Midshaft ulna and radius fractures in adults
- Nathaniel Nye, MD
Nathaniel Nye, MD
- Adjunct Assistant Professor of Family Medicine
- Uniformed Services University
- Anthony Beutler, MD
Anthony Beutler, MD
- Associate Professor of Family Medicine
- Uniformed Services University
- Section Editors
- Patrice Eiff, MD
Patrice Eiff, MD
- Section Editor — Adult Orthopedics; Sports-Related Injuries
- Professor of Family Medicine
- Oregon Health & Science University
- Chad A Asplund, MD, FACSM, MPH
Chad A Asplund, MD, FACSM, MPH
- Associate Professor of Health and Kinesiology
- Director of Athletic Medicine
- Head Team Physician
- Georgia Southern University
The hand is a vital structure for a multitude of motor tasks, and the forearm contributes a great deal to the hand's versatility. The forearm allows the hand to interact with objects remote from the body, and enables it to pronate and supinate, capabilities that are essential for many activities of daily living, as well as technical skills such as those required for music and sports. The forearm also plays an important role in protecting the head and torso from trauma, which explains in part why fractures of the forearm are among the most common fractures.
Given the many important roles of the forearm, it is no surprise that forearm fractures can result in considerable disability, especially if treated improperly. The epidemiology, clinical anatomy, assessment, diagnosis, and management of midshaft fractures of the radius and ulna in adults will be reviewed in this topic, including Galeazzi and Monteggia fracture-dislocations. Distal forearm fractures and pediatric midshaft forearm fractures are discussed separately. (See "Distal radius fractures in adults" and "Midshaft forearm fractures in children" and "Proximal fractures of the forearm in children".)
EPIDEMIOLOGY AND RISK FACTORS
Although forearm fractures are relatively common, studies of the epidemiology of diaphyseal fractures of the forearm are scant. The incidence of diaphyseal fracture of the radius, ulna, or both is reported to be approximately 1 to 10 per 10,000 persons per year, although rates vary by age and sex. Studies show a bimodal distribution with the highest incidence among young males aged 10 to 20 years (10:10,000) and females over age 60 (5:10,000) [1-3]. Diaphyseal forearm fractures occur far less frequently than distal forearm fractures [1,2].
Risk factors for diaphyseal forearm fractures include sports participation, postmenopausal status, osteoporosis, and frequent walking on icy surfaces (eg, as occurs in cold climates such as Canada or Sweden) [1,2]. Football and wrestling are the highest-risk sports with 0.48 and 0.21 midshaft forearm fractures per 10,000 high-school athletic exposures, respectively . While postmenopausal status increases the risk for both distal and midshaft forearm fractures, it increases the risk for distal fractures far more (nearly an order of magnitude in some studies) [1,2,5].
Galeazzi fractures (radial midshaft fractures with distal radioulnar joint [DRUJ] instability) account for 7 percent of all forearm fractures. Of all fractures involving only the radial shaft, one in four is a true Galeazzi injury. The less common Monteggia fracture dislocation (fracture of the proximal third of the ulnar shaft with dislocation of the radial head) comprises 1 to 2 percent of all forearm fractures .
- Jónsson B, Bengnér U, Redlund-Johnell I, Johnell O. Forearm fractures in Malmö, Sweden. Changes in the incidence occurring during the 1950s, 1980s and 1990s. Acta Orthop Scand 1999; 70:129.
- Bengnér U, Johnell O. Increasing incidence of forearm fractures. A comparison of epidemiologic patterns 25 years apart. Acta Orthop Scand 1985; 56:158.
- ALFFRAM PA, BAUER GC. Epidemiology of fractures of the forearm. A biomechanical investigation of bone strength. J Bone Joint Surg Am 1962; 44-A:105.
- Swenson DM, Yard EE, Collins CL, et al. Epidemiology of US high school sports-related fractures, 2005-2009. Clin J Sport Med 2010; 20:293.
- Streubel P, Pesantez R. Diaphyseal fractures of the radius and ulna. In: Rockwood and Green's Fractures in Adults, 8th ed, Court-Brown CM, Heckman JD, McQueen MM, et al. (Eds), Wolters Kluwer Health, Philadelphia 2014. p.1121.
- Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg Am 2003; 85-A:2343.
- Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989; 71:159.
- Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and the ulna on supination and pronation. J Bone Joint Surg Br 2002; 84:1070.
- Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am 1982; 64:14.
- Eiff M, Hatch R. Radius and Ulna Fractures. In: Fracture Management for Primary Care, 3rd ed, Saunders/Elsevier, Philadelphia 2012. p.102.
- Yanagibayashi S, Yamamoto N, Yoshida R, Sekido M. Magnetic Resonance Imaging Visualizes Median Nerve Entrapment due to Radius Fracture and Allows Immediate Surgical Release. Case Rep Orthop 2015; 2015:703790.
- Spar I. A neurologic complication following Monteggia fracture. Clin Orthop Relat Res 1977; :207.
- Engber WD, Keene JS. Anterior interosseous nerve palsy associated with a Monteggia fracture. A case report. Clin Orthop Relat Res 1983; :133.
- Suganuma S, Tada K, Hayashi H, et al. Ulnar nerve palsy associated with closed midshaft forearm fractures. Orthopedics 2012; 35:e1680.
- Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am 1998; 80:1733.
- Reckling FW. Unstable fracture-dislocations of the forearm (Monteggia and Galeazzi lesions). J Bone Joint Surg Am 1982; 64:857.
- Schulte LM, Meals CG, Neviaser RJ. Management of adult diaphyseal both-bone forearm fractures. J Am Acad Orthop Surg 2014; 22:437.
- Zych GA, Latta LL, Zagorski JB. Treatment of isolated ulnar shaft fractures with prefabricated functional fracture braces. Clin Orthop Relat Res 1987; :194.
- Atkin DM, Bohay DR, Slabaugh P, Smith BW. Treatment of ulnar shaft fractures: a prospective, randomized study. Orthopedics 1995; 18:543.
- Handoll HH, Pearce P. Interventions for treating isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev 2012; :CD000523.
- HUGHSTON JC. Fracture of the distal radial shaft; mistakes in management. J Bone Joint Surg Am 1957; 39-A:249.
- Kloen P, Wiggers JK, Buijze GA. Treatment of diaphyseal non-unions of the ulna and radius. Arch Orthop Trauma Surg 2010; 130:1439.
- Anderson LD, Sisk D, Tooms RE, Park WI 3rd. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975; 57:287.
- Hertel R, Eijer H, Meisser A, et al. Biomechanical and biological considerations relating to the clinical use of the Point Contact-Fixator--evaluation of the device handling test in the treatment of diaphyseal fractures of the radius and/or ulna. Injury 2001; 32 Suppl 2:B10.
- Ross ER, Gourevitch D, Hastings GW, et al. Retrospective analysis of plate fixation of diaphyseal fractures of the forearm bones. Injury 1989; 20:211.
- Stevens CT, ten Duis HJ. Plate osteosynthesis of simple forearm fractures: LCP versus DC plates. Acta Orthop Belg 2008; 74:180.
- Jones DB Jr, Kakar S. Adult diaphyseal forearm fractures: intramedullary nail versus plate fixation. J Hand Surg Am 2011; 36:1216.
- Rehman S, Sokunbi G. Intramedullary fixation of forearm fractures. Hand Clin 2010; 26:391.
- Choi SJ, Ahn JH, Ryu DS, et al. Ultrasonography for nerve compression syndromes of the upper extremity. Ultrasonography 2015; 34:275.
- EPIDEMIOLOGY AND RISK FACTORS
- MECHANISM OF INJURY
- CLINICAL PRESENTATION AND EXAMINATION
- CLASSIFICATION OF MIDSHAFT FOREARM FRACTURES
- Questions for characterizing fractures
- Galeazzi fractures
- Monteggia fractures
- RADIOGRAPHIC FINDINGS
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- INITIAL TREATMENT AND FOLLOW-UP
- Isolated ulnar shaft (“nightstick”) fracture
- - Initial treatment
- - Definitive treatment
- - Follow-up radiographs
- Isolated radial shaft fracture
- - Initial treatment
- Galeazzi fracture-dislocations
- - Initial treatment
- Combined radius and ulna (both-bone) fractures
- - Non-operative treatment
- - Operative treatment
- Monteggia fracture-dislocations
- RETURN TO SPORT OR WORK
- SUMMARY AND RECOMMENDATIONS