Union time in conventional and selective bicortical 4-screw fixation was Union rate and infection was Non-union was observed in 5 and 3 cases of fractures in conventional and the selective group respectively. Conclusions: For treatment of the transverse or oblique diaphyseal fractures of the forearm, fixation by a same length 3. Because of lesser impact on host bone and smaller incision, the selective 4-screw insertion can be an alternative technique for treatment of these fractures.
Keywords: Forearm, Fracture, Fixation 1. Background The forearm has an important role in the function of the upper extremity thus, loss of forearm motion resulting from a poorly treated fracture can be disabling.
The preferred method for diaphyseal fracture of the forearm is ORIF using plate and screws. Selection of the plate type is controversial as some investigators prefer LCP, whereas most of the others recommended DCP and have reserved LCP for those who have fractures in the metaphysis or have osteoporotic bone. Anatomic reduction allows maintaining normal alignment of the length and distal or proximal radioulnar joints and restoration of normal supination and pronation functions 1 - 4.
Anderson et al has reported that plating is the most physiologic type of fixation for forearm shaft fractures. In his study with acute forearm diaphyseal fractures, Chapman et al. Although open reduction and internal fixation with DCP is the most commonly accepted treatment method for adult forearm diaphyseal fractures, however, this technique has some disadvantages such as extensive soft tissue or periosteal damage and refracture after plate removal 2 , 5 , 6.
This complication is related to the size of plate, surgical technique, stress from screw holes, bone atrophy or osteonecrosis of the cortex under the plate 1 , 3 , 9. In conventional plating, screw placement is used in all holes of plate, except at the fracture line. Though the new plates such as LC- DCP are used to minimize periosteal stripping, there is a tendency to use the least hardware. This may facilitate a more physiologic process for fracture healing by less damage to the local soft tissue and bone 10 - Mast et al.
According to this concept, we felt that fewer screws at each site of fracture with standard plate length may decrease the complications related to more screw placement in conventional DCP. This can be true in nonweight-bearing bones such as radius or ulna. The choice of plate will depend on the size of the bone and pattern of fracture. The length of plate is ultimately dependent on the degree of fracture comminution, and fixation of at least 6 cortices is used in conventional forearm plating Emphasis on this point of view is important that although the insertion of all screws in a standard plate can have more stability, however, more periosteum or cortical damage can occur during drilling of the bone.
Objectives The purpose of the present study was to evaluate the hypothesis that use of selected screw insertion in a standard length DC plate for treatment of forearm diaphyseal fractures can provide enough stability, enhance bone healing and decrease complication rates when compared with use of conventional 6 or more hole fixation plates.
From Sept to Oct , our protocol was open reduction and internal fixation for forearm fractures using a 3. We treated forearm fractures with the same type of plate but inserted 4-selective screw holes. If we felt that by this technique rigid fixation could not be achieved, then we operated as per the routine method and the patient was excluded from study.
The study was approved by the ethics committee at our university and informed consent was taken from all patients. Adult patients over 18 years-old with closed fracture of the radius, ulna or both bones of the forearm that were operated by senior residents were included.
The fractures were classified according to OTA classification system. Type C or open fractures were excluded. Spiral type ulna and transverse comminuted radius. For maximum stability with a long plate on a comminuted fracture, the screw holes at the end of the plate as well as those closest to the fracture must be filled a threads per length.
The instrumentation is characterized by a new 2. All of the instrumentation has a bronze coloration. In those instances where small DC plates are chosen, one must be certain that the plate has sufficient length to neutralize the bending forces present and allow firm and rigid immobilization of the fracture.
In tall individuals for whom the small 3. This will provide adequate holding of the plate for a sufficient length of time to allow both early motion of the extremity and sound union of the fracture.
Use of the wrong implant may prejudice an otherwise excellent open reduction, as shown in Fig. The LC-DC plate has many experimental advantages, especially in open fractures. Since the plate surface is indirect and contact between the plate and the bone is kept to a minimum, loss of blood supply to the cortex is minimized Fig. Most of the cortex remains viable, a marked advantage in open fractures. Note that the length of the hole 3. A short 3. The radius was fixed with an eight-hole 3.
The ulna was fixed with a six-hole 3. Note the short plate compared with the relatively long ulna, allowing a long lever-arm effect. No immobilization was necessary; good forearm rotation returned.
In osteopenic bone, the improved holding power of the screws in this new form of internal fixation may be helpful, but not at any sacrifice of the more important principle of anatomical reduction.
Achieving and maintaining anatomical reduction is more difficult with that technique; therefore, in forearm fractures, the indications are limited Fig.
Site of Plate Application The ulnar plate is applied to the medial border Fig. Occasionally, removal of bony irregularities from this surface will aid in the placement of the plate. The radial plate application will depend on the surgeon's choice of incision. Since we favor the anterior approach, the radial plate is applied ideally to the flat surface of the lower third of that bone.
Through this same anterior approach the plate may be fixed to the anterior or lateral surface of the middle third and the anterior surface of the upper third. Occasionally, difficulty may be encountered in applying the plate laterally through the anterior incision.
If posterior approaches are preferred, especially in the middle third of the radius, the plates are fixed to the lateral or dorsolateral surfaces. Bone Grafts Bone grafts are rarely required in the forearm, if concepts of biological fixation are followed.
However, if marked comminution is present with some loss of soft tissues or actual bone loss, as in an open fracture, then a cancellous bone graft is indicated. The bone graft must not be placed along lacerations in the interosseous membrane, as this may favor a cross-union; it should be placed at sites distant from that membrane, to fill all gaps in the bone and to bridge the fracture Fig.
Cancellous grafting is especially indicated if there has been significant bone loss in open fractures. In these instances we prefer internal fixation with a plate to bridge the gap and the use of a cancellous bone graft, usually applied on the fifth to seventh day into a granulating wound, to ensure union Fig.
On rare occasions, however, an external frame may be used. This method may be applied to the forearm, but it is not recommended, except for comminuted fractures of the distal end of the radius and contaminated open fractures with or without sepsis. If external fixation is used as the definitive treatment in diaphyseal fractures, bone grafting should be used to minimize the risk of nonunion. Wound Closure Skin closure must be carried out using a meticulous atraumatic technique and with no tension.
Suction drainage will reduce hematoma formation and is always used postoperatively, where possible. Not infrequently, in fractures of both bones of the forearm, swelling of the forearm muscles makes closure of one incision without tension difficult. Under these circumstances, we do not hesitate to leave a portion of one wound open, even if it leaves a part of the implant exposed.
This has been frequent in our practice; therefore, patients should be informed that they may require a secondary closure of one wound.
The ulnar wound, located so close to the subcutaneous a b Fig. The LCDC plate. The different undercuts greatly reduce the contact area between the plate and the bone Fig. The different undercuts greatly reduce the contact area between the plate and the bone a b Fig. The locking compression holes allow placement of standard cortex and cancellous bone screws on one side or threaded conical locking screws on the opposite side of each other. Threaded hole section for locking screws.
DCU hole section for standard screws. Locking screw in threaded side of plate hole. Cortex screw in compression side of plate hole: d Use of locking plate internal fixator for a gunshot to forearm AB with bone loss, fixed with a locking plate CD for better holding power Fig.
Site of plate application Fig. Bone grafts to forearm. Initial treatment was debridement, open wound treatment, and fixation with pins and plate. Upon referral at 12 weeks, the pins were removed, and after wound healing, a plate was applied to the anterior surface of the radius.
The radial wound, over soft tissues, may be safely left open throughout a portion of its length, since careful placement of the metal implant will bury it under a muscle cover. With early functional rehabilitation, the swelling rapidly disappears from the arm, and it is usually a simple matter to close the wound on the fifth to the seventh postoperative day with sterile tapes or fine sutures.Those fragments with precarious soft tissue attachments, and which are not essential for anatomical reduction, should not be internally fixed. Essay Topic: RightCollege Choosing a college is engage and hopefully convince the reader that you would work, its industry of operations and recruitment process.
However, if marked comminution is present with some loss of soft tissues or actual bone loss, as in an open fracture, then a cancellous bone graft is indicated.
The overall union rate in all fractures was Conclusions: For treatment of the transverse or oblique diaphyseal fractures of the forearm, fixation by a same length 3.
From Sept to Oct , our protocol was open reduction and internal fixation for forearm fractures using a 3. With stable internal fixation, the precise time of bone union is difficult to determine. Because of lesser impact on host bone and smaller incision, the selective 4-screw insertion can be an alternative technique for treatment of these fractures. Statistical analysis was performed using t-test and Chi-square tests with SPSS version 13 software; significant difference was considered when the P value was less than 0.