Radius and ulnar shaft fractures

Radius and ulnar shaft fractures, if treated inadequately, can result in significant dysfunction of the upper limb. This is due to the important role that the forearm plays in positioning of the hand through pronation and supination (at the proximal and distal radioulnar joint) as well as through flexion and extension at the elbow and wrist.

Epidemiology

Radius and ulnar shaft fractures are common fracture patterns and can be 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.

Associations

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

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 a height where an axial load is applied through the hand to the forearm. 

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 wrist joints are included to assess for proximal or distal extension of the fracture. 

Radiology report

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 fracture
  • angulation, displacement and shortening
• open vs closed: gas in soft tissues or foreign bodies
• underlying bony pathology (e.g. pathological fractures)
• carefully assess the elbow and wrist for secondary injuries (be careful, as these will be suboptimally 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 immobilization and is only indicated in patients that are not surgical candidates. Cast immobilization 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 includes external fixation (indicated in patients with severe soft tissue injury), ORIF (with or without bone grafting), or intramedullary nailing ¹. The majority of patients undergoing surgical management will undergo ORIF with or without bone grafting depending on the degree of bone loss or comminution ³. Union rates for ORIF are >95% with compression plating. Union rates where the fracture is severely comminuted and bridge plating is used are up to 88%. Intramedullary nailing is typically used for surgical candidates where there is poor soft tissue integrity.

Complications

• synostosis
• infection
• compartment syndrome
• non-union (5-12%)
• malunion
• neurovascular injury
• refracture