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Best Way to Treat Forearm Fractures in Adults

Posted on: 11/30/1999
Many patients and health care professionals look to the Mayo Clinic for advice on unusual or challenging problems. In this report, Mayo surgeons present the case of a 32-year-old man with a forearm fracture sustained in a car accident.

Forearm fracture sounds like a straight-forward problem. But surgeons face the difficulty of determining the best way to treat even seemingly simple problems like this one.

For example, can this patient be treated nonsurgically with a cast or splint immobilization? If surgery is required, what's the best way to hold the fractured bone together until it heals? Should a metal plate and screws be used or is a long (intramedullary) nail down in the center of the bone better?

The authors present the current evidence for best practice with adult forearm fractures of the long bones of the forearm (called diaphyseal fractures). They review studies from 1975 to the present and offer the following information: 1)advantages and disadvantages of plate and screw fixation, 2) the advantages of intramedullary nails, 3) reasons why surgery is necessary, and 3) comparative results between plates with screws versus intramedullary nails.

Let's start with why nonsurgical treatment is not recommended for diaphyseal forearm fractures in adults. Studies show that without surgical correction (and only using cast or splint immobilization) for these kinds of fractures, patients end up with a high rate of malunion, malalignment, and deformity. The fractured ends of the bone tend to rotate and don't line up properly. Forearm and wrist deformities occur affecting function and use of the forearm, wrist, and hand.

That's why surgery is recommended to line up the broken bones and hold them in place until healing occurs. For a long time, nonunion of forearm fractures in adults was a big problem (even with plate fixation). But better plate materials and improved surgical techniques helped bring the nonunion rate down from 20 per cent to five per cent.

The upside of plate and screw fixation is that it holds the bone in place nicely and prevents rotation. The downside is that the hardware can cause pain and can poke into the nerves causing numbness. Removing the hardware also increases the risk of nerve injury and even refracture.

Some surgeons have tried using the intramedullary nail. Placed down the center of the bone, the nail holds everything together with fewer problems. The surgeon makes a smaller incision (which means a smaller scar). With the nail, there is less damage to the bone and less risk of refracture when it's removed.

With all those positives on the side of using the intramedullary nail instead of the plate and screw system, the natural question is: how do the results compare between these two approaches? There isn't an easy or straightforward answer to that question and here's why.

First of all, there aren't any studies that directly compare the two treatments. Any conclusions made come from looking all the studies over and making judgments that haven't been tested.

Second, in some studies the patients had one of the two forearm bones broken (radius or ulna) and some had both bones broken. The differences between the two bones are enough that ulnar fractures can't be compared to radial fractures as if they were the same. And treating fractures of both bones is clearly different than just treating one forearm bone fracture.

The outcome of this study (reviewing results of current treatment for adult forearm fractures) is a clear picture of the need for future research. A direct comparison of results between plate and screw fixation and intramedullary nail fixation is needed.

Given all the uncertainty and possible disadvantages for each treatment approach, you may be wondering how did this Mayo patient get treated in the end? He did have both forearm bones broken. The fracture was an open one -- meaning the skin was cut open leaving the bone at risk for infection. The radius was in pieces (not just a clean single break across the bone).

Those factors led the surgeons to do an open incision with plate and screw fixation. They cleaned out the wound to prevent infection. They made every effort to avoid injuring the bone and attached muscles. They examined the fracture site to see if there was enough bone loss to need a bone graft (bone graft wasn't needed). The metal plate was attached using three screws on both sides of the fracture. Final outcomes/results were not reported for this particular patient.

References:
David B. Jones, Jr, MD, and Sanjeev Kakar, MD. Diaphyseal Forearm Fractures: Intramedullary Nail Versus Plate Fixation. In The Journal of Hand Surgery. July 2011. Vol. 36-A. No. 7. Pp. 1216-1230.

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