Both-Bone Forearm Diaphyseal ORIF (Radius & Ulna)

The core principle. The radius and ulna form a functional unit, a forearm joint, linked proximally at the proximal radioulnar joint, distally at the distal radioulnar joint (DRUJ), and along the shaft by the interosseous membrane. The radius rotates around a relatively fixed ulna to produce pronation and supination, sweeping in its characteristic lateral radial bow so that it clears the ulna. Because of this, a displaced both-bone shaft fracture is biomechanically equivalent to an intra-articular fracture: anything less than anatomical restoration of length, rotation, axial alignment and the radial bow compromises rotation. (The biomechanics and deforming forces are laid out in full under Background and Evidence.) Absolute indications - Displaced both-bone forearm fracture in an adult (the overwhelming majority) where closed treatment fails to maintain reduction

• Open fractures, managed with debridement plus plate fixation when the soft tissues allow
• Galeazzi fracture (radial shaft plus DRUJ disruption), a fracture of necessity
• Monteggia fracture (proximal ulna plus radial head dislocation), requiring anatomic ulna fixation
• Fractures with compartment syndrome requiring fasciotomy, stabilising the skeleton at the same setting Relative indications - Minimally displaced both-bone fractures in adults, still usually fixed because even minor malalignment costs rotation
• Segmental or comminuted patterns, managed with bridge-plating principles to restore length, alignment and rotation
• Polytrauma, where early skeletal stabilisation aids overall management Contraindications and cautions - Absolute: active infection at the operative site (treat infection first) or a non-reconstructable, contaminated soft-tissue envelope (temporise with external fixation)
• Relative: children with substantial remodelling potential, in whom most both-bone fractures are managed by closed reduction or flexible intramedullary nailing rather than rigid plating; and severe comorbidity precluding anaesthesia Named forearm fracture-dislocations. These patterns define the injuries that demand operative fixation and the joints you must not miss:

Why cast treatment fails in adults. Powerful deforming forces act on the radius that a cast cannot neutralise: biceps and supinator supinate the proximal fragment, pronator teres acts at the mid-shaft, and pronator quadratus pronates the distal fragment. Maintaining the radial bow and interosseous space in plaster is unreliable, and historical closed-treatment series in adults show high rates of malunion, loss of rotation and nonunion, which is why rigid plate fixation became the standard. Timing and open fractures. Open fractures need urgent debridement with tetanus and antibiotic prophylaxis; definitive plate fixation at the index procedure is appropriate for most Gustilo I to IIIA injuries with a clean, closable wound. With severe contamination or type IIIB to IIIC injuries, consider temporary external fixation and staged definitive fixation. Compartment syndrome demands emergent fasciotomy and must not wait for fixation logistics. Goals of fixation — the Four Restorations. Restore length, restore rotation (using the bicipital tuberosity and radial styloid relationship and the oblique fracture-line key), restore axial alignment in both planes, and restore the radial bow in both magnitude and apex location. Setup and consent. Supine, arm on a radiolucent hand table, upper-arm tourniquet, the arm prepared and draped free to allow full pronation and supination and intra-operative imaging. General or regional (supraclavicular or axillary block) anaesthesia, antibiotic prophylaxis at induction, tetanus cover for open injuries. Counsel specifically regarding PIN and nerve injury, radioulnar synostosis, loss of forearm rotation, nonunion or malunion, infection, compartment syndrome, possible bone graft, and later plate removal with refracture risk.

The goal is to anatomically reduce and rigidly fix each bone through separate incisions, protecting the posterior interosseous nerve and the interosseous membrane, restoring the radial bow, and confirming rotation and the radio-ulnar joints on the table. The exposure of each bone is laid out in full as the first steps of the sequence below.

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Galeazzi — specific sequence. Anatomically reduce and plate the radius (usually through the Henry approach). Then reduce and test the DRUJ: if it is reduced and stable, splint in supination; if it is reduced but unstable, pin the DRUJ in supination with one or two K-wires proximal to the joint for about six weeks and consider the TFCC; if it is irreducible, open the DRUJ, because the extensor carpi ulnaris tendon is the classic interposed structure preventing reduction. Monteggia — specific sequence. Anatomically reduce and plate the ulna, restoring length, alignment and the subtle ulnar bow. The radial head usually reduces once the ulna is anatomic; confirm the radiocapitellar line. If the radial head will not stay reduced, the ulna is not truly anatomic (residual angulation or length) or there is interposition, so revisit the ulnar reduction.

Rehabilitation | Phase | Timing | Immobilisation | Rehabilitation | |-------|--------|----------------|----------------| | 1 | 0 to 2 weeks | Well-padded plaster slab for comfort | Early gentle active motion of elbow, wrist and fingers (rigid fixation) | | 2 | 2 to 6 weeks | Removable splint as needed | Progressive active pronation/supination, elbow and wrist motion; wound review at 10 to 14 days | | 3 | 6 to 12 weeks | Splint for heavy tasks only | Strengthening as union advances; hand therapy for stiffness and oedema | | 4 | 12 weeks and beyond | None | Return to manual work and contact sport after radiographic union and restored strength | With rigid fixation, early active motion of the elbow, wrist and fingers is encouraged from the outset. Light activities and desk work resume within one to two weeks as comfort allows; driving returns when the patient can control the vehicle safely and is out of the slab; heavy manual work and contact sport wait for radiographic union and restored strength, commonly three to four months or more. Forearm rotation can continue to improve for several months. Plate removal — counsel carefully. Routine plate removal is NOT recommended. Diaphyseal forearm plate removal carries a notable refracture risk (reported around 5 to 25 percent). Remove plates only for a clear indication (symptomatic hardware or infection) and only after solid union, generally not before 18 to 24 months, and protect the forearm from significant loading for several weeks afterwards.

Synostosis surveillance. Track pronation and supination at each visit; a plateau or loss of rotation prompts imaging. If synostosis is suspected, CT confirms the bridge and its maturity; intervene (excision with interposition, with or without radiotherapy or indomethacin prophylaxis) only once it is mature, then rehabilitate aggressively. Special situations. Open both-bone fractures need staged soft-tissue care with close observation for infection and compartment syndrome. A Galeazzi injury is often immobilised post-operatively in supination if the DRUJ was unstable or pinned, and the DRUJ wires come out at about six weeks before mobilising rotation. A Monteggia injury needs confirmation and protection of the radial head reduction, with early gentle motion once the ulnar fixation is stable.

The forearm as a joint. The radius and ulna form a functional unit linked proximally at the proximal radioulnar joint, distally at the DRUJ, and along the shaft by the interosseous membrane. The radius rotates around a relatively fixed ulna to produce pronation and supination, sweeping in its characteristic lateral radial bow so that it clears the ulna. A displaced both-bone shaft fracture is therefore biomechanically equivalent to an intra-articular fracture: anything less than anatomical restoration of length, rotation, axial alignment and the radial bow compromises rotation. This is the central principle driving operative management. The radial bow — anatomy and significance. The radius is not straight: it has a lateral (apex-radial) radial bow that lets it rotate around the ulna without impinging. The bow is quantified by its maximum height and its location along the radius (the Schemitsch and Richards method, using the contralateral radius as the template). Restoring the bow correlates with recovery of forearm rotation and grip strength; an over-straightened radius narrows the interosseous space and blocks rotation. The interosseous membrane (its central band is the key stabiliser) links the bones and transfers load, so preserving the interosseous space is essential to rotation. Why cast treatment fails — the deforming forces. Powerful muscle forces act on the radius that a cast cannot neutralise: biceps and supinator supinate the proximal fragment, pronator teres acts at the mid-shaft, and pronator quadratus pronates the distal fragment. Maintaining the radial bow and interosseous space in plaster is unreliable, and historical closed-treatment series in adults show high rates of malunion, loss of rotation and nonunion, which is why rigid plate fixation became the standard. Key evidence. Anderson and colleagues (1975) established compression-plate fixation as the standard for adult both-bone forearm fractures with high union rates. Schemitsch and Richards (1992) showed that restoration of the normal radial bow, both its magnitude and location, correlates with recovery of forearm rotation and grip strength after plate fixation. Chapman and colleagues (1989) confirmed high union and functional rates with 3.5 mm compression-plate fixation in a large series. Bot and colleagues (2011) reported long-term functional outcomes after plate fixation, and Goldfarb and colleagues (2005) documented functional recovery and residual deficits, reinforcing the importance of anatomical reduction.