Malunions and Nonunions of the Forearm

doi:10.1016/j.hcl.2007.02.005

Hand Clinics

Volume 23, Issue 2, May 2007, Pages 235-243

https://doi.org/10.1016/j.hcl.2007.02.005 Get rights and content

Modern techniques allow for high rates of union in the treatment of diaphyseal forearm fractures. In the case of nonunion, addressing the biology and stability of the fracture will similarly yield high union rates, but slightly decreased functional outcomes. Malunion of forearm fractures typically results in loss of range of motion and grip strength. Restoration of the anatomical relationships of the forearm yields functional results. Understanding and recreating the anatomy of the forearm is the key to obtaining good functional outcomes.

Section snippets

Treatment

Historically, poor results were obtained by closed treatment of adult forearm fractures [1], [2]. Hughston [3] reported 92% unsatisfactory results with closed treatment of radial shaft fractures. In the adult population, closed reduction is very difficult to achieve and maintain, often resulting in malunion and subsequent loss of rotation of the forearm [4], [5]. In 1945, Evans [6] noted the difficulty in determining rotational deformity in forearm fractures and the resultant loss of rotation

Nonunion

With the application of Arbeitsgemeinschaft für Osteosynthesefragen (AO) principles, compression plating has been successful in achieving union and restoring function of the forearm. Anderson and colleagues [10] first reported their 10-year experience with compression plating in 1975. Overall union rates for the radius and ulna were 98% and 96%, respectively. It was their protocol during this time to perform autogenous iliac crest bone grafting for all fractures with comminution greater than

Malunion

In the early reports of success with compression plating, the outcome of union was universally evaluated, however, malunion was not directly addressed. Functional outcome was frequently used as a surrogate to malunion before meaningful measurements for acceptable angular and rotational deformities. As our understanding of the relationship between the radius and ulna evolved from thinking of them as two independent bones to a dynamic and dependent “functional joint,” the importance of malunion

Summary

Overall, malunions of the forearm can lead to functional deficits of motion and instability at the distal radioulnar joint. Corrective osteotomies are technically challenging and require meticulous preoperative planning to restore the anatomy. Complications occur frequently and patients should be counseled appropriately before surgery. Functional outcomes are best if correction is performed within 1 year of the original injury. Likewise, complications seem to be less severe and occur less

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Cited by (40)

Complications and Revision Surgery of Forearm Fractures
2023, Hand Clinics
The Effect of Forearm Shortening on Forearm Range of Motion
2022, Journal of Hand Surgery
Citation Excerpt :
This feature of our study allowed for highly accurate and comparable supination and pronation measurements. Previous articles have documented the effects of malunions and nonunions on forearm supination and pronation.8,16,17 We demonstrated that pronation and supination decreased as the magnitude of shortening was increased; however, compared with prior studies,10 our results did not show a linear relationship between the loss of forearm range of motion and the amount shortened.
Osseous shortening of the forearm is performed during forearm replantation; however, no large clinical reviews have discussed its effects on patient outcomes. A recent cadaver study demonstrated the progressive loss of forearm pronation/supination ranges of motion with increased shortening lengths using external fixation. Our study aimed to quantify the effects of shortening on passive forearm motion using internal fixation after 2, 4, and 6 cm of mid-forearm shortening.
A volar Henry approach and direct approach to the ulna were used on 8 cadaveric specimens. The forearms were sequentially shortened by 2, 4, and 6 cm. Fixation was performed on the volar surfaces of the radius and ulna. Pronation and supination of the forearms were tested by applying 1 Nm of torque at baseline and after the fixation of both the radius and ulna using osteotomy. Radiographs and measurements were obtained at each phase to determine the maximum radial bow and radioulnar gap. Data were analyzed using a linear mixed-effects model.
Greater shortening of the radius and ulna led to progressively greater reductions in both pronation and supination range of motion. Larger differences were seen in supination at 2–4 cm of shortening and in pronation at 4–6 cm of shortening. Changes in supination were found to be associated with the radial bow and radioulnar gap; changes in pronation were found to be associated with the radial bow and radial bow’s location.
This study demonstrates that quantifiable effects on passive forearm motion occur after osseous shortening of the forearm.
This information may improve surgeons’ and patients’ understanding of the changes in forearm motion expected after shortening in the setting of replantation or tumor resection or in the setting of limb salvage of a mangled extremity.
One-bone forearm reconstruction and distal radioulnar joint fusion for emergency one-stage operation in traumatic major bone defect of forearm
2020, Injury
Citation Excerpt :
The bony structure of the forearm consists of the ulna, radius and associated articulations radius. The length of the ulna and radius is critical to the proper function of the forearm [1,2]. Due to the unique rotation function of the forearm, the treatment of ulnar and radius fractures should be considered as an intra-articular fracture, which requires anatomic reduction to restore normal function.
Major bone defects in forearm caused by severe trauma is a real challenge for orthopedic surgeons. This study aimed to evaluate the role of one-bone forearm (OBF) reconstruction combined with distal radioulnar joint fusion (DRUJF) as a rescue option under this difficult situation.
In total, 18 patients with major bone defects in forearm caused by severe trauma were selected from 2003 to 2017 and followed up for 2 to 16 years. All patients were managed in the Emergency Department and received emergency one-stage OBF combined with DRUJF. In addition, patient demographics, surgical techniques, clinical outcomes and complications were collected from the medical records.
The mean age of patients was 41.5 years (ranging from 23 to 58 years), with 11 males and 7 females. The mean time to union was 5.8 months; 17 patients had complete union, and 1 patient had infection with nonunion requiring secondary procedures. According to the criteria of Chen, 3 patients had a grade-I functional outcome, 14 patients had a grade-II functional outcome, and 1 patient had a grade-III functional outcome. Based on the Peterson scoring system, the outcome was excellent for 3 patients, good for 13 patients, fair for 1 patient, and poor for 1 patient.
OBF reconstruction combined with DRUJF was an alternative surgical procedure as the emergency stage-one intervention for the treatment of traumatic major bone defects in forearm, which may be more functionally and cosmetically superior than forearm amputation.
Use of Masquelet technique in treatment of septic and atrophic fracture nonunion
2019, Injury
Citation Excerpt :
Similar distributions can be found in the literature. Non-union of extremities after fracture has an average incidence at the tibia of 8.7% [53,54]; the femur only slightly less at 6.1% [55] and the upper extremity 5% [56–59]. The mean age between genders also differed significantly (p < 0.004) with male patients being on average 6.7 years younger than female which might be related to postmenopausal osteoporosis [60,5].
Treatment of atrophic non-unions and large bone defects or infections remains a challenging task for the treating surgeon. In the herein study, we present our experience of the 'Masquelet technique' according to the 'diamond concept' for the treatment of complex long bone reconstruction procedures.
Between February 2010 and March 2015, 150 patients (mean age 51.4) with atrophic and- /or infected non-unions were included in this prospective study. All patients received autologous bone graft, a graft expander (TCP (tricalcium phosphate)) and BMP (bone morphogenic protein). Clinical and radiological parameters were assessed at 6 weeks, and at 3, 6 and 12 months. The SF-12 questionnaire was used to evaluate the subjective health of patients.
A successful bony consolidation of the non-unions was observed in 120 (80%) cases with a median healing time of 12.1 months. The mean defect gap was 4.4 cm. Initial infection was documented in 54 cases. The most frequently identified pathogen was staphylococcus epidermidis and staphylococcus aureus. A successful removal of microorganisms with subsequent healing was achieved in 39 cases (72%). The SF-12 scores of subjective physical and mental health increased from PCS 31.5 preoperatively to 36.7 one year postoperatively, while MCS increased from 45.5 to 48.7.
Our study showed that the Masquelet technique according to the 'diamond concept' is a valid method to treat complex atrophic non-unions with large bone defects and associated infection. Following the principles of the 'diamond concept' (targeted optimization of tissue engineering and bone regeneration) a high rate of success can be expected in these difficult reconstruction cases.
Treatment of Infected Forearm Nonunions With Large Complete Segmental Defects Using Bulk Allograft and Intramedullary Fixation
2016, Journal of Hand Surgery
Citation Excerpt :
No cases had recurrence of infection. Infected nonunion of the forearm is a substantial clinical problem.1,4,6 The forearm may be considered a complex joint requiring restoration of length and alignment to maximize function.
The purpose of this study is to report the results of a series of infected forearm nonunions treated from 1998 to 2012 using a staged reconstruction technique.
At a median of 42 months follow-up, 7 patients who had an average segmental defect of 4.9 cm (range, 2.3–10.4 cm) were available for clinical and radiographic evaluation. Treatment consisted of serial debridement, implantation of an antibiotic cement spacer, and staged reconstruction using a bulk radius or ulna allograft with intramedullary fixation.
All 7 patients ultimately achieved solid bone union, although 4 patients (57%) required additional surgery, consisting of autologous bone grafting and plating, to achieve healing at 1 of the allograft-host junction sites. No patient had recurrence of infection, and all reported substantial improvement with increased function and decreased pain.
Our approach ultimately resulted in a 100% union rate without recurrence of infection, although many patients may require additional surgery to attain healing at both allograft-junction sites. Using bulk allograft provides the ability to span a large defect while reconstituting the forearm anatomy.
Therapeutic V.
The missing effect of human recombinant Bone Morphogenetic Proteins BMP-2 and BMP-7 in surgical treatment of aseptic forearm nonunion
2016, Injury
Citation Excerpt :
If exact reconstruction of length is not achieved, malalignment or dislocation of the distal radio-ulnar joint may occur. Successful management of nonunion of the forearm requires the development of a comprehensive surgical treatment concept which considers the forearm and its adjacent joints, elbow, and wrist, as a complex functional unit [18]. Comprehensive studies have demonstrated nonunion rates below 5% and low complication rates after surgical revision of nonunion of radius and/or ulna diaphysis [19,20].
In this cohort study, the surgical revision concept of open compression plating and autologous bone grafting with and without additional application of BMP for treatment of aseptic ulna and/or radius shaft nonunion was evaluated. The purpose was to evaluate the clinical and radiological outcome, and to determine any difference in osseous healing, range of time between revision surgery and bone healing, and postoperative complications between the cohort groups.
Between 01/2005 and 03/2015, a prospective, randomised, controlled cohort study was performed in a Level I Trauma Centre. Forty-nine patients were treated with the diagnosis of aseptic diaphyseal ulnar and/or radial shaft nonunion using compression plating and autologous bone grafting. Additional biological augmentation using BMP-2 or BMP-7 was performed in 24 patients. Clinical and radiological follow-up was performed six weeks, three and six months after revision surgery in accordance to the system by Anderson.
The study group consisted of 38 men and 11 women with a median age of 44 years (range 19–77). Twenty-four out of 49 patients obtained compression plating either with autologous iliac crest bone grafting (11/24 patients) or cancellous bone grafting (13/24 patients) and additional application of BMP-2 (4/24 patients) or BMP-7 (20/24 patients). The remaining 25 patients did not receive any additional application of BMP, but autologous bone grafting. The median follow-up was 15 months (range 6–54 months). Forty-six out of 49 nonunion healed within 12 months after revision surgery with a median time to union of six months. The clinical outcome, as assessed using the system by Anderson, as well as osseous healing, duration of time interval between revision surgery and bone healing, and postoperative complications did not demonstrate significant differences between the cohort groups.
Atrophic/oligotrophic forearm nonunion healed irrespective of additional application of BMP combined with autologous bone grafting. For successful treatment, radical resection of fibrous nonunion tissue and internal compression plate fixation is required with the aim of achieving high degree of rigid stability. Also, correction of angular deformities, restoration of length, and precise axial alignment of the distal radio-ulnar joint are mandatory prerequisites to successfully achieve bone healing.

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Malunions and Nonunions of the Forearm

Section snippets

Treatment

Nonunion

Malunion

Summary

Injury

Injury

Orthop Clin North Am

Injury

Hand Clin

J Hand Surg [Am]

J Hand Surg [Am]

Injury

Treatment of forearm fractures in adults with particular reference to plate fixation

J Bone Joint Surg Br

Fractures of both bones of the forearm in adults

J Bone Joint Surg Am

Fractures of the distal radial shaft. Mistakes in management

J Bone Joint Surg Am

The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm

J Bone Joint Surg Am

The effects of angular and rotational deformities of both bones of the forearm: an in vitro study

J Bone Joint Surg Am

Rotational deformities in the treatment of fractures of both bones of the forearm

J Bone Joint Surg

Medullary fixation of forearm fractures

J Bone Joint Surg Am

Treatment of fractures of the radius and ulna with compression plates

J Bone Joint Surg Am

Treatment of isolated fractures of the ulnar shaft

Orthopedics

Compression-plate fixation in acute diaphyseal fractures of the radius and ulna

J Bone Joint Surg

Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna

J Bone Joint Surg Am