[Management of forearm shaft fractures : Challenges and solution approaches]

Forearm shaft fractures are the most common fractures of the upper extremity in young adults. By definition, these fractures are diaphyseal fractures; however, due to the complex functional unity formed by the forearm shaft during motion both bone forearm fractures are treated as intra-articular fractures [1, 3]. This is why the gold standard of treatment in adults is osteosynthesis. The aim of the surgical intervention is the anatomical reduction with exact reconstruction of length, shaft axis and rotation. This particularly concerns Monteggia and Galeazzi fractures where the adjacent joint needs to be addressed and/or the joint must be fixated to gain a precise joint position [2, 9]. Instability of the interosseous membrane must also be kept in mind, which is classically accompanied by comminuted radial head fractures (Essex-Lopresti injury) but can also occur with shaft fractures after complex and massive trauma [9, 10]. Complications with these three types of injury occur when the joint involvement is overlooked and hence must be specifically searched for [9]. A typical complication after forearm fractures is the formation of pseudarthrosis [4, 5, 11, 12]. For prevention, a procedure must be selected that preserves the soft tissue and periosteum as much as possible; locking plates enable a stable fixation without compression of the periosteum [1, 4]. Nerve damage can occur either posttraumatically or after surgical intervention and is frequently seen with very proximal forearm fractures [3, 5, 12]. Refractures are rarely seen with inlaying implants but commonly occur after implant removal, which is why it should be done 24 months postoperatively at the earliest [2, 5, 13]. With concomitant fractures of the radius and ulna there is a high risk of synostosis which often leads to considerable impairment of movement [5, 11, 12]. In some cases, especially with traumatic brain injury, a synostosis cannot be avoided even with preventative measures and subsequently must be resected [5]. Furthermore, insufficient osteosynthesis or implant failure can lead to axial malalignment and subsequently to limited rotational mobility [5]. The renewed open anatomical reduction with compression osteosynthesis and secure plate fixation, fixated with three screws proximal and distal to the fracture, enables an exact reconstruction of the bone shape as well as the avoidance of secondary malalignment through implant loosening [1, 5].