ABSTRACT

CORRESPONDING AUTHOR:
Dr. K. Harsha Kumar,
Associate Professor,
Department of Orthopaedics,
Narayana Medical College,
Nellore, Andhra Pradesh.
E-mail: drharshaortho@gmail.com

ABSTRACT: BACKGROUNDS AND OBJECTIVES: Sixty cases of fracture both bone forearm in adults were operated and fixed using various instruments in Narayana Medical College and Hospital, Nellore. The study period was June 2009 to June 2013. The case were followed up from four months to ten months. METHODS: Most of the cases were young adult male with age ranging between 17 to 73 years. The functional outcome of different modalities of surgical treatment of diaphyseal fracture of both bone forearm in adults are interpreted. We have fixed 17 patients with Dcp, 13 patients with Lcdcp, 14patients with Semitubular plating and 16 patients with Intramedullary nailing. Most cases were operated within three days of injury. Anaesthesia and Tourniquet was used for all cases. Thompsons approach was used for proximal radial fractures and Henrys approach was used for distal radial fractures. Ulna was exposed along its posterior border. Intramedullary nailing was done along radial syloid process and distal tip of olecranon in radius and ulna respectively. Closed reduction under C-arm in intramedullary procedure and open reduction and internal fixation when plating was done. Above elbow p.o.p slab were applied for all operated case. Sutures were removed at 10^th Post-operative day. Mobilization were started after suture removal in plating cases. In Intramedullary nailing cases mobilization started after clinical and radiological union. RESULTS: By Anderson Scoring System out of 14 cases of Dcp 75 %were excellent, 25% were satisfactory. Out of 11cases of Lcdcp 72.7% were excellent, 18.2% were satisfactory, 9.1% were unsatisfactory. Out of 13cases of Semitubular plating 69.2%were excellent, 23.1% were satisfactory, 7.7% were unsatisfactory. Out of 14 cases of Intramedullary nailing with Talwakar square nails 42.9% were excellent, 21.4% were satisfactory, 21.4% were unsatisfactory, 14.3%had failure results. INTERPRETATION AND CONCLUSION: Open reduction and internal fixation can be considered as the treatment of choice if there were no contraindications for this because it is important to maintain length, opposition, axial alignment and rotation alignment if a good range of movement of forearm is to be restored. This is achieved in the present study.

KEYWORDS: Dcp; Lcdcp; Semitubular; Intramedullary; Thomsons; Henry’s; Radialstyloid; Olec-ranon; POP; Talwakar square nail.

INTRODUCTION: AIMS AND OBJECTIVES OF STUDY:

• To study the functional activity of upper extremity after treatment.
• To study the radiological and functional outcome in different modalities of surgical treatment of diaphyseal fractures of forearm in adults.
• Complications associated with different modalities of treatment.

METHODOLOGY: METHODS: Most of the patients presented to hospital within 24 hours of injury of forearm. Only 7 patients presented within a week after sustaining the injury.

90% of the patients presented with injured forearm supported with hand. While 10% patients came with their injured limb immobilized with POP.

On admission of the patient, careful history was elicited from the patient or attendants to reveal the mechanism of injury. The patients were examined clinically for signs of fracture displacements, deformity, neuro vascular status associated injuries and for vital signs.

Treatment Protocol: After thorough clinical evaluation x-ray of the affected forearm was taken in both anteroposterior and lateral view including wrist and elbow joints. The limb was immobilized in above elbow slab with positioning the forearm according to the site of fracture with sling.

The patient was taken up for surgery after routine investigations Hb%.

Urine Routine RBS.

Blood grouping and typing HIV/Hbs Ag.

ECG.

RESULTS:

CC=0.378; P<0.108 (Non-significant):

Chi-square for age groups alone=19.111; P<0.002 (HS)

From the above table it is evident that the distribution of male and female cases in various age groups is statistically same. Contingency coefficient of 0.378 was found to be statistically non-significant (P<0.108).

However, when age groups alone considered, a significant chi-square (c²=19.111; P<0.002), value was observed, revealing that frequencies of age groups differed significantly.

From the table it is clear that as the age increased, number of cases decreased linearly and significantly. Maximum cases were recorded in the age group of 15-25 (33.3%) and least was in the age group of 66-75 (3.7%). All the values for male and female cases for different age groups are diagrammatically represented in Fig. 20.

Figure 2: Frequency of male and female patients in various age groups.

Fig. 2: Frequency of male and female Patients in Various age Groups

CC=0.390; P<0.140 (Non-significant)

A non-significant association was observed between implant used and Supination and pronation movements (CC=0.390; P<0.140). From the table, it is clear that most of the implants had the supination and pronation <10o. Only few cases in all the implants had the supination and pronation <20. In >20o supination and pronation, one case each was reported from LC-DCP and semi tubular playing, whereas 5 cases had supination and pronation >20o in IMN. All these frequencies are combined and diagrammatically represented in Fig. 29.

Fig. 4: Distribution of sample by implant used and supination and pronation

Fig. 4: Distribution of sample by implant used and supination and pronation

DISCUSSION: Functional forearm is very essential for an individual for social and economical thriving. Fractures of the forearm bones may result in severe loss of function unless adequately treated. The relationship of the radiohumeral, radioulnar, ulnohumeral radiocarpal, distal radioulnar joint and the interosseous space must be perfect, otherwise some functional impairment will result.⁵

In addition to regaining length, opposition and axial alignment, achieving rotational alignment is necessary, if a good range of pronation and supination is to be restored.⁴ Malunion and nonunion occur more frequently because of difficulty in reducing and maintaining reduction of two parallel bones in the presence of the pronating and supinating muscles that have angulatory as well as rotational influences.^50,52 Because of these factors surgical management for displaced diaphyseal fractures in the adult is generally accepted.

In our series 60 patients were treated by different surgical modalities.

Open reduction and internal fixation with dynamic compression plating, limited contact dynamic compression plating, semitubular plating or closed intramedullary nailing using square nail randomly.

In our series 16 patients were treated with dynamic compression plate and screws, 11 patients with limited contact dynamic compression plate and screws, 13 patients with semitubular plate and screws and 14 patients with square nails.

Age incidence

In the present study the age distribution was between 15-75 years. The youngest patient was 17 years and the oldest was 73 years. The commonest age group was 15-25 years (37.3%). The mean age in our study was 30.8 years in male and 41.9 in females.

Sex Distribution: Our series had a male preponderance with 59.2 male patients and 40.8 female patients.

Mode of Injury: In our series 55.6% cases had road traffic accident (RTA), 37% cases had fall and 7.4% had assault (direct blow). So the commonest mode of injury in our study is by road traffic accidents.

Side Affected: In our study the most commonly affect side was right with right side incidence being 64.8% and left side incidence being 35.2%.

CONCLUSION: Increased incidence of forearm fractures were probably due to increasing road traffic accidents and fall.

• Forearm fractures occurred more commonly in second and third decade.
• Predominance of males were seen in these fractures.
• Open reduction and internal fixation can be considered as the treatment of choice if there were no contraindications for this because it is important to maintain length, opposition, axial alignment and rotation alignment if a good range of movement of forearm is to be restored. This is achieved in the present study.
• DCP system, LC DCP system or semitubular system gave optimum fixation and allowed immediate mobilization.
• Excellent results were achieved with it in terms of mobility and union without deformity.
• Prophylactic antibiotics before surgery helped in reduction of rate of infection.
• Patients were comfortable and more secure socially without external immobilization after rigid fixation.
• To conclude DCP or LC DCP offers excellent results in displaced diaphyseal fractures of forearm bones in adults and to be considered as first line of management.

Under certain circumstances where patient is not fit for open reduction and internal fixation or where there is need for:

Least Invasive Procedure:

• Technically easy procedure
• Short operating time
• Reduced risk of infection
• Decreased hospital stay
• Economic procedure

Intramedullary nailing with square nails can be considered as first line of management.

SUMMARY: Present study consists of 60 cases of diaphyseal fractures of forearm, treated surgically with follow up ranging from 4 months to 10 months. In 6 cases, follow up was not possible, so 54 cases were considered for the study. The age group ranged between 15 to 75 years commonest being 15-25 years. Predominance of males were seen in 32 cases out of 54 cases studied (59.3%). Right side was more common (64.8%) than left side (35.2%).

Road traffic accident was the commonest mode of trauma (55.6%), followed by fall on out stretched hand (37.0%) followed by assault (7.4%). Direct trauma was the main mechanism of injury in these cases.

Middle 3^rd was the commonest fracture site of both bones (42.6%) followed by junction of middle and lower 3^rd (31.5%), followed by lower 3^rd (14.8%), and middle and upper 3^rd (11.1%). Transverse fracture was the commonest (50%) followed by oblique fracture (25.9%) followed by comminuted fracture (24.1%).

By open reduction and internal fixation, 16 cases were treated with DCP, 11 cases were treated with LCDCP and 13 cases were treated with semitubular plating. By closed reduction and medullary fixation with square nail, 14 patients were treated.

For open reduction, separate incisions were used for radius and ulna

Thompson’s approach was used for upper half of radial fractures, Henry’s approach for lower half of radial fractures, ulna was exposed by direct approach.

For closed reduction and medullary nailing radial styloid was used in 11 patients, lister’s tubercle approach was used in 3 patients. Olecranon approach was used to fix all ulna fractures.

The results were based on Anderson et al. scoring system.

In the present study, with dynamic compression plating there were 12 patients (75 %) with excellent results and 4 patients (25%) with satisfactory results.

In limited contact dynamic compression plating, 8 patients (72.7%) with excellent results, 2 patient (18.2%) satisfactory result and 1 patient (9.1%) results were unsatisfactory.

In semitubular plating 9 patients (69.2%) results were excellent, 3 patients (23.1%) with satisfactory results and 1 patient (7.7%) results were unsatisfactory.

Radiological union of fracture occurred in all the cases. The union time of radius and ulna was almost the same.

The unsatisfactory results for limited contact dynamic compression plating and semitubular plating are related to the degree of injury sustained, type of fracture, periosteum stripping, evacuation of fracture haematoma.

By Anderson’s Scoring System, with closed reduction and medullary nailing 6 patients (42.9%) showed excellent results, 3 patients (21.4%) satisfactory, In 3 patient

(21.4%) unsatisfactory and failure in 2 patients (14.3%).

The reason for non-union was distraction of fracture site after nailing.

In closed reduction and medullary fixation with square nails 1 patient had superficial infection at ulnar portal, 1 patient with deep infection at ulnar portal with implant migration. One patient with delayed union with implant migration and two non-union cases.

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