Overview
Restoring the anatomic relationship between the radius and ulna with rigid fixation is the aim of treatment. In adults, closed treatment is essentially limited to the most infirm patients. ORIF of the radius and ulna reliably leads to union and good results.
Modern intramedullary nailing gives satisfactory results, but plate fixation remains superior. Campbell routinely plates both-bone forearm fractures in adults.
3.5 mm limited-contact dynamic compression plates (LC-DCP) are the most commonly used implants.
Intramedullary nails are reserved for soft-tissue envelopes too damaged for safe plating. Even then, a nail is often used for one bone (usually the ulna) and a plate for the other (usually the radius).
Open Fractures
Minimal contamination: Thorough debridement and irrigation, then immediate ORIF.
Gross contamination: Debridement and irrigation, splinting or temporary fixation, repeat debridement, then ORIF once the wound bed is satisfactory.
Soft tissues that do not allow internal fixation: Intramedullary nails, to limit the zone of injury and exposure to metal.
Compartment syndrome: The risk rises with higher-energy patterns (33% in AO/OTA group C fractures, Auld et al.).
Fixation Strategy by Fracture Pattern
Pattern | Fixation |
|---|---|
Butterfly fragment | Lag screws (2.0, 2.4 or 2.7 mm) for anatomic reduction, then a neutralization plate |
Transverse or short oblique | Compression plating |
Extensive comminution | Bridge plate of appropriate length (contoured to restore the radial bow) |
Distal ulnar fractures where a 3.5 mm plate is too bulky | 2.7 mm plates with locking screws (lower profile, still rigid), or metaphyseal plates with 3.5 mm screws and a thin distal end |
Surgical Technique (Technique 62.14)
1. Plan the Order of Fixation
If anatomic reduction is possible → fix the radius first.
If both bones are comminuted → fix the radius first.
If the radius is comminuted and the ulna is simple → the ulna can be reduced and fixed first.
2. Radius
Use a volar (Henry) approach for most fractures. A dorsal Thompson approach can be considered when fixation is needed proximal to the biceps tuberosity, although Campbell prefers the volar approach.
Preserve the periosteum on the proximal and distal fragments.
Clear hematoma and debris from the fracture ends.
Transverse fractures: Apply a 3.5 mm LC-DCP in compression. Provisional fixation away from the definitive plate helps (see Campbell's Concepts).
Oblique or butterfly fragments: Fix them with 2.0 or 2.4 mm lag screws before applying the plate.
Extensive comminution: Use a bridge plate of appropriate length. The plate must be contoured to restore the anatomic radial bow.
3. Ulna
After fixing the radius, approach the ulna through the interval between the flexor carpi ulnaris and extensor carpi ulnaris. The same plating strategies apply.
Dissection is usually limited to the dorsal surface of the ulna, preserving periosteum, with the plate placed on the dorsal (extensor) side.
4. Final Checks
After both bones are fixed, confirm reduction and fixation on fluoroscopy, and confirm clinically that a full arc of pronation and supination is present.
Close the wounds in standard fashion.
Campbell's Concepts: Technical Tips
Approach to the radius: Campbell prefers the volar approach. The Thompson approach is of limited use in most cases. With careful dissection and good anatomic knowledge, the annular ligament can be exposed from the volar side, avoiding the often difficult dissection of the posterior interosseous nerve through the supinator.
Provisional fixation: So that the plate can be contoured without having to control unstable fragments at the same time, the side of the bone away from the definitive small-fragment plate can be held provisionally with a modified pointed tenaculum or a 2.0 mm minifragment plate.
Postoperative Care
Usually only a soft dressing is needed.
If the diaphyseal fractures have been fixed anatomically (not bridged), weight bearing and range of motion are allowed as tolerated.
Limit weight bearing if bone quality is a concern, if long segments have been bridged, or if fixation is short-segment (very proximal or distal patterns).
Related Injury: Isolated Ulnar Shaft Fracture
Most heal uneventfully without surgery. Proximal-third fractures may displace progressively, and surgery is recommended for more than 50% displacement and more than 8° of angulation (Coulibaly et al.).
Related Injury: Galeazzi Fracture-Dislocation
Suspect a DRUJ injury when you see:
A fracture at the base of the ulnar styloid
DRUJ widening on the AP view
Dislocation of the ulna relative to the radius on a true lateral view
More than 5 mm of radial shortening compared with the contralateral wrist
Treatment: ORIF of the radius through an anterior Henry approach with a 3.5 mm compression plate. Anatomic, rigid fixation of the radius usually reduces the DRUJ; confirm this on fluoroscopy.
DRUJ stress test: With the elbow at 90°, stress the DRUJ in neutral, supination and pronation. If it is not grossly unstable, splint in the most stable position, usually supination.
Unstable DRUJ:
Two K-wires transfixing the DRUJ in supination, through four cortices so they can be retrieved if they break. Remove them at 4 weeks and start active rotation.
Alternatively, fix the ulnar styloid or repair the TFCC.
In an open DRUJ dislocation, the TFCC can be repaired with sutures through drill holes in the ulnar fovea, tied over a bone bridge after radial fixation.
An irreducible DRUJ usually means soft-tissue interposition and requires open reduction.
Reference
Cosgrove CT. Fractures of the shoulder, arm, and forearm. In: Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Philadelphia: Elsevier; 2026. Chapter 62, Technique 62.14.