10 Forearm Fractures: Open Reduction Internal Fixation

10.Forearm Fractures: Open Reduction Internal Fixation

Steven J. Morgan

Indications

The radius and the ulna form a complex articulation that permits elbow, forearm, and wrist motion. Loss of normal angular alignment results in loss of forearm supination and pronation (1,2). Angular deformity in single bone fractures of the forearm with associated soft-tissue injury result in dislocation. Isolated ulna fractures are often referred to as Monteggia fractures and are recognized as having an associated injury or dislocation of the proximal radioulnar joint. Isolated fractures of the radius are accompanied by a distal radioulnar joint (DRUJ) dislocation and are often called a Galeazzi fracture. Open reduction and internal fixation (ORIF) of displaced forearm fractures in the skeletally mature patient remains the standard treatment for displaced forearm fractures. Internal fixation allows for maintenance of fracture alignment during healing while the patient performs functional range of motion with the arm. Outcomes following internal fixation provide better results than nonoperative treatment (3,4,5,6,7,8).

Isolated ulna fractures resulting from a direct blow remain the exception to this general rule. The 鈥渘ight stick鈥� fracture, as it is commonly called, does not have the degree of soft-tissue injury recognized in other fractures of the forearm, and the likelihood of acute instability of the distal or proximal radioulnar articulations is absent. Fractures involving the distal third of the ulna should be evaluated closely and observed carefully over time as angular deformity can result in significant functional impairment at the DRUJ. Operative fixation of isolated ulna fractures, regardless of injury mechanism, is recommended in open fractures, fractures angulated greater then 10 degrees in any plane, and in fractures with greater than 50% comminution (9).

Initial Evaluation, Management, and Surgical Planning

Initial evaluation of the patient and the radiographs is necessary for developing a treatment plan. A detailed history related to mechanism of injury, hand dominance, occupation,

P.144


previous injury, and associated medical problems is required. The entire extremity needs to be carefully examined for associated injuries. Circumferential inspection of the extremity should be performed to identify the presence of an open fracture as well as to assess the extent and severity of the soft-tissue injury. Any violation of the skin in reasonable proximity to the fracture should be enough to consider the injury an open fracture. Ecchymosis, fracture blisters, and edema suggest that the soft tissue absorbed significant energy and the index of suspicion for compartment syndrome should be high. Palpation for tenderness and instability should be performed from the shoulder to the hand. The elbow, wrist, and carpal bones should receive special attention.

Injuries to the DRUJ or proximal radioulnar joint, scaphoid fractures, and carpal instability are common. Neurological examination should be focused and include the motor and sensory status of the radial (posterior interosseous, superficial radial), ulnar, and median nerves. Vascular examination should focus on the perfusion of the extremity and should include palpation of the brachial radial and ulnar pulses.

Initial radiographic evaluation, prior to the application of splinting material, should consist of orthogonal radiographs (AP and lateral) that include both the wrist and the elbow. In situations when the physical examination indicates additional injury or radiographs are inadequate or inspire suspicion that associated injuries exist, joint specific views of the wrist and elbow should be obtained. Radiographic evaluation should never inhibit the overall care of the patient. In the patient with multiple injuries as well as in the patient with soft-tissue injury or neurological or vascular compromise, a provisional reduction and splint should be applied prior to obtaining radiographs. Traction radiographs often facilitate evaluation of comminuted fractures. Difficult to obtain without proper sedation, these radiographs are best obtained following induction of anesthesia prior to surgery. Stress radiographs of the joints for associated instability can also be obtained at this time, and fluoroscopy is often helpful in this regard.

Initial management of the forearm fracture following the physical examination consists of basic open-fracture wound management (if present) and gross realignment and splint immobilization of the forearm to limit pain and further soft-tissue injury while definitive fracture fixation is pending. In cases of marked angulation or vascular compromise, realignment should be performed immediately. In a Monteggia fracture with a dislocated radial head, gentle traction and supination with conscious sedation or regional anesthesia (Bier block) is necessary to reduce the dislocation. In most other situations, adequate analgesia will permit gross realignment and splint application of the forearm. A long-arm posterior splint is preferred. A sugar tong splint, while adequate in many patients, can result in unnecessary skin breakdown in the supracondylar area. Following any manipulation, the neurological and vascular status of the extremity should be reevaluated and documented.

The timing of surgery is largely dependent on the condition of the soft tissues and the general condition of the patient. Internal fixation is warranted on an emergent basis for open fractures, impending or frank compartment syndrome, and irreducible dislocation with impending skin breakdown or neurological deficit. In other situations, the surgery can be performed in a more elective setting. The reduction, however, becomes more difficult with time, and additional soft-tissue dissection may be required to achieve reduction when fracture fixation is delayed beyond 72 hours. Several studies on open fractures have shown no increased morbidity with immediate plate fixation (6,10). Repeat irrigation and debridement are dictated by the severity of the soft-tissue injury and viability following initial plate fixation. In the patient with multisystem trauma and an open forearm fracture, external fixation following irrigation and debridement may be used as a temporizing measure until the patient's general condition is allowed to improve.

The implant of choice for forearm fracture fixation is a 3.5-mm plate that allows for dynamic compression and application of lag screws through the plate. These implants are available in full contact and limited contact designs. They are available in either titanium or stainless steel from a variety of manufacturers. In theory, low-contact plates limit devitalization of the underlying bone, and titanium decreases the likelihood of stress shielding. Excellent results can be achieved with any of these implant choices. Recently, locked compression plates have been introduced as a fixation option. Their role in diaphyseal fractures of the forearm remains

P.145


undefined and to a large extent appears to be unnecessary except in cases of significant osteoporosis (11). In adults, reconstruction and one-third tubular plates are contraindicated.

Implant selection and size, with reasonable variations, should be determined following full evaluation of radiographs and characterization of the fracture pattern. Implant templates are available to aid in this process and should be used liberally. Traditional technique has called for the use of plates that can obtain a minimum of 6 cortices of fixation on either side of the fracture. The use of long plates with spaced screws is also an option. More important, a well thought-out surgical plan should be developed to achieve reduction and fixation. This is paramount when utilizing indirect reduction aids to restore length and alignment.

General Surgical Technique

While regional anesthesia can be utilized in these cases, general anesthesia is preferred so that accurate postoperative assessment of neurological function and evaluation for compartment syndrome can be ensured. The patient is positioned supine and the arm is placed on a radiolucent arm board. Following the induction of anesthesia, a nonsterile tourniquet is applied, and in the case of comminuted fractures, traction radiographs are obtained by applying longitudinal traction to the hand while an assistant or the surgeon applies counter traction in the upper arm.

The extremity is prepped and draped in a standard fashion. In the case of open fractures, the tourniquet is not utilized so that further anoxic injury to the traumatized soft tissue can be avoided. In closed fractures, the limb is exsanguinated and the tourniquet is inflated to 250 psi. Surgical incisions are then drawn on the extremity, and the fracture site is localized with the C-arm and marked. In general, the least comminuted fracture is approached first to aid in the indirect reduction of the other fracture(s). In noncomminuted fractures, the radius is generally approached first. Loop magnification may be utilized for volar forearm dissections to better recognize and control bleeding vessels. Bipolar cautery is utilized when the surgeon is working in close proximity to the nerves, and small ligature clips are utilized liberally during the dissection.

Surgical Approaches

Flexor Carpi Radialis Approach

For fractures involving the distal third of the radius, a volar approach based on the flexor carpi radialis (FCR) is utilized. The surgical incision is located just radial to the FCR tendon (Fig. 10.1). Following the skin incision, the FCR tendon sheath is split longitudinally and the FCR tendon is retracted ulnarly. The floor of the tendon sheath is then incised. The flexor pollicis longus (FPL) is then encountered and

P.146


retracted ulnarly; this action adds further protection to the median nerve. The pronator quadratus is then incised, elevated from the periosteum, and retracted ulnarly to expose the distal third of the radius (Fig. 10.2). This exposure offers the benefit of avoiding direct dissection of the radial artery, which the FCR sheath protects.

The surgical incision is based just radial to the FCR tendon

Figure 10.1. The surgical incision is based just radial to the FCR tendon.

A. The floor of the tendon sheath is incised. The FPL is encountered and retracted ulnarly. B. The pronator quadratus is elevated from the periosteum and retracted ulnarly.

Figure 10.2. A. The floor of the tendon sheath is incised. The FPL is encountered and retracted ulnarly. B. The pronator quadratus is elevated from the periosteum and retracted ulnarly.

Volar Approach of Henry

The extensile volar approach of Henry is utilized for most fractures of the proximal radius (12). Adequate exposure can be obtained from the biceps tuberosity to the distal-radial articular surface. The surgical skin incision extends from the biceps tendon to the radial styloid, generally following the lateral aspect of the FCR (Fig. 10.3). In the distal aspect of the incision, the radial artery is in close proximity to the volar fascia, and careful scissor dissection initiated proximally and proceeding distally will keep the surgeon from injuring this structure. The proximal plane between the brachioradialis and the FCR should be developed (Fig. 10.4).

The radial artery is mobilized and retracted in the direction dictated by associated soft-tissue conditions. Loop dissection is tremendously helpful when dissecting the radial artery because it allows for recognition of the small vascular branches that are associated with the artery and their subsequent clip ligature or cautery.

The superficial radial nerve should be protected. The nerve is found on the under surface of the proximal brachioradialis. It pierces the fascia and emerges on the superficial surface of the brachioradialis. Deep dissection distally includes incising the pronator quadratus

P.147


from its radial attachment such that it is dissected off the underlying periosteum and retracted ulnarly along with the FPL (Fig. 10.5).

Figure 10.3. The surgical incision is based just radial to the FCR tendon.

 The volar fascia is opened to expose the brachioradialis and the FCR muscles

Figure 10.4. The volar fascia is opened to expose the brachioradialis and the FCR muscles. The interval between these muscles is developed bluntly. The sensory branch of the radial nerve courses beneath the brachioradialis and pierces the volar fascia in the distal third.

The proximal pronator teres can be detached by pronating the forearm and releasing the tendinous attachment from the radius (Fig. 10.6). In an alternative, the pronator teres attachment can be preserved and the tendon can be elevated from the volar surface of the radius to accommodate a submuscular/tendinous plate (Fig. 10.7).

The supinator is elevated from the periosteum with an elevator and retracted radially while the flexor digitorum superficialis is elevated and retracted ulnarly to expose the

P.148


biceps tuberosity (Fig. 10.8). In this area, bipolar cautery should be utilized secondary to the proximity of the posterior interosseous nerve.

The distal third of the radial shaft is exposed with retraction of the brachioradialis radially and FCR ulnarly. The radius is relatively flat in this zone, and the plate generally needs minimal contouring

Figure 10.5. The distal third of the radial shaft is exposed with retraction of the brachioradialis radially and FCR ulnarly. The radius is relatively flat in this zone, and the plate generally needs minimal contouring.

The pronator teres has been elevated sharply to expose the middle third of the radius.

Figure 10.6. The pronator teres has been elevated sharply to expose the middle third of the radius.

Dorsal or Thompson Approach

The Thompson approach is an extensile exposure to the radius that offers complete access from the radial head to the distal articular surface (13). Secondary to the risk to the posterior interosseous nerve and irritation caused by dorsal plate fixation of the overlying tendons, this approach is used less frequently than the FCR or Henry approaches. The dorsal approach is reserved for open fractures with a dorsal-based soft-tissue lesion, fractures that require exploration of the posterior interosseous nerve, and select proximal-third radial fractures. The skin excision extends from the lateral epicondyle to the ulnar aspect of Lister's tubercle (Fig. 10.9).

The pronator attachment can be preserved and the tendon can be elevated from the volar surface of the radius allowing submuscular/tendinous placement of a plate.

Figure 10.7. The pronator attachment can be preserved and the tendon can be elevated from the volar surface of the radius allowing submuscular/tendinous placement of a plate.

The Henry approach can be extended to the proximal third of the radius if needed. The probe shows the insertion of the bicipital tendon.

Figure 10.8. The Henry approach can be extended to the proximal third of the radius if needed. The probe shows the insertion of the bicipital tendon.

P.149


The interval between the extensor carpi radialis brevis (ECRB) and the extensor digitorum comminus (EDC) is developed proximally. The interval between the muscles is more easily recognized in the distal forearm (Fig. 10.10). Once this interval is developed, the posterior interosseous nerve (PIN) is localized as it emerges from the mid substance of the supinator muscle. The nerve must be dissected out of the supinator while care is taken to protect the branches of the nerve to the supinator muscle (Fig. 10.11).

The dorsal approach to the radius is marked along a line from the lateral humeral epicondyle to the ulnar side of Lister's tubercle

Figure 10.9. The dorsal approach to the radius is marked along a line from the lateral humeral epicondyle to the ulnar side of Lister's tubercle.

As in the volar approaches, loop magnification can be beneficial. The arm is supinated to expose the attachment of the supinator and the pronator teres, both of which are detached and subperiosteally elevated toward their origins. As the approach is developed distally, the abductor pollicis longus (APL) and the extensor pollicis brevis are obliquely crossing the radius (Fig. 10.12). The muscles are elevated from the underlying periosteum and retracted either radially or ulnarly to facilitate exposure. In the most distal aspect of the approach, the interval between the ECRB and the extensor pollicis longus (EPL) is developed. As with all approaches to the forearm, the extent of dissection is based on the fracture location and the length of the plate to be utilized.

Dorsal Approach to the Ulna

The subcutaneous nature of the ulna facilitates a direct dorsal approach to the entire ulna. The arm is flexed on the table to provide access to the subcutaneous border and needs to be supported during dissection (Fig. 10.13). The interval is between the extensor carpi ulnaris (ECU) and the flexor carpi ulnaris. To avoid subcutaneous placement of internal fixation, the ECU is retracted and the dorsal aspect of the ulna is exposed (Fig. 10.14).

The subcutaneous nature of the ulna also facilitates percutaneous plate placement, particularly in comminuted fractures. Following indirect reduction of the ulna by either plate fixation of the radius or provisional reduction utilizing an external fixator, 2-cm incisions

P.150


are made along the subcutaneous border of the ulna, and the overlying skin is mobilized from the deep tissue with an elevator directed toward the fracture. The plate is then inserted along the bone until it is exposed in the opposite incision. The process is visualized with an image intensifier. The plate is then secured to the bone with screws via the two small incisions and strategically placed stab incisions along the subcutaneous border of the ulna (Fig. 10.15). When placed percutaneously in this manner, plates lie along the subcutaneous border and thus increase the likelihood of symptoms related to the internal fixation.

The dorsal investing fascia is examined to define the interval between the ECRB and the EDC

Figure 10.10. The dorsal investing fascia is examined to define the interval between the ECRB and the EDC.

The forearm is pronated, which brings the PIN closer to the operative field and may increase the risk for injury

Figure 10.11. The forearm is pronated, which brings the PIN closer to the operative field and may increase the risk for injury.

Reduction and Plate Fixation Techniques

The fracture pattern dictates the technique utilized for reduction and internal fixation. Soft tissues are retracted with right angle retractors or strategically placed (extraperiosteally when possible) small Homan retractors. Broad retractors should be avoided to eliminate unnecessary soft-tissue stripping (Fig. 10.16). In transverse and short, oblique


fracture patterns, direct reduction followed by lag screw and compression plating techniques are recommended. Pointed reduction forceps or serrated reduction forceps are used to grasp the bone and draw it out to length; the fracture is then reduced under direct visualization (Fig. 10.17).

 The dorsal fascia is incised along this interval. The APL crosses the dorsal surface of the radius obliquely in the distal portion of the exposure.

Figure 10.12. The dorsal fascia is incised along this interval. The APL crosses the dorsal surface of the radius obliquely in the distal portion of the exposure.

The subcutaneous approach to the ulna is marked with the elbow flexed and the forearm in neutral rotation. The fracture site should be palpated to determine the midpoint of the incision.

Figure 10.13. The subcutaneous approach to the ulna is marked with the elbow flexed and the forearm in neutral rotation. The fracture site should be palpated to determine the midpoint of the incision.

The subcutaneous approach to the ulna is marked with the elbow flexed and the forearm in neutral rotation. The fracture site should be palpated to determine the midpoint of the incision.

Figure 10.14. A. The plate along the subcutaneous border of the ulna should be placed so that it lies beneath the ECU and is recessed dorsal to the subcutaneous border of the ulna. B. This reduces painful symptoms related to a prominent plate that most frequently occurs when the forearm is placed on a rigid surface.

Oblique fracture patterns are temporarily maintained in a reduced position by placing the pointed reduction forceps perpendicular to the fracture line. Compression across the fracture should then be obtained with a lag screw. When the fracture orientation permits, lag screw fixation through the plate (after compression of the fracture with the plate) will enhance the stability of the construct. In transverse fractures, a contoured plate is secured to the bone with a bicortical screw in the most distal aspect of the plate after the surgeon ensures it is centered on the bone. Opposite the fracture, an additional bicortical screw is

P.153


placed in an eccentrically drilled hole to compress effectively the fracture as it is tightened. Prior to final tightening, the clamps anchoring the plate to the bone should be loosened or removed to allow the plate to slide in relationship to the compressing screw. The clamps are then removed and two additional screws are placed in the neutral position on either side of and in close proximity to the fracture. Additional screw fixation is unnecessary in bone of regular quality. In poor quality bone, a minimum of six to eight cortices of fixation should be obtained on either side of the fracture or use of a locked plate device should be considered.

 An incision measuring 2 cm is made over the subcutaneous proximal ulna and carried down to the periosteum

Figure 10.15. An incision measuring 2 cm is made over the subcutaneous proximal ulna and carried down to the periosteum. The subcutaneous tissue is elevated from the periosteum by pushing a plate along the subcutaneous border of the ulna. With the plate inserted, a separate 2-cm incision is made over the plate at the distal ulna. The plate is then centered on the bone at both ends and screws are placed. If additional screws are required closer to the fracture, stab wounds are made over the plate and screws are inserted percutaneously.

Exposure is facilitated through the use of right-angle retractors and small Weber clamps. Extensive dissection of soft tissue with wide exposure of the fracture site is avoided.

Figure 10.16. Exposure is facilitated through the use of right-angle retractors and small Weber clamps. Extensive dissection of soft tissue with wide exposure of the fracture site is avoided.

Pointed reduction forceps or serrated reduction forceps are used to grasp the bone and draw it out to length. The fracture is reduced under direct visualization.

Figure 10.17. Pointed reduction forceps or serrated reduction forceps are used to grasp the bone and draw it out to length. The fracture is reduced under direct visualization.

Comminuted fractures are fixed utilizing indirect reduction techniques and the application of a bridge plate. In this situation, individual reductions of the comminuted fragments are avoided and dissection in the area of the main fracture should be limited. Restoration of length and alignment can be obtained by several methods. The fracture can be brought out to length by the surgeon grasping the bone with pointed reduction forceps or serrated reduction forceps on opposite sides of the fracture, drawing it out to length, and then clamping the plate to the bone to maintain length while screw fixation is obtained.

More reliable methods for restoring and maintaining length and alignment include application of the plate to the distal aspect of the bone with one or two screws placed in the neutral position, then the application of a push-pull screw in the proximal aspect of the plate. A tension distraction device or a lamina spreader is then utilized to push the fracture out to length. During this process, two loosely applied clamps placed perpendicular to one another around the plate will control alignment during the distraction process (Figs. 10.18 and 10.19). When the bone is appropriately brought out to the correct length, two screws are placed in the neutral position; one in close proximity to the fracture and one in the most proximal aspect of the plate. With good indirect technique, bone grafting is not required even in comminuted fractures (Fig. 10.20) (14).

Following plate fixation of both bones of the forearm, the range of motion and the stability of both the proximal and distal radial and ulnar articulations should be checked. In Galeazzi fractures, if the DRUJ is stable through a full range of motion no immobilization is required. If it is only stable in supination, the extremity should be initially splinted and then casted in supination for 6 weeks. If the DRUJ is unstable in all positions, the joint should be reduced and pinned with a 2.0-mm Kirschner (K) wire, and ulnar styloid fractures should be repaired. The extremity should then be immobilized in a cast in the reduced position for 6 weeks.

In Monteggia fractures, if the radial head is not reduced, the fracture reduction needs to be carefully checked to ensure that anatomic length of the ulna has been restored. If

P.154


P.155


the radial head remains dislocated and the ulna has been correctly reduced, then the proximal radioulnar joint should be explored and the annular ligament reconstructed. If the joint is reduced and stable, then no additional immobilization is required, but if it is unstable, then it should be reduced in a stable position, usually supination, for 6 weeks.

 Indirect reduction of the ulna is depicted. A laminar spreader and screw are used for distraction of the fracture. The dental pick is used to tease the wedge fragment into position.

Figure 10.18. Indirect reduction of the ulna is depicted. A laminar spreader and screw are used for distraction of the fracture. The dental pick is used to tease the wedge fragment into position. The laminar spreader is then gradually released, and the fracture is compressed with an eccentrically placed screw.

A lamina spreader is utilized to push the fracture out to length. During this process, two loosely applied clamps placed perpendicular to one another around the plate will control alignment.

Figure 10.19. A lamina spreader is utilized to push the fracture out to length. During this process, two loosely applied clamps placed perpendicular to one another around the plate will control alignment.

In both-bone forearm fractures, failure to achieve full range of motion under anesthesia suggests residual mal-alignment of the fracture. In all cases, full length radiographs should be obtained in the operating room to ensure accurate fracture reduction. The tourniquet, if utilized, should be deflated prior to closure and hemostasis obtained. The

P.156


deep structures, such as the pronator teres, supinator, and pronator quadratus, are placed back in their anatomic locations but do not require repair. The fasciae on both the volar and dorsal exposures are not closed to decrease the likelihood of a compartment syndrome following closure. The skin is then closed with an interrupted no. 2-0 absorbable suture in the subcuticular layer and either a running subcuticular stitch or interrupted nonabsorbable suture.

A both-bone forearm fracture treated with compression plating of the radius and bridge plate fixation of the ulna is shown. A long plate with minimal screw insertion was utilized to minimize bone devitalization

Figure 10.20. A,B. A both-bone forearm fracture treated with compression plating of the radius and bridge plate fixation of the ulna is shown. A long plate with minimal screw insertion was utilized to minimize bone devitalization.

Postoperative Care

If instability is not found in the proximal or distal radioulnar joint, the surgical incision sites are dressed, and with the wrist in neutral or slight dorsiflexion, a light, volar, wrist splint is applied. This postoperative immobilization is provided to rest the soft tissues and increase the comfort of the patient in the immediate postoperative period. The splint is discontinued on the first postoperative visit, and active-assisted range of motion of the upper extremity is initiated at that time as tolerated. The patient is encouraged to begin using the extremity for activities of daily living, with restrictions against lifting objects greater than 10 to 15 pounds. The lifting restriction is eased at 6 to 10 weeks depending on clinical and radiographic signs of fracture union, and typically all restrictions are removed at approximately 3 to 4 months. Return to work is encouraged with restrictions in the first 7 to 10 days following surgery, and return to sport is allowed 4 to 6 months following injury. Radiographs are obtained on the second postoperative visit, typically 6 weeks following injury, then on a 4 to 6 week basis thereafter until union.

Patients are instructed that the hardware will be retained indefinitely unless complications arise related to internal fixation. Hardware removal before 1 year should be avoided. When it is performed, the patient should be carefully counseled regarding the inherent risk of nerve injury and refracture (15,16).

Recommended Readings

1. Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and the ulna on supination and pronation. J Bone Joint Surg Br2002;84(7):1070鈥�1074.

2. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of both bones of the forearm in adults. J Bone Joint Surg Am 1992;74:1068鈥�1078.

3. Anderson LD, Sisk TD, Tooms RE, et al. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am1975;57:287鈥�297.

4. Burwell HN, Charnley AD. Treatment of forearm fractures in adults with particular reference to plate fixation. J Bone Joint Surg Br 1964;46:404鈥�425.

5. Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am1989;71:159鈥�169.

6. Duncan R, Geissler W, Freeland AE, et al. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma1992;6:25鈥�31.

7. Mih AD, Cooney WP, Idler RS, et al. Long-term follow-up of forearm bone diaphyseal plating. Clin Orthop 1994;299:256鈥�258.

8. Moed BR, Kellam JF, Foster JR, et al. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am1986;68:1008鈥�1017.

9. Mackay D, Wood L, Rangan A. The treatment of isolated ulnar fractures in adults: a systematic review. Injury 2000;31(8):565鈥�570.

10. Jones JA. Immediate internal fixation of high-energy open forearm fractures. J Orthop Trauma 1991;5(3):272鈥�279.

11. Leung F, Chow SP. A prospective, randomized trial comparing the limited contact dynamic compression plate with the point contact fixator for forearm fractures. J Bone Joint Surg Am 2003;85(12):2343鈥�2348.

12. Henry WA. Extensile exposures. 2nd ed. New York: Churchill Livingstone; 1973:100.

13. Thompson JE. Anatomical methods of approach in operations on the long bones of the extremities. Ann Surg 1918;68:309.

14. Wright RR, Schmeling GJ, Schwab JP. The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. J Orthop Trauma 1997;11(4):288鈥�294.

15. Beaupre GS, Csongradi JJ. Refracture risk after plate removal in the forearm. J Orthop Trauma 1996;10:87鈥�92.

16. Langkamer VG, Ackroyd CE. Removal of forearm plates: a review of complications. Bone Joint Surg Br 1990;72:601鈥�604.