What is the recommended surgical approach for a forearm fracture?

Surgical Approach for Forearm Fractures

Open reduction and internal fixation (ORIF) with plate fixation is the recommended surgical approach for most adult forearm fractures, with specific surgical approaches determined by fracture location and pattern.

Indications for Surgical Management

• Surgery is indicated for forearm fractures with:
  • Failed closed reduction
  • Unstable reduction
  • Significant displacement or angulation
  • Complex dislocations with soft tissue interposition
  • Palmar displacement of distal fragment
  • Interfragmentary gap >3 mm
  • Involvement of more than one-third of the articular surface 1

Preoperative Assessment

• Diagnostic imaging is crucial for surgical planning:
  • Standard radiographs (3-view) should be the first imaging modality 1
  • CT without IV contrast is recommended for:
    • Identifying occult fractures
    • Assessing fragment displacement
    • Evaluating articular incongruity when radiographs are equivocal 1
  • MRI without IV contrast is appropriate for evaluating associated soft tissue injuries 1

Surgical Approach Options

1. For Both-Bone Forearm Fractures

• Traditional Approach: Separate incisions for radius and ulna

  • Radius: Volar (Henry) approach or dorsal (Thompson) approach
  • Ulna: Direct subcutaneous approach 2

• Single Volar Approach: The mediolateral windows approach can be used for distal radius and ulna fractures

  • Advantages: Minimizes risk of heterotopic ossification of the interosseous membrane and vascular-nervous lesions
  • Contraindications: Open fractures, Monteggia, Galeazzi, or Essex-Lopresti lesions 3

• Volar vs. Dorsal Approach for Proximal Radius Fractures:

  • Both approaches show similar outcomes in terms of:
    • Duration of procedure
    • Time to union
    • Range of forearm rotation
    • Complication rates 4

2. For Specific Fracture Types

• Distal Radius Fractures:

  • Minimally displaced: Can be treated with closed reduction and cast immobilization
  • Displaced/unstable: ORIF with volar plating is preferred 1, 5

• Isolated Ulnar Shaft (Nightstick) Fractures:

  • Nondisplaced: Can be managed with functional forearm brace
  • Displaced: ORIF with plate fixation 6, 5

• Radial Head Fractures:

  • Mason type I: Splint for 5-7 days or sling with early range-of-motion exercises
  • Mason type II-IV: ORIF or radial head replacement depending on fracture pattern 6, 5

• Olecranon Fractures:

  • Nondisplaced with intact extensor mechanism: Nonsurgical treatment
  • Displaced: ORIF with tension band wiring or plate fixation 6

Fixation Methods

• Plate fixation is the preferred method for most adult forearm fractures 2
• 3.5mm dynamic compression plates (DCP) or limited contact-DCP are commonly used
• Adequate fixation requires at least 6 cortices of fixation on each side of the fracture 2

Postoperative Management

• Progressive range of motion exercises should begin after the immobilization period (typically 3-4 weeks)
• Full recovery is expected within 6-8 weeks 1
• Directed home exercise programs including active finger motion exercises are recommended 1

Complications to Monitor

• Joint stiffness (most common)
• Chronic pain
• Recurrent instability
• Post-traumatic arthritis
• Radial nerve injury
• Infection
• Nonunion 1, 4

Special Considerations

• Hardware removal is not necessary for all patients but carries a risk of refracture if performed 2
• Smoking increases the rate of nonunion and leads to inferior clinical outcomes 1
• Diabetic patients require close monitoring of skin to prevent pressure points and breakdown 1

By following these evidence-based recommendations for surgical approach selection and fixation techniques, optimal outcomes can be achieved for patients with forearm fractures.