What is the appropriate management for a radius and ulna fracture?

Management of Radius and Ulna Fractures

For adult diaphyseal both-bone forearm fractures, proceed directly to open reduction and internal fixation (ORIF) with plate and screw constructs, as closed treatment leads to malunion and loss of forearm rotation. 1

Location-Specific Management Algorithm

Distal Radius Fractures (Most Common)

Age-Based Decision Making:

• Geriatric patients (≥65 years): Default to non-operative treatment with immobilization regardless of radiographic displacement, as surgery does not improve long-term patient-reported outcomes 2

• Non-geriatric patients (<65 years): Operate when post-reduction radiographs show ANY of the following 2:

  • Radial shortening >3mm
  • Dorsal tilt >10 degrees
  • Intra-articular step-off >2mm

Initial non-operative treatment: Sugar-tong splint followed by short-arm cast for minimum 3 weeks for nondisplaced or minimally displaced fractures 3

Operative technique selection: Choose any fixation method (volar locking plates, dorsal plates, external fixation, or percutaneous pinning) based on surgeon preference and fracture pattern, as no technique shows superior long-term outcomes 2. However, volar locking plates provide faster return to function within the first 3 months despite equivalent long-term results 2

Critical pitfall: Screen for median nerve injury, which commonly complicates distal radius fractures 3

Diaphyseal Both-Bone Forearm Fractures

Surgical management is mandatory because closed treatment results in malunion and loss of forearm rotation due to disruption of the anatomic relationships between the proximal and distal radioulnar joints and interosseous space 1, 4

Operative approach:

• Simple fractures: Plate and screw fixation with rigid constructs 1
• Complex fractures: Flexible plate constructs or intramedullary nails based on strain theory to control motion at the fracture site 1

Surgical sequence for combined fractures: Address the ulna first to achieve alignment, then fix the radius 5

Isolated Midshaft Ulna (Nightstick) Fractures

Treatment depends on displacement:

• Minimal displacement/angulation: Immobilization alone 3
• Significant displacement/angulation: Surgical fixation 3

Radial Head Fractures

Suspect when: Limitations of elbow extension and supination following trauma, even if initial imaging is negative 3

Management: Use Mason classification to guide treatment decisions 3

Pain Management Protocol

Implement multimodal, opioid-sparing analgesia for all patients including local anesthetics, NSAIDs, acetaminophen, ice, elevation, compression, and cognitive therapies 2

Rehabilitation Strategy

Home exercise programs are equivalent to supervised therapy, so allow patient preference to guide this decision 2. Focus specifically on preventing finger stiffness regardless of the chosen rehabilitation setting 2

Key Clinical Pitfalls to Avoid

• Do not operate on geriatric patients based solely on radiographic parameters - strong evidence shows no benefit 2
• Do not attempt closed treatment for adult diaphyseal both-bone fractures - this leads to malunion and functional loss 1, 4
• Do not miss median nerve injuries with distal radius fractures 3
• If initial imaging is negative but clinical suspicion remains: Splint and repeat radiography in 7-14 days 3

Expected Outcomes

Surgical fixation of both-bone forearm fractures generally produces good results with only modest losses of forearm strength and rotation 1. Notable complications include nonunion, malunion, and refracture after device removal 1