Nonunions of the Forearm

Fig. 6.1

a, b Anteroposterior (AP) and lateral of nonunion after failed closed treatment. c, d AP and lateral of after repair of nonunion

A 45-year-old, right-hand dominant, day laborer, who was a 2-pack-per-day smoker, sustained a direct blow to his ulnar forearm, resulting in a fracture of the shaft of the ulna. It was decided, in conjunction with the patient, to treat his fracture with nonoperative methods. He subsequently went on to develop an atrophic nonunion. Once nonoperative treatment was exhausted, the patient underwent nonunion takedown, rose-petaling of both fracture ends, reestablishing of the canals, application of a corticocancellous autograft, open reduction and internal fixation with an interfragmentary compression screw, and then the fracture was neutralized with a 3.5 mm locking compression plate The patient stopped smoking as well and went on to heal his nonunion uneventfully.

Case 2 (Fig. 6.2)

Fig. 6.2

a, b Anteroposterior (AP) and lateral after gunshot wound. c, d AP and lateral with established “asymptomatic” nonunion

A 37-year-old, right-hand dominant male sustained a gunshot wound to his ulna. He refused surgical intervention and was treated with closed methods. At his last follow-up, he had 55° of supination and 35° of pronation. He continued to refuse surgical interventions, stating that he had adequate function and eventually was lost to follow-up.

Case 3 (Fig. 6.3)

Fig. 6.3

a, b Anteroposterior (AP) and lateral of delayed presentation of right proximal radius fracture. c, d AP and lateral at 1 year with healed proximal radius fracture despite a delayed presentation

A 63-year-old, left-hand dominant male had end-stage renal disease as a result of poorly controlled diabetes mellitus. He sustained multiple orthopedic and general surgery injuries, including a proximal radius fracture that was identified 4 months after his initial accident. The patient was treated by closed methods for medical reasons and also because the patient refused surgical intervention. He was definitively managed in an orthosis which eventually healed at 12 months after his accident. He was able to obtain 15° of pronation and 40° of supination and had function appropriate for his daily needs.

Case 4 (Fig. 6.4)

Fig. 6.4

a, b Anteroposterior (AP) and lateral after initial plating. Length was re-established. c, d AP and lateral with nonunion of radius and failure of hardware. e, f AP and lateral after repeat osteosynthesis and iliac crest bone graft. g, h AP and lateral after healing of nonunion

A 26-year-old, right-hand dominant male sustained a handgun gunshot wound to the forearm, resulting in a 3-cm bone defect of the radius. Initially, this was plated out to length and not grafted. The fixation ultimately failed, and a nonunion ensued. He also had a significant decline in his forearm rotation, resulting in 25° of supination and 35° of pronation. The patient was taken back to the operating room, a corticocancellous graft was harvested from the patient’s ipsilateral iliac crest, and a repeat osteosynthesis was performed. The patient went on to heal, and his supination improved to 55° and pronation to 50°.

Case 5 (Fig. 6.5)

Fig. 6.5

a, b Anteroposterior (AP) and lateral of initial gunshot wound to right radius. c, d Immediate post-op AP and lateral of revision open reduction internal fixation with vascularized fibular strut and plate. e, f 11-month post-op AP and lateral showing complete healing of nonunion with complete incorporation of vascularized fibula

A 34-year-old, left-hand dominant male sustained a gunshot wound to the radius with a resulting 4-cm bone defect. The patient was treated initially with irrigation and debridement of devitalized bone and soft tissue, application of an antibiotic-impregnated cement spacer, and plate fixation. The patient was lost to follow-up and returned a year later. The construct had ultimately failed and the patient had decreased function with 45° of supination and 55° of pronation. He desired to have repeated surgical treatment and returned to the operating room for a joint intervention with plastic surgery. A vascularized fibula was harvested and then insetted. He subsequently went on to heal successfully with the vascularized fibular graft. His supination improved to 60°, and pronation stayed the same at 55°.

Case 6 (Fig. 6.6)

Fig. 6.6

a, b Anteroposterior (AP) and lateral at initial injury showing obvious soft tissue defect and significant bony injury. c, d AP and lateral showing temporizing external fixation and the significant bone loss from the injury and after debridement. e, f AP and lateral after “bridging” internal fixation of wrist and open reduction internal fixation of radius and ulna. Cement spacer placed in radial defect. g Follow-up radiograph showing development of radioulnar synostosis. (h, i) AP and lateral of subsequent removal of hardware from ulna and Darrach procedure. j, k Final follow-up AP and lateral with healed ulna, stable radius with retained cement and establishment of radioulnar synostosis

A 39-year-old, right-hand dominant sustained multiple traumatic injuries, including lower extremity amputations and open fractures of his right radius and ulna and concomitant massive soft tissue injury to the right forearm. The patient’s forearm fractures were initially treated with a temporary external fixator. Once the patient was stable medically, he returned to the operating room, where the external fixator was removed, the radius was plated out to length, and an antibiotic-impregnated cement spacer was inserted. The definitive plan was to take the patient back to the operating room to remove the cement spacer and insert a corticocancellous graft; however, a radioulnar synostosis began to form. The bridging wrist plate was removed. The patient continued with symptomatic ulna hardware and ulnar-sided wrist pain, necessitating hardware removal from the ulna and a Darrach procedure. At that point, an intra-operative fluoroscopic stress test was performed, which confirmed that the radioulnar synostosis had matured and the decision was made to leave the cement spacer in place as the patient had essentially developed a one-bone forearm.