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Goyal, Patil, Patel, and Rai: Fractures of the radius and ulna in adults: An analysis of factors affecting outcome


Introduction

The union with normal anatomical restoration is critical to achieve an optimal outcome for mids haft fractures of radius and ulna in adults because radius moves around ulna in pronation and supination movements. These objectives are achieved by open reduction and plate fixation. In other studies, the outcome measures other than union have received very little attention and the inclusion of fractures of single bone with fractures of both bones (radius and ulna) cannot be compared with.1,2,3 This study was to determine the relationship of outcome to modality of treatment, type of fractures and presence of associated injuries in adults who sustained fractures of the shafts of both radius and ulna. Measures of outcome investigated were patient satisfaction (amount of pain), rotation of forearm, radiographic findings and work status.4

Table 1
Rating Subjective Objective Radiographic
4 No pain Combined loss of forearm rotation <300 Fracture united .combined malalignment (radius and ulna)<200
3 Mild pain, present with overuse Combined loss of forearm rotation 31-600 Union, with combined malalignment 21-400
2 Moderate pain present with routine activities Combined loss of forearm rotation 61-900 Union, with combined malalignment >400
1 Severe pain prevent routine activities Combined loss of forearm rotation >900 Nonunion,synostosis or osteomyelitis

Materials and Methods

Inclusion criteria

  1. Mature patients above 18 years of age

  2. Fractures of mid-shaft radius and ulna.

  3. Patient treated at ACPM medical college and Hospital.

  4. Total 80 patients were evaluated by all the authors.

Exclusion criteria

  1. Patients under the age of 18 years.

  2. Patients with malunion.

Complete information was available for 80 patients who had sustained mid-shaft fractures of radius and ulna. Data collection and radiographic findings were standardized for all 80 patients. All 80 patients were followed at least 24 months from union has occurred. Out of 80 pt,45 were male and 35 were female. Average age of patients was 29 yrs (ranging from 15 years to 79 y ears). In 43 patients right limb was involved. 30 fractures were open and 50 were closed.

Two methods of treatment were utilized

  1. Open reduction with plating (ORIF)

  2. Closed reduction with square nailing

The method of treatment was chosen by surgeon and the type of injury. Minimal displacement of closed fractures were the most frequent indication for closed reduction, and marked comminution was the primary reason for treatment with square nails and plaster. All reductions were performed under IVRA with c-arm machine monitoring. The definitive treatment was ORIF in 40 patients, CRIF in 40 patients. The union was defined as presence of bridging callus across the fracture site and nonunion was identified by the absence of callus within twenty-eight weeks following injury. The standards for alignment of radiographs were based on Sage's study, which defined normal as nine degrees of radial and six degrees of dorsal bowing of the radius and zero degrees in both planes for the ulna. The end result ratings were made on a 14 point scale in four

Categories: (a) according the level of pain in the injured limb; (b)by the range of forearm rotation; (c) radiographic criteria of union, synostosis, and malunion; and (d) economic- impact of the injury on the patient's employment status (Table 1).

Results

Subjective Outcomes

80 percent of patients reported no pain, with no difference between patients with open and those with closed fractures. 82 percent of patients treated with ORIF were pain free at their 24 months, and 62 percent treated with CRIF. Effect observed in group A (ORIF) was 82.8% and effect observed in group B(CRIF) was 66.7%. Out of 80 patients, none of the patienst had significant loss of wrist or elbow motion com pared to the uninjured side. Average decrease in forearm rotation was 29 degrees with loss of slightly more supination than pronation. No significant difference was present in the loss of forearm rotation between closed and open fractures.

Radiographic Outcomes

The union occurred in 93 percent of radius fractures and 97 percent of ulna fractures. An average time for union was 17.7 weeks for the radius and 18.3 weeks for ulna. The union was more frequent after closed than after open fractures. Difference was most apparent in radius fractures and opened fracture compared to closed injuries. 11 percent of open fractures developed nonunions, average time for union was 18 percent longer for open than for closed fractures of the radius. 32 percent longer for open fractures of the ulna. Frequency and time for union were unaffected with the method of treatment. After 36 months of treatment the amount of forearm rotation lost was directly proportional to the loss of normal alignment.66 percent of patients had less than twenty degrees of malalignment of the radius and ulna. No difference was present between those patients with open and closed fractures. Modality of treatment, however, had a significant effect on the final radiographic alignment. 81 percent of patients treated with ORIF had less than 20 degrees combined malalignment of the radius and ulna.

Economic outcomes

90 percent of patients with closed fractures and 97 percent of those with open fractures returned to the same work after injury. Difference may be because of the fact that nearly all patients with open fractures were treated by ORIF, while many with closed fractures were treated with CRIF. All patients treated with ORIF returned to the same work following injury more frequently than those treated with CR IF. Presence of other injuries had little effect on the ability of patients to return to the same work following injury. Pain affected the patient’s ability to return to the same work following injury. The strongest correlation was with the amount of forearm rotation lost.88 percent of patients who did not return to the same work lost at least sixty one degrees of forearm rotation and only 21 percent of patients who returned to the same work lost this much rotation.

Complications

Infection: Infection rate was 9 percent in open fractures and 1.5 percent in closed fractures. Infections were not observed in open fractures treated by immediate ORIF. Infections resolved with surgical debridement and appropriate antibiotic therapy.

Nerve palsy: There were Ten palsies recorded prior to treatment. There were no post op palsy.5,6

Synostosis: No patient had synostosis

Figure 1

Patient 1

https://s3-us-west-2.amazonaws.com/typeset-media-server/33e034fb-1425-4205-b661-878689ff5beaimage1.png

Figure 2

Patient 2

https://s3-us-west-2.amazonaws.com/typeset-media-server/33e034fb-1425-4205-b661-878689ff5beaimage2.png

Discussion

Present study deals with 80 cases of midshaft radius ulna fractures. Operavtive methods were compression plating (3.5mm DCP) and interamedullary nailing by square radius ulna nail. Fracture were common in male as well as in females. Right sided forearm is more involved than left. Transverse and oblique fracture were more common than middle third fracture.

In this study, mode of injuries were vehicular accident and fall from height. In this comparative study of fractures of radius ulna by plating versus nailing excellent result in plating were 80.6% as comopared to nailing that is 76.2%. In complication superficial infection rate was more common in plating than nailing. None of the patients required implant removal for infection.

Their were 5 cases of delayed union plating (2) nailing(3). One each case of nailing and plating has compound fracture has comminution on admission. Delayed union cases were treated with bone grafting and slab, they finally heal by 6-7 months. Thus complication rate was less in plating (13.33%) as compared to nailing which was (26.66%). After success full closed nailing, soft tissue envelop around the fracture is well preserved with good blood supply to bone ends, because of this biologically fracture healing is rapid in closed nailing.7 But in open nailing union will be little slow, after plate fixation union will be still more slow due to some soft tissue disturbances. The nail is straight and elastic implant often taking shape of bones, straight nail in the curved canal, but it does not alter bowing of radius8 and final range of motion. The result was proved at the end of 36 months.

Conclusion

Out of 80 patients, at the end of 36 months end results following treatments of fractures of the shaft of radius and ulna were good to excellent regardless of the method of treatment, except for longer time to unite and high rate of infection, outcomes of open and closed fractures were also similar. Results with ORIF were better than CRIF, as ORIF minimizes malalignment and resulting loss of forearm rotation.9 The above two factors were related to ability to return to same work following injury. The interpretation of radiological finding was associated with radiological alignment and functional limitation.

Acknowledgement

We are thankful to dept. of orthopaedics for cooperation

Source of Funding

None.

Conflict of Interest

None.

References

1 

Henry Greay Anatomy of the Human BodyEight Edition

2 

L D Anderson T D Sish R E Tooms W I Park Compression plate fixation in acute diaphyseal fractures of the radius and ulnaJ Bone Joint Surg197557287297

3 

J Bohler Treatment of fracturesWright, Bristol 1936421

4 

LD Anderson Sisk T D Tooms R E Park Park III, W. I.: Compression plate fixation in acute diaphyseal fractures of the radius and ulnaJ Bone Joint Surg197557-A287297

5 

H N Burweli A D Charnley Treatment of forearm fractures in adults with particular reference to plate fixationJ Bone Joint Surg196446-B404424

6 

M W Chapman J E Gordon A G Zissimos Compression plate fixation of acute fractures of the diaphyses of the radius and ulnaJ Bone Joint Surg198971-A159169

7 

E M Evans Fractures of the radius and ulnaJ Bone Joint Surg1951548561

8 

Y H Lee S K Lee M S Chung G H Baek H S Gong K H Kim Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of forearm in adultsJ Bone Jonit Surg Am20089018911898

9 

T D Botting Post traumatic radioulnar cross-unionJ Trauma197011624



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