Outline:  
Fracture of shafts of radius and ulna is a fracture of radial and ulnar shafts occurring simultaneously. It often occurs in the middle or lower one-third of the radius and ulna in elder children and adults. Fractures caused by direct violent force are often transverse or comminuted with the fracture lines being mostly at the same level. And it may be open fracture due to serious damage of local soft tissues. Fractures caused by transmitted force occur mostly in the condition that the palm touches the ground first when falling down. The force transmitted to the middle or upper section leads to transverse radial fracture and the residual force results in oblique ulnar fracture through traction of interosseous membrane to the ulna.
 
The fracture lines are commonly not at the same level, with the radial fracture line being superior to the ulnar fracture line. A greater violence may cause open fracture because of penetration of the fractured end into the skin. A turned-round violence may cause spiral fracture by resulting in extreme pronation or supination of the forearm. The fracture lines are not at the same level, with the ulnar fracture line superior to the radial fracture line. In the case of complete fractures of the two bones, the fracture ends may overlap, spiral, angulate and displace laterally. There may occur compartment syndrome of antebrachial fascia in the fractures of serious displacement or soft tissue injury.

Major points for diagnosis  
1. There is a definite traumatic history of falling, blowing or crushing.

2. The patient complains of severe pain in the forearm, and intolerance of motion.

3. The physical findings are marked swelling, tenderness, angulation or shortened deformity, pseudoarthrosis motion and bony crepitus.

4. Generally there is a small wound on the skin in open fracture due to stabbing of the bone stump, and the protruded end of fracture sometimes may be drown back into the wound.

5. If the patient complaint of serious pain with swelling, numbness and cold or cyanosis of the fingers, and the pain is aggravated by passive motion of the fingers, it is an indication of compartment syndrome of antebrachial fascia.

6. The roentgenogram may reveal the type of fracture and the direction of displacement. The roentgen-ographic examination should include both the upper and the lower radioulnar joints to avoid missing diagnosis of separation or dislocation of upper or lower radioulnar joints.

Treatment:   
Manipulative reduction and splintage may be applied for all closed fractures, regardless of their locations and types. In the cases of marked swelling, the reduction and fixation should not be performed until the swelling subsides basically. The open fracture with small and less contaminated wound can be dealt with in the same way as the closed fracture after its debridement and suture. The operative treatment should be applied as early as possible for the cases of severe open fracture or fracture with compartment syndrome of antebrachial fascia.
 
Reduction:
The patient takes a supine position. Medicinal analgesia or brachial plexus anesthesia is given, with the shoulder abducted to the angle of 90°, and the forearm in neutral position for the case of fracture in the middle or lower one-third and in supine position for the case of fracture in the upper one-third. Then, two assistants apply pulling traction to correct overlapped, spiral or angulated deformity. When the double fractures of both radial and ulnar shafts are unstable, the ulna should be first reduced for fracture in the upper one-third, and the radial first for fracture in the lower one-third. As for the fracture in the middle section, it should be decided according to the stabilities of fractures of the two bones.

For the case of incomplete reposition of overlapped displacement after traction because of antebrachial muscularity and swelling with bleeding after fracture, the bending and apposing manipulations may be taken to achieve reduction. For the case of oblique or serrated fracture with dorsolateral displacement, the turning-back manipulation may be taken to achieve reduction. For the case in which the broken ends of radius and ulna have drawn together, the bone-separating manipulation may be taken. The operator puts his thumbs and the second, third and fourth fingers respectively on the palmar and the dorsal aspects of the fracture site. Then, he makes an effort to enlarge the spaces between the radius and the ulna to maximal extent, making the interosseous membrane restore its tensity and the fracture ends of radius and ulna drawn together separate respectively toward radial and ulnar sides.
 
Fixation:   
While maintaining the traction, the operator puts bone-separating pad and flat pad properly. When the fracture lines lie at the same level, the bone-separating pad should be put in the middle of the fracture line, otherwise it should be put between the two fracture lines (see Fig. 13). For the case of lateral or angulation displacement, two-point or three-point pressure with flat pads may be respectively applied, and the pads should be fixed with adhesive plaster. Then, wrap the forearm with cotton cushions, first place palmar and dorsal splints, and then radial and ulnar splints. The dorsal splint should superiorly reach the process or olecranon and inferiorly get to the point 1 cm distal to the transverse carpal crease.

The palmar splint should superiorly be at the same level with the transverse cubital crease and inferiorly be at the same level with the transverse carpal crease. The radial splint should superiorly reach the head of radius and inferiorly get to the styloid process of radius. And the ulnar splint should superiorly be at the same level with the process of olecranon and inferiorly reach the basal part of the fifth metacarpal bone. First tie two strings on the middle part, then on the two ends, neither too tightly nor too loosely. The patient is asked to flex his elbow to 90°, his forearm is then suspended before the chest on a supporting board in neutral position (see Fig. 14). The duration of fixation is 6 to 8 weeks for adults, and 3 to 4 weeks for children.

Functional exercise:   
The patient with obviously swollen and painful limbs in the early stage may only practice fist-clenching exercise, but his fingers should extend and flex as forcefully as he can. After swelling has subsided, the patient will be encouraged to practice his elbow joint exercises. If the pain in the diseased arm has been obviously relieved, the range of activities may be properly enlarged. Rotation activities of the forearm should not be done until the fixation is removed.
     
Herbal therapy:  
Internal treatment based on syndrome differentiation
1. In the early stage

Main symptoms and signs:
Swelling and pain in the forearm swelling, distension and impaired movement of the finger or fever, fullness and distension of the abdomen.

Therapeutic methods:
Promoting blood flow to remove the stasis, and removing the swelling to relieve pain.

Recipe and herbs:
Modified Huoxue Zhitong Decoction. Specifically, Danggui (Radix Angelicae Sinensis)10 g, Chishaoyao (Radix Paeniae Rubrae)10 g, Chuanxiong (Rhizoma Ligustici Chuanxiong)10 g, Honghua (Flos Carthmi)6 g, Zhechong (Eupolyphaga seu Steleophaga)10 g, Sanqi (Radix Notoginseng)9 g, Yanhusuo (Rhizoma Corgdalis)15 g, Lulutong (Fructus Liquidambaris )10 g, Zelan ( Herba Lycopi Lucidi)10 g, Danshen (Radix Salviae Miltiorrhizae )10 g and Gancao (Radix Glycyrrhizae )5 g.

2. In the middle stage
Main symptoms and signs:
Alleviated pain, subsided swelling, and hypoporosis.

Therapeutic methods:
Removing the stasis and reuniting the bone, regulating qi to alleviate pain.
 
Recipe and herbs:
Modified Xinshang Xuduan Decoction. Specifically, Dangguiwei (Extremitas Radix Angeticae Sinensis)12 g, Zhechong ( Eupolyphaga seu Steleophaga)10g, Ruxiang (Gummi Olibanum)5 g, Moyao ( Myrrha )5 g, Danshen (Radix Salviae Miltiorrhizae)10 g, Xuduan (Radix Dipsaci)12 g, Duanzirantong (Pyritum Carcinatum ) (to be decocted first)20g, Gusuibu (Rhizoma Drynarii)12 g, Zelan (Herba Lycopi Lucidi )10 g, Yanhusuo ( Rhizoma Corydalis )15 g, Sumu (Lignum Sappan)10 g and Gancao (Radix Glycyrrhizae )5 g.

3. In the late stage
Main symptoms and signs:
Muscular atrophy, adhesion between tendon and bone, rigidity of the joint with impaired movement.

Therapeutic methods:
Relaxing muscles and tendons, activating collaterals, and freeing joint movement.

Recipe and herbs:
Modified Kuanjin Powder. Specifically, Qianghuo (Rhizoma seu Radix Notopterygii)10 g, Fangfeng (Radix Ledebouriellae Divaricatae)10 g, Xuduan (Radix Dipsaci)10 g, Chishaoyao (Radix Paeniae Rubrae)10 g, Guizhi (Ramulus Cinnamomi Cassiae)6 g, Danggui (RadixAngelicae Sinensis)10 g, Dilong ( Lumbricus )15 g, Ruxiang ( Gummi Olibanum)10 g, Moyao (Myrrha)10 g, Mahuang (Herba Ephedrae)6 g, Chenpi (Pericarpium Citri Reticulatae)10 g and Gancao (Radix Glycyrrhizae)5 g.