|SYMPOSIUM - DISTAL RADIAL FRACTURES
|Year : 2020 | Volume
| Issue : 2 | Page : 66-69
One bone forearm for massive gap nonunion of distal radius: Our experience and literature review
Lawrence Kisku1, Riddhideb Barman1, Amit Ranjan Vidyarthi1, Sarkar Pushpal Pijush1, Mohammad Nasim Akhtar1, Sanjay Keshkar2
1 Department of Orthopaedics, ESIC Medical College and Hospital, Joka, India
2 Department of Orthopaedics, ESIC Medical College and Hospital, Joka; Ex Faculty, National Institute for the Locomotor Disability; Faculty, West Bengal University of Health Sciences, West Bengal, India
|Date of Submission||04-Jul-2020|
|Date of Decision||18-Jul-2020|
|Date of Acceptance||25-Jul-2020|
|Date of Web Publication||10-Sep-2020|
Prof. and Head, Orthopaedic, ESIC Medical College and Hospital, Joka, Kolkata - 700 104, West Bengal
Source of Support: None, Conflict of Interest: None
Background: Large defect or massive gap of nonunion distal radius is a rare entity but not uncommon. It usually presents with manus valgus deformity with a disability and difficult to treat. Due to the extensive gap with surrounding soft tissue scarring, the usual method of gap grafting may not be feasible in these cases. In such cases, the creation of one bone forearm has been found to be a sound and excellent method of treatment. The purpose of this paper is not only to present the results of 5 patients of massive gap nonunion of the distal radius treated by one bone forearm but also to review the relevant literature. Materials and Methods: Five cases of posttraumatic massive gap nonunion of radius were treated by the creation of one bone forearm in the past 8 years. The male-to-female ratio was 4:1 with age ranging from 16 years to 35 years. In all cases, ulnar transposition and fixation in the neutral rotation were done to create one bone forearm. Three cases underwent monoaxial distraction of distal radius to correct distal radio-ulnar joint prior to the definitive procedure of one bone forearm. Results assessed by clinico-radiological evaluation. Finally, literature related to the treatment of such cases were searched by Google search, and systematic review on the subject was done. Results: The follow-up period ranges from 4 to 8 years with an average of 4.5 years. According to clinico-radiological evaluation, one patients came out with excellent result and the remaining 3 had a good result. In toto, all five patients had good functional outcomes. Conclusions: To produce “one bone forearm” for massive gap nonunion of the distal radius is not an outdated but still a dependable, effective, and economical procedure with lesser complication, good outcome, shorter hospital stay, and easier postoperative maintenance.
Keywords: Bone grafting, distal radius fracture, gap nonunion of radius, nonunion, one bone forearm
|How to cite this article:|
Kisku L, Barman R, Vidyarthi AR, Pijush SP, Akhtar MN, Keshkar S. One bone forearm for massive gap nonunion of distal radius: Our experience and literature review. J Orthop Dis Traumatol 2020;3:66-9
|How to cite this URL:|
Kisku L, Barman R, Vidyarthi AR, Pijush SP, Akhtar MN, Keshkar S. One bone forearm for massive gap nonunion of distal radius: Our experience and literature review. J Orthop Dis Traumatol [serial online] 2020 [cited 2020 Nov 28];3:66-9. Available from: https://www.jodt.org/text.asp?2020/3/2/66/294737
| Introduction|| |
Large defect or massive gap of nonunion distal radius is a rare entity but not uncommon. It usually presents with manus valgus deformity with a disability and difficult to treat. Every orthopedic surgeon is confronted with such a problem where most of the radius except the lower end may be missing. If this defect remains uncorrected for a longer time, secondary deformities develop, resulting in a short and crooked forearm with limitation of movements of elbow and wrist. The usual treatment of gap grafting is not practicable in these cases, not only due to the extensive gap but also because of the scarring of soft tissues over it. If at all done, the gap grafting fails to provide adequate stability and motion required for moderate-to-heavy work of the involved upper limb. In such cases, ulnar transposition (at the lower end) resulting in a one bone forearm has been recommended in literature as 'one go' procedure and found to be a sound and excellent method of treatment. The purpose of this paper is to present review of 5 patients treated with this procedure by us in the past 8 years.
| Materials and Methods|| |
Five cases of post-traumatic gap nonunion of distal radius were treated by the creation of one bone forearm in the last 8 years. All cases of posttraumatic gap nonunion of distal radius had a history of multiple operations elsewhere before presenting to us. Male-to-female ratio was 4:1 with age ranging from 16 years to 35 years. The detailed demography of all cases is shown in [Table 1]. All patients had the discomfort of using the upper limb due to marked instability. To counter this instability, “one bone forearm” was created in all patients. Ulnar transposition was done in all 5 cases.
The operative technique of creation of one bone forearm: All cases were operated under tourniquet by using posterior approach. All five cases of gap nonunion of radius underwent ulnar transposition for which the incision starts over the ulna and goes toward the lower end of the radius. The soft tissues are erased from the ulna as well as the radius. The ulna is osteotomised a little longer than the actual length required to bring it in alignment with the lower end of the radius. After ulnar transposition, the bones are aligned in neutral rotation (mid prone position) and fixed internally or externally by appropriate fixation device. The wound was closed under a negative suction drain. Tourniquet was released, dressing was done, and long arm plaster slab was given. The suction drain was removed after 48 h. Peri-operative and postoperative period was uneventful in all cases. Sutures were removed after 2–3 weeks, and then above-elbow (A/E) cast was given for 6 weeks followed by below-elbow (B/E) cast till radiological bony union. After bony union, movements of elbow and wrists were started with a forearm fracture brace.
Joshi External Stabilizing System (JESS) distraction: One case of posttraumatic gap nonunion of radius had severe manus valgus deformity with soft-tissue contracture. In this case, we used JESS distracter for gradual correction of deformity and contracture, after which the second-stage definitive surgery of creation of one bone forearm was done by the method mentioned above and is the only case where fixation was done by plate and screw. All other cases underwent one-stage surgery of “one bone forearm” and fixed by intramedullary nail.
Removal of the implant: After about 1-year of achieving solid union, removal of implants was advised. All four cases of intramedullary fixation accepted the advice for the reason that they had some kind of discomfort at the wrist due to protrusion. One case of plate and screw was not willing for removal hence not done.
| Results|| |
The average healing time was 4 months. The longest follow-up was 8 years and the shortest 3 years. The results were graded by clinico-radiological evaluation according to the criteria given in [Table 2]. One out of 4 cases of posttraumatic gap nonunion of the distal radius where intramedullary fixation was used, had excellent result [Figure 1], and rest 4 cases had a good result. One case of posttraumatic gap nonunion of the distal radius where 2 stage procedure (JESS distraction followed by plate and screw fixation) was used, also had good result [Figure 2].
|Figure 1: (a) Preoperative radiograph showing massive gap nonunion of distal radius 2. (b) Postoperative radiograph showing ulnar transposition and fixation by nail to create “one bone forearm” 3. (c) Final follow-up radiograph after implant removal showing solid union (one bone forearm) 4. (d-f) Final follow-up showing excellent clinical results|
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|Figure 2: Preoperative radiograph showing massive gap nonunion of distal radius with manus valgus deformity 2. (b) Postoperative radiograph (Stage – 1 operation) showing Joshi External Stabilizing System distraction of distal radius 3. (c) Final follow-up radiograph after Stage 2 surgery showing solid union of ulnar transposition with plate fixation to create “one bone forearm”|
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| Discussion|| |
There are only a few reports in the-literature of this procedure. Hey Groves EW (1921) and Watson-Jones transposed ulna to lower end of the radius in one case each., Vitale performed radio-ulnar fusion in 2 cases. Lowe did side to side radio-ulnar fusion without internal fixation “in 4 patients and ulnar transposition in three. Lloyd-Roberts presented 3 cases of defective lower end of the ulna for which radio-ulnar fusion was done. The results of literature mentioned above,,,,, of created one bone forearm and also the cases of congenital radioulnar synostosis; they all support that reasonably good function of the upper limb is obtainable without the need of supination or pronation. The only prerequisite for getting good results in these cases is the normal hand with normal radiocarpal and ulna-humeral joint. In other words, “one bone forearm” is based on the principle that the upper end of the ulna is responsible for the stability of elbow joint and lower end of radius for wrist joint. With this procedure, the deforming growth of the remaining bone is controlled. Radial or ulnar deviation of hand and instability of the elbow and wrist are all corrected. The movements at both the joints are also restored, and the function of the hand improves considerably. The loss of pronation and supination is compensated by movements at the shoulder. We prefer to do end to end fusion, taking a little more length of the long bone to provide a compression force, because “side to side fusion” as used by Lloyd-Roberts leaves shearing stress and there are chances of delayed union or nonunion, although he has supplemented all his cases with cancellous bone grafting to eliminate nonunion. Our contention is that if end-to-end fusion is done, chances of nonunion are considerably less, and bone grafting as advocated by Moore is needed only in a small percentage of cases. In our series, only 1 case required cancellous bone grafting. The functional results of one bone forearm after the loss of ulna or radius have been good provided the forearm should be in neutral with no supination or pronation., All 5 cases in our series were fixed in neutral rotation. Two of our 5 patients had a full range of flexion and extension of wrist and elbow; however, 3 had limitation of wrist extension, which improved a bit after removal of the implant. This is comparable with other reports. None of our patients had shown a problem with their Activity of daily living and household activity. At the last follow-up it came to our notice that 2 of them are studying, 2 are engaged employed in some factory, and one is running his own business. They all are satisfied with the result.
| Conclusions|| |
Ulnar transposition to produce “one bone forearm” for massive gap nonunion of the distal radius is still a dependable, effective, and economical procedure with lesser complication, good outcome, shorter hospital stay, and easier postoperative maintenance.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Agrawal ND, Mittal RL. One bone forearm; a reconstructive procedure for defects in the forearm bones. Indian J Orthopaedics 1975;9:63-8.
Hey Groves EW, Transposition of ulna to lower end of radius In: Hey Groves EW (Editor) Modern methods of treating fractures. 2nd
edition. Bristol John Wright and Sons Ltd.; 1921. p. 320.
Watson-Jones R. Reconstruction of the forearm after loss of the radius. Br J Surg 1934;22:23.
Vitale CC. Reconstructive surgery of defects in the shaft of' the ulna in children. J Bone Joint Surg 1952;34-A: 804.
Lowe HG. Radio-ulnar fusion for defects in the forearm bones. J Bone Joint Surg (Br) 1963;45-B: 351-9.
Lloyd-Roberts GC. Treatment of defects of the ulna in children by establishing cross-union with the radius. J Bone Joint Surg Br 1973;55:327-30.
Moore JR. Delayed autologus bone graft in the treatment of congenital pseudoarthrosis. J Bone Joint Surg (Am.) 1949;31-A: 23-39.
Reid RL, Baker GI. The single-bone forearm-A reconstructive technique. Hand 1973;5:214-9.
Castle ME. One-bone forearm. J Bone Joint Surg Am 1974;56:1223-7.
[Figure 1], [Figure 2]
[Table 1], [Table 2]