Forearm Nailing

Sang Ki Lee

Fractures of the radius and ulna should be stabilized in order to ensure axial and rotational alignment¹ and plate osteosynthesis is the treatment of choice for achieving anatomic reduction and fracture stability and preventing angular deformity or shortening.² An additional advantage of plating is early active motion and use of the injured extremity.² Functional outcomes, in addition to these benefits, have made plate osteosynthesis the procedure of choice for the treatment of both bone forearm fractures. However, although this technique usually results in adequate reduction and satisfactory healing, it has been criticized because of necessary soft tissue dissection and periosteal stripping. The fracture hematoma and blood supply are violated with surgical treatment and may result in bone necrosis and infection.³ Experimental studies⁴, ⁵, ⁶ and ⁷ have shown that marked osteoporosis occurs when a rigid plate is fixed to intact bone. Rhinelander,⁸ Olerud and Danckwardt-Lilliestrom,⁵ and Jacobs et al.⁹ have shown cortical avascularity and an osteolytic process that erodes the necrotic cortical bone in dogs with compression plating. Also, a 2.3% to 4% rate of nonunion,¹⁰,¹¹ a 1.9% to 30.4% rate of refracture,¹², ¹³, ¹⁴ and ¹⁵ and a 0.8% to 2.3% rate of infection¹⁶,¹⁷ have been reported as complications of plate fixation of forearm fractures. In an effort to avoid these problems, intramedullary nailing has been proposed as an alternative method for stabilizing forearm fractures. This technique is commonly used for other long bones, employing the principles of indirect reduction, minimal or no periosteal stripping, smaller incisions and less soft tissue dissection with decreased vascular disruption in hopes of faster fracture healing, decreased infection rate, and less need for bone grafting.³ However, intramedullary nailing has not been widely used for fixation of forearm fractures because of its limited indications, reportedly high rates of nonunion, and need for additional immobilization. Recently, good results were reported following the treatment of forearm fractures in adults with forearm intramedullary (IM) nail.¹⁸,¹⁹

INDICATIONS

The indications for intramedullary nailing of both bone forearm fractures are simple diaphyseal fracture; types I, II, or IIIA open fractures; closed fracture with poor overlying skin and severe swelling; a segmental fracture; or a single bone forearm fracture. This technique should be avoided in active infection, Monteggia fractures, Galeazzi fractures, comminution and length-unstable fractures, patients who are unable to tolerate longer duration of immobilization and require early rehabilitation, open physes, and a medullary canal smaller than 3 mm. Relative contraindications include patients with osteoporosis.

PATIENT POSITIONING

Supine positioning is most useful for intramedullary nailing of forearm fractures. Both a traction device and a radiolucent table may be required to aid in reduction and evaluation. The affected arm may be placed over the patient’s torso. Alternatively, lateral positioning may be used for isolated ulnar nailing.

For accessing the starting point for ulnar fractures, 90 degrees of elbow flexion, 90 degrees of shoulder external rotation, and forearm neutral position are necessary. Elbow extension
also should be possible. Elevate the bed and place a padded bolster under the patient’s forearm. The image intensifier should come from patient’s lateral side.

For radial nailing, the forearm is pronated to allow for an entry point in distal end of the radius. The image intensifier should come from cephalad.

SURGICAL APPROACHES

The first step in forearm nailing is preoperative planning. Verify radiographically the diameter of the medullary canal of the injured bone(s). Choose a diameter nail that will be able to be inserted with minimal reaming, to minimize the risk of incarceration during insertion. Estimate screw length for reference during the procedure. It may be necessary to template the normal forearm to more accurately estimate the length.

Ulna

To expose the implant entry point, a longitudinal 1-cm long incision is made at the tip of the olecranon. Dissection is carried down sharply through the subcutaneous tissues and the triceps tendon. Care should be taken to avoid the ulnar nerve, which sits medial to the olecranon. Establish the implant insertion point by using the awl to perforate the cortex (Fig. 4.1). Multiplanar fluoroscopy is helpful when verifying proper entry point. The cannula may be used in conjunction with the awl to protect the soft tissues. Start the awl in the center of the olecranon process, directly in line with the proximal intramedullary canal of the ulna.

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