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Introduction ⬇

Mechanism of Injury ⬆ ⬇

  • Radial diaphyseal fractures may be caused by direct trauma or indirect trauma, such as a fall onto an outstretched hand.
  • The radial shaft in the proximal two-thirds is well padded by the extensor musculature; therefore, most injuries severe enough to result in proximal radial shaft fractures typically result in ulna fracture as well. In addition, the anatomic position of the radius in most functional activities renders it less vulnerable to direct trauma than the ulna.
  • Galeazzi fractures may result from direct trauma to the wrist, typically on the dorsolateral aspect, or a fall onto an outstretched hand with forearm pronation.
  • Reverse Galeazzi fractures may result from a fall onto an outstretched hand with forearm supination.

Evaluation ⬆ ⬇

Clinical Evaluation

  • Patient presentation is variable and is related to the severity of the injury and the degree of fracture displacement. Pain, swelling, and point tenderness over the fracture site are typically present.
  • Elbow range of motion, including supination and pronation, should be assessed; rarely, limited forearm rotation may suggest a radial head dislocation in addition to the diaphyseal fracture.
  • Galeazzi fractures typically present with wrist pain or midline forearm pain that is exacerbated by stressing of the distal radioulnar joint in addition to the radial shaft fracture.
  • Neurovascular injury is rare.

Radiographic Evaluation

  • AP and lateral radiographs of the forearm, elbow, and wrist should be obtained.
  • Radiographic signs of distal radioulnar joint injury are:
    • Fracture at base of the ulnar styloid
    • Widened distal radioulnar joint on AP x-ray
    • Subluxed ulna on lateral x-ray
    • >5-mm radial shortening
  • Ulnar variance is most associated with presence of distal radioulnar joint instability in the presence of a radial shaft fracture.

Classification ⬆ ⬇

Orthopaedic Trauma Association Classification of Fractures of the Radial Shaft

See Fracture and Dislocation Compendium at:https://ota.org/research/fracture-and-dislocation-compendium

Treatment ⬆ ⬇

Proximal Radius Fracture

  • Nondisplaced fractures may be managed in a long arm cast. Any evidence of loss of radial bow is an indication for open reduction and internal fixation. The cast is continued until radiographic evidence of healing occurs.
  • Displaced fractures are best managed by open reduction and plate fixation using a 3.5-mm DC plate.

Galeazzi Fractures

  • Open reduction and internal fixation is the treatment of choice because closed treatment is associated with a high failure rate.
  • Plate and screw fixation (3.5-mm DC plating) is the treatment of choice.
  • An anterior Henry approach (interval between the flexor carpi radialis and the brachioradialis) typically provides adequate exposure of the radius fracture, with plate fixation on the flat, volar surface of the radius.
  • The distal radioulnar joint injury typically results in dorsal instability; therefore, a dorsal capsulotomy may be utilized to gain access to the distal radioulnar joint if it remains dislocated after fixation of the radius. Kirschner wire fixation may be necessary to maintain reduction of the distal radioulnar joint if unstable. If the distal radioulnar joint is believed to be stable, however, postoperative plaster immobilization may suffice.
  • Postoperative management
    • If the distal radioulnar joint is stable: Early motion is recommended.
    • If the distal radioulnar joint is unstable: Immobilize the forearm in supination for 4 to 6 weeks in a long arm splint or cast.
    • Distal radioulnar joint pins (large diameter and bury), if needed, are removed at 6 to 8 weeks.

Complications ⬆

  • Malunion: Nonanatomic reduction of the radius fracture with a failure to restore rotational alignment or lateral bow may result in a loss of supination and pronation as well as painful range of motion. This may require osteotomy or distal ulnar shortening for cases in which symptomatic shortening of the radius results in ulnocarpal impaction.
  • Nonunion: This is uncommon with stable fixation, but it may require bone grafting.
  • Compartment syndrome: Clinical suspicion should be followed by compartment pressure monitoring with emergency fasciotomy if a compartment syndrome is diagnosed.
    • One should assess all three forearm compartments and the carpal tunnel.
  • Neurovascular injury
    • This is usually iatrogenic.
    • Superficial radial nerve injury (beneath the brachioradialis) is at risk with anterior radius approaches.
    • PIN injury (in the supinator) is at risk with proximal radius approaches.
    • If no recovery occurs, explore the nerve at 3 months.
  • Radioulnar synostosis: This is uncommon (3% to 9% incidence).
    • The worst prognosis is with distal synostosis, and the best is with diaphyseal synostosis.
  • Neurovascular injury: This is uncommon, associated with gunshot injury or iatrogenic need for anatomic restoration of the radial fracture to ensure adequate healing and biomechanical function of the distal radioulnar joint.
  • Refracture: reported to be as high as 30% after plate removal (associated with large fragment implants). One should wait at least 1 year after surgery before plate removal.