Fractures of Both Radius and Ulna

A great amount of force is necessary to fracture both the radius and ulna. This injury occurs most often from vehicular trauma, falls from a height, or a direct blow to the forearm. The magnitude of the force determines the type of injury. A moderate force produces transverse or mildly oblique fractures. Comminuted and segmental fractures are produced by a high-impact force. As one might expect, these fractures are often displaced. Open fractures of the radius and ulna are second only to tibia fractures because of the subcutaneous location of the entire ulna and the distal portion of the radius.

Nondisplaced fractures of both bones are exceedingly rare because the force necessary to produce the injury is also sufficient to displace it. However, in this event, a long-arm cast is applied, and frequent reevaluation for potential displacement is necessary.

Displacement of both bones is generally the rule. Examination reveals swelling, deformity, and tenderness of the forearm. Careful assessment of the neurovascular status is imperative. Nerve injuries can be seen with severe open fractures but fortunately are uncommon with most closed injuries. Because of the excellent collateral circulation of the forearm, vascular compromise is generally not a major problem if either the radial or ulnar circulation is intact.

The fractures are clearly visible on the radiographs. Angulation and longitudinal alignment are easily evaluated, but changes in rotational alignment may be subtle. A rough estimate of rotational alignment can be made by noting the normal orientation of various bony prominences of these bones. On the anteroposterior radiograph, the radial styloid and radial (bicipital) tuberosity normally point in opposite directions, whereas the ulnar styloid and coronoid process do so on the lateral view. A change in this arrangement suggests rotation malalignment. Since these bones are also oblong rather than circular in their cross-sectional appearance, a sudden change in the bone's width at the fracture site is another clue to a rotational deformity.

Although there are some reports of adequate reduction using closed techniques, the potential for these injuries to subsequently displace, in spite of cast immobilization, makes this alternative unpredictable. An exception is the injury in a child. A child's ability to remodel bone and compensate for some malalignment makes closed reduction possible. Otherwise, these injuries invariably require open reduction and internal fixation, most commonly with compression plating and screws. The use of external fixation may be necessary in situations where infection is possible, such as severe open fractures, comminution, or bone loss. Internal fixation is delayed until the risk of infection is diminished.

Potential complications include reduced ability to supinate and pronate, osteomyelitis, nonunion, malunion, neurovascular injury, and compartment syndrome. Recognizing the development of a compartment syndrome is particularly important to prevent debilitating ischemic contractures of the forearm. The diagnostic findings are palpable induration of the area, pain with passive movement of the fingers, and pain that appears to be disproportionate to the physical findings. The presence of a palpable pulse does not exclude the diagnosis of compartment syndrome. Alterations in sensation and the pulse are late findings. Direct measurements of elevated compartment pressures confirm the diagnosis.

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