High-yield overview

Supine on an Arm Table | Two Separate Incisions | Restore the Radial Bow | Prevent Synostosis

2 incisionsSeparate radius and ulna exposures with a skin bridge

~10 mmMagnitude of the normal lateral radial bow to restore

3.5 mmStandard compression or locking plate for forearm diaphyseal fractures

SupineSingle positioning on a radiolucent arm table

Critical Must-Knows

Two SEPARATE incisions with a generous skin bridge of at least 5 to 7 cm - never a single incision across the interosseous membrane - minimise radioulnar (cross-union) synostosis.
Volar Henry internervous plane: brachioradialis (radial nerve) and pronator teres / flexor carpi radialis (median nerve).
Restore the radial bow: a single lateral bow of about 10 mm with its apex near the junction of the middle and distal thirds (about 60 percent of forearm length from the distal end).
The posterior interosseous nerve (PIN) is the critical structure at risk on the radius, especially in the dorsal Thompson approach through supinator - keep the forearm pronated.
Do NOT place bone graft in the interosseous space - it provokes synostosis; the forearm is a functional joint that needs anatomic length, alignment and rotation.

When & Why

What it exposes. The combined two-incision approach gives independent, direct access to both the radial and ulnar diaphyses so each bone is reduced and plated through its own exposure: the volar Henry (or dorsal Thompson) to the radius and the direct dorsoulnar approach to the subcutaneous ulna. It is the workhorse exposure for ORIF of displaced both-bone forearm fractures in adults. Why two incisions, never one. The forearm is a functional joint whose motion depends on anatomic length, rotation and the radial bow. A single incision crossing the interosseous membrane strips the soft tissues of both bones, devascularises fragments and dramatically increases the rate of radioulnar (cross-union) synostosis - a complication that permanently abolishes pronation-supination and is extremely difficult to treat. Two separate incisions preserve the interosseous membrane, respect each bone's soft-tissue envelope, and allow early motion. Position & landmarks. The patient is supine on a radiolucent table with the affected arm on a hand table and a high-arm tourniquet. The limb is draped free so it can rotate from full supination (for the volar Henry radius exposure) to pronation (for the ulna and the dorsal Thompson radius exposure), letting both incisions be completed from one position. An image intensifier is brought in from the head of the table. Surface landmarks: for the volar Henry, the brachioradialis and flexor carpi radialis tendons (with the biceps tendon and radial styloid marking proximal and distal extent); for the dorsal Thompson, a line from the lateral epicondyle to Lister's tubercle; and for the ulna, the entire subcutaneous (dorsoulnar) border from olecranon to ulnar styloid. Incision planning. Mark two separate longitudinal incisions, each centred over its fracture under fluoroscopy, separated by a skin bridge of at least 5 to 7 cm of healthy skin. Never connect the incisions across the interosseous membrane.

Mark the skin bridge before incising

Draw both incisions on the skin with the limb in neutral rotation and confirm the fracture levels under fluoroscopy before cutting. A skin bridge of at least 5 to 7 cm over healthy skin prevents edge necrosis and stops both plates sharing one devascularised soft-tissue envelope - the situation that breeds infection and synostosis.

The Exposure

All three exposures use a true internervous plane, so each interval can be developed without denervating muscle. Work the radius and the ulna as two independent dissections, protecting the PIN, the radial artery and leash of Henry, and the ulnar neurovascular bundle.

The three internervous planes
Exposure	Plane (lateral to medial)	Nerves	Typical use
Radius - Volar Henry	Brachioradialis and pronator teres / FCR	Radial nerve and median nerve	Workhorse for most diaphyseal radial fractures
Radius - Dorsal Thompson	ECRL / ECRB and extensor digitorum communis	Radial nerve and posterior interosseous nerve	Proximal-third radial fractures
Ulna - dorsoulnar	Extensor carpi ulnaris and flexor carpi ulnaris	Posterior interosseous nerve and ulnar nerve	Direct subcutaneous exposure of the ulna

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Image Needed: Clinical PhotoHigh Priority

Intra-operative photograph of a two-incision both-bone forearm ORIF showing two separate longitudinal wounds over the radius and ulna separated by an intact skin bridge, with plates applied to the volar radius and the subcutaneous ulnar border.

Context: A verified image is being sourced for this exposure.

Pending image generation or sourcing

Exposure sequence

Step 1Plan and mark the two incisions

Confirm the patient is supine on a radiolucent arm table with a high-arm tourniquet and the limb draped free for full pronation and supination.
Mark two separate longitudinal incisions over each fracture under fluoroscopy, keeping a skin bridge of at least 5 to 7 cm.
Never connect the incisions across the interosseous membrane - this is the cardinal error that precipitates synostosis.

Step 2Radius - volar Henry, superficial dissection

Incise skin and superficial fascia along the brachioradialis line.
Identify and protect the superficial branch of the radial nerve and the lateral antebrachial cutaneous nerve as they cross the proximal wound over brachioradialis.
Open the fascia and define the interval between brachioradialis (lateral) and pronator teres / flexor carpi radialis (medial) - a true internervous plane (radial versus median).

Step 3Radius - volar Henry, deep dissection

Proximally, identify and ligate the leash of Henry (radial recurrent vessels) to mobilise brachioradialis.
Retract brachioradialis laterally, carrying the radial artery and superficial radial nerve with it; retract FCR and FDS medially - the radial artery is never retracted medially.
Expose the radius by sweeping pronator teres (proximal) and pronator quadratus (distal) off the bone subperiosteally, pronating and supinating to deliver the desired surface.
Near the bicipital tuberosity, supinate to bring the supinator and biceps insertion into view and strip supinator off the radius subperiosteally, keeping the PIN protected.

Step 4Ulna - dorsoulnar exposure

Incise directly onto the subcutaneous border of the ulna.
Develop the interval between extensor carpi ulnaris (dorsal, PIN) and flexor carpi ulnaris (volar, ulnar nerve).
The ulnar nerve and ulnar artery lie volar to FCU - protect them by staying strictly subperiosteal on the ulnar border.
Distally, identify and protect the dorsal sensory branch of the ulnar nerve.

Step 5Radius - dorsal Thompson (alternative, proximal third)

Reserved for proximal-third radial shaft fractures; incise along the line from the lateral epicondyle to Lister's tubercle.
Develop the interval between ECRL / ECRB (radial nerve) and extensor digitorum communis (PIN).
Identify the PIN as it emerges from supinator, pronate the forearm to carry the nerve away, then elevate or split supinator from its radial insertion subperiosteally to expose the proximal shaft.

Protect the posterior interosseous nerve - pronate, stay subperiosteal

The PIN is the most important structure at risk on the radius. It emerges between the superficial and deep heads of supinator and winds around the radial neck within its substance, where it is vulnerable in the dorsal Thompson approach and the proximal deep Henry exposure. Injury causes loss of finger and thumb extension while sparing sensation and radial wrist extension. Pronate the forearm to carry the nerve away from the dorsal field, stay strictly subperiosteal on bone, and never let a retractor lever on the radial neck.

Henry versus Thompson - the PIN is the deciding factor

The volar Henry keeps dissection anterior to supinator and therefore anterior to the PIN, which is why it is safer and the default for most radial shaft fractures. The dorsal Thompson works through supinator and brings the PIN into the field - choose it for proximal-third fractures only when you can confidently identify, pronate-protect and gently retract the nerve.

Dangers & Extensions

Structures at risk, by layer

Danger structures and how to protect them
Layer	Structure at risk	Protection
Superficial (radius)	Superficial radial nerve and lateral antebrachial cutaneous nerve	Identify early, gentle retraction, avoid traction in the proximal volar wound
Superficial (distal ulna)	Dorsal sensory branch of the ulnar nerve	Identify distally and protect
Deep (radius, Henry)	Radial artery and the leash of Henry (radial recurrent vessels)	Ligate the leash; retract the artery laterally with brachioradialis, never medially
Deep (radius, Thompson / proximal Henry)	Posterior interosseous nerve in supinator	Pronate the forearm; stay subperiosteal on bone; no retractor on the radial neck
Deep (ulna)	Ulnar nerve and ulnar artery	Stay subperiosteal on the subcutaneous border
Interosseous	Interosseous membrane	Do not violate; prevents synostosis

Extensile options. The volar Henry extends proximally into the antecubital fossa to reach the bicipital tuberosity and elbow, and distally to the volar wrist and distal radius. The dorsal Thompson extends proximally to the lateral elbow and distally to the dorsal wrist. The ulnar approach runs along the entire subcutaneous border from olecranon to ulnar styloid, so it can be lengthened freely in either direction. Closure. Irrigate copiously and achieve meticulous haemostasis. Close the deep fascia loosely over each plate - do not strangulate muscle and never close across the interosseous space. Re-approximate the elevated origins of supinator or pronator where they were raised, then close subcutaneous tissue and skin, ensuring the skin bridge stays well perfused. A suction drain is rarely required.

Procedures Through This Approach

Both-bone forearm fracture ORIF - the principal operation done through this exposure.
Isolated diaphyseal radius or ulna fractures, Monteggia and Galeazzi fracture-dislocations, and revision fixation or plate removal. Sequencing. As a general rule, reduce and plate the simpler, less comminuted fracture first - very often the ulna, because its straight subcutaneous border makes length and rotation straightforward to restore - then use the fixed bone as a template for length and rotation of the other. For highly comminuted fractures, restore length by using the plate as a bridge and confirm against the contralateral forearm. Restore the radial bow. The radius carries a single lateral bow of about 10 mm (range roughly 7 to 15 mm) with its apex near the junction of the middle and distal thirds, about 60 percent of forearm length from the distal end. Use pre-contoured 3.5 mm forearm plates and confirm magnitude, apex location and rotational alignment fluoroscopically before final screws.

Plating strategy by fracture pattern
Pattern	Strategy	Plate length	Additional measure
Transverse	Compression plating	3.5 mm LC-DCP, six cortices each side	Eccentric screw placement for compression
Short oblique or spiral	Lag screw and neutralisation plate	3.5 mm plate spanning the fracture	Interfragmentary lag screw first
Comminuted (B/C)	Bridge plating	Longer locking plate bypassing comminution	Restore length using the contralateral side as a guide
Segmental bone loss	Bridge plate with bone graft	Long plate, defect grafted away from the interosseous space	Consider primary shortening within acceptable limits

Plating principles. Use a 3.5 mm limited-contact dynamic compression or locking compression plate; for a simple fracture aim for six cortices (three bicortical screws) each side, with longer bridge plates for comminution. Apply an interfragmentary lag screw for suitable oblique or spiral patterns before the neutralisation plate. The radial plate sits on the flat volar (tension) surface and the ulnar plate on the subcutaneous border; use locking screws in osteoporotic bone or periarticular comminution. Bone graft. Reserve autograft for genuine bone loss or marked comminution, and never place it in the interosseous space between the radius and ulna. Check the radioulnar joints. After fixation, assess the proximal radioulnar joint (exclude a Monteggia pattern - confirm the radial head is reduced and stable) and the distal radioulnar joint (exclude a Galeazzi pattern - confirm the ulnar head is stable) through a full arc of pronation and supination. If either is unstable, reduce and stabilise it.

Viva & Exam Focus

Mnemonic

FOREARMOperative workflow - two-incision both-bone ORIF

Fluoroscopy and position

Supine, arm table, free draping for supination and pronation

One bone first

Reduce and plate the simpler fracture to set length

Radial exposure

Volar Henry between brachioradialis and flexor carpi radialis

Expose and protect nerves

PIN pronated; superficial radial nerve and radial artery lateral

Anatomic radial bow

Contour the plate to restore the lateral bow

Recheck radioulnar joints

Proximal and distal radioulnar joint stability through full arc

Move early

Early pronation-supination to prevent synostosis

Mnemonic

SYNOSTOSISPreventing radioulnar synostosis

Separate incisions

Never one incision across the interosseous membrane

Yield a skin bridge

Keep at least 5 to 7 cm of intact skin between wounds

No graft in the interosseous space

Cancellous graft provokes cross-union if placed between the bones

Only light subperiosteal dissection

Preserve the soft-tissue envelope of each bone

Stable anatomic fixation

Rigid plating so motion can begin immediately

Two-bone reduction

Restore length, rotation and the radial bow

Operate early

Definitive fixation within about the first three weeks

Start early motion

Active pronation-supination as soon as stable

Interosseous membrane preserved

Do not violate the space between radius and ulna

Sterile haemostasis

Meticulous irrigation and control of bleeding

Clinical Decision Scenarios

Practise clinical reasoning and management decisions out loud

Viva scenarioStandard

Clinical prompt

“A 28-year-old sustains a closed both-bone forearm fracture in a fall onto an outstretched hand. Describe your surgical approach and the principles of fixation.”

Practical approach

I would first complete an ATLS trauma survey, as these are often high-energy injuries with associated head, chest or other limb trauma, and examine the limb for open injury and compartment syndrome (pain on passive stretch, a tense forearm) while documenting radial, ulnar, median, anterior interosseous and posterior interosseous nerve function plus radial and ulnar pulses. Imaging is AP and lateral radiographs of the forearm including the elbow and wrist to exclude Monteggia and Galeazzi patterns. A displaced both-bone forearm fracture in an adult is treated operatively with ORIF and plating of both bones, because the forearm is a functional joint and any residual angulation, length mismatch or loss of the radial bow restricts pronation-supination. I position the patient supine on a radiolucent arm table with a high-arm tourniquet and the limb draped free, and use two separate incisions with a skin bridge of at least 5 to 7 cm - a volar Henry approach to the radius and a direct dorsoulnar approach to the ulna - never a single incision across the interosseous membrane. For the radius I develop the internervous plane between brachioradialis (radial nerve) and FCR and pronator teres (median nerve), ligate the leash of Henry and retract brachioradialis, the radial artery and the superficial radial nerve laterally, sweeping pronator off the bone subperiosteally. For the ulna I incise onto the subcutaneous border and develop the interval between ECU (PIN) and FCU (ulnar nerve), staying subperiosteal to protect the ulnar neurovascular bundle. I usually fix the simpler fracture first to restore length, then template the other bone, applying 3.5 mm compression or locking plates with six cortices each side and taking care to restore the radial bow of about 10 mm with its apex at the middle-to-distal third junction. I place no graft in the interosseous space and re-check the proximal and distal radioulnar joints through a full arc for stability, then close fascia loosely over each plate and begin early active pronation-supination.

Key clinical points

ATLS survey first; exclude compartment syndrome and document nerves

Radiographs must include the elbow and wrist to detect Monteggia and Galeazzi patterns

Two separate incisions with a skin bridge - never a single trans-interosseous incision

Volar Henry plane: brachioradialis (radial) and FCR or pronator teres (median)

Ulnar plane: extensor carpi ulnaris (PIN) and flexor carpi ulnaris (ulnar nerve)

Restore the radial bow of about 10 mm with 3.5 mm plates and six cortices per side

No graft in the interosseous space; re-check the radioulnar joints; move early

Common pitfalls

Treating the forearm as a long bone rather than a joint, accepting imperfect reduction

Using a single incision across the interosseous membrane, inviting synostosis

Failing to restore the magnitude or apex location of the radial bow

Missing an associated Monteggia or Galeazzi lesion by not imaging the elbow and wrist

Prolonged immobilisation instead of early motion

Further questions

“How would you manage an open both-bone forearm fracture, and how do you judge whether the distal radioulnar joint is stable after a Galeazzi pattern?”

Viva scenarioAdvanced

Clinical prompt

“Six months after a both-bone forearm ORIF a patient has almost no pronation or supination and a CT confirms a radioulnar synostosis. How do you explain this and what are the options?”

Practical approach

Radioulnar (cross-union) synostosis is a recognised complication of both-bone forearm fractures. The principal risk factors are a single incision across the interosseous membrane, bone graft or bone dust left in the interosseous space, high-energy injury with extensive soft-tissue stripping, fractures at the same level, an operating delay, and prolonged immobilisation; a bony bridge forms across the interosseous membrane and physically blocks rotation. Prevention - the key teaching point - rests on two separate incisions with a skin bridge, meticulous subperiosteal dissection that preserves the interosseous membrane, no bone graft between the bones, stable fixation that permits early motion, and early active pronation-supination. For the established synostosis I document the fixed position and functional deficit and obtain a CT to define the extent and maturity of the cross-union and its relationship to the implants, counselling the patient that results are imperfect and recurrence is common. If the limb is fused in a functional position and the patient copes, observation and functional adaptation are reasonable. For a disabling block I excise the synostosis, removing bone from the interosseous space and supplementing with an interposition graft or flap (for example an anconeus muscle flap, or silicone or fat interposition) to reduce recurrence, using NSAIDs and sometimes single-fraction radiotherapy as adjuvants to suppress heterotopic bone, followed by intensive early motion. Recurrence is the main problem, and outcomes are best when a mature synostosis is excised in a motivated patient with a strong therapy programme.

Key clinical points

Synostosis is a cross-union between radius and ulna across the interosseous membrane

Risk factors: single incision, interosseous graft, high energy, same-level fractures, delay, immobilisation

Prevention: two incisions, no interosseous graft, stable fixation and early motion

CT defines the extent and maturity of the cross-union

Non-operative care is reasonable if the limb is in a functional position

Operative option is excision with interposition, NSAIDs and sometimes radiotherapy

Recurrence is common and outcomes are imperfect

Common pitfalls

Blaming patient factors instead of the preventable surgical choices (single incision, interosseous graft)

Resecting an immature synostosis too early, risking recurrence

Excising without interposition or adjuvant prophylaxis

Promising full restoration of rotation after resection

Further questions

“Which operative choices most strongly predict synostosis, and what interposition materials are used after excision?”

Viva scenarioAdvanced

Clinical prompt

“After fixing a proximal-third radial shaft fracture through a dorsal Thompson approach, the patient cannot extend the fingers or thumb, although wrist extension and sensation are preserved. What is the diagnosis and how do you manage it?”

Practical approach

This is a posterior interosseous nerve (PIN) palsy. The PIN is motor only, which is why sensation is intact; it supplies the finger and thumb extensors and extensor carpi ulnaris, while the radial wrist extensors are supplied proximal to the PIN and so wrist extension is preserved - making the pattern of lost finger and thumb extension with preserved sensation and retained radial wrist extension classic. In the dorsal Thompson approach the PIN is at risk as it emerges from between the two heads of supinator and winds around the radial neck within supinator, injured by retraction, traction, a retractor levering on the radial neck, or a laceration; failure to pronate the forearm, which carries the PIN away from the dorsal field, is the typical technical error. I perform a full motor and sensory examination, document the deficit precisely, exclude a tight dressing or compartment syndrome, and review the operative note for whether the nerve was identified and protected. Most deficits are neurapraxia from traction and recover; I splint the fingers and thumb in a functional position to prevent contracture, counsel the patient on the expected timeline, and arrange electrophysiological studies at around three to four weeks to grade the injury. If there is no clinical or electrophysiological recovery by about three months I would consider surgical exploration, and for a permanent palsy, tendon transfers (for example ECRL to EDC, with palmaris longus or FCR rerouting) restore active finger and thumb extension. Prevention in future cases is to identify the PIN, keep the forearm pronated during supinator dissection, stay subperiosteal on bone, and avoid retractors levering on the radial neck.

Key clinical points

PIN palsy: loss of finger and thumb extension with preserved sensation and radial wrist extension

The PIN is motor only and is at risk in supinator during the dorsal Thompson approach

Pronation of the forearm carries the PIN away from the dorsal field

Most deficits are neurapraxia and recover

Splint to prevent contracture and arrange electrophysiology at three to four weeks

Consider exploration if there is no recovery by about three months

Tendon transfers are the salvage for a permanent palsy

Common pitfalls

Confusing a PIN palsy with a complete radial nerve palsy (sensation is intact in PIN injury)

Reassuring the patient of full recovery without electrophysiological grading

Not splinting, allowing extension contractures to develop

Delaying exploration indefinitely when there is axonotmesis

Further questions

“How does the clinical picture differ between a PIN palsy and a high radial nerve injury, and what tendon transfers restore finger and thumb extension?”

Exam day cheat sheet

Combined two-incision both-bone forearm approach - exam-day essentials

Position & setup

Supine on a radiolucent arm table, high-arm tourniquet, limb draped free
Rotate from supination (volar radius) to pronation (ulna, dorsal radius)
Two separate longitudinal incisions with a skin bridge of at least 5 to 7 cm
C-arm from the head of the table

Internervous planes

Radius - Volar Henry: brachioradialis (radial) and pronator teres or FCR (median)
Radius - Dorsal Thompson: ECRL and ECRB (radial) and EDC (PIN)
Ulna: ECU (PIN) and FCU (ulnar nerve)
All three are true internervous planes

Structures at risk

PIN in supinator - pronate to protect (Thompson and proximal Henry)
Radial artery and leash of Henry - ligate the leash, retract artery laterally
Superficial radial nerve and lateral antebrachial cutaneous nerve proximally
Ulnar nerve and artery volar to FCU - stay subperiosteal
Dorsal sensory branch of the ulnar nerve distally

Restore the radial bow

Single lateral bow of about 10 mm (range roughly 7 to 15 mm)
Apex at the middle-to-distal third junction, about 60 percent from the distal end
Pre-contoured 3.5 mm forearm plates
Confirm magnitude, apex and rotation fluoroscopically

Fixation principles

3.5 mm compression or locking plates
Six cortices each side for a simple fracture; bridge plates for comminution
Lag screw before neutralisation for oblique or spiral patterns
Fix the simpler fracture first to set length
No bone graft in the interosseous space

Closure & synostosis prevention

Close fascia loosely over each plate; never across the interosseous space
Preserve the skin bridge
Re-check proximal and distal radioulnar joint stability through a full arc
Early active pronation-supination once stable
Triad: two incisions, no interosseous graft, early motion

References

Diaphyseal both-bone forearm fractures in adults are managed worldwide by open reduction and internal fixation with plating of both the radius and the ulna through two separate incisions. The principle that the forearm is a functional joint, requiring anatomic restoration of length, rotation and the radial bow, is common to the AO Foundation, BOA/BOAST guidance, AAOS, and the European (EFORT/advanced orthopaedic practice) and Australasian (advanced orthopaedic practice) examination systems. Side-by-side principles (where guidance converges): | Body | Position on forearm shaft fractures | |------|-------------------------------------| | AO Foundation | Anatomic reduction and stable 3.5 mm plating of both bones; two separate approaches to preserve the interosseous membrane; early motion; lag screw and neutralisation for simple patterns, bridge plating for comminution | | BOA / BOAST (open fractures) | Urgent washout and staged soft-tissue care for open injuries; definitive fixation once the soft-tissue envelope permits; antibiotic and tetanus prophylaxis | | OTA / AAOS | Operative fixation for displaced adult both-bone fractures; non-operative only for undisplaced or low-demand patients | Population and outcome evidence: - Diaphyseal forearm fractures show a bimodal distribution - high-energy injuries in young adults (often men) and lower-energy fractures in older adults.

Modern compression-plating series report union in the great majority of adult both-bone fractures, with functional outcome driven by restoration of the radial bow and rotation rather than by patient age. Global practice variation: In well-resourced settings, pre-contoured locking plates and routine fluoroscopy are standard and the volar Henry approach is the workhorse for the radius. In resource-limited settings the same biomechanical principles are achieved with standard small-fragment implants and the subcutaneous ulnar exposure is unchanged; external fixation has a limited role for polytrauma or open injuries as a temporising measure. Consent (globally applicable): discuss posterior interosseous or superficial radial nerve injury, radioulnar synostosis, non-union or mal-union with loss of the radial bow and restricted rotation, compartment syndrome, infection, symptomatic hardware, and the small possibility of re-operation for removal of metalwork or synostosis excision.

Evidence

Compression-Plate Fixation in Acute Diaphyseal Fractures of the Radius and Ulna

Anderson LD, Sisk TD, Tooms RE, Park WI • Journal of Bone and Joint Surgery (Am) (1975)

Landmark series establishing compression plating as the standard for adult diaphyseal forearm fractures, reporting high union rates with rigid plating of both the radius and the ulna, demonstrating that stable fixation permits early motion, and setting the benchmark for plate-and-screw fixation against non-operative and intramedullary methods.

Evidence

The Effect of Malunion on Functional Outcome After Plate Fixation of Fractures of Both Bones of the Forearm in Adults

Schemitsch EH, Richards RR • Journal of Bone and Joint Surgery (Am) (1992)

Defined the normal lateral radial bow in magnitude and location; showed that restoration of the radial bow and radial length correlated with improved grip strength and range of motion, and that residual malunion predicted poorer functional outcome - underpinning the operative imperative to anatomically restore the radial bow.

Evidence

Compression-Plate Fixation of Acute Fractures of the Diaphyses of the Radius and Ulna

Chapman MW, Gordon JE, Zissimos AG • Journal of Bone and Joint Surgery (Am) (1989)

Large clinical series of compression plating for acute forearm diaphyseal fractures, confirming very high union rates with plate fixation of both bones, supporting early active motion after stable fixation, and reinforcing plating as superior to conservative management for displaced adult fractures.

Evidence

Cross-Union Complicating Fracture of the Forearm

Vince KG, Miller JE • Journal of Bone and Joint Surgery (Am) (1987)

Defined radioulnar (cross-union) synostosis as a complication of both-bone forearm fractures and associated it with high-energy injury, fractures at the same level, and bone graft or dissection in the interosseous space - supporting two separate incisions and avoidance of interosseous dissection to prevent cross-union.

Evidence

Prognostic Factors for Functional Outcome Following Open Reduction and Internal Fixation of Fractures of Both Bones of the Forearm

Droll KP, Perna P, Potter J, Hildebrand KA • Journal of Orthopaedic Trauma (2007)

Measured residual function after anatomic plating of both-bone forearm fractures and found that some patients retain deficits in grip strength, endurance and forearm rotation despite good reduction, with higher-energy injury predicting poorer recovery - highlighting that anatomic fixation does not guarantee full restoration of strength and motion.