months to complete
• 4-6 w brace or splint
• We do not advocate routine plate removal in the
asymptomatic patient

48. General
• Open fractures
• Infection
• Multiply-injuredpatients with head trauma
• Delayed internal fixation
Surgical (less common)
• Narrowing the interosseous space by nonanatomic reduction
• Use of too long screws
• Bone grafting
 Indomethasin and Radiotherapy
Radio-Ulnar Synostosis

49. Assessment of peripheral n. function:
• Making a fist (median and ulnar n.)
• Wrist and finger extension (radial n.)
• Abd. of extended fingers (ulnar n. when radial n.is intact)
• Extension in the IP joint of the thumb (posterior interosseous n.)
• Flexion in the IP joint of the thumb (anterior interosseous n.)

50. Assessment of Blood Supply
• Lesion of the medial collateral ligament complex of the
elbow?
• Lesion of the lateral collateral ligament complex of the
elbow?
• Lesion of radio-carpal ligaments?
• Pending or established compartment syndrome?

51. • Collateral circulation of the forearm in the presence of either isolated radial or
ulnar arterial damage is usually sufficient to maintain viability of the hand and
forearm.
• Viability may even be maintained if both the radial and ulnar arteries are
damaged because the longitudinally orientated collateral vessels may still
provide sufficient blood supply
• If one major artery is intact and there is adequate perfusion to the hand, the
damaged vessel does not have to be repaired.
• However, in combination with nerve injuries, it has been argued that recovery
of the associated nerve lesion will be improved by an enhanced blood supply
and vascular repair is therefore advocated.

52. Assessment of Bony Injury
Proximal radio-ulnar joint
• Dislocation or abnormally wide joint space?
• Direction of the dislocation?
• Is the annular ligament probably torn or has the radial
head just slipped out of the intact annular ligament?

53. Interosseous membrane
• Is the membrane torn? If so, proximally or distally?
Distal radio-ulnar joint
• Dislocation
• Abnormal separation
• Shortening of the radius relative to the ulnar head

54. • Nerve injuries in closed forearm fractures are relatively
uncommon.
• posterior interosseous n. most commonly
• Most nerve injuries are neuropraxias

55. • Collateral circulation of the forearm in the presence of
either isolated radial or ulnar arterial damage is usually
sufficient to maintain viability of the hand and forearm.
Viability may even be maintained if both the radial and
ulnar arteries are damaged because the longitudinally
orientated collateral vessels may still provide sufficient
blood supply