forearm fracture

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management principle evidence based ,radius ulna fracture,


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Sir, it;s an excellent presentation. please, permit me for a copy, to teach my residents of my Orthopaedic Dep.

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Presentation Transcript



Slide 2:

QUICK ASSESSMENT OF NERVE INJURIES 3.Making a fist 1.Extension of hand and finger 2.Making a O.K (kiloh-nevin sign) Van Der Wurff, P, R H Hagmeyer, and W Rijnders. “Case Study: Isolated Anterior Interosseous Nerve Paralysis: The - Kiloh-Nevin Syndrome.” The Journal of Orthopaedic and Sports Physical Therapy 6, no. 3 (1984): 178-80. doi:2065


ASSESSMENT OF ASSOSCIATED BONY INJURIES Proximal radio-ulnar joint Dislocation Abnormally wide joint space? Direction of the dislocation? Look for elbow joint tenderness Interosseous membrane Is the membrane torn? If so, proximally or distally? Distal radio-ulnar joint Dislocation Abnormal separation Shortening of the radius relative to ulna


ASSESSMENT OF OTHER INJURIES High incidence of associated musculoskeletal injuries Out of 119 patients with forearm fractures second injury was found in 114 pts. Ligamentous injury in 79 patients; Second bony injury was found in 9 patients. Associated injury of the distal radio- ulnar joint was found in 71 patients ( Goldberg HD, Young JW, Reiner BI, et al. Double injuries of the forearm: a common occurrence. Radiology 1992) 5

Essex-Lopresti lesion  :

Essex- Lopresti lesion Essex-Lopresti lesion refers to longitudinal disruption of the radioulnar interosseous membrane and proximal migration of the radius associated with fractures involving the proximal radioulnar joint, the distal radioulnar joint, or both sites


RATIONALE FOR TREATMENT 10 degrees of angulations of one or both bones of the forearm resulted in a loss of ROM of 20 degrees of pronation and supination . With 20 degrees of angulations significant restriction in passive rotation of the forearm was observed . Significantly greater loss of ROM in forearms with middle-third deformities than with distal-third deformities, more supination being lost than pronation . The greater decrease of ROM in middle-third deformities was attributed to the loss of the radial bow where the two forearm bones overlap at the extremes of pronation and supination Matthews LS, Kaufer H, Garver DF, et al. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm.JBJS (Am) 1982. Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. JBJS(Am) 1984




NONOPERATIVE TREATMENT Results achieved by Sarmiento could not be repeated in subsequent studies . Knight and Purvis, 1949. Knight RA, Purvis GD:  Fractures of both bones of the forearm in adults. J Bone Joint Surg 1949; 31A:755


INDICATION OF NON OPERATIVE TREATMENT Isolated undisplaced fractures of the ulna Operative treatment is contraindicated because of the patient's general condition . The patient should be advised that open reduction and internal fixation may be required to obtain anatomic reduction and that the quality of the reduction is the key element for restoration of full function. Mackay D, Wood L, Rangan A. The treatment of isolated ulnar fractures in adults: a systematic review. Injury 2000;31(8):565–570. 37. Sarmiento A, Latta LL, Zych G, et al. Isolated ulnar shaft fractures treated with functional braces. J Orthop Trauma 1998;12(6):420–423;


NAILING Vs PLATING 1.Intramedullary nails are not as strong and do not maintain forearm reduction as well as plate osteosynthesis. Schemitsch EH, Jones D, Henley MB, et al. A comparison of malreduction after plate and intramedullary nail fixation of forearm fractures. J Orthop Trauma 1995;9(1):8–16. 58. Jones DJ, Henley MB, Schemitsch EH, et al. A biomechanical comparison of two methods of fixation of fractures of the forearm. J Orthop Trauma 1995;9(3):198–206 2.Moreover, the use of intramedullary nails is limited by the configuration of the fracture and the presence and severity of associated injuries. Selection of the correct length and diameter of the nail with reference to the configuration of the fracture is critical . Sage FP. Medullary fixation of fractures of the forearm. A study of the medullary canal of the radius and a report of fifty fractures of the radius treated with a prebent triangular nail. Am J Orthop 1959;4 A:1489–1516


NAILING Vs PLATING 1.The anatomical reduction cannot be as accurate as can be achieved with plating. If open reduction is chosen intramedullary, nailing combines the disadvantages of open reduction with the disadvantages of the implant itself. we do not advocate its use in displaced, unstable fractures in adults . Bucholz, Robert W.; Heckman, James D.; Court-Brown, Charles M. Rockwood & Green's Fractures in Adults, 6th Edition 2.Plate osteosynthesis is superior to other treatments because it permits anatomical reconstruction but also is associated with improved function . Rosacker JA, Kopta JA. Both bone fractures of the forearm: A review of surgical variables associated with union. Orthopaedics 1981;4:1353â .Hadden WA, Reschauer R, Seggl W. Results of AO plate fixation of forearm shaft fractures in adults. Injury 1983;15(1):44–52 .Dodge HS, Cady GW. Treatment of fractures of the radius and ulna with compression plates. J Bone Joint Surg Am 1972;54(6):1167–1176. . Hertel R, Pisan M, Lambert S, et al. Plate osteosynthesis of diaphyseal fractures of the radius and ulna. Injury 1996;27(8):545–548


NAILING OR PLATING 244patients had 330 acute diaphyseal fractures of the radius and ulna which were treated with ASIF compression plates and followed for from four months to nine years. The over-all rate of union for the radius was 97.9 per cent and for the. ulna, 96.3 per cent ASIF compression plates, therefore, provided a successful method for obtaining union and restoring optimum function after acute diaphyseal fractures of the forearm. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna JBJS 1975 vol 57(LD Anderson, D Sisk, RE Tooms and WI Park )

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J Orthop Trauma, 2006 Mar;20(3):157-62; Lindvall EM, Sagi HC : Selective screw placement in forearm compression plating: results of 75 consecutive fractures stabilized with 4 cortices of screw fixation on either side of the fracture. A prospective study in 63 pts. The overall union rate after the index procedure was 97.1% for the radius and 97.6% for the ulna. Fixation with a standard length compression plate and FOUR CORTICES of screw fixation on either side of the fracture seems to be a stable construct for diaphyseal forearm fractures Am J Orthop (Belle Mead NJ), 2007 : Clinical results of minimal screw plate fixation of forearm fractures. A retrospective study in 78 fractured bones plated using "minimal" screw technique--less than the traditionally recommended 6 cortices of screw purchase. Union rate of 91% (71/78). All nonunions were atrophic and occurred in open fractures with bone loss . PLATING (HOW MANY CORTICES)

Long term result of plate osteosynthesis:

Long term result of plate osteosynthesis Plate osteosynthesis of diaphyseal fractures of the radius and ulna.Hertel RPisan M Lambert S Ballmer FT . Injury 2005 133 consecutive patients were treated for a fracture of the shaft of one or both forearm bones (134 forearms in total). All fractures were stabilized with AO/ASIF 3.5 mm stainless-steel dynamic compression plates . with an average age of 37.5 years (range, 16-63) 127 of 132 forearms (96.2 per cent) underwent problem-free consolidation before 6 months .This study confirms the safety and efficacy of plate osteosynthesis in forearm shaft fractures: a high union rate and low complication rate can be anticipated . The data presented form the most reliable information on this subject currently available with the longest and highest rate of follow up(2.7-15.2 years) of a sufficient number of patients using a single implant system in a single institution .


TIMING OF PLATE REMOVAL High rate of refracture after plate removal 4%-25% Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg Am 1989;71(2):159– 169 Dodge HS, Cady GW. Treatment of fractures of the radius and ulna with compression plates. J Bone Joint Surg Am 1972;54(6):1167–1176 Labosky DA, Cermak MB, Waggy CA. Forearm fracture plates: to remove or not to remove. J Hand Surg (Am) 1990;15(2):294–301. 88. Deluca A, Lindsey RW, Ruwe A. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am 1988;70(9):1372–1376 The bone should be allowed to remodel before the plate is removed. It has been suggested that remodeling takes up to 21 months to complete. Do not advocate routine plate removal in asymptomatic patient . Rosson JW, Petley GW, Shearer JR. Bone structure after removal of internal fixation plates. J Bone Joint Surg Br 1991;73(1):65–67. 92. Rosson JW, Shearer JR. Refracture after the removal of plates from the forearm. An avoidable complication. J Bone Joint Surg Br 1991;73(3):415–417


OPERATIVE TREATMENT INTRAMEDULLARY NAILING Sage FP devised triangular intramedullary nails . While the ulnar nail was straight, the radial nail was bent to restore the radial bow nonunion occurred in 6.2% of patients with delayed union in 4.9% High incidence of malunion and poor function in those fractures that united . (Medullary fixation of fractures of the forearm. A study of the medullary canal of the radius and a report of fifty fractures of the radius treated with a prebent triangular nail. Am J Orthop 1959)

Slide 17:

Zinar et al.,. reported union rates of 93% and 97% in a total of 339 fractures treated with modified nails that were bent to conform to the radial bow before insertion. Crenshaw and Staton reported 100% union in 37 fractures using the ForeSight nail system (Smith & Nephew, Memphis, Tenn ). Static locking was performed in 20% of these fractures to control rotational instability . 1996. Zinar DM, Street D, Wolgin M: Intramedullary nailing of the forearm . The science and practice of intramedullary nailing ,   2nd ed. Baltimore: Williams & Wilkins; 1996 INTRAMEDULLARY NAILING (STATIC LOCKING NAIL)

Slide 18:

The average time to fracture union was 14 weeks. One nonunion of an open comminuted fracture of the middle third of the ulna. Advantages of an interlocking intramedullary nail system for the radius and ulna technically straight for ward, it allows a high rate of osseous consolidation requires less surgical exposure and operative time than does plate osteosyn the sis . (Interlocking Contoured Intramedullary Nail Fixation for Selected Diaphyseal Fractures of the Forearm in AdultsYoung Ho Lee, MD 1 , Sang Ki Lee, MD 2 , Moon Sang Chung, MD 1 ,Goo Hyun Baek, MD 1 , Hyun Sik Gong, MD 1 and Kyung Hwan Kim, MD 1 ) The Journal of Bone and Joint Surgery (American) . 2008 INTRAMEDULLARY NAILING (STATIC LOCKING NAIL)


NEWER IMPLANTS True-Flex prebent, titanium nonreamed forearm nails. Radius and ulna intramedullary nail system


INTRAMEDULLARY NAILING INDICATIONS: segmental fractures poor skin conditions (e.g., burns) selected nonunions or failed compression platings, multiple injuries diaphyseal fractures in osteopenic patients selected type I and type II diaphyseal fracture massive compound injuries for which nonreamed ulnar nails can be used as an internal splint to maintain forearm length while extensive soft-tissue loss is treated. Almost any diaphyseal forearm fracture can be repaired with an intramedullary nail. CONTRAINDICATIONS: (1) an active infection, (2) a medullary canal smaller than 3 mm, and (3) an open physis Anderson LD, Bacastow DW:  Treatment of forearm shaft fractures. Contemp Orthop 1984


BONE GRAFTING 1.In particular, the use of bone graft was not associated with a higher rate of union . Ring d  Rhim RCarpenter CJupiter JB J Trauma. 2005 Aug;59(2):438-41; discussion 442. 2 . Acute bone grafting of diaphyseal forearm fractures did not affect the union rate or the time to union. Diaphyseal forearm fractures treated with and without bone graft WEI S. Y. BORN C.T.ABENE A.ONG A.HAYDA R.DELONG W. G.The Journal of trauma1998. 3.This study suggests that routine use of bone grafting in comminuted forearm fractures is not indicated.J Orthop Trauma. 1997may 11(4) 288-94 The necessity of acute bone grafting in diaphyseal forearm fractures: a retrospective review. Wright RR Schmeling GJ Schwab JP.

Slide 22:

HOW TO DEAL WITH BONE LOSS Segmental bone defects less than 5 cm 1.Corticocancellous bone graft from illiac crest; Ref-Grace TG,Eversman WW ,The management of segmental bone loss associated with forearm fracture. JBJS 62 A-1150-1155(1980) 2.Autologus fibula graft ; Miller RC ,phalen GS ,The repair of defect of the radius with fibular bone graft .JBJS 29/629-636,(1947) 3.Replacement of the segment Ref Tuli SM Traumatic extrusion of the diaphysis of radius ulna succesfully treated by replacement JBJS (745-749 )1967. Ref. Dr.Harish Rao and Dr.S. Patil Traumatic extrusion and replacement of autoclaved diaphyseal segment of radius :A case report ..Hand surgery vol.9 dec 2004


VASCULARISED FIBULA GRAFT .FOR BONE DEFECT MORE THAN 5 cm . 1.Jupiter JB, Gerhard HJ, Guerrero J, Nunley JA, Levin LS. Treatment of segmental defects of the radius with use of the vascularized osteoseptocutaneous fibular autogenous graft. J Bone Joint Surg Am 1997;79:542 The average length of the fibular autogenous graft was 7.9 centimeters ,


VASCULARISED FIBULA GRAFT .FOR BONE DEFECT MORE THAN 5 cm 2.Microsurgery. 2004;24(6):423-9.Reconstruction of large posttraumatic skeletal defects of the forearm by vascularized free fibular graft.Adani R Delcroix L Innocenti M, Marcoccio I, Tarallo L, Celli A Ceruso MThe length of bone defect ranged from 6-13 cm . Fibular grafts allow the use of a segment of diaphyseal bone which is structurally similar to the radius and ulna and of sufficient length to reconstruct most skeletal defects of the forearm. The vascularized fibular graft is indicated in patients with intractable nonunions where conventional bone grafting has failed or large bone defects, exceeding 6 cm, are observed in the radius or ulna.

BONE LOSS MORE THAN 5 cm(cont.):

BONE LOSS MORE THAN 5 cm(cont.) 3.J Hand Surg Br. 2005 Feb;30(1):67-72.Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones.Safoury Y. All fractures united with good soft-tissue healing and resolution of infection. One patient required additional cancellous bone grafting. The mean period required for radiographic bone union was 4 months. Reconstruction of only the radius provided a stable forearm with a reasonable range of forearm rotation .


ATROPHIC NONUNION WITH GAP MOD.NICOLL’S grafting The tricorticocancellous strut bone grafting under optimal compression, augmented with intramedullary fixation, provides a promising solution to difficult problem of an atrophic nonunion of forearms bones with gap . 2010  Vol 44(1) 84-88Gap nonunion of forearm bones treated by modified Nicoll's technique Dinesh K Gupta 1 , Gaurav Kumar Indian journal of orthopaedics Nicoll BA. The treatment of gaps in long bones by cancellous insert grafts. J Bone Joint Surg Br 1956;38:70-82


ILLIAC BONE GRAFT(SPIRA) Spira E. Bridging of bone defects in the forearm with iliac graft combined with intramedullary nailing. J Bone Joint Surg Br 1954;36:642-6

Slide 28:

Open Fractures of the Forearm Q.What needs to be done? Q.Definitive Surgery early or late ?

Management protocol for open fractures:

Management protocol for open fractures Anderson etal. Pin and plaster External fixator Ulnar nail-Requiring graft/flap Cast and window –single bone compound #s Anderson and Bacastow, 1984. Anderson LD, Bacastow DW:  Treatment of forearm shaft fractures with compression plates. Contemp Orthop 1984; 8:17. Anderson et al., 1975. Anderson LD, Sisk TD, Tooms RE, et al:  Compression-plate fixation in acute diaphyseal fractures of the radius and ulna.   J Bone Joint Surg   1975; 57A:287

Slide 30:

Open Fractures of the Forearm Duncan et al. reported 90% acceptable results in 103 Gustilo type I, type II, or type IIIA open diaphyseal forearm fractures treated with immediate débridement and compression plate and screw fixation . Their results with type IIIB and type IIIC injuries were poor ,( Duncan et al., 1992. Duncan R, Geissler W, Freeland AE, et al:  Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma 1992 ).

Slide 31:

Jones reported 55 good results in a small series of type IIIB and type IIIC injuries treated in a similar fashion. Two of three patients with type IIIC injuries had poor results after immediate débridement and compression plate and screw fixation . Immediate open reduction and internal fixation of type I and type II open diaphyseal forearm fractures is appropriate if thorough débridement is performed. Treatment of type III injuries should be individualized, with consideration given to the mechanism and force of injury, associated injuries, and the condition of the patient before and after injury (Jones, 1991 . Jones JA:  Immediate internal fixation of high-energy open forearm fractures. J Orthop Trauma 1991; 5:272 débridement is performed). Open Fractures of the Forearm(cont.)

Management protocol for open fractures:

Management protocol for open fractures Campbells clinic - Delayed internal fixation using compression plate in type III Primary debridement in type I and II open fractures and internal fixation.


HOW TO DEAL WITH # COMPLICATED BY INFECTION/OSTEOMYELITIS In children with osteolysis of distal half of ulna – Single bone forearm(ULNIUS) Adults –Upto 9 1/2 cm of distal ulna can be exicised and stabilised with LASSO tech.

INDICATION Single bone forearm (ULNIUS):

INDICATION Single bone forearm (ULNIUS) 1.Defective ulna OMKarakurt L et al. Acta Orthop Traumatol Turc 2003;37(1): 70-2. 2. Partial defect of ulna .Kitano K , Tada K. J Pediatr Orthop. 1985 May-June; 5(3): 290-3 3.Congenital Pseudoarthrosis of ulna .Durga Nagaraju K et al. J Paedatr Orthop.March 2007; 16(2), 150-2. 4.Malignant and aggressive tumors.Kesani AK ,Tuy B et al .CORR 2007;464:210 5. Trauma, Tumor or Congenital defect. Peterson CA, Maki’s et al. J Hand Surg(Am) 1995 July;20(4):609-18. .Ulnius: A one bone forearm in children Peterson, Hamlet A. JPOB 17(2):95-101, March 2008.

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HOW TO DEAL WITH MALUNION/SYNOSTOSIS 1.J Hand Surg Eur Vol. 2011 Feb;36(2):102-6. Epub 2010 Aug 23. Corrective osteotomy in forearm fracture malunion improves functional outcome in adults. Chia DS ,Lim YJ, Chew WY The corrective operations were done using oblique or wedge osteotomies . The patients recovered well, with statistically significant improvement in forearm rotation and Disabilities of the Arm, Shoulder, and Hand (DASH) scores. 2.Treatment of radioulnar synostosis by radical excision and interposition of a radial forearm adipofascial flap Journal of Hand Surgery Volume 29, Issue 6 , Pages 1143-1147, November 2004 Adil Esmail MD Eon K. Shin MD 3 . Treatment of synostosis with the use of medications(Indomethacin), or the interposition of silicone, fat, or muscle. Failla JM, Amadio C, Morrey BF. Post-traumatic proximal radio-ulnar synostosis. Results of surgical treatment. J Bone Joint Surg Am 1989;71(8):1208–1213

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Surgical resection with adjuvant radiotherapy Jupiter JB, Ring D. Operative treatment of post-traumatic proximal radioulnar synostosis. J Bone Joint Surg Am 1998;80(2):248–257 .

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