Session I - Upper Extremity

Open Reduction and Plating vs. Intramedullary Nailing for Diaphyseal Forearm Fractures: A Prospective Randomized Study

Cory A. Collinge, MD; Dolfi Herscovici, Jr., DO, Florida Orthopaedic Institute, Tampa, FL

Introduction: Open reduction and plating is the treatment of choice for diaphyseal fractures of the forearm. Because intramedullary nailing in long bone fractures reduces soft tissue dissection, some surgeons have proposed intramedullary nailing of these fractures. Results, however, have been inconsistent. The purpose of this study is to prospectively compare results of intramedullary nailing with open reduction and internal fixation in the treatment of diaphyseal forearm fractures.

Materials and Methods: Thirty-six patients with 37 diaphyseal forearm fractures were prospectively entered into this IRB-approved trial All had consent prior to randomization to either open reduction and plating or intramedullary nailing. Fifteen fractures involved the dominant arm and 22 occurred in the non-dominant arm. Group 1 consisted of 19 fractures treated with open reduction and internal fixation using 3.5 mm. dynamic compression plates. There were 13 men and 6 women with a mean age of 26.9 years (range 15-72 years). There were two open fractures (both grade I) and 8 involved polytrauma patients, including 4 with ipsilateral upper extremity trauma. Ten cases had displaced fractures of the radius and the ulna, 6 had fracture of the radius only and 3 had only an ulna fracture. Group 2 included 18 forearm fractures treated with reamed intramedullary nailing, 14 dynamically and 4 statically locked. There were 8 men and 10 women with a mean age of 25.6 years (range 15-69 years). There were 5 patients with open injuries (one Gustillo and Anderson grade I, three grade II, one grade IIIa), 2 with significant ipsilateral upper extremity trauma, and 7 who had multisystem injuries. Ten cases had fractures of both bones, 5 had fractures of the radius only and 3 had only an ulna fracture. A protocol for follow-up included a standardized questionnaire, physical and radiographic examination, and completion of the Musculoskeletal Assessment Survey by the patient at 6 and 12 months postoperatively.

Results: Six patients were lost to follow-up, 3 refused to be examined and 1 underwent above elbow amputation, leaving 27 forearm fractures (14 in group 1, 13 in group 2) with adequate follow-up. Mean operative time for group 1 was 97 minutes (range 50-135 min), 67 minutes for one-bone fractures and 113 min for two-bone injuries. Mean C-arm time was 0.4 min (range 0.2-0.8 min). Mean blood loss was 37cc. Thirteen of 14 fractures in this group healed after the index surgery. Complications included one nonunion which healed after revision plating and bone grafting, one wound infection requiring irrigation, debridement and antibiotics, and a transient iatrogenic posterior interosseous nerve palsy. Range of motion is shown in Table 1. Functional outcomes assessment of forearm fractures in this group, as evaluated by Anderson et al. (JBJS 57A: 287-297, 1975), revealed 10 excellent, 2 satisfactory, and 1 unsatisfactory result, with 1 failure. The mean Musculoskeletal Function Assessment/ Injury and Arthritis Survey scores was 19 (range 1-63). Mean operative time for group 2 was 74 minutes (range 29-130 min), with a mean of 59 minutes for one-bone fractures and 89 minutes for both-bone fractures. The mean C-arm time was 3.1 minutes and mean blood loss was 53cc. Eleven of 13 fractures healed after the index procedure. Complications included two nonunions which healed after nail removal, plating and bone grafting. There was one infection which was successfully treated with operative wound debridement and antibiotics. Four patients had hardware pain, with two undergoing removal of hardware after the fractures had healed. Range of motion is described in Table 1. Group 2 included 7 excellent, 2 satisfactory, and 2 unsatisfactory results, with 2 failures, according to Anderson's criteria. For this group the mean Musculoskeletal Function Assessment/ Injury and Arthritis Survey scores was 33.

Table 1- Mean range of motion (degrees)

	Wrist extension	Wrist flexion	Pronation	Supination	Elbow  extension	Elbow flexion
ORIF-6 mo	70	69	62	67	0	137
ORIF-12 mo	71	71	63	66	-1	140
Nails-6 mo	55	55	68	52	6	138
Nails-12 mo	56	58	65	62	2	139

Discussion: Intramedullary nailing of forearm fractures has been described with varying results. We have prospectively collected data on a group of patients randomized to treatment with open reduction and plating, or intramedullary nailing. We have shown similar incidences of union and complications between these 2 groups, however improved range of motion and outcomes scores were seen in those patients treated with open reduction and plating. Finally, intramedullary nailing of these fractures appears to be technically more challenging and requires more intraoperative radiation than plating.

Conclusions: While good functional results can be obtained with intramedullary nailing of forearm fractures, open reduction and internal fixation of forearm remains the treatment of choice for most forearm fractures.