Treatment of diaphyseal non-unions of the ulna and radius

All patients treated in our centre for diaphyseal forearm non-unions during the 24-year period between 1975 and 1999 formed the initial cohort. They were extracted from an AO-database into which all patients for fracture care at our hospital were entered during that time. On average, 21 patients per year were treated for diaphyseal fractures of the forearm. The number of patients that was treated yearly for a non-union of the forearm declined during that period for two reasons. Firstly, our department was, and still is, a tertiary referral centre for failed fixation and/or non-unions starting in the 1970s and 1980s. Secondly, the technique of fixation became better known and union rates after primary surgery for forearm fractures improved. Additional cases between 2002 and 2008 were entered into the study cohort at admission for treatment by the senior author (P.K.). A non-union was defined as absence of healing after 4 months, or evident failure of treatment prior to that [22]. All patients with skeletal immaturity, congenital forms of non-union, or a follow-up of <12 months were excluded. As a result, 47 patients were included in the study cohort, which consisted of 35 men and 12 women with an average age of 37 years (range 16–76 years). The indications for treatment of the non-union were pain, limited function, forearm deformity and/or hardware failure.

Twenty-one fractures involved the left arm, 25 fractures involved the right arm and 1 patient fractured both arms. The mechanism of injury was a motorised vehicle accident in 26 patients, a fall in 12, and a crush injury in 9. The pattern of injury was a fracture of the diaphyseal radius and ulna in 18 patients, an isolated fracture of the diaphyseal ulna in 15, an isolated fracture of the diaphyseal radius in 7, a Monteggia fracture in 5, and a Galeazzi fracture-dislocation of the forearm in 2 patients. According to the AO classification of ulnar and radial shaft fractures [23], there were 6 type-A1, 1 type-A2, 7 type-A3, 13 type-B1, 4 type-B2, 11 type-B3, 3 type-C1, and 2 type-C2 fractures. Eighteen fractures (38%) were open; according to the system of Gustilo and Anderson [24, 25], there were six type-1, four type-2, and seven type-3A fractures. For one open fracture the Gustilo and Anderson type could not be determined. Eleven patients were polytraumatic with at least one more fracture in other areas. Ten patients had an associated nerve injury, two ulnar nerve lesions, five radial nerve lesions, a median nerve lesion, a combined radial and median nerve lesion and a brachial plexus lesion. One patient had a radial artery lesion, which was acutely repaired. The percentage of smokers was 58%. Prior treatment consisted of cast immobilisation in eight cases. Thirty-three patients received 1 previous operative treatment, which consisted of plate fixation in 22 (1 with primary grafting), external fixation in 3, and K-wires/Rush pins in 3. Five patients were converted early from a cast to plate fixation after an average of 9 days (range 4–20 days). In one patient external fixation was early switched to plate fixation and in one patient plate fixation was early switched to external fixation. Two patients underwent plate fixation twice, and one patient received an intramedullary nail twice after undergoing plate fixation twice. In one patient previous treatment was unknown. There were 51 non-unions in 47 patients, including a non-union of the radius in 16 patients, the ulna in 27 patients and of both ulna and radius in 4 patients. Four of the 18 patients that had initially broken both forearm bones produced non-unions of both radius and ulna, seven produced a non-union of the radius, and seven produced a non-union of the ulna. Four of the non-unions were classified as atrophic (8%), 13 as hypertrophic (25%) and 34 as oligotrophic (67%) [26].

The time between the injury and the index surgery that resulted in healing averaged 16 months (range 2–312 months). Sixteen surgeons were involved. Principles of surgery were consistently a thorough debridement of avital tissues, removal of failed hardware, restoration of alignment, length, rotation, stable fixation using compression if possible (tensioner device and/or lag screws), optimisation of a bone forming environment (including bone grafting if needed) allowing for early motion. Index surgery for non-union consisted of open reduction and plate fixation in combination with a graft in 30 cases (59%), open reduction and plate fixation alone in 14 cases (27%), and only a graft in 7 cases (14%). Grafting was performed in 32 cases with autogenous cancellous graft. Donor sites were the iliac crest in 24, olecranon in 7 and distal radius in 1. In four cases a tricortical iliac crest block was used and in one case a vascularised fibula graft was used. No use has been made of bone graft substitutes.

Follow-up data were obtained by retrospective review of medical records and selective invitations for a free clinical and radiographic examination when insufficient data were available. The retrospective character of the study withheld us from recording functional scores such as the DASH. The final functional result was therefore assessed in accordance to the system used by Anderson and colleagues [1] at the most recent visit at the orthopaedic outpatient service at our institution. This scoring system, which was recently used by Ring et al. [22] in a comparable study, rates an united fracture with <10° loss of elbow or wrist motion and <25% loss of forearm rotation as excellent, a healed fracture with <20° loss of elbow or wrist motion and <50% loss of forearm rotation as satisfactory, a healed fracture with more than 30° loss of elbow or wrist motion and more than 50% loss of forearm rotation as unsatisfactory, and a malunion, non-union, or unresolved chronic osteomyelitis as failure.