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Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA 91206
Ph: (818) 409-8000

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Our 32-year-old son had a car accident while he was in town visiting us. He broke both bones in his right forearm. He was unconscious so we had to make a quick decision without being able to consult with his wife about the surgery. In the end, we decided (based on the surgeon's comments) to have a plate and screws put in instead of a long nail down the center of the bone. We are second guessing whether we did the right thing. Could they have put a cast on his arm and avoided surgery? We never even thought to ask that question. What would you have done?

Nonsurgical treatment with cast or splint immobilization is not recommended for diaphyseal forearm fractures in adults. Diaphyseal fracture refers to a break in the long shaft of the bones (in this case in the forearm). 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. In a situation like yours, the family must rely on the information, opinions, and recommendations of the surgeon. Hopefully your son will have a good result but be aware that no matter how a fracture like that is treated, there are potential problems that can develop. You made the best decision possible under the circumstances.


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