Radius and ulnar shaft fractures

Epidemiology

Radius and ulnar shaft fractures are a common fracture pattern and can be as a result of either direct or indirect trauma. They are also known as “both bone forearm fractures” ^1,2,4.  These fractures have a bimodal age distribution and typically occur in young males aged between 10-20 years or females over the age of 60 years.

Pathology

Mechanism

The mechanism may either be by direct trauma to the forearm, such as a direct force to the forearm, or indirectly, such as a motor vehicle accident or fall from height where an axial load is applied through the hand to the forearm. 

Associated injuries/conditions include:

• Galeazzi fractures
• Monteggia fractures
• Essex-Lopresti injuries
• Compartment syndrome

Radiographic features

Plain radiography

Although transverse fractures are usually easy to identify, oblique or spiral fractures can be very difficult to identify in a single view. The radiographic series comprises an AP and a lateral projection to allow adequate assessment of angulation, displacement and shortening. It is essential both the elbow and wrists joints are included to assess for proximal or distal extension of the fracture. 

Report checklist

In addition to reporting on the presence of a fracture, a number of features should be assessed and commented on:

• fracture
  • location and extension to metaphysis/epiphysis/articular surface
  • type of fracture (transverse, spiral, oblique)
  • comminution/segmental
  • angulation, displacement and shortening
• open vs. closed; gas in soft tissues or foreign bodies
• underlying bony lesions (i.e. pathological fractures)
• carefully assess the elbow and wrist for secondary injuries (be careful, as these will be sub-optimally imaged unless dedicated views are obtained)
• post-operative

Treatment and prognosis

Treatment may be non-operative or operative.

Non-operative management is usually cast or brace immobilisation and is only indicated in patients that are not surgical candidates. Cast immobilisation typically extends above the elbow to allow for control of forearm rotation 1. Non-operative management is associated with higher rates of non-union ¹.

Operative management ¹ includes external fixation (indicated in patient with severe soft tissue injury), ORIF (with or without bone grafting) or intra-medullary nailing. Majority of patient undergoing surgical management will undergo ORIF with ³ or without bone grafting depending on the degree of bone loss or comminution. Union rates for ORIF are > 95% with compression plating. Union rates where the fracture is severely comminuted and bridge plating is used has union rates up to 88%. Intra-medullary nailing is typically used for surgical candidates where there is poor soft tissue integrity.

Complications include:

• Synostosissynostosis
• Infectioninfection
• Compartmentcompartment syndrome
• Nonnon-union (5-12%)
• Malunionmalunion
• Neurovascularneurovascular injury
• Refracturerefracture