Bracing of stable shaft fractures of the ulna

The Use of Nitinol Staples as Reduction Aids in Fixation of Forearm Diaphyseal Fractures: Surgical Technique and Case Series

Forearm diaphyseal fractures are common orthopedic injuries that typically require surgical intervention using various implants and approaches. Maintaining reduction while simultaneously achieving compression in radial and/or ulnar shaft fractures during compression plate application can be challenging, particularly with unstable segmental and/or transverse fracture patterns. Nitinol compression staples have become increasingly used as a reduction aid because of their ability to provide continuous compression between the staple legs at the fracture site, low profile, and ease of application. These staples have the potential to be an effective means of maintaining reduction and applying compression before definitive plate fixation for radial and ulnar shaft fractures. We present our surgical technique and an associated patient series detailing our institution's experience, highlighting favorable outcomes and potential considerations when using nitinol compression staples for forearm fracture management.

Risk Factors for Failure of Nonsurgical Management of Ulnar Shaft Fractures

PURPOSE

Isolated ulnar shaft fractures are frequently managed nonsurgically. However, rates of nonsurgical treatment failure remain substantial, and risk factors for the failure of nonsurgical management are not well described. This study investigated radiographic and patient-specific risk factors for the failure of nonsurgical management of isolated ulnar shaft fractures.

METHODS

A retrospective review of patients with ulnar shaft fractures initially treated nonsurgically was performed at two tertiary referral centers over a 19-year period from 2001 to 2020. Patient- and injury-related variables, surgical interventions, and plain radiographic measurements were recorded. The outcome of interest was failure of nonsurgical management, defined as failure to achieve fracture union nonsurgically within 3 months of injury.

RESULTS

One hundred fifty four patients initially treated nonsurgically for isolated ulnar shaft fractures were included. Twenty six patients (17%) experienced failure of nonsurgical management; these included five nonunions, 16 delayed unions, and 10 conversions to surgical management. Patients who experienced failure of nonsurgical management had a higher prevalence of diabetes mellitus, a higher employment rate, and fractures with higher initial median posteroanterior and lateral translations, fracture gap, and angulation; 83% of the patients with an initial fracture gap of ≥4 mm and 41% of the patients with an initial fracture angulation of >10° failed nonsurgical management.

CONCLUSIONS

Although most ulnar shaft fractures heal successfully with nonsurgical management, a substantial percentage of these fractures do not. Patients who are currently working, have diabetes mellitus, or have fractures with an initial fracture gap of ≥4 mm or an initial fracture angulation of > 10° may be more likely to fail nonsurgical treatment, although additional studies with larger sample sizes are needed to confirm these associations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic IV.

Management of Isolated Ulnar Shaft Fractures

» Most isolated ulnar shaft fractures are stable and heal without complication regardless of treatment protocol.» Casting above the elbow may create unwanted stiffness without enhancing union rates.» Defining unstable fractures and determining which injuries would benefit from operative management remain a challenge.» Recent development of intramedullary devices has shown promise in preliminary studies, but more vigorous investigation is needed to determine their role.

Does operative fixation of isolated fractures of ulna shaft results in different outcomes than non-operative management by long arm cast?

OBJECTIVE

The optimal treatment for isolated fractures of ulnar shaft is debatable. The purpose of this study was to compare functional outcomes and radiological union in patients treated for isolated fractures of the ulnar shaft by open reduction and internal fixation and a long arm cast.

METHODS

This prospective study was conducted at level I trauma center from November 2014 to March 2016. 30 patients with isolated fractures of ulnar shaft were randomized to two groups to receive treatment by open reduction and internal fixation by plates and screws and a long arm cast. Outcome assessment was done by Disabilities of Arm Shoulder and Hand (DASH) score, range of motion at wrist and elbow, grip strength and radiological union. Quantitative variables were summarized Mean or Median. Normality was assessed using Kolmogorov-Smirnov test. Independent samples t-test and Mann-Whitney test were used for normally distributed variables and non-normally distributed variables respectively. Categorical variables were summarized as proportions. Effect of the intervention for categorical variables was assessed using Chi-square test.

RESULTS

There was no difference between the groups for pain on Visual Analogue Scale (VAS), grip strength, DASH score, and union at the end of 12 months. There was no difference between the groups for range of motion at the elbow and wrist. 12 (85.7%) patients in the ORIF group and 15 (93.7%) in the cast group united at the end of 12 months. The mean time to union was 13 weeks in the ORIF group and 18 weeks in the cast group.

CONCLUSION

Open reduction and internal fixation results in anatomical restoration of ulna, but this does not translates to better functional outcomes in short term (12 months).

Treatment of Ipsilateral Distal Humerus and Diaphyseal Ulna Fractures by Using an Olecranon Osteotomy and Intramedullary Nail

OBJECTIVE

To evaluate the results of treatment of an osteotomy of the olecranon and an ulnar diaphyseal fracture with a single nail, in cases with an ipsilateral ulnar diaphyseal fracture and a comminuted fracture of the distal humerus.

DESIGN

Retrospective clinical study.

SETTING

University-affiliated teaching hospital.

PATIENTS

Eight patients with comminuted fractures of the distal humerus and ipsilateral ulnar diaphyseal fractures were included.

INTERVENTION

Using a transolecranon approach, internal fixation of the distal humeral fracture with medial and lateral plates was performed. The ulnar diaphyseal fracture and additional osteotomy were fixed using a locked intramedullary nail. Subjective pain assessment was performed by using a visual analog scale (VAS).

RESULTS

There were 6 (75%) male and 2 (25%) female patients, with a mean age of 40.9 (range, 32-56) years. The mean follow-up period was 24.6 (range, 12-36) months. All patients achieved union of the ulnar diaphyseal fracture and olecranon osteotomy. Union of the distal humeral fracture was observed in 7 (87.5%) patients. The mean time to union was 16.3 (range, 12-22) weeks, mean visual analog scale score was 1.8 (range, 0-3), median elbow performance score was 85 (range, 70-95), and median disabilities of the arm, shoulder, and hand score was 17.9 (range, 5-45.8).

CONCLUSIONS

Osteotomy of the olecranon and ulnar diaphyseal fracture using an intramedullary nail was a cosmetically advantageous and safe technique that enabled rehabilitation during the early postoperative period.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Results of 70 consecutive ulnar nightstick fractures

BACKGROUND

Adult isolated ulnar shaft fractures (IUSFs) are uncommon, and treatment remains controversial. The purpose of this study was to compare results of operative (reduction internal fixation (RIF)) and nonoperative treatment (NOT) in patients with IUSF.

MATERIAL AND METHODS

A retrospective case-control analysis was undertaken on patients diagnosed with IUSF between 2002 and 2008 at a Level I teaching trauma center. Clinical outcomes consisted of complications and functional ability.

RESULTS

Seventy patients had a mean age of 44.6 years (18-86) and a body mass index (BMI) of 27.9 (17-47). The mechanism of injury included high-energy injuries (60/70, 85.7%), low-energy falls (8/70, 11.4%), and sports (2/70, 2.9%). Treatment consisted of 33/70 (47.1%) NOT and 37/70 (52.9%) RIF. The AO/OTA fracture classification was 48 A1, 20 B2, and two C1. The level of activity (LOA) was 60 without restrictions, six with restrictions, and three who did not return to work. The function determined by range of motion was 55/70 (78.6%) full, 11 slightly limited, and one severely limited. A total of 14 nonunions (NUs) and 17 malunions (MUs) occurred. NOT was associated with NU (χ(2)=0.001) and MU (χ(2)=0.000), respectively. Fracture angulation ≥8° was related to the inability to return to previous LOA (ρ=0.406, p=0.001). Secondary displacement >2mm contributed to MU (R(2)=0.238, p=0.000) and NU (R(2)=0.076, p=0.021). NU was related to a minor functional result (ρ=0.315, p=0.009).

CONCLUSIONS

IUSF treatment remains challenging in the adult population. Nonoperative treatment of displaced fractures produces a high risk of complications, and the fracture characteristics determine patient outcome.

LEVEL OF EVIDENCE

Level III.

A systematic review of the non-operative treatment of nightstick fractures of the ulna

Most patients with a nightstick fracture of the ulna are treated conservatively. Various techniques of immobilisation or early mobilisation have been studied. We performed a systematic review of all published randomised controlled trials and observational studies that have assessed the outcome of these fractures following above- or below-elbow immobilisation, bracing and early mobilisation. We searched multiple electronic databases, related bibliographies and other studies. We included 27 studies comprising 1629 fractures in the final analysis. The data relating to the time to radiological union and the rates of delayed union and nonunion could be pooled and analysed statistically.

We found that early mobilisation produced the shortest radiological time to union (mean 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures treated with above- or below-elbow immobilisation and braces had longer mean radiological times to union (9.2 weeks, 9.2 weeks and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1% and 0.8%, respectively). There was no statistically significant difference in the rate of non- or delayed union between those treated by early mobilisation and the three forms of immobilisation (p = 0.142 to p = 1.000, respectively). All the studies had significant biases, but until a robust randomised controlled trial is undertaken the best advice for the treatment of undisplaced or partially displaced nightstick fractures appears to be early mobilisation, with a removable forearm support for comfort as required.

Cite this article: Bone Joint J 2013;95-B:952–9.

Retrospective analysis demonstrates no advantage to operative management of distal ulna fractures

BACKGROUND

Isolated fracture of the distal one third of the ulna (the "nightstick fracture") is a common injury no clear consensus on its optimal management. The purpose of this study is to compare the clinical outcomes of operatively and non-operatively treated distal ulna fractures.

METHODS

Patients treated over a 5-year period at a level I trauma center for distal ulna fracture were identified and medical records were analyzed. Data were collected on demographics, injury mechanism, fracture pattern, type of treatment, estimated time to osseous healing, and complications. Estimated bony healing time was analyzed with the t test, and treatment types were analyzed with the chi-square test.

RESULTS

Forty-seven patients with 48 ulna fractures met inclusion criteria for the study. Mean follow-up was 36 weeks. One third of the group was female and mean patient age was 43 years. Eighteen ulnas were treated operatively. There was not a significant difference in the non-operative and operative groups regarding proportions of patients with angulation greater than 15° or 25% or greater translation. There was no significant difference in time to bony consolidation. The operative group had more complications, but the rate was not significantly different than the non-operative group.

CONCLUSIONS

Isolated distal ulna fractures, including those angulated greater than 15° or translated more than 25%, appear to heal well with non-operative treatment. Operative treatment of closed isolated distal ulna fractures does not appear to confer a treatment advantage when compared to non-operative treatment.

Management of isolated ulnar shaft fractures

Isolated fractures of the ulnar shaft are common forearm injuries. Although seemingly benign, they may be complicated by nonunion, radioulnar synostosis, and loss of motion. Unstable fractures are those that are displaced more than 50 percent, angulated more than 10 degrees, or are located in the proximal third of the ulna. Stable fractures are managed well with forearm bracing. Unstable fractures are reliably treated with open reduction and internal fixation with compression plating.

Isolated and combined fractures of the diaphysis of the radius and ulna

In summary, treatment of diaphyseal fractures requires accurate assessment of the injury to rule out concomitant ligamentous injury at the wrist or the elbow. Minimally displaced ulnar fractures can be managed with bracing. Displaced diaphyseal fractures of the radius and ulna should be plated, usually with 3.5-mm compression plates using AO technique. Complications may still occur but can be minimized if strict attention to technique is followed.

The effects of ulnar axial malalignment on supination and pronation

BACKGROUND

Forearm fractures are common injuries in both adults and children. Despite efforts to obtain anatomical alignment, axial rotational malunions occur, resulting in a decreased range of motion and a poor appearance. The objective of this study was to quantify loss of forearm rotation after simulation of ulnar malunions in supination and pronation.

METHODS

Six fresh-frozen cadaveric upper extremities (mean age at the time of death, 79.4+/-2.8 years) were used to quantify loss of forearm rotation after simulation of axial rotational malunions of the ulna. First, maximum forearm rotation in supination and pronation was measured at torques of 6.8, 13.6, and 20.4 kilograms-centimeter applied with use of a custom jig. Following a midshaft ulnar osteotomy, a custom adjustable internal fixation plate was used to simulate axial rotational malunions of the ulna of 0, 15, 30, and 45 degrees in both directions. Measurements in supination and pronation were then repeated at the prespecified torques. Analysis of variance, with a p value of 0.05, was used for statistical analysis.

RESULTS

In all instances, a decrease in forearm rotation after simulation of the ulnar rotational malunion was accompanied by an increase in rotation in the opposite direction. Supination and pronation were significantly influenced, whereas the total arc of rotation was not affected by ulnar rotational malunion. At a torque of 20.4 kilograms-centimeter, pronation malunions of 15, 30, and 45 degrees resulted in a mean loss of supination (and standard error of the mean) of 5+/-1, 11+/-1, and 20+/-1 degrees, respectively, and supination malunions of 15, 30, and 45 degrees resulted in a mean loss of pronation of 4+/-1, 10+/-2, and 18+/-4 degrees, respectively. The ratio of the simulated rotational malunion to the loss of motion was larger than one.

CONCLUSIONS

Ulnar rotational malunions do not lead to a significant change in the total arc of forearm rotation. Instead, loss of motion in one direction is accompanied by increased motion in the opposite direction. Even with a 45-degree ulnar rotational malunion, forearm rotation decreases no more than 20 degrees.

The treatment of isolated ulnar fractures in adults: a systematic review

The treatment of isolated ulnar fractures remains controversial, with different authors recommending both surgical and non-surgical management. We undertook a systematic review of the current literature in order to assess whether any conclusions can be drawn. A total of 33 series involving 1876 patients were identified as suitable for analysis. Data from these papers were combined by method of treatment. The results of the non-operative treatment of minimally displaced ulnar fractures with a stable configuration were uniformly good. Below elbow plaster cast, functional brace and early mobilisation all produced similar results. An above elbow cast was unnecessarily restrictive. To preserve forearm rotation, widely displaced or unstable fractures are best treated by open reduction and internal fixation. Guidelines based on cadaveric and clinical studies exist to predict fracture stability and the extent of acceptable displacement. However, these have not been verified in clinical studies. Compression plate fixation gave reliable results in these cases. Other methods lacked sufficient published data to be recommended.

Isolated ulnar shaft fractures treated with functional braces

OBJECTIVE

To report the results from functional bracing of isolated ulnar shaft fractures.

DESIGN

Retrospective review.

SETTING

Two university hospitals.

PATIENTS

Isolated ulnar shaft fractures in 444 patients were stabilized in functional braces that permitted full range of motion of all joints.

INTERVENTION

Prefabricated braces that extended from below the elbow to above the wrist were applied within the first week after the initial injury.

OUTCOME MEASURES

Union of the fracture, fracture angulation, and final range of motion of the forearm were evaluated.

RESULTS

Two hundred eighty-seven patients were available for follow-up (65 percent). Union took place in 99 percent of the fractures. Shortening of the ulna averaged 1.1 millimeters (range 0 to 10 millimeters). Final radial angulation averaged 5 degrees (range 0 to 18 degrees). Dorsal angulation averaged 5 degrees (range 0 to 20 degrees). Average loss of pronation was greatest in fractures of the proximal third of the ulna, averaging 12 degrees. Fractures in the distal third averaged a loss of 5 degrees of pronation.

CONCLUSIONS

Functional bracing is a viable therapeutic alternative in the management of isolated ulnar shaft fractures. It is associated with a 99 percent union rate and good to excellent functional results in more than 96 percent of patients.