Intramedullary Fixation of Forearm Fractures
Section snippets
History and results with unlocked nailing
The anatomy of the forearm is part of the reason that intramedullary nailing has been historically problematic. Restoration of function, mainly the reestablishment of pronosupination, is highly dependent on the restoration of length, rotational alignment, and anatomic bow of the radius. The interdependence of 2 bones (the radius and ulna) and the bow of the radius have made intramedullary fixation difficult. Straight implants can work well in the ulna because of its slightly S-shaped but
Biomechanics
Intramedullary fixation of forearm fractures has been evaluated biomechanically compared with closed treatments and with plate fixation. Rush pinning would not be expected to have significant rotational control of forearm fractures because of their lack of interlocking fixation. However, Rush pinning was found to be at least superior to functional bracing with regard to rotational stability. Ono and colleagues18 evaluated rotational stability of 6 cadaveric fractured forearms with Rush pinning
Indications/advantages over plate osteosynthesis
Intramedullary nailing techniques have been performed with success in the adolescent and pediatric population. Most of the experience in this population involves the use of unlocked flexible nails, which can provide adjunctive treatment in patients who would otherwise be treated with casting. In cases in which reduction would be unacceptable with casting alone, or in cases in which earlier range of motion may be desired, flexible unlocked intramedullary nailing can be performed.
In the adult
Contraindications
As with most internal fixation methods, active infection is a contraindication to intramedullary nailing. As with most intramedullary nailing techniques done elsewhere, canal diameter can also be a limiting factor. Canal diameter smaller than 3 mm is typically a contraindication for intramedullary nailing, although this differs based on the type of implant used.
Open physis in the pediatric/adolescent population precludes the use of large implants that potentially violate these areas. Nails that
Nail design
Forearm nail design has attempted to address the problems previously outlined, including restoring anatomic bow of the radius and allowing interlocking to prevent shortening and rotation. Nails, regardless of the metal used, must possess a modulus of elasticity favoring stiffness for rigidity while being malleable to a degree that ensures safe passage within the medullary canal. McLaren and colleagues26 recommended that the lower modulus of elasticity of titanium forearm nails facilitates
Surgical technique
Preoperative planning is essential to determine if nail fixation is feasible. Radiography of the contralateral forearm can help with determining length, canal diameter, and the contour of the nail (if this option is available or required with the implant used). The procedure is performed under tourniquet control. Multiple positioning options are available. Supine positioning either with a radiolucent table or with an inverted image intensifier are both good options. Lateral positioning can also
Pitfalls
As with any intramedullary nailing procedure, a narrow canal diameter can prevent insertion of intramedullary implants. Therefore, preoperative planning is essential to prevent this potential problem. Proximal interlocking screws can place the posterior interosseous nerve in danger if inserted too anteriorly. Ensuring that a parallel entry point is obtained in the radius is crucial to prevent protruding through the cortex or splitting the distal fragment.1
Results and complications using interlocking nails
Interlocking nails have been developed specifically for the forearm to avoid problems with poor control of rotation and axial length seen with unlocked intramedullary methods. One of the earlier developments of an interlocking nail was developed by Lefevre and initially reported in 1990.27 In a separate series, 20 subjects who underwent interlocked ulnar nailing using the Lefevre nail was reported in 1992.28 Fractures included completely displaced ulnar fractures and fractures of the radius and
Summary
The use of intramedullary nails in the treatment of forearm fractures has proven successful in more recent years, especially with the use of interlocking nails to control length and rotation. As with many procedures, proper patient selection cannot be overemphasized. Plate fixation remains the gold standard for treatment of most adult forearm fractures. However, intramedullary nailing can be an excellent alternative in cases of extensive soft-tissue injuries, such as the mangled or burned
References (33)
- et al.
The conservative treatment of fractures of the shaft of the radius and ulna in adults
Lancet
(1952) - et al.
A reconstruction operation for comminuted fracture of the upper third of the ulna
Am J Surg
(1937) - et al.
Intramedullary nailing of pathological forearm fractures
Injury
(2002) - Crenshaw AH, Perez EA. Fractures of the shoulder, arm, and forearm. Campbell's Operative Orthopaedics...
Fracture of both bones of the forearm. Study of two hundred cases
Surg Gynecol Obstet
(1928)Fracture of the distal radial shaft: mistakes in management
J Bone Joint Surg
(1957)Rotational deformity in the treatment of fractures of both bones of the forearm
J Bone Joint Surg
(1945)- et al.
Medullary fixation of forearm fractures
J Bone Joint Surg
(1957) - et al.
Compression-plate fixation in acute diaphyseal fractures of the radius and ulna
J Bone Joint Surg
(1975) - et al.
Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna
J Bone Joint Surg
(1989)
Zur behandlung von vorderarmfrakturen mit bolzung
Münch Med Wochenschr
Intramedullary fixation of fractures of the forearm
South Med J
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
J Bone Joint Surg
Rigid medullary fixation of forearm fractures
South Med J
Intramedullary forearm nailing
Clin Orthop
Antebrachium fractures: rush pin fixation today in the light of late results
J Trauma
Cited by (23)
Radial and Ulnar Shaft Fractures
2022, Skeletal Trauma of the Upper ExtremityIntramedullary nailing of adult forearm fractures: Results and complications
2021, InjuryCitation Excerpt :Intramedullary nailing is a load-sharing device and is a good treatment option for fixation of complex fractures [14]. Forearm fractures with severe soft-tissue injury may be ideal for intramedullary osteosynthesis since plate fixation can cause wound complications or deep infections [23]. Intramedullary nailing is also an effective treatment for forearm nonunions [24,25].
Intramedullary nail fixation of non-traditional fractures: Clavicle, forearm, fibula
2017, InjuryCitation Excerpt :Radial nails are inserted distally. The entry portal varies depending on the manufacturer’s implant design, however generally 5 mm proximal to the articular surface [30,36]. Lister’s tubercle serves as the primary landmark for the radius entry point.
New interlocking intramedullary radius and ulna nails for treating forearm diaphyseal fractures in adults: A retrospective study
2014, InjuryCitation Excerpt :Schöne was the first to use silver nails for radial and ulnar medullary fixation in 1913, and subsequently various nails were developed to stabilise forearm fractures [10,21]. Recently, good results were reported for treating forearm fractures in adults with the ForeSight nail system (Smith and Nephew, Memphis, Tennessee) [22]. However, in each patient, the nail required intra-operative bending to create the anatomic bow of the radius and the serpentine shape of the ulna [1,6].
Pediatric forearm fractures: Spotting and managing the bad actors
2012, Journal of Hand Surgery
No funding or support has been provided for this study.