Original Research Article DOI: 10.18231/2395-1362.2017.

0027

Comparison of Intramedullary Nailing to Plating for Both-bone Forearm Fractures

in Adult
Mohammed Khaja Nizamoddin Zamiruddin Khateeb1,*, Mohammed Nazim Akbar2
1Assistant Professor, ESIC Medical College, Kalaburagi, 2Assistant Professor, Dept. of Orthopaedics, GIMS Kalaburagi
Karnataka, India

*Corresponding Author:
Email: nizam.in4u@gmail.com

Abstract
Background: Plate osteosynthesis most commonly used technique for the treatment of both bone forearm fractures in adults.
Plating can disrupt the periosteal blood supply. There are chances of refracture after implant removal. The purpose of this study
was to assess early results of Nailing and Plating to stabilize the fractures and to compare the functional results of the two groups
and to review the literature.
Methods: From May 2011 to September 2016 in the Department of Orthopaedics, MMCRI Mysore, Kamareddy Ortho & Trauma
Care Hospital and ESIC MC Kalaburagi, total of 60 patients of both bones forearm fractures were treated. 30 were treated with
plating and 30 with nailing.53 patients were available for the follow up. Follow up was for one year. Functional results were
assessed by Anderson et al criteria.
Results: Average surgery time in plating group was 68 minutes, and 43 minutes in nailing group. Average union time for radius &
ulna was 7.8 and 8 weeks in nailing group and 9.3 and 9.6 weeks in plating group. There was 1PIN palsy; 2 tourniquet palsy, 1
deep infection, 1 superficial infection, 1 implant failure, no delayed union and 3 non-unions in plating group. In nailing group no
infection; two delayed union and no cases of nail migration. No synostosis, malunion, nail bending or cortical perforation.
Conclusion: We conclude that Plate osteosynthesis is the implant of choice for all diaphyseal fractures of both bones forearm.
Intramedullary nailing is an attractive alternative. Complication rates are lower as compared to plating, application of above elbow
cast after nailing is a drawback of the procedure.

Keywords: Plate osteosynthesis, Intramedullary Nailing, Diaphyseal Fractures, Bothbone Forearm.

Introduction The technique is commonly used in paediatric

Both bone forearm fractures are not uncommon. fractures of forearm. Intramedullary nailing has not been
Healing occurs reliably after closed treatment but widely used for fixation of forearm fractures because of
malunion, with resultant decreased rotation of the its limited indications and need for additional
forearm, is common and has been associated with poor immobilization.(11) In these studies poor results may be
results.(1,2) Rotation of the forearm is a complex because, nailing was performed by open reduction. The
interaction between the radius and ulna and the advantages of IM fixation over plating include small
restoration of this movement depends on both an incisions, shorter duration of anesthesia, limited soft-
accurate reduction of the fractures and early initiation of tissue dissection, rapid union, and excellent recovery of
post-operative movement.(3) Loss of rotation impedes range of motion.(12) However, open reduction and plating
function of the upper limb and activities of daily living. allow a more anatomic repair for most fractures.(13) This
Most of the of fractures of both bones of the forearm in may result in more accurate restoration of the radial bow,
adults is treated operatively and there are various modes which, although unproven, may more completely restore
of internal fixations available, the choice of which forearm rotation. We conducted a randomized
depends on the treating surgeon.(4) prospective comparative study to investigate whether the
When treated conservatively forearm fractures is result of closed intramedullary nailing are comparable to
thick with complications of casting, compartment plate osteosynthesis. The aim of our study was to
syndrome, malunion, and bayonet apposition.(5) Plate evaluate the results of internal fixation of diaphyseal
osteosynthesis is the most commonly used technique for fractures of both bones forearm treated by plate
the treatment of diaphyseal forearm fractures in adults. osteosynthesis and closed intramedullary nailing and to
However, application of a plate can disrupt the periosteal compare the functional results of the two groups.
blood supply and may increase the probability of delayed
fracture union.(6,7) Skin incisions that may be unsightly Materials and Methods
and also associated with risk of refracture after implant 60 patients with diaphyseal fractures of both bones
removal.(8) In an effort to reduce these problems, forearm who met the inclusion and exclusion criteria
intramedullary nailing has been proposed as an were randomly chosen for a prospective study. Thirty
alternative method for stabilization and maintaining the (30) patients were treated by plate osteosyntheis and 30
reduction of forearm fractures.(9,10) patients were treated by closed intramedullary nailing.
Square nails were used for intramedullary nailing.
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Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

The inclusion criteria were: 1) age more than 18 over the tip of olecranon, triceps insertion was incised.
years 2) patient not subjected to any other form of Entry portal was made with the straight awl at a point 5
treatment 3) all open Grade 1 (Gustillo and Anderson(14)) to 8 mm from the dorsal cortex and 5 mm from the lateral
and closed fractures without neurovascular deficit. cortex over the olecranon. No reaming was done. After
Exclusion criteria were: 1) skeletally immaturity 2)very reduction of the fracture by traction and manipulation
narrow intramedullary canal 3) fractures older than 10 under image intensifier a nail of the proper size was
days before treatment 4) single bone fractures 5)presence selected and inserted in the canal and hammered after
of neurovascular deficit and 6) patient with head injuries. reducing the fracture, leaving only 5 mm outside the
All study participants were followed up for a minimum bone end. Fracture site was seen under image intensifier
of one year. during hammering to avoid the distraction at the fracture
Cases with the closed fractures were immobilized in site. Skin sutures were applied.
the above elbow POP slab as the initial management. In For radius nailing 1 to 1.5 cm incision was given
the open cases wound was examined for detailed injury extending distally from the dorsal margin of joint surface
and for the neurovascular status of the limb and washed at a point just lateral to Lister's tubercle. The dissection
with copious amount of normal saline and initial care was carried out between the extensor carpi radialis
was given in emergency including thorough debridement longus and extensor carpi brevis tendon. The entry portal
of wound. Prophylactic treatment against tetanus was was made with the straight awl directly in line with the
given and broad spectrum antibiotic were given to medullary canal. At the dorsal margin of joint a straight
prevent the infection. awl was introduced at an angle of 45° to joint surface.
Plating Group: There were 30 patients in this group. After entering the bone 1 to 1.5 cm, the angle of the awl
Out of these, 27 patients were available for follow up. was dropped to the axis of bone and continued another 1
Mean age was 32 years with age range from 20 to 54 cm in line with the medullary canal of bone. Rest of the
years. Nineteen patients (19) were male. Right extremity technique was same as used for the ulnar nailing except
was involved in majority of the cases. RTA was most that the nail was bent regularly to approximate the bow
common mechanism of injury affecting 15 patients. of the radius prior to the insertion.
Eighteen (18) patients had middle third fractures. Four Plating: Both fractures were exposed and reduced
patients had open fractures. Five (5) patients had another before fixation of either, fracture having less
associated injury. Average injury operation interval was comminution was fixed first. Plates were applied using
7.7 days. the AO principles.(15) Henry approach was used for
Nailing Group: There were 30 patients in this group. fracture fixation. Ulna was exposed by subcutaneous
Out of these, 26 patients were available for the follow approach. Plate was applied using the AO principles
up. Mean age was 34 year with age range from 19 to 57 (Small fragment DCP/1/3 Tubular plate and 3.5 mm
year. Seventeen (17) patients were male. Right extremity cortical screws).
was involved in 14 cases. RTA was most common Post-operative: In both methods above elbow slab was
mechanism of injury affecting 14 patients. Seventeen applied till suture removal. In plating group slab was
(17) patients had middle third fractures. Four patients discarded after suture removal and the active movement
had open fractures. Five (5) patients had another of the elbow and the wrist started. In the plating group
associated injury. Average injury operation interval was above elbow cast was applied after suture removal if
8.2 days (Table 1). internal fixation was not rigid which was decided by the
Surgical Procedure: Patients were given the brachial operating surgeon during the surgery. In the nailing
plexus block using the supraclavicular approach. (Fig. 1) group above elbow cast were applied after suture
Nailing: Square nails were used for intramedullary removal for 4 to 6 weeks and cast removed when early
nailing. Nail size was determined prior to surgery. The signs of union were noticed, and active movement of
required length was determined by measuring the elbow and wrist started. Heavy and the strenuous
uninvolved limb directly. Ulna was measured with a activities were avoided till solid union occurred in all
measuring tape from the tip of olecranon to ulnar styloid. cases. Patients were regularly followed up at 6,12,18,24
One (1) cm was subtracted from this measurement. weeks and finally at 1 year. At every follow up clinical
Radius length was determined by subtracting the 2.5 cm. and the radiological examination was done and the
from the ulnar measurement. Preoperatively diameter movements of the elbow and the wrist recorded.
was determined by measuring the narrowest diameter of Clinically union was considered when there was no
the intramedullary canal on either AP and lateral view of tenderness at the fracture site on stressing. Radiological
the x-ray of the fractured forearm. During the surgery union of fracture was judged to be present when on
diameter was confirmed by trial. Snug fitting nail was x-ray there was obliteration of fracture line with the
selected to avoid the overriding of the oblique and evidence of bridging callus. (Fig. 2 & 3) Those fractures
comminuted fractures. Patient was laid supine on the OT which required more than 6 months to unite and had no
table with the affected limb positioned on the arm board. additional operative procedure performed were
Image intensifier was positioned over the affected limb. classified as delayed union. Those fractures which failed
For ulnar nailing 1 cm longitudinal incision was made to unite without another operative procedure were
Indian Journal of Orthopaedics Surgery 2017;3(2):135-142 136
Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

classified as non-unions. Functional results were radius showed union in 24(93.2%) patients and ulna in
assessed by Anderson et al (1975) criteria.(16)(Table 2) 22(86.8%) of patients. In one patient both ulna and
Statistical Analysis: The t test for independent samples radius resulted in non-union. In another patient radius
was used to compare the 2 groups for age at time of was united but ulna resulted in non-union due to implant
injury, mechanism of injury, sex, side of fracture, level failure. Average union time for radius was 7.8 weeks, for
of fracture, pattern of fracture, associated injuries, and ulna 8 weeks. In plating group both radius and ulna
time interval for surgery. The Fisher exact test and showed union in 26(96.29%) of patients. There were 1
unpaired t test were used to calculate and compare the non-union for both ulna and radius which were in same
groups. For all analyses, a P>0.05 was considered patient. Average union time for radius was 9.3 weeks and
significant. Statistical analyses were performed using for ulna 9.6 weeks (p>0.05). There was 1posterior
SPSS 24.0 (SPSS Inc., Chicago, Ill). The results are interosseous nerve injury; 2 cases of tourniquet palsy, 1
tabulated in Table 1. deep infection, 1 superficial infection, 1 implant failure,
no delayed union and 3nonunion in plating group. In
Results nailing group there was1 implant failure, no infection;
Average surgery time in plating group was 68 two delayed union and no cases of nail migration. (Table
minutes, with range from 48 to 85 minutes. In nailing 3)(Fig. 6) There was no synostosis, malunion, nail
group average surgery time was 43 minutes with range bending or cortical perforation by nail. Functional results
from 42 to 64 minutes (p>0.05). In the plating group were assessed by Anderson et al criteria. Functional
21patients required no immobilization. Six patients were results in plating group were excellent in 22 (80%) of
immobilized for 6 weeks. In nailing group all patients patient, satisfactory in 2(6.6%), failure in 3(13.2%).
were immobilized for a period of 4 to 6 weeks after There was no unsatisfactory result in plating group. In
suture removal. Average follow-up was from 12 months nailing group result were excellent in 18 (68.7%),
to 18months. Patients having the follow up of less than satisfactory in 7(24.8%), unsatisfactory in 1(6.2%) and
one year were not included in the study. In nailing group no failure. (Fig. 4)

Table 1: Patient profile

S.no. Parameter Plating Nailing P value Significance
group(27) group(26)
1. Mean age 32 34 p>0.05 Not significant
2. Sex Male 19 17 p>0.05 Not significant
Female 08 09
3. Side Right 15 14 p>0.05 Not significant
Left 12 12
4. Mechanism of RTA 15 14 p>0.05 Not significant
injury
Self-fall 09 08
Assault 03 04
5. Level of fracture Upper/3 03 04 p>0.05 Not significant
Middle/3 18 17
Lower/3 06 05
6. Closed or open Closed 23 22 p>0.05 Not significant
Open 04 04
7. Pattern of fracture 14 16 p>0.05 Not significant
Transverse
Oblique 09 07
Spiral 02 02
Communited 02 0
Segmental 0 1
8. Associated injury Clavicle 02 02 p>0.05 Not significant
Humerus 01 02
Contralateral 0 0
forearm
Hand 2 1
Others 0 0
9. Time for 7.7 8.4 P<0.05 significant
operation(days)
Indian Journal of Orthopaedics Surgery 2017;3(2):135-142 137
Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

Table 2: Anderson et al(13) Criteria was used in grading the functional outcome
Results Union Flexion and extension at Supination and pronation
elbow joint
Excellent Present <10° loss < 25% loss
Satisfactory Present <20° loss < 50% loss
Unsatisfactory Present >20° loss >50% loss
Failure Non – union or unresolved chronic osteomyelitis

Table 3: Complications in both the groups

Complications Plating group Nailing group
Superficial infection 1 0
Deep infection 1 0
Delayed union 0 2
Nonunion 3 1
Implant failure 1 1
Nerve palsy(PIN) 1 0
Tourniquet palsy 2 0

Fig. 1: Operative steps both the groups

Indian Journal of Orthopaedics Surgery 2017;3(2):135-142 138

Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

Fig. 2: Pre and post up x-rays along with fracture union-plating group

Fig. 3: Pre and post up x-rays along with fracture union-nailing group

Fig. 4: Functional results in plating and nailing groups

Indian Journal of Orthopaedics Surgery 2017;3(2):135-142 139

Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

Fig. 5: Duration of fracture union and time interval for operation in both groups

Fig. 6: Patient with range of motion and complications

Discussion arm, forearm supination (68%), wrist flexion (84%),

Fracture of both bones of the forearm is relatively wrist extension (63%), and grip (75%). In addition, the
common injuries which can challenge the treating injured arms had a significantly reduced active range of
surgeon. Healing occurs relatively after closed treatment forearm supination (90%), forearm pronation (91%) and
but malunion with resultant decreased rotation of the wrist flexion (82%).(19) Possible complications include
forearm is common and has been associated with poor compartmental syndrome, delayed union or nonunion
outcomes. Loss of rotation impedes function of the upper and refractures after extraction of the plate.(20,21) A high
limb and activities of daily living.(17) Compression plate frequency of intraoperative nerve injuries has also been
fixation has become the treatment of choice for fractures reported. The reported incidence of transient dorsal
of both bone forearm. Several studies have shown good nerve palsy is 7 to 10% of all patients with radius fracture
results.(18) Droll et al compared injured arms to uninjured treated by plating .Incidence of radioulnar synostosis of
arms, following internal fixation of the forearm the plate fixation is reported in the literature is 2% to 9%.
fractures, and found that injured arms had reduced Though plating for both forearm bones fracture is a
strength of forearm pronation (70%) of that of the normal sound practice and adheres to the principles of

Indian Journal of Orthopaedics Surgery 2017;3(2):135-142 140

Mohammed K. N. Z. Khateebet al. Comparison of Intramedullary Nailing to Plating for Both…….

osteosynthesis, a straight plate is unable to maintain and incisions are smaller, and there is less soft tissue
preserve the radial bow, essential for normal rotational dissection, resulting in preservation of osseous blood
movements of the forearm. Use of closed intramedullary supply, which aids in fracture union. Also unlike
nails for treatment of diaphyseal fractures of forearm in compression plating, intramedullary devices are stress
nailing group can achieve good results. In 1913 sharing rather than stress shielding, which leads to
Schone(22) first used the silver nails for radial and ulnar peripheral periosteal callus that may facilitate the
medullary fixation, and subsequently various nails were stronger fracture union. Despite this abundant callus a
developed to stabilize forearm fractures. Vom Saal mechanical block to the forearm rotation had not been
(1954) developed the first square nail.(23) reported to our knowledge.(20) In our study there was no
Talwalkar(1967) treated 72 cases of both bone forearm case of radioulnar synostosis. The disadvantage of
fractures by square nail and resulted in 100% union intramedullary nailing procedure is that it requires a
rate.(24) longer duration of immobilization (until bridging callus
Duration of surgery was longer in plating group than is observed) compared to plate osteosynthesis. Even with
nailing group because operative technique is more the disadvantage of longer duration of immobilization of
demanding due to meticulous soft tissue dissection the forearm and radiation hazard to patient and surgeon.
required for exposure (p>0.05). Nailing does not provide We believe that intramedullary nailing is a reasonable
rigid fixation and some form of bracing is required for approach with good results.
initial 6 to 8 weeks. Plating in general does not require
external bracing. One patient in plating group who Conclusion
showed nonunion had open fracture and developed the From our comparative study we conclude that
deep infection 1 month after surgery. Another patient anatomical reduction and stable internal fixation should
who had nonunion of ulna had loosening of screws. 2 continue to be the standard method of treatment for
Patients in nailing group showed delayed union. fracture of both bones of the forearm in adults. Plate
Tourniquet palsy occurred in 2 cases which was transient osteosynthesis is the implant of choice. Intramedullary
and recovered after 3 months. Duration of surgery in nailing is an attractive alternative for the treatment of
both these cases was 43 and 68 minutes.(Fig. 5) shaft fractures involving both forearm bones in adults.
Tourniquet palsy in these cases may be due to high Complication rates are lower as compared to plate
pressure in the cuff. Two patients had superficial osteosynthesis, although application of above elbow cast
infection which was treated by intravenous antibiotics after nailing is a drawback of the procedure.
and recovered completely. One patient who had deep
infection had open fracture of middle third by fall. Acknowledgement
Radius was comminuted and ulna had transverse We sincerely thank Dr Abdul Ravoof, Professor
fracture. Wound was debrided at the day of injury and Dept. of Orthopaedics, AIIMS Adichunchanagiri, Dr
intravenous antibiotics were started. Another patient had Giridhar SR, MMCRI Mysore, Dr Marthand Kulkarni
implant failure having fracture of middle third of forearm for helping us through the case series. Ever since I began
by RTA. this study, innumerable people have participated by
There was no infection in nailing group this may be contributing their time, energy and expertise. To each of
because all the surgeries in this group were performed by them and to others whom I may have omitted through
closed reduction under image intensifier. Percentage of oversight, I owe a debt of gratitude for the help and
excellent results was higher in plating when compared to encouragement. I express my gratitude to all the patients
nailing group. Restoration of pronation and supination and their families who performed the backbone of this
depends upon the anatomical alignment and restoration study.
of normal bow. As the nailing was performed after
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