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The Journal of Bone and Joint Surgery (American). 2004;86:2440-2445
© 2004 The Journal of Bone and Joint Surgery, Inc.

Ununited Diaphyseal Forearm Fractures with Segmental Defects: Plate Fixation and Autogenous Cancellous Bone-Grafting

David Ring, MD1, Christian Allende, MD2, Koroush Jafarnia, MD3, Bartolome T. Allende, PhD2 and Jesse B. Jupiter, MD1

1 Department of Orthopaedic Surgery, Massachusetts General Hospital, ACC 525 (D.R.) and ACC 527 (J.B.J.), 15 Parkman Street, Boston, MA 02114. E-mail address for D. Ring: dring{at}partners.org
2 Department of Orthopaedic Surgery and Rehabilitation, Sanatorio Allende, Hipolito Yrioyen 384, Cordoba 5000, Argentina
3 Department of Orthopaedics, Baylor College of Medicine, 17270 Red Oak Drive, Suite 200, Houston, TX 77090.

Investigation performed at Massachusetts General Hospital, Boston, Massachusetts, and Sanatorio Allende, Cordoba, Argentina

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from the AO Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

Background: With current techniques of plate-and-screw fixation, diaphyseal nonunions of the radius and ulna are unusual. The few reports that have been published have discussed the use of structural corticocancellous bone grafts for the treatment of atrophic nonunions that are associated with osseous defects. We reviewed the rate of union and the functional results in association with the use of plate-and-screw fixation and autogenous cancellous (nonstructural) bone grafts.

Methods: Thirty-five patients with an atrophic ununited diaphyseal fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and autogenous cancellous bone-grafting. A segmental osseous defect with an average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty of the original fractures had been open. Eleven patients had had treatment of a deep infection before referral to us. The nonunion involved both forearm bones in eight patients, the radius alone in sixteen patients, and the ulna alone in eleven patients.

Results: The atrophic nonunion was associated with an open fracture in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation of the forearm in nine, and infection in eleven. All fractures healed without additional intervention within six months. Two patients had a subsequent Darrach resection of the distal part of the ulna for the treatment of arthrosis of the distal radioulnar joint. After an average duration of follow-up of forty-three months, the final arc of motion averaged 121° in the forearm, 131° at the elbow, and 137° at the wrist, with an average grip strength of 83% compared with that of the contralateral limb. According to the system of Anderson and colleagues, five patients had an excellent result, eighteen had a satisfactory result, eleven had an unsatisfactory result (because of elbow stiffness related to associated elbow injuries in three and because of wrist stiffness in eight), and one had a poor result (because of malunion).

Conclusions: When the soft-tissue envelope is compliant, has limited scar, and consists largely of healthy muscle with a good vascular supply, autogenous cancellous bone-grafting and stable internal plate fixation results in a high rate of union and improved upper limb function in patients with diaphyseal nonunion of the radius and/or ulna.

Level of Evidence: Therapeutic study, Level IV (case series [no, or historical, control group]). See Instructions to Authors for a complete description of levels of evidence.


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Letters to the Editor:

Read all Letters to the Editor

Ununited diaphyseal forearm fractures with segmental defects
Edward Calif, et al.
JBJS Online, 7 Dec 2004 [Full text]
Dr. Ring responds to Dr. Calif
David Ring
JBJS Online, 9 Dec 2004 [Full text]