JBJS | Current Concepts Review - Chronic Disorders of the Forearm*

The Journal of Bone & Joint Surgery, Volume 78, Issue 6

Current Concepts Review | June 01, 1996

Current Concepts Review - Chronic Disorders of the Forearm*

ROBIN R. RICHARDS, M.D., F.R.C.S.(C)†, TORONTO, ONTARIO, CANADA

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

The Journal of Bone & Joint Surgery. 1996; 78:916-30

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Introduction

The forearm fulfills an important role in the integrated function of the upper extremity. It maintains a stable link between the elbow and the wrist, provides an origin for many of the muscles that insert on the hand, and allows rotation of the wrist to position the hand more effectively in space. Acute injuries can involve different components of the forearm unit simultaneously, thus necessitating integrated treatment of all of the injured structures for recovery of function^{14,22,48,68,71,107}. Chronic disorders of the forearm interfere with the stability, strength, and rotatory motion required to allow effective function of the hand. The treatment of these disorders is complex, as they involve both bone and soft-tissue structures; moreover, the lack of a generally accepted classification system leads to confusion regarding diagnosis and treatment. The anatomical location of the forearm between the elbow and the wrist has not inspired the intense scrutiny by subspecialists that has been provoked with regard to the hand, wrist, and elbow. The purpose of the current review is to discuss chronic skeletal disorders of the forearm in adults.

†Division of Orthopaedic Surgery, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, Ontario M5B 1W8, Canada.

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Anatomical diagram showing the soft-tissue structures joining the radius to the ulna. Note the interosseous membrane, the annular ligament, and the capsule of the distal radio-ulnar joint.

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Posteroanterior and anteroposterior radiographs of the forearm, made after a fracture of the distal aspect of the radius. The radiograph on the left was made with the forearm in pronation and that on the right, with the forearm in supination. With pronation, the radius shortens. Radiographs of the forearm should be made with the forearm in neutral rotation so that the true ulnar variance, if any, can be determined.

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Technique of Schemitsch and Richards¹¹⁹ for measuring the amount and location of maximum radial bow. The amount is determined by drawing a line from the bicipital tuberosity to the most ulnar aspect of the radius at the wrist. A perpendicular line is drawn from this line to the radius at the point of maximum radial bow, and the distance is measured in millimeters. The location of maximum radial bow is determined by dividing the distance from the bicipital tuberosity to the point of maximum bow by the length of the entire bow. The value is expressed as a percentage.

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Cross-sectional computed tomographic scan of the proximal aspect of the forearm, revealing a type-III proximal radio-ulnar synostosis¹³⁸. The synostosis was the result of heterotopic ossification after a two-incision repair of a distal rupture of the biceps tendon. (Reprinted, with permission, from: Richards, R. R., and Corley, F. G., Jr.: Fractures of the shafts of the radius and ulna. In Rockwood and Green's Fractures in Adults, edited by C. A. Rockwood, Jr., D. P. Green, R. W. Bucholz, and J. D. Heckman. Ed. 4, vol. 1, p. 903. Philadelphia, Lippincott-Raven, 1996.)

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Anteroposterior radiograph showing a non-union of the distal aspect of the ulna, radio-ulnar impingement, and osteoarthrotic changes between the distal stump of the ulna and the radius. Radio-ulnar impingement is most common after resection of the distal aspect of the ulna, but it also can occur in association with a non-union of the distal aspect of the ulna.

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Radiograph showing a chronic anterior dislocation of the radial head, caused in part by a malunion of the radius. A plate was applied to the radius without re-establishment of the radial bow. Radial osteotomy combined with a soft-tissue repair of the attenuated annular ligament will be needed to obtain a stable reduction of the radial head. (Reprinted, with permission, from: Richards, R. R.: Elbow anatomy, biomechanics and instability. In Soft Tissue Reconstruction in the Upper Extremity, p. 142. New York, Churchill Livingstone, 1995.)

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Radiograph made eight years after a Sauvé-Kapandji¹¹⁸ procedure. The distal aspect of the ulna is fused to the distal aspect of the radius, and there is an iatrogenic pseudarthrosis of the distal aspect of the ulna.

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Radiograph showing a radio-ulnar synostosis, created operatively with use of a tricortical autogenous graft from the iliac crest. Two 4.5-millimeter screws were used in the radius and ulna to apply compression. A position of 30 degrees of pronation was chosen. The arthrodesis was successful, and the painful instability was alleviated.

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TABLE I CLASSIFICATION OF CHRONIC DISORDERS OF THE FOREARM

Congenital and developmental disorders

Hemimelia

Madelung deformity

Radio-ulnar synostosis

Multiple hereditary exostoses

Epiphyseal arrest

Acquired disorders

Skeletal tissue

Biological disorders

Infection

Non-union

Refracture after removal of plate

Heterotopic ossification

Mechanical disorders

Malunion

Impingement

Ulnocarpal

Radio-ulnar

Instability

Distal radio-ulnar joint

Proximal radio-ulnar joint

Migratory instability and chronic

Essex-Lopresti lesions⁴³

Incongruity

Distal radio-ulnar joint

Proximal radio-ulnar joint

Soft tissue

Neural compression

Soft-tissue contracture

Volkmann contracture

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TABLE I CLASSIFICATION OF CHRONIC DISORDERS OF THE FOREARM

Congenital and developmental disorders

Hemimelia

Madelung deformity

Radio-ulnar synostosis

Multiple hereditary exostoses

Epiphyseal arrest

Acquired disorders

Skeletal tissue

Biological disorders

Infection

Non-union

Refracture after removal of plate

Heterotopic ossification

Mechanical disorders

Malunion

Impingement

Ulnocarpal

Radio-ulnar

Instability

Distal radio-ulnar joint

Proximal radio-ulnar joint

Migratory instability and chronic

Essex-Lopresti lesions⁴³

Incongruity

Distal radio-ulnar joint

Proximal radio-ulnar joint

Soft tissue

Neural compression

Soft-tissue contracture

Volkmann contracture

Anatomy of the Forearm

Normal function of the forearm requires intact skeletal structures; a normal interosseous membrane; stable proximal and distal radio-ulnar joints; and normal soft-tissue structures, including the muscles, nerves, and vessels that are in the forearm and that traverse it. In the distal aspect of the forearm, the radius dwarfs the ulna and accounts for 80 per cent of the force transmitted from the wrist to the forearm¹⁰⁰. The relative amount of force transmitted to the forearm from the wrist is closely associated with the relative lengths of the radius and ulna. Normally, the two bones are of nearly equal lengths^51,63. Ulnar variance results if they are not. Positive ulnar variance results when the ulna is longer than the radius distally, and negative ulnar variance occurs in the opposite situation. Palmer and Werner¹⁰⁰ found that shortening of the radius by even a small amount dramatically increased the amount of force transmitted to the ulnar aspect of the wrist.

The ulna is a relatively straight bone that progressively enlarges proximally in the forearm. At the elbow, the ulna provides the site of attachment for both the medial and the lateral collateral ligament. At the level of the wrist, the ulna accepts a small proportion of the load transmitted to the forearm by the carpus. In the proximal aspect of the forearm, the ulna accepts proportionately more load because of the transference of load from the radius through the interosseous membrane and the addition of local muscle forces. At the elbow, the radius transmits 60 per cent of the transarticular load, depending on the position of the forearm when the measurement is made^57,139. The radius has a gentle curve as it traverses the forearm. This curve, or bow, has been shown to be of crucial importance to the normal range of rotation of the forearm and to the strength generated by the muscles of the forearm, as reflected in grip strength¹¹⁹.

The radial head is a circular structure that articulates with the capitellum. The radial head is concave in order to accommodate the convex capitellum. The head tapers to form the radial neck and, just distal to the neck, the attachment of the biceps tendon arises from the radial tuberosity. The proximal aspect of the ulna forms the sigmoid notch, which articulates with the trochlea. Articular cartilage covers approximately 240 degrees of the external surface of the radial head. The articular surface of the lesser sigmoid fossa forms a 60 to 80-degree arc. Accordingly, the range of allowable rotation of the proximal aspect of the radius is approximately 180 degrees. The radial collateral ligament arises from the lateral epicondyle and inserts onto the annular ligament. The annular ligament arises from the lesser sigmoid notch and encircles the radial head, holding it in contact with the ulna.

The articular surfaces of the distal radio-ulnar joint are trochoid (pulley-like). The concavity of the sigmoid notch is rather shallow, with dorsal and volar margins. The dorsal margin is more acutely angled than the volar margin. The head of the ulna is semicylindrical, with a 130-degree dorsal-to-volar arc. The contour of the ulnar head is similar to that of the radial head. The radius of the sigmoid notch is greater than that of the distal aspect of the ulna. In mid-rotation, the sigmoid notch can accept between 60 and 80 degrees of the articular convexity of the distal aspect of the ulna. In the extreme positions of rotation, less than 10 per cent of the sigmoid notch may be in contact with the distal aspect of the ulna. Accordingly, stability depends heavily on the soft-tissue structures that surround the distal radio-ulnar joint. The distal articular surface of the ulna articulates with the triangular fibrocartilage. The triangular fibrocartilage originates from the distal aspect of the radius and inserts at the base of the ulnar styloid process. The ulnar styloid process is the distal projection of the subcutaneous ridge of the ulnar shaft and extends between two and six millimeters toward the triquetrum.

The triangular fibrocartilage and associated soft-tissue structures provide stability to the ulnar aspect of the carpus while allowing for stable rotational motion. In addition, the triangular fibrocartilage cushions forces transmitted along the ulnar aspect of the wrist. The concave triangular fibrocartilage is two millimeters thick where it arises from the radius, five millimeters thick peripherally in the area of the ulnar styloid process, and thinnest centrally. The volar aspect gives rise to the volar ulnolunate and ulnotriquetral ligaments. These ligaments arise with their base across the lunate and the triquetrum, and they attach to the ulnar aspect of the ulnar styloid process in intimate relationship to the volar aspect of the triangular fibrocartilage. The ulnar collateral ligament and the dorsal and volar radio-ulnar ligaments are not distinct structures but are formed by capsular condensations.

The interosseous membrane is of critical importance to normal function of the forearm (Fig. 1). This structure generally is thin and translucent, with little intrinsic strength. A central band of ligamentous tissue, approximately twice the thickness of the interosseous membrane on either side, is a consistent anatomical pattern in the forearm. Hotchkiss et al.⁶², in a study of cadavera, demonstrated that the central band contributed 71 per cent of the longitudinal stiffness of the interosseous membrane. The central band arose from the radius proximally and from the ulna distally. The mean thickness of the central band was 0.94 millimeter, and the mean width was 3.5 centimeters.

Biomechanics of the Forearm

The longitudinal axis of rotation of the forearm passes through the articular surface of the radial head, the interosseous membrane, and the articular surface of the ulna at the distal radio-ulnar joint⁹¹. During pronation and supination, the radius rotates around this axis, which is not parallel to either the radius or the ulna. Both the supinator and the biceps muscle supinate the forearm. The biceps is a stronger supinator when the forearm is pronated and the elbow is flexed. Supination strength is normally greater than pronation strength. Pronation occurs by the action of the pronator quadratus and pronator teres muscles. The pronator teres is also a weak elbow flexor and is a more effective pronator when the elbow is extended. The normal range of rotation of the forearm is 75 degrees of pronation and 85 degrees of supination. Normally, only a small amount of rotation of the forearm occurs through the elbow joint⁹⁸. Most normal activities of daily living can be accomplished with an arc of 100 degrees of rotation, with equal amounts of pronation and supination⁹⁵. Adams and Holley⁴ demonstrated that rotation of the forearm, particularly pronation, produced strains in the triangular fibrocartilage. The highest strains occurred in the radial portion of the triangular fibrocartilage, particularly with axial loading when the forearm was pronated.

Rabinowitz et al.¹⁰⁴ studied the relative roles of the interosseous membrane and the triangular fibrocartilage complex in stability of the forearm. After excision of the radial head, a maximum of seven millimeters of proximal migration of the radius occurred under axial compression. Disruption of either the central band of the interosseous membrane or the triangular fibrocartilage complex in isolation had little effect on load or displacement. If both the interosseous membrane and the triangular fibrocartilage complex were incompetent, proximal migration occurred and the radial stump abutted the capitellum. Rabinowitz et al. demonstrated that the central band of the interosseous membrane was the crucial stabilizing structure and that the triangular fibrocartilage complex resisted proximal migration of the radius and participated in load transfer. An and Morrey⁶, as well as Palmer et al.¹⁰¹, reported that rotation of the forearm produced proximal migration of the radius with increasing radiocapitellar contact.

Schuind et al.¹²² performed a biomechanical study of the distal radio-ulnar ligaments. The palmar radio-ulnar ligament was taut in supination, and the dorsal radio-ulnar ligament was taut in pronation. The length of the palmar radio-ulnar ligament decreased to 71 per cent of its resting length in pronation and that of the dorsal radio-ulnar ligament, to a mean of 90 per cent of its resting length in full supination. The radio-ulnar ligaments were found to have material properties similar to those of the radiocarpal ligaments. King et al.⁷⁰ demonstrated, in a study of cadavera, that rotation of the radius about the ulna is accompanied by volar translation of the ulna in supination and by dorsal translation of the ulna in pronation. Adams³ showed that radial deformity alters the kinematics of the distal radio-ulnar joint and distorts the triangular fibrocartilage. Of all of the radial deformities, shortening had the greatest influence on the function of the distal radio-ulnar joint. Adams² also found that excision of all but the peripheral two millimeters of the triangular fibrocartilage did not cause significant kinematic or structural changes in the distal radio-ulnar joint.

Clinical Assessment

Patients who have a disorder of the forearm report pain, loss of motion, weakness, and difficulty in performing their normal activities of daily living. Patients should be specifically questioned regarding their ability to perform normal activities of daily living. Patient-based questionnaires have become a recognized method of obtaining semiquantitative data on the degree of functional impairment imposed by musculoskeletal disorders. Beaton and Richards⁹ demonstrated that when disease-specific questionnaires were administered to patients who had pain in the shoulder they provided more information than that provided by a generic health-outcome instrument alone.

Physical examination of patients who have a chronic disorder of the forearm necessitates an objective clinical assessment of the relative lengths of the radius and ulna, the range of rotation of the forearm, and strength. Stability of the distal radio-ulnar joint is assessed by differential ballottement of the distal aspect of the ulna relative to the radius. There is wide variation among individuals in the amount of laxity in the distal radio-ulnar joint. Laxity does not indicate instability unless such maneuvers reproduce the symptoms.

Radiographic Assessment

Radiographic examination of the forearm necessitates that anteroposterior and lateral radiographs be made with the forearm in neutral rotation^42,101. These radiographs are most easily made by having the patient sit in a chair, with the shoulder abducted and the upper extremity placed on the radiographic table. This method of positioning ensures that the forearm is in neutral rotation and minimizes the effect of rotation when the relative lengths of the radius and ulna are assessed (Fig. 2). A lateral radiograph with the forearm in neutral rotation should also be made. The location and amount of maximum radial bow can be determined with the method of Schemitsch and Richards¹¹⁹ (Fig. 3). A line is drawn from the bicipital tuberosity to the most ulnar aspect of the radius at the wrist. A perpendicular is drawn from the point of maximum radial bow to this line. The height of the perpendicular (defined as maximum radial bow) is measured in millimeters. The distance from the bicipital tuberosity to the previously measured perpendicular at the point of maximum radial bow is then measured and is recorded as a percentage of the length of the entire bow (the distance from the mid-point of the bicipital tuberosity to the most ulnar aspect of the subchondral bone of the distal aspect of the radius). This measurement is termed the "location of maximum radial bow"¹¹⁹. Radiographs of the contralateral forearm must be made in order to determine the variance from normal for individual patients.

Radiographic examination of the proximal and distal radio-ulnar joints is challenging. Anteroposterior, lateral, and oblique radiographs should always be made. Tomograms are also useful, particularly for assessing the presence and extent of heterotopic ossification. However, the usefulness of conventional tomograms is limited by their inability to provide cross-sectional images. Bressler et al.²⁰ reported on the value of assessing heterotopic bone with computed tomographic scans. Computed tomographic scans are also useful for assessing radio-ulnar synostoses (Fig. 4). Computed tomographic scans that provide cross-sectional views of the proximal and distal radio-ulnar joints are very helpful for assessing the sphericity and articular conformity of the articular surfaces and the presence or absence of translational motion of the articular surfaces relative to each other⁷⁰.

Classification of Chronic Disorders of the Forearm

I have classified chronic disorders of the forearm according to whether the disorder is congenital or developmental, or acquired (Table I). The acquired disorders are then subdivided according to primary involvement of the bone or soft tissue. Skeletal disorders are further subclassified according to whether they are biological or mechanical. Biological disorders include infection, non-union, refracture after removal of the plate, and heterotopic ossification. Mechanical disorders affect either the diaphyses of the forearm or the radio-ulnar joints. Disorders of the proximal and distal radio-ulnar joints are subclassified according to the presence or absence of impingement, instability, and incongruity¹⁰⁹. Impingement in the forearm occurs primarily at the distal radio-ulnar joint and refers to either contact of the distal aspect of the ulna against the ulnar aspect of the carpus or, if the distal aspect of the ulna has been resected, to impingement of the ulnar stump against the radius¹¹. Ulnocarpal impingement is also referred to as ulnocarpal abutment and the ulnar impaction syndrome. Incongruity refers to disorders of the articular surface that prevent normal rotational movement of either the proximal or the distal radio-ulnar joint. Because the forearm functions as an integrated unit, limitation of motion of either of these joints affects the forearm as a whole. Instability can affect either joint or, in its most severe form, the forearm unit as a whole. A patient may have various combinations and permutations of these disorders (Fig. 5).

The treatment of a variety of chronic disorders is discussed according to the classification system just described.

Operative Approaches to the Forearm

The radius and ulna should usually be approached through separate incisions in a patient who has a chronic disorder of the forearm. The ulna is easily exposed throughout its length by a longitudinal incision made directly over its subcutaneous border. The radius can be exposed through either a dorsal or a volar incision. If a dorsal (Thompson¹³²) approach to the radius is used, great care must be taken to avoid injury to the posterior interosseous nerve. Young et al.¹⁴³ reviewed the results of operative treatment of palsy of the posterior interosseous nerve of the forearm in forty patients. Sixteen patients had an iatrogenic injury, fifteen had a traumatic lesion, and nine had a non-traumatic lesion. In the series of Schemitsch and Richards¹¹⁹, one of two patients who had been managed with a posterior approach to the proximal aspect of the radius sustained an iatrogenic lesion of the posterior interosseous nerve. Such an injury was much less likely to occur in association with a volar (Henry⁶¹) approach to the radius. Tabor et al.¹²⁵ found the posterior interosseous nerve to be in proximity (mean distance, 11.3 millimeters) to the site of insertion of a locking screw in the proximal aspect of the radius. The risk of injury to this nerve is so high that I do not use the dorsal approach for acute injuries in the proximal aspect of the forearm.

In patients who have a chronic disorder of the forearm, the posterior interosseous nerve can, with care, be safely identified and retracted. The nerve must be identified so that it is not injured. It can be identified either proximal or distal to the supinator muscle and can be traced through the muscle. In the distal aspect of the forearm, the nerve can be found in the fourth dorsal compartment. The nerve has a mean diameter of 1.3 millimeters in the distal part of the forearm. The dorsal approach is particularly useful for treating disorders of the proximal aspect of the forearm and the proximal radio-ulnar joint. There is much less risk of injury to the posterior interosseous nerve with the volar approach, although the skin incision must be long to expose the proximal aspect of the radius from this direction. In the proximal aspect of the forearm, the ulna and the proximal radio-ulnar joint can be safely exposed through one incision, as described by Boyd¹⁷. This approach is particularly useful in the treatment of malunions and non-unions of the proximal aspect of the ulna.

Biological Disorders of the Forearm

Infection

The need to maintain or restore rotation of the forearm as part of the treatment of an infection of the forearm presents challenges not seen with infections of other long bones. The principles of drainage of abscesses and débridement of dysvascular bone apply to the forearm, as they do to other anatomical locations. Most infections of the forearm develop after open fractures⁵⁵. Recent experience has demonstrated that immediate open reduction of open fractures of both bones of the forearm is not associated with an increased risk of infection and may help to prevent it^41,67,88,121. The extent of involvement of the long bones by deep infection can be substantial. If resection of an intercalary portion of one bone or both bones of the forearm becomes necessary, application of an external fixator can be useful for maintaining soft-tissue length^37,121. Often, the fixator can be applied in such a way that rotation of the forearm can be maintained during treatment, particularly if the radio-ulnar joints are intact. Calhoun et al.²⁵ reported the successful treatment of two chronic infections of the forearm with use of Ilizarov fixation and antibiotic-impregnated polymethylmethacrylate beads.

Intercalary diaphyseal defects of more than six centimeters can be treated with vascularized fibular bone-grafting¹⁴¹. The fibula provides a good-size match for either the radius or the ulna, and plate fixation can be used to gain immediate stability at the time of bone-grafting. The peroneal artery is a suitable-size match for either the radial or the ulnar artery, and either end-to-end or, more commonly, end-to-side anastomoses can be performed depending on the vascular anatomy in a particular limb. Dell and Sheppard³⁸ reported on four patients who had an infection at the site of a non-union of the forearm that was treated with vascularized fibular grafts and conversion to a one-bone forearm after as many as six previous procedures. The fibula was fixed to the ulna proximally and to the radius distally with internal means, and this was supplemented with an external fixator in three of the four patients. All bone junctures healed, although supplemental cancellous bone-grafting was needed in one. Wood¹⁴² reported the results of twenty-one vascularized fibular transfers for reconstruction of the upper extremity. Primary union occurred after fifteen procedures, and union was eventually achieved after seventeen. The most favorable results were in patients who had had reconstruction of the forearm, with union occurring in all of them. Haque⁵⁸ reported on a patient in whom diaphyseal hematogenous osteomyelitis was treated with creation of a one-bone forearm. (This method of reconstruction will be discussed later.) The ulna was radialized after resection of the radius. This resulted in a stable and functional limb.

Non-Union

Non-union of the forearm has become less frequent since the advent of reliable methods of internal fixation. Many authors have reported rates of union of more than 90 per cent after rigid internal fixation of fractures of the forearm^{7,23,24,29,40,65,97,119,129}. Nevertheless, non-union can occur, and it is usually related to bone loss associated with severe injuries or inadequate immobilization, or both^18,113. Patients who have a non-union of one bone or both bones of the forearm often have had inadequate internal fixation and an infection may have developed, usually as a consequence of an open fracture. Stress fracture of the radius after non-union of the ulna has been reported, as has fatigue fracture of a plate in the forearm used in conjunction with an above-the-elbow cast^36,105. Non-unions of the forearm are classified according to whether infection is present. If it is, the principles of treatment that I described must be integrated with the method of treatment for the non-union. In particular, abscesses must be drained and infected bone must be debrided if it is necrotic. The treatment of non-unions of the forearm associated with infection should be staged to minimize the possibility of losing autogenous bone-graft material by implantation into an infected site. Maintenance of soft-tissue length is important when treating a non-union, in order to preserve the proper soft-tissue tension and to prevent impingement⁶⁹. Stable internal fixation is the mainstay of treatment for non-unions.

Before the advent of rigid methods of internal fixation, bone-grafting was used as a biological method of internal fixation in the forearm²⁶. Bone-grafting is needed when there is an intercalary defect and to provide osteoinductive and osteoconductive material when an atrophic non-union is being treated¹⁴¹. Although bone-grafting is helpful in the treatment of a non-union, care must be taken to minimize the amount of bone formation in the area of the interosseous membrane. Misplacement of, or an overzealous biological response to, the graft material can lead to the formation of heterotopic bone and even to synostosis. Moroni et al.⁹² reported on the use of composite bone-grafting (a combination of autogenous graft and cortical bone allograft) and plate fixation for the treatment of eight non-unions of the forearm with segmental bone loss. In all eight forearms, union and recovery of function were achieved.

Refracture after Removal of the Plate

Refracture of the forearm occasionally occurs after removal of the plate that was used for treatment of a fracture^{29,39,82,114,137}. Beaupré and Csongradi¹⁰ reported prevalences of refracture of 0, 6, 7, and 21 per cent, after removal of seventy-six one-third tubular plates, 177 small-fragment dynamic-compression plates, ninety-one semitubular plates, and ninety-six large-fragment dynamic-compression plates, respectively. The prevalence of refracture can be minimized by the use of a 3.5-millimeter dynamic-compression plate as opposed to a larger plate system²⁹. Refracture usually occurs through either the original site of the fracture or an adjacent screw-hole. Routine removal of the plate is not necessary after fixation of diaphyseal fractures of the radius. Removal of the plate is occasionally indicated for irritation of the overlying soft tissue. If the plate is left in situ, there is an increased risk of fracture at the plate-bone junction if additional trauma occurs. It is uncertain if removal of the plate reduces this risk for patients participating in contact sports. Schemitsch and Richards¹¹⁹ removed the plate from twenty-four patients. For the four patients who had a refracture, the mean interval from insertion to removal was ten months, compared with sixteen months for the patients who did not have a refracture. If removal of the plate is indicated, it should be delayed until eighteen months after application^72,110,114.

Heterotopic Ossification

Heterotopic ossification can develop at any location throughout the length of the forearm. Small quantities of heterotopic bone may be of little functional importance, but larger deposits can restrict rotation. Severe heterotopic ossification can lead to synostosis or cross-union, eliminating rotation completely. Most synostoses of the forearm in adults are a result of heterotopic ossification. The common causes of heterotopic ossification include trauma, burns, brain or spinal cord injury, and genetic conditions. Immobilization in a cast after a fracture⁵⁶ and a delay in operative treatment have both been associated with cross-union after fracture of both bones of the forearm¹³⁸. Failla et al.⁴⁶ reported synostosis of the proximal aspect of the forearm in response to debris deposited at the time of a repair of the distal biceps tendon through two incisions. Regardless of its location, substantial heterotopic ossification restricts rotation of the forearm, with the most severe form being synostosis. Although motion of the shoulder and wrist can compensate to some extent for restriction in the normal amount of rotation, many of the normal activities of daily living, such as opening a door, using a fork, and holding a telephone, can be compromised⁹⁵.

Operative treatment is considered, after the initial illness or injury has stabilized, if it is technically possible to resect the heterotopic bone and if the patient is sufficiently symptomatic to make the risks of an operation worthwhile. The timing of resection of heterotopic bone remains controversial because of the risk of recurrent ossification. Failla et al.⁴⁵, after a review of the experience with twenty patients over a forty-two-year period, recommended that operative resection be delayed for twelve months after the injury but be performed within three years. Monitoring of serial bone scans or serum enzyme levels is not recommended as a method for determining the optimum time for resection⁴⁷. Maturation of the heterotopic bone should be noted on radiographs before resection is considered. The bone is considered to be mature when serial radiographs demonstrate that the extent of the heterotopic ossification is not increasing, that the margin between the heterotopic bone and the soft tissue is distinct, and that trabeculation of the bone is occurring. I resect heterotopic bone when the injury or systemic illness has stabilized, when additional new-bone formation is not observed, when the bone that is present appears mature radiographically, and when the patient can cooperate with an intensive rehabilitation program. If there is an associated contracture of the interosseous membrane, it should be released at the time that the heterotopic bone is resected.

Vince and Miller¹³⁸ classified synostoses into three types, depending on the location of the cross-union. Type I involves the distal radio-ulnar joint; type II, the non-articular portion of the radius and ulna; and type III, the proximal one-third of the radius and ulna (Fig. 4). Bone fragments left in the interosseous space and bone screws that broach the opposite cortex are common in type-II and III cross-unions. The results of operative excision for type-II cross-unions have been favorable, but the rate of recurrence has been high (five of seven in the series of Vince and Miller¹³⁸) after excision of types I and III. Breit¹⁹ reported a good result in a twenty-eight-year-old woman who had had resection for a post-traumatic synostosis, obliteration of the dead space with muscle, prevention of formation of a hematoma, and early mobilization. Maempel⁷⁹ reported two successful excisions for the treatment of a traumatic radio-ulnar synostosis; he interposed a silicone sheet between the bones of the forearm after resection. Failla et al.⁴⁵ found that eleven of their twenty patients benefited from excision for the treatment of a post-traumatic proximal radio-ulnar synostosis.

After resection of heterotopic bone, additional treatment is recommended to reduce the rate of recurrence. Treatment with radiation, indomethacin, or bisphosphonates has been advocated^{1,8,32,60,77,112,120,131}. Abrams et al.¹ reported on two patients who had received low-dose radiation after successful resection for a post-traumatic synostosis. Both patients regained a nearly full range of motion. Cullen et al.³⁴ used a single fraction of low-dose (800-centigray) limited-field radiation for four patients after excision of synostotic bone. All four patients recovered between 115 and 120 degrees of rotation of the forearm. There was no radiographic evidence of recurrence. I have managed patients with indomethacin, administered orally, for a period of three weeks postoperatively. The optimum duration of such therapy is uncertain, although courses as short as ten days have been reported to be effective after hip arthroplasty performed without cement⁷⁸. A program of active motion is instituted the day after the operation. Thermoplastic splints are used to relieve pain between mobilization sessions. Some authors have used continuous passive motion to encourage early motion after resection¹¹⁵.

Mechanical Disorders of the Forearm

Malunion

Schemitsch and Richards¹¹⁹ reported on fifty-five patients who had been managed with plate fixation for a fracture of both bones of the forearm. They found significantly less rotation of the forearm (p < 0.05) and less grip strength (p < 0.005) when the radial bow had not been restored during reduction of the fracture. Increased radial bow (overreduction) and loss of the radial bow (underreduction) both affected the outcome. Maintenance of the normal radial bow is recognized to be important in the treatment of fractures of the forearm.

Malunion of the radial or ulnar diaphysis is associated with restricted rotation of the forearm⁴⁴. In a study of angular deformity in ten cadaver specimens, Matthews et al.⁸⁰ found little loss of rotation with 10 degrees of angulation; 20 degrees of angulation caused a functional loss of motion. Sarmiento et al.¹¹⁷ demonstrated, in 105 patients, that 10 degrees of angulation of the radius or ulna restricted rotation of the forearm by a mean of 34 degrees. Tarr et al.¹²⁷ showed, in six cadaver specimens, that rotatory deformities of the forearm produced a loss of rotation that was equal to the degree of deformity. Trousdale and Linscheid¹³⁴ retrospectively reviewed the results of twenty-seven corrective osteotomies for malunited fractures of the forearm. The osteotomies had been performed at a mean of seventy-three months after the injury. There had been twenty radial osteotomies, two ulnar osteotomies, and five osteotomies of both bones of the forearm. Patients who had had the operation within twelve months after the injury gained a mean of 79 degrees of rotation of the forearm, compared with a mean improvement of only 30 degrees in patients who had had the osteotomy more than twelve months after the injury. Tajima and Yoshizu¹²⁶ reported on twenty-three neglected Monteggia injuries that were treated with corrective osteotomy. They performed thirteen ulnar osteotomies, three radial osteotomies, two osteotomies of both bones of the forearm, and five excisions of the radial head. They did not describe the results in detail, but the best results were obtained after open-wedge osteotomy of the ulna. Tetsworth et al.¹³⁰ reported on lengthening and correction of deformity in thirteen forearms with use of the Ilizarov technique. The mean increase in ulnar length was 58 per cent, and the mean increase in radial length was 23 per cent. The mean duration of treatment was five months (range, three to 6.7 months). There was a total of nine complications.

Ulnocarpal Impingement

Impingement of the distal aspect of the ulna on the carpus is the most common of the mechanical disorders that affect the forearm. Chronic impingement is associated with attritional tears of the triangular fibrocartilage as a result of the increased transmission of force across the ulnar aspect of the wrist when this mechanical phenomenon occurs^84,99. Patients who have this disorder should have careful radiographic evaluation of the length of the radius relative to the ulna, with the forearm in neutral rotation. Comparison of the symptomatic and contralateral wrists is useful, as the goal of treatment is to restore the normal relationship between the two bones. The mainstay of treatment for this condition is an ulnar shortening osteotomy. Although this procedure is primarily indicated for the treatment of impingement, Cooney et al.³¹ reported it to be a helpful adjunct in the repair of tears of the triangular fibrocartilage. Preoperatively, it is necessary to make sure that incongruity or instability, or both, do not coexist with the impingement syndrome. Minor-to-moderate amounts of instability can be corrected with a shortening osteotomy, although major instability necessitates capsular repair to restore stability to the distal radio-ulnar joint.

A variety of techniques for shortening of the ulna, including transverse, step-cut, chevron, and oblique osteotomies, have been described. Rayhack et al.¹⁰⁶ reported the results of a precision oblique osteotomy for shortening of the ulna. A 45-degree oblique osteotomy combined with interfragmentary screw fixation was associated with union at a mean of eleven weeks in seventeen extremities. In contrast, transverse osteotomy was associated with union at a mean of twenty-three weeks in twenty-two extremities and with non-union in one extremity¹⁰⁶. Richards and Bowen¹¹¹ described the use of reduction forceps for intraoperative radiography and application of a plate during ulnar osteotomy. They reported that the use of the forceps maintains the position of the osteotomy while an intraoperative radiograph is made and while the definitive plate fixation is applied. Chun and Palmer³⁰ reported the results of ulnar shortening osteotomy for the treatment of ulnar impaction syndrome in thirty wrists (twenty-seven patients). The result was excellent in twenty-four wrists, good in four, fair in one, and poor in one. Complications were rare, and there were no non-unions. Minami et al.⁸⁶ performed a hemiresection-interposition arthroplasty of the distal radio-ulnar joint in association with repair of the triangular fibrocartilage for the treatment of impingement. Pain was relieved in ten of sixteen wrists, and postoperative complications occurred in seven wrists (six patients). Two wrists needed a reoperation⁸⁶. Bilos and Chamberland¹³ reported the results of excision of the distal aspect of the ulnar head in seven patients who had positive ulnar variance in association with a tear of the triangular fibrocartilage complex. Six patients had complete relief of, or a marked decrease in, symptoms with this technique, whereby the function and basic anatomy of the distal radio-ulnar joint is preserved. Resection of the normal distal aspect of the ulna (the Darrach procedure³⁵) is not recommended for the treatment of isolated ulnocarpal impingement, as chronic instability of the ulnar stump and radio-ulnar impingement may develop and as ulnar shortening osteotomy is an effective treatment for ulnocarpal impingement.

Radio-Ulnar Impingement

Impingement can occur between the ulnar cortex of the radius and the stump of the ulna after resection of the distal aspect of the ulna. This phenomenon is usually painful. A related phenomenon is radio-ulnar convergence after resection of the distal aspect of the ulna⁷⁶. Radio-ulnar impingement can also occur in association with a non-union of the distal aspect of the ulna. This condition is more easily prevented than treated. For severe conditions, the creation of an operative synostosis between the radius and ulna may be necessary to prevent painful radio-ulnar impingement.

Instability

Chronic instability can affect either the distal or the proximal radio-ulnar joint. Instability is usually the sequela of trauma and can lead to long-term dysfunction after the original osseous injury has healed. Divergent instability is usually seen in association with massive trauma and is rare in the chronic situation. Multidirectional instability can also occur. The type of treatment depends on the direction of displacement and the presence or absence of other disorders, such as malunion or impingement.

Distal Radio-Ulnar Joint

Isolated instability of the distal radio-ulnar joint can occur, although the condition is most commonly seen in association with a fracture of the distal aspect of the radius^49,83,90,124. The condition can also occur in association with a fracture of the radial head (an Essex-Lopresti lesion)⁴³. Most patterns of instability involve the dorsal structures. Volar instability, although less common, can also occur, particularly in association with malunion of one of the bones of the forearm. Laxity of the distal radio-ulnar joint must be differentiated from instability related to generalized ligamentous laxity; this is done by examination of the contralateral wrist.

Treatment of instability of the distal radio-ulnar joint necessitates repair of the attenuated dorsal or volar radio-ulnar ligaments, or both. As the dorsal structures are most commonly involved, this can usually be accomplished with a primary dorsal capsuloligamentous repair. If there is severe soft-tissue deficiency, autogenous tendon graft may be needed. The ipsilateral palmaris longus, if present, may be used to provide graft material. Petersen and Adams¹⁰² performed a biomechanical evaluation of the results of reconstructions of the distal radio-ulnar joint. They found that radio-ulnar sling procedures, tenodesis, and reconstructions of the ulnar collateral ligament all failed to restore the natural stability of the joint. Petersen and Adams assessed a subgroup of four different radio-ulnar sling procedures, each involving creation of a ligamentous tether or sling by means of a tendon graft attached to the radius and encircling the ulnar neck. Of the three types of reconstructions, the radio-ulnar sling was the most effective. Dorsal instability (ulna dorsal) is treated with a dorsal capsuloligamentous repair, although studies have suggested that the palmar radio-ulnar ligament may also be important and may need augmentation or repair¹²². A technique combining simultaneous reconstruction of the dorsal and volar radio-ulnar ligaments has been described⁶⁶. I use a dorsal capsulorrhaphy and a postoperative program of splinting in supination¹⁰⁹. The splint helps to hold the ulna in the reduced position and protects the reconstructed forearm while healing occurs. Mobilization of the forearm is initiated, in a gradual fashion, three to four weeks after the repair. The splint is worn for three months after the operation.

Volar instability of the distal radio-ulnar joint (ulna volar) is less common than dorsal instability and is thought to be related primarily to attenuation of the volar and dorsal radio-ulnar ligaments and the distal interosseous membrane. Gosselin et al.⁵⁴ reported volar dislocation of the distal aspect of the ulna as a result of inadequate contouring of a compression plate used to treat a Galeazzi fracture. Volar instability of the distal radio-ulnar joint is treated with augmentation of the volar radio-ulnar ligamentous structures. Because volar instability is less common than dorsal instability, there has been less experience with this method of reconstruction. Pronation of the forearm tends to minimize subluxation at the distal aspect of the ulnar joint and is the recommended position of immobilization after a volar repair of the distal radio-ulnar ligaments.

Proximal Radio-Ulnar Joint

Instability of the proximal radio-ulnar joint is usually the result of trauma. Subluxation or dislocation of the proximal radio-ulnar joint can occur as part of a Monteggia injury, after a fracture¹²³ or malreduction of the radius, or as an iatrogenic problem after arthrotomy without repair of the annular ligament. The so-called pulled elbow in children is thought to be due to longitudinal subluxation of the radial head within the annular ligament. The condition also has been reported in adults⁵. Dislocation of a prosthetic radial head has been documented⁵⁹. Instability in association with malunion of the radius or ulna may necessitate osteotomy of the involved bone in addition to a repair of the annular ligament (Fig. 6). Capsular repair of the annular ligament can be achieved by careful dissection of the ligament, arthrotomy, and imbrication of the ligament with braided non-absorbable suture material¹⁰⁸.

Migratory Instability and Chronic Essex-Lopresti Lesions

In 1951, Essex-Lopresti⁴³ described an association between fractures of the radial head and dislocation of the distal radio-ulnar joint, indicating an injury to the interosseous membrane and the ligaments of the distal radio-ulnar joint. If the injury is recognized early, resection of the radial head should be avoided and open reduction or replacement of the radial head should be considered. A comprehensive discussion of the treatment of acute Essex-Lopresti lesions is outside of the scope of the current review; however, there have been several excellent reviews on this subject^44,50,69,73.

Either primary or secondary resection of the radial head can lead to proximal migration of the radius, resulting in ulnocarpal impingement¹²⁸. This type of longitudinal instability can be referred to as migratory and represents a form of chronic Essex-Lopresti lesion. Trousdale et al.¹³⁵ reported on twenty patients who had sustained concomitant injuries of the lateral compartment of the radiohumeral joint and the ipsilateral distal radio-ulnar joint. The diagnosis was delayed in fifteen patients. Excision of the radial head led to severe pain at the distal radio-ulnar joint. Preservation of the radial head was associated with better elbow and wrist scores. Bell et al.¹² subclassified chronic posterior subluxation according to whether there was associated proximal migration of the radius. Posterior displacement did not usually cause a functional deficit other than loss of rotation of the forearm. When there was associated proximal migration of the radius, a cosmetic deformity was noted. Treatment of this condition requires careful assessment of the cause. Morrey et al.⁹⁴ reported a mean of 1.9 millimeters of proximal radial migration in thirteen patients at a mean of twenty years after excision of the radial head. Goldberg et al.⁵² noted more than one millimeter of proximal migration of the radius in eight of thirty-six patients who had had excision of the radial head because of trauma. Two patients who had migration of more than four millimeters had pain in the wrist. If proximal migration of the radius causes major pain in the wrist, I perform an ulnar shortening osteotomy combined with plate fixation to re-establish neutral ulnar variance.

Incongruity of the Distal Radio-Ulnar Joint

Articular incongruity of either the proximal or the distal radio-ulnar joint produces pain and restricts the normal range of rotation of the forearm. When the symptoms justify operative treatment, the therapeutic choices are limited. There is no widely available replacement arthroplasty for reconstruction of the distal radio-ulnar joint. Therefore, the surgeon must consider resection arthroplasty to be the mainstay of treatment^35,85. Bowers¹⁵ as well as Watson and Gabuzda¹⁴⁰ described methods of resection arthroplasty for the treatment of incongruity of the distal radio-ulnar joint. Resection of the distal aspect of the ulna in its entirety has been associated with instability and is best avoided in young, active patients¹¹. If such a resection is performed, some method of soft-tissue reconstruction should be used to stabilize the remaining portion of the ulna^16,53,136.

The distal radio-ulnar joint can be reconstructed with capsular interposition or the use of autogenous tendon graft or fascia lata graft, or both. In 1985, Bowers¹⁵ reported that his procedure was useful in the treatment of both rheumatoid arthritis and post-traumatic osteoarthrosis of the distal radio-ulnar joint. Thirty-two of thirty-eight patients had good relief of pain after the operation. Twenty-three (85 per cent) of twenty-seven patients who had rheumatoid arthritis had a mean of 84 degrees of stable, painless pronation and a mean of 77 degrees of supination. Six of eleven patients who had degenerative or trauma-induced osteoarthrosis had a mean of 80 degrees of painless pronation and a mean of 80 degrees of supination. Imbriglia and Matthews⁶⁴ reported an excellent result in thirteen patients, a good result in four, a fair result in three, and a poor result in three patients after a hemiresection-interposition arthroplasty for the treatment of chronic post-traumatic dorsal subluxation of the distal aspect of the ulna. Two patients who had ulnocarpal impingement had an improvement after a shortening osteotomy of the ulna. Watson and Gabuzda¹⁴⁰ reported good and excellent results in twenty-four of thirty-two patients who had had matched resection of the distal aspect of the ulna for the treatment of a post-traumatic disorder of the distal radio-ulnar joint. The main difference between the technique of Watson and Gabuzda and that of Bowers is that the former procedure involves reshaping a five-to-six-centimeter portion of the ulna, thus obviating the need for interposition of tissue. Resection of the ulnar styloid process is usually necessary¹⁴⁰. The results in the series of Watson and Gabuzda were related to the severity of the initial injury.

An alternative to resection arthroplasty of the distal radio-ulnar joint is the Sauvé-Kapandji¹¹⁸ procedure, a distal radio-ulnar arthrodesis with creation of a pseudarthrosis in the distal part of the ulna (Fig. 7). Sanders et al.¹¹⁶ reported an excellent result after this procedure in six of nine patients and a good result in three patients, all of whom had post-traumatic osteoarthrosis. Minami et al.⁸⁷ performed the Sauvé-Kapandji procedure in fifteen patients who had osteoarthrosis of the distal radio-ulnar joint. Rotation of the forearm improved from a mean of 66 degrees of pronation and 65 degrees of supination preoperatively to a mean of 78 and 82 degrees postoperatively. Instability of the ulnar stump and radio-ulnar convergence were noted in twelve wrists. Minami et al. concluded that the results of this procedure were satisfactory. My own experience with this technique has been less favorable because of residual problems of instability and radio-ulnar impingement affecting the ulnar stump.

Incongruity of the Proximal Radio-Ulnar Joint

Incongruity of the proximal radio-ulnar joint is usually treated with resection of the radial head. Prosthetic replacement of the radial head is possible, although there is no substantial evidence that the results after resection combined with replacement of the radial head are better than those after resection alone. Hotchkiss et al.⁶², in a study of cadavera, demonstrated that silicone radial head implants were much less stiff than the intact interosseous membrane. Replacement of the radial head with a silicone prosthesis has been associated with the development of particulate synovitis and should be avoided in patients who have rheumatoid arthritis¹³³. Prosthetic fractures have been reported by Mayhall et al.⁸¹ and by Morrey et al.⁹³. The use of metal prostheses has been described²⁷. Metal radial head replacements are much more rigid than silicone replacements, and there is no evidence that they are superior, although silicone-induced synovitis is avoided. Metal implants are less deformable than silicone replacements, and a much greater operative exposure is required to remove them. Proximal migration of the radius can occur after resection of the radial head, although this complication is rare after resection for the treatment of chronic incongruity. Broberg and Morrey²¹ reported the results in twenty-one patients at a mean of fifteen years after excision of the radial head that had been delayed for one month to more than twenty years. Four patients had a Mason type-II fracture and sixteen, a Mason type-III fracture. Sixteen of their patients had a good result, demonstrating the effectiveness of this treatment after closed treatment had failed. Crawford³³ reported the late development of radial tunnel syndrome after excision of the radial head.

Chronic instability of the forearm that is recalcitrant to treatment by the means described may necessitate the operative creation of a radio-ulnar synostosis (Fig. 8). This situation is most common after severe trauma; after resection of a tumor; or after multiple failed attempts at reconstruction, usually involving excision of a portion of the ulna^28,74,96. Peterson et al.¹⁰³ reported the results of operative radio-ulnar synostosis, which they referred to as a one-bone forearm, in nineteen patients. Ten forearms were positioned in neutral rotation and nine, in varying degrees of pronation (mean, 24 degrees). Primary union occurred in thirteen patients, and complications were noted in ten. Peterson et al. concluded that, although creation of a one-bone forearm remained a viable alternative for treatment, the results were less predictable than previously reported.

Overview

In summary, chronic disorders of the forearm lead to substantial limitation of function of the forearm and compromise the function of the upper extremity as a whole. Careful clinical and radiographic assessment can help to identify the exact cause of the dysfunction, and the classification system that I have described can be used as a guide to appropriate treatment. New methods of imaging may help to define further the role of the soft tissues in common disorders of the forearm. A variety of therapeutic techniques are available to restore function of the forearm. Although experience with many of the operative techniques is still evolving, the short-term results are being documented. With time, the long-term results will be known, and this will allow more rational choices with regard to treatment. As treatment does not always restore normal function, more attention needs to be focused on the prevention of these chronic disorders by optimizing the treatment of fractures of the forearm. Modern methods of functional outcome analysis should be used to define better the impact of loss of rotation of the forearm and of grip strength on the global function of the upper extremity.

NOTE: The author wishes to thank Margot MacKay, A.N.S.C.A., B.Sc. A.A.M., Division of Biomedical Communications, Department of Surgery, University of Toronto, for creating Figure 1.

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