Session VI Upper Extremity

Indications for Bone Grafting in Acute Diaphyseal Forearm Fractures

Sanjay Misra, MD, Peter L. McGanity, MD, Robert C. Schenck, MD, Fred G. Corley, MD

Department of Orthopaedics, University of Texas Health Science Center, San Antonio, TX

The purpose of this study was to determine the indications for acute bone grafting in diaphyseal forearm fractures. There has been no study to support the statement made in standard orthopaedic textbooks that diaphyseal forearm fractures with more than 1/3 circumferential comminution need to be bone grafted. A retrospective review of 203 patients with diaphyseal fractures of the radius and/or the ulna that were treated with open reduction and internal fixation but without bone grafting between 1987-1994 was conducted. 12 fractures were lost to follow-up (6%). The remaining 191 patients with total of 298 diaphyseal forearm fractures of the radius and/or ulna were reviewed. Age range was between 18-54 years (Avg. age 32.8). There were 113 males, 78 females. The Orthopaedic Trauma Association (OTA) fracture classification was used so the comparisons could be made to in future reports. Group A included OTA class I-III (non comminuted), Group B included OTA class IV-VI (comminuted), and Group C included OTA class VII (segmental bone loss). This study only included Group A and Group B fractures (w/no bone grafting), because all Group C (with segmental loss) were are all bone grafted. Group B consisted of 101 /117 (86%) fractures with more than 1/3 comminution. There were 14/74 (19%) Group A open fractures and 29/117 (25%) open Group B fractures.

Union was defined as healing in less than six months. Delayed union was defined as healing without any additional surgical procedure after longer than six months. Non union was defined as requiring one or more additional surgical procedures to achieve union. All the definitions were drawn from literature. Union occurred in 73 (98.6%) of 74 Group A fractures, and 110 (94%) of 117 Group B fractures. The Wilson Quadratic 95% confidence interval for union rate in Group A was 90-99% and for Group B was 93-99%. There was not a significant difference in non union rates between the two groups. Fishers Exact test Chi Square = 1.4 and p=0.15.

There was one infected non union in an open Group A fracture. In Group B, there were 4 delayed unions (3 in open fractures) and 7 non unions. All non unions healed with additional procedures. There were 5 superficial infections, which resolved with antibiotics. There was one deep infection in a diabetic patient which required debridement and hardware removal.

Previous authors have recommended acute bone grafting in forearm diaphyseal fractures with more than 1/3 communition. Bone grafting is associated with donor site morbidity and its complications including synostosis in both bone forearm fractures. This study showed that open reduction and internal fixation without bone grafting produces excellent rates of union. From this study we conclude that acute bone grafting of OTA Class I-VI (Group A & B) forearm fractures of radius and/or ulna may not be necessary. Bone grafting may be warranted in Group C fractures with segmental loss.