AN EXPERIENCE OF TREATMENT FOREARM FRACTURES BY CLOSED NAILING
DR.K.HYDAR. ORTHOPAEDIC SURGEON, MALABAR HOSPITAL, MANJERI, KERALA, INDIA.

Introduction.

The Forearm fracture requires an aggressive and exacting management, as it serves an important role in the upper extremity function. There are a variety of options for treating fractures of forearm like cast immobilization. Plate fixation, Intramedullary fixation and external fixation.

Aim of the study is to asses the result of closed nailing, which is less traumatic, less expensive, and to find out the anatomical and functional acceptance of the procedure.

Patients & Method.

In this study 78 forearm fracture ( both bone 58 & single bone 20) treated by closed nailing during December 2000 to June 2003 ( 30 months) at Malabar Hospital, Manjeri, Kerala, India. Age group varies from 12 years to 60 years. 44 were male and 34 were female patients. 26 patients sustained injury following road traffic accidents and 52 patients sustained injury following fall.

After closed manipulative reduction under image intensifier, fixation done with square Nail by closed method. All cases were done under regional block anesthesia. In 30 cases ulna was fixed first and the rest of the cases radius first. In 9 cases because of soft tissue interposition reduction was not stable, so stab incision was made and reduction performed with help of bone leaver. All patients were discharged on the 2nd day. Suture removal was done on 10th day, POP slab converted to above elbow cast for 4 to 6 weeks. After removal of the plaster patient was sent for physiotherapy for 5 days

Results.

AGE GROUP 10 – 20 YEARS.


Fracture
Site

No.
Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
6
1
6
8
8
11
0
1
1

Middle 3rd
10
0
6
8
8
11
0
0
0

Distal 3rd
11
0
6
8
8
12
0
0
1


27
1
6
8
8
11
0
0
2

AGE GROUP 21 – 30 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
2
1
6
8
8
11
1
0
1

Middle 3rd
6
1
6
8
8
11
0
1
1

Distal 3rd
7
0
6
8
10
12
0
0
0


15
2
6
8
8
11
1
1
2

AGE GROUP 31 – 40 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
1
1
6
8
8
10
0
0
0

Middle 3rd
7
0
6
8
8
11
0
0
0

Distal 3rd
8
0
6
8
10
12
0
0
0


16
1
6
8
8
11
0
0
0


AGE GROUP 41 – 50 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
1
1
6
8
8
10
0
0
0

Middle 3rd
5
1
6
8
8
12
0
0
1

Distal 3rd
6
0
6
8
8
12
0
0
1


12
2
6
8
8
12
0
0
2



AGE GROUP 51 – 60 YEARS.


Fracture
Site

No.

Difficulty
in
Reduction Union Complication

Clinical
Radio
logical
Func-
tional
Work
Infection
Delayed
Union

Nail
Migration

Proximal
3rd
2
0
6
8
10
10
0
1
1

Middle 3rd
3
1
6
8
10
12
0
0
1

Distal 3rd
3
0
6
8
10
12
1
0
0


8
1
6
8
10
12
1
1
2

Total 78 7 1 3 8


Results were analyzed by dividing the patients in to different groups depending on age and site of fracture.

In the 1st group, there were 27 patients in the age group of 10 – 20 years, of which 6 had proximal 3rd fracture, 10 had middle 3rd and 11 had distal 3rd fractures. One fracture had difficulty in reduction because of soft tissue interposition. Clinical union by 4-6 weeks and radiological union by 6-8 weeks. All cases had functional union by 10 weeks.

In one of the case of proximal 3rd fracture had delay in union by 2 weeks. Two patients had nail migration which removed after 3 months.

In the 2nd group patients between the age group of 21-30 years, there were 15 patients; of this 2 fractures had difficulty to reduce. All fractures were united Clinically by 6 weeks, radiologically by 6-8 weeks, and functionally by 10 weeks. One case was delayed to unite by 3 weeks. Two patients had nail migration.

In the 3rd group there were 16 patients; one patient had proximal fractures, 7 patients had middle and 8 patients had distal 3rd fractures. One fracture had difficulty in reduction. All cases had functional union by 8 weeks. There were no delayed union or nail migration.

In the 4th group, there were 12 patients, of which 2 had difficulty in reduction. 2 patients had nail migration which was removed after 3 months.

In the 5th group there were 8 cases. In one case reduction was difficult One patient had superficial infection and one had Delayed union. 2 patient had nail migration.





Of these 78 cases, 7 cases had difficulty in reduction which is more in proximal 3rd fractures (4 proximal 3rd and 2 Middle 3rd fracture) especially in muscular patients. These cases were reduced with bone lever through a stab incision.

Delayed union was seen in 3 cases, which was also more in proximal 3rd and Middle 3rd fractures. One patient had superficial infection which is treated with antibiotics.

Of the 78 cases, 8 cases had nail migration, which was treated by nail removal after clinical and functional union.

All cases were united clinically by 6 weeks and radiologically by 8weeks. Functional union by 10-12 weeks. Patients were started working after 12 weeks.

Discussion

Closed nailing for the forearm fractures showed good results, comparing to the other modes of treatment. For forearm fractures DCP is still the gold standard treatment. But considering short operating time (30 – 40 mints) surgical trauma, infection, short hospital stay, less expense and minimal scar, closed nailing is to be considered as an alternate method of treatment.

In this present study, closed nailing gives better results in younger age group of patients (10-20 years). Difficulty in reduction is more in muscular patients and in proximal 3rd fractures. So selection of cases is important for closed nailing. Better results were with Middle and distal 3rd fractures and in younger age group 10-20 years.

Selection of nail is important, considering the length and size of nail. Chances of migration is more in thin and shorter nail. One disadvantage of nailing is the need for immobilization for 6 – 8 weeks . Nail migration may effect elbow and wrist movements.

Conclusion

• Closed Nailing for forearm fracture gives better results.
• For patients of younger age group (10-20) had better results.
• Compared to proximal fractures middle and distal fractures are easy to treat by closed method.
• Considering the economics, trauma, medicine, hospital stay, infection, non-union, bone grafting, and cosmetic aspect closed nailing gives better results




****