Background: With current techniques of plate-and-screw fixation,
diaphyseal nonunions of the radius and ulna are unusual. The few reports that
have been published have discussed the use of structural corticocancellous
bone grafts for the treatment of atrophic nonunions that are associated with
osseous defects. We reviewed the rate of union and the functional results in
association with the use of plate-and-screw fixation and autogenous cancellous
(nonstructural) bone grafts.
Methods: Thirty-five patients with an atrophic ununited diaphyseal
fracture of the forearm were treated with 3.5-mm plate-and-screw fixation and
autogenous cancellous bone-grafting. A segmental osseous defect with an
average size of 2.2 cm (range, 1 to 6 cm) was present in each patient. Twenty
of the original fractures had been open. Eleven patients had had treatment of
a deep infection before referral to us. The nonunion involved both forearm
bones in eight patients, the radius alone in sixteen patients, and the ulna
alone in eleven patients.
Results: The atrophic nonunion was associated with an open fracture
in twenty patients, suboptimal fixation in twenty-two, a fracture-dislocation
of the forearm in nine, and infection in eleven. All fractures healed without
additional intervention within six months. Two patients had a subsequent
Darrach resection of the distal part of the ulna for the treatment of
arthrosis of the distal radioulnar joint. After an average duration of
follow-up of forty-three months, the final arc of motion averaged 121° in
the forearm, 131° at the elbow, and 137° at the wrist, with an average
grip strength of 83% compared with that of the contralateral limb. According
to the system of Anderson and colleagues, five patients had an excellent
result, eighteen had a satisfactory result, eleven had an unsatisfactory
result (because of elbow stiffness related to associated elbow injuries in
three and because of wrist stiffness in eight), and one had a poor result
(because of malunion).
Conclusions: When the soft-tissue envelope is compliant, has limited
scar, and consists largely of healthy muscle with a good vascular supply,
autogenous cancellous bone-grafting and stable internal plate fixation results
in a high rate of union and improved upper limb function in patients with
diaphyseal nonunion of the radius and/or ulna.
Level of Evidence: Therapeutic study, Level IV (case
series [no, or historical, control group]). See Instructions to Authors for a
complete description of levels of evidence.