Comparative study between hybrid fixation and dual plating in the management of both bone forearm fractures involving proximal half of radial shaft in adult patients

Abstract

Background: Both bone forearm fractures in adults are conventionally managed with plate fixation for both radius and ulna. The fractures involving proximal half of radial shaft need extensive muscle dissection, periosteal stripping and carry a risk of posterior interosseous nerve injury. Hybrid fixation for such fractures with titanium elastic nail system (TENs) for radial fixation and standard plating for ulnar fracture is a potentially safer alternative for these fractures. The purpose of this study is to compare the outcomes of the aforementioned hybrid fixation to conventional dual plating for adult both bone forearm fractures involving proximal half of the radial shaft.
Methods: Adult patients with both bone forearm fractures involving proximal half of the radial shaft were randomly divided into a hybrid fixation(A) and dual plating(B) groups over a two-year period. The patients were followed for a minimum of six months and radiological and functional outcomes were compared.
Results: Radiological and functional outcomes between the two groups were comparable with the exception of wrist dorsiflexion which was significantly reduced in the hybrid fixation group. The surgical duration was significantly shorter in hybrid fixation group. Loss of reduction and nail entry point pain were major complications in the hybrid fixation group. Hypertrophic radial scar and transient posterior interosseous nerve palsy were major complications in the dual plating group.
Conclusion: Hybrid fixation using plate osteosynthesis for ulnar fracture and TENs for radial fracture is a valid option for treatment of adult both bone forearm fractures involving the proximal half of radial shaft with a shorter surgical duration and less soft tissue complications when compared to open reduction and plate osteosynthesis for both the fractures.

Full text

Abstract
Original Article Journal of Bone and Joint Diseases| May-Aug 2020 | 35(2): 19-24
Introduction
Forearm sha fractures are among the most commonly
observed fractures in orthopedic practice[1]. While multiple
treatment options have been advocated for these fractures in
pediatric patients with surgical treatment being preferred in
older children, the treatment of most of the adult forearm
fractures is surgical[2]. A variety of surgical options have been
explored for the treatment of these injuries in older children
and adults. Intramedullary elastic nai ling and plate
osteosynthesis have been the commonly used modalities for
the treatment of forearm fractures in older children and adults,
respectively[3,4,13,14]. e least explored option of hybrid
xation with one of the two fractured bones being treated with
plate osteosynthesis and other with an intramedullary device
in adult patients has been analyzed in very few studies[5,6,7].
ese few studies have reported good radiological and
functional outcomes with hybrid xation. However, a larger
volume of evidence is still needed to establish the equivalence
between hybrid xation and standard plating methods for the
treatment of both bone forearm fractures in adults.
For forearm fractures with involvement of proximal half of the
radial sha, the plating methods require careful dissection
around the posterior interosseous nerve and can potentially
injure the same because of its variable location[8]. Moreover,
the muscular bulk in the proximal forearm requires extensive
exposure and periosteal stripping which may lead to muscle
necrosi s, so  tissue injur y a nd even compartment
syndrome[4-7]. e closed elastic intramedullary nailing for
these fractures has been successfully used in young and older
children with functional outcomes comparable to plating
methods[9]. ese are associated with reduced periosteal and
so tissue damage and do not hinder the process of natural
fracture healing. e fracture healing occurs on the principles
of relative stability and additional protection to the fracture
can be provided by a long-arm cast or splint. However, there is
paucity in literature regarding the use of hybrid xation in
adult both bone forearm fractures[10]. We aempted to
explore the outcomes of hybrid xation with titanium elastic
nail system (TENs) for radial sha fractures and standard
plating ( compression or bridge mode ) for ulnar fractures in
adult both bone forearm fractures involving proximal half of
¹Department of Orthopedics, Hamdard Institute of Medical Sciences and Research,
New Delhi, India.
²Department of Orthopedics, Lady Hardinge Medical College, New Delhi, India.
Address of Correspondence:
Dr. Javed Jameel,
Hamdard Institute of Medical Sciences and Research, New Delhi, India
E-mail: javedjameel@gmail.com
Background: Both bone forearm fractures in adults are conventionally managed with plate xation for both radius and ulna. e
fractures involving proximal half of radial sha need extensive muscle dissection, periosteal stripping and carry a risk of posterior
interosseous nerve injury. Hybrid xation for such fractures with titanium elastic nail system ( TENs) for radial xation and standard
plating for ulnar fracture is a potentially safer alternative for these fractures. e purpose of this study is to compare the outcomes of
the aforementioned hybrid xation to conventional dual plating for adult both bone forearm fractures involving proximal half of the
radial sha.
Methods: Adult patients with both bone forearm fractures involving proximal half of the radial sha were randomly divided into a
hybrid xation(A) and dual plating(B) groups over a two-year period. e patients were followed for a minimum of six months and
radiological and functional outcomes were compared.
Results: Radiological and functional outcomes between the two groups were comparable with the exception of wrist dorsiexion
which was signicantly reduced in the hybrid xation group. e surgical duration was signicantly shorter in hybrid xation group.
Loss of reduction and nail entry point pain were major complications in the hybrid xation group. Hypertrophic radial scar and
transient posterior interosseous nerve palsy were major complications in the dual plating group.
Conclusion: Hybrid xation using plate osteosynthesis for ulnar fracture and TENs for radial fracture is a valid option for treatment of
adult both bone forearm fractures involving the proximal half of radial sha with a shorter surgical duration and less so tissue
complications when compared to open reduction and plate osteosynthesis for both the fractures.
Keywords: Adult fractures; hybrid xation; forearm fractures; plate xation; proximal radius
Arvind Kumar¹, Rizwan Khan¹, Dushyant Chouhan², Rajesh Arora¹, Sandeep Kumar¹, Javed Jameel¹
Comparative study between hybrid xation and dual plating in the management
of both bone forearm fractures involving proximal half of radial sha in adult
patients
19 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 19-24
© 2020 by Journal of Bone and Joint Diseases | Available on www.jbjdonline.com | doi- 10.13107/jbjd.2020.v35i02.016
is is an Open Access article distributed under the terms of the Creative Commons Aribution Non-Commercial License (hp://
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whic h permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

the radial sha and compared the radiological and functional
outcomes with a control group that was treated with standard
plating for both the fractures.
Materials and methods
e study was conducted in a tertiary care center aer
obtaining the clearance from the institutional ethical
commiee. e study was a prospective one conducted over a
two year period between June 2017 to June 2019 and the
enrolled and patients were followed for a minimum period of 6
months aer surgery. Adults with both bone forearm fractures
with involvement of proximal half of the radial sha were
included. Only those cases that were planned for denitive
internal xation were enrolled. Open fractures, delayed
presentatio n of more than 3 week s, fractures wit h
neurovascular injuries, pathological fractures, cases with signs
of old bony injury on the affected forearm, associated wrist or
elbow joint injuries and patients with a known history of
smoking or tobacco consumption and metabolic disorders
were excluded. e enrolled patients were randomized
(permuted block randomization method) into two groups,
gro up A tha t u nd er wen t h yb ri d xati on with an
intramedullary xation using titanium elastic nail system
(TENs) for radial sha fracture and standard plating for ulnar
sha fracture, and group B which underwent standard plating
for both radial and ulnar sha fractures. All the surgeries were
performed by the senior authors who had an experience of
more than 10 years in upper limb trauma. Radiological and
functional assessments were made by the non-operating
authors.
Surgical procedure:
All surgeries were performed under tourniquet control, either
in general or regional anesthesia or both. In Group A, the ulnar
sha fracture was xed using a 3.5mm locking compression
plate (LCP) or dynamic compression plate (DCP) and
intramedullary TENs were used for xation of radial sha
fracture. e ulna was approached using the standard
subcutaneous approach with a plane between Flexor Carpi
Ulnaris and Extensor Carpi Ulnaris. e TENs for the radial
sha fracture was inserted in a retrograde manner through an
entry point over the lister tubercle using a small 1-2 cm
incision for exposure. e diameter of the nail was kept
approximately half to two-thirds of the diameter medullary
Kumar A et al www.jbjdonline.com
20 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 19-24
Figure 1: Preoperative (a, b) and six month follow up radiographs (c, d) of an adult both bone fracture
treated with hybrid xation using titanium elastic nail for radial fracture and standard plating for ulnar
fracture showing consolidated union of both the fractures.
Figure 2: Preoperative (a, b) and six month follow up radiographs (c, d) of an adult both bone fracture treated
with standard plating for both radial and ulnar fractures showing consolidated union of both the fractures.
Functionaloutcome Union
Lossoflexion-
extensionatelbow
joint
Lossofsupination-
pronationofaffected
forearm
Excellent Present <10% <25%
Satisfactory Present <20% <50%
Unsatisfactory Present >20% >50%
Failure Notpresent Any Any
Table 1. Criteria for funconal outcomes in the forearm fractures by
Anderson et al.[11]
Function Pointscore
Pain(45points)
None 45
Mild 20
Moderate 15
Severe 10
Motion(20points)
100degreesarc 20
50-100degreesarc 15
Lessthan50degreesarc 5
Instability(10points)
Stable 10
Moderateinstability 5
Grossinstability 0
Dailyfunction(25points)
Combinghair 5
Feedingoneself 5
Hygiene 5
Puttingonshirt 5
Puttingonshoes 5
Table 2: Mayo elbow performance score.[12]

canal at the isthmus of the radius. e nail was inserted up to
the terminal extent of the medullary canal under uoroscopic
control. e near end of the nail was bent and buried inside the
wo und. All a emp ts were made to pe rform cl osed
intramedullary nailing of the radial fracture. In cases with
failed aempts of closed intramedullary nailing, a small
incision, sufficient enough to expose the fracture was made
over the fracture site in the plane of either Henry’s anterior
approach or ompson’s posterior approach to the radial sha
and an open reduction was performed. In Group B, the radius
sha fracture was approached using either ompson’s
posterior approach or Henry's anterior approach and the ulnar
sha fracture was exposed using a standard subcutaneous
approach. Plating methods depending upon the fracture
paern for xation of both radial and ulnar sha fractures. In
both the groups, the simpler fracture was stabilized rst. In
both ulnar and radial comminuted fractures, the less
comminuted one was xed rst. e surgical duration was
recorded in all cases.
Postoperative care:
All fractures in group A were kept in an above elbow plaster
splint or cast for a period of four weeks postoperatively, while
in group B the fractures were supported by an arm pouch for
two weeks. e patients were discharged on the 2nd or 3rd
postoperative day aer wound inspection with the exception
of cases with clinical suspicion of wound infection. Sutures
were removed at two weeks postoperatively. Range of motion
exercises around elbow, forearm, and wrist were started in
group B as early as from 1st post-operative day, while in group
A, supervised followed by independent elbow exion-
extension and wrist range of motion exercises were started
aer four weeks and the limb was kept supported in a
removable above elbow posterior splint during the rest of the
time until the signs of radiological union were evident.
Supination and pronation exercises were started only aer the
radiological union of both the bones was evident on follow-up
radiographs.
Follow up:
All patients were followed at two weeks postoperatively for
suture removal and to look for early complications. Second
follow up was at four weeks for group A to document radial
sha fracture displacement and for initiation of exercises, and
at six weeks postoperatively for group B for radiological and
functional evaluation. ereaer, the patients in each group
were followed at every six-week interval for radiological and
functional assessment for the next six months and every three
months aer that. However, only six months follow up
assessments for each patient were charted to maintain
uniformity in results.
Radiological assessment -
Standard radiographs were obtained at second follow up and
six weekly thereaer until the fracture was deemed united or
not united based on radiographs. A fracture was considered as
united when bridging bone was formed around the fracture
site with appreciable trabecular or cortical continuity within
four months follow up. Delayed union was present when
radiological signs of bridging bone appeared aer four months
of follow up. Nonunion was dened as the absence of
radiological signs of unions for up to a period of six months.
21 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 19-24
Kumar A et al www.jbjdonline.com
Variable GroupA(Hybridixation) GroupB(Dualplating) Remarks
Number 29 27 Comparable
numbers
Male:femaleratio 20:09 2:01 Similarsexratio
Meanage(inyears) Mean=30.82 Mean=31.33 p=0.857(Non-
signiicant)
SD=10.45 SD=10.37
Meansurgicalduration(inminutes) Mean=56.51 Mean=79.70 p<0.005
SD=3.97 5.2 (Signiicant)
Meanforearmsupination(indegrees) Mean=79.72 Mean=78.70 p=0.523
SD=6.69 SD=4.97 (Non-signiicant)
Meanforearmpronation(indegrees) Mean=77.89 Mean=80.70 p=0.060
SD=5.86 SD=4.99 (Non-signiicant)
Meanlossofsupinationpronationarc
(indegrees) Mean=12.43 Mean=11.44 p=0.305
SD=3.00 SD=4.11 (Non-signiicant)
Meanelbowlexion(indegrees) Mean=137.68 Mean=136.96 p=0.527
SD=4.81 SD=4.74 (Non-signiicant)
Meanelbowextension(indegrees) Mean=-3.73 Mean=-1.62 p=0.717
SD=5.99 SD=5.58 (Non-signiicant)
Meanlossofelbowlexion-extension
arc(indegrees) Mean=2.80 Mean=3.73 p=0.531
SD=5.68 SD=5.22 (Non-signiicant)
Meanwristdorsilexion(indegrees) Mean=32.13 Mean=77.81 p<0.005
SD=3.48 SD=4.11 (Signiicant)
Meanwristpalmarlexion(indegrees) Mean=75.48 Mean=75.44 p=0.973
SD=4.21 SD=4.22 (Non-signiicant)
MeanMayoelbowperformancescore
(outof100) Mean=92.24 Mean=90.55 p=0.409
SD=4.13 SD=10.03 (Non-signiicant)
Table 3: Paents profile and funconal outcomes
Variable GroupA(Hybrid
ixation) GroupB(dualplating)
Caseswithdelayedunion 5 2
Caseswithnon-union 0 0
Functionalscoreaccordingto
Andersoncriteria Excellent-26 Excellent-22
Satisfactory-3 Satisfactory-5
Unsatisfactory-0 Unsatisfactory-0
Failure-0 Failure-0
MeanMayoelbowperformance
score(outof100) 92.24 90.55
Complications
Woundinfection 0 4
Fracturedisplacement 5 0
Transientposteriorinterosseous
nervepalsy 0 3
Entrypointpain 5 0
Hypertrophicscar 0 5
Radialfracturesitepain 0 3
Totalcomplications 10 15
Table 4: Radiological assessment, performance scores, and complicaons

Functional assessment -
To maintain uniformity in the assessment of functional
outcomes, the functional assessment was made using the
criteria of Anderson et al.[11]( Table 1) and Mayo elbow
performance score[12]( Table 2) at six months follow up
which was also the cut-off limit for marking a fracture as united
or non-united.
Statistical analysis was performed using IBM ® SPSS 22
soware (IBM SPSS Statistics for Windows, Version 22.0.
Armonk, NY: IBM Corp.). e parameters related to
radiological and functional outcomes were compared among
the two groups and differences with a p-value < .05 were
considered signicant.
Results
A total of 61 patients were enrolled in the study, out of which
56 patients ( group A = 29, group B = 27) were available for
assessment at a minimum of six months follow up period.
Male to female ratio was 20:9 in group A and 2:1 in group B.
e mean age was 30.8 years in group A and 31.3 years in
group B. Among the various parameters studied, statistically
signicant differences were noted in relation to two
parameters, rst, the surgical duration which was less for
hybrid xation as compared to the dual plating group, and
second the wrist dorsiexion which was reduced for hybrid
xation group at six months follow up. Detailed results are
presented in Table 3. Union was evident in all the cases by the
end of six months (Figures 1 and 2).
Complications
Delayed union was observed in 5 cases in group A and 2 cases
in group B. As far as the functional outcomes were concerned,
the results were comparable. e complication rate was
slightly higher in group B (dual plating group) (Table 4).
However, the types of complications in the two groups were
different with posterior interosseous nerve palsy, wound
infection and a hypertrophic scar on radial incision site being
noted in group B only. e hypertrophic scar did not affect the
functional capacity of the affected limb. e posterior
interosseous nerve palsy was transient and recovered in all the
affected cases without any intervention. None of the patients
developed any deep infection. All wound infection cases had a
supercial infection which responded well to oral antibiotics
without any surgical intervention. Fracture site pain was mild
to moderate in intensity and was managed symptomatically
with analgesics when required. e elastic nail entry point
pain was probably related to a prominent nail tip and got
improved in cases that underwent nail removal following the
union.
Discussion
Fractures of forearm sha have classically been treated with
open re du ct io n a nd in ternal xat io n u si ng pl ate
osteosynthesis. Forearm fractures being considered
equivalent to articular fractures need anatomical reduction
and stable xation to permit early mobilization. However, the
problem occurs when the proximal third of the radial sha is
involved. e muscle bulk in this region is more voluminous.
When anterior Henry’s approach is used there is damage to
pronator teres and supinator muscles which are usually
stripped off to gain exposure. is can affect the functional
strength of the forearm. And when posterior ompson’s
approach is used, it carries a risk of injury to the posterior
interosseous nerve. Moreover, frequently, these fractures have
been associated with excessive swelling and performing open
procedures for both the fractures results in increased so
tissue damage and aggravating the swelling. e wound
closure in such cases can be under increased tension and
carries a risk of compartment syndrome and wound
dehiscence. An open procedure for ulnar fracture and a closed
one for the proximal radius sha fracture can effectively
reduce these risks. Closed methods of radius sha xation
include intramedullary solid nail insertion, rush nail insertion,
interlocking nail xation, and titanium elastic nail insertion.
e problem associated with nonlocking intramedullary nails,
especially the square nails is their non-elastic nature which
leads to mismatch with normal radial bowing and thus leading
to loss of reduction[15]. e rush nail is a exible nail and can
take the shape of the radial bow when inserted but does not
car ry a ny inhe rent st ab il ity and fu nc ti on like an
intramedullary spacer. ere is a need for prolonged cast
immobilization and the additional risk of non-union[16].
Interlocking nails need insertion of locking bolts proximally
and distally which again carries the risk of injuring posterior
interosseous nerve proximally and Extensor Pollicis Longus
and supercial radial nerve distally [17]. TENs had been
successfully used for pediatric and adolescent forearm
fractures and helps avoiding the shortcomings related to open
procedures[13,14]. e titanium elastic nail has its own
inherent stability with three-point pressure stabilization
inside the intramedullary cavity which provides relative
stability at the fracture site. e stability gets further
augmented when one of the two bones of the forearm is xed
with plate osteosynthesis. e usual period of immobilization
in such xation is up to four weeks and functional outcomes
do not vary much with fracture displacement[10,18].
e application of TENs for xation of proximal radial sha
fractures has been shown to have favorable functional
outcomes in the past few studies[5,6,7]. Our results support
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23 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 19-24
Kumar A et al www.jbjdonline.com
these results and indicate several advantages of TENs nailing
over open xation with plates. e procedure is so tissue
friendly, avoids the risk of muscle and nerve damage and
signicantly reduces surgical time. e only functional
limitation observed in our results is related to the limited
dorsiexion of the wrist because of the protruding end of the
nail. e same can be corrected aer removal of the implant
once a consolidated union at fracture has been obtained. e
complications related to TENs nailing were very few and far
simple compared to the dual plating group. Five patients had
entry site pain which was probably related to the prominent
end of the nail and ve patients had fracture site displacement.
Although the union was delayed in 5 cases in the hybrid
xation group, none of the patients developed non-union. e
complications related to wound infection, hypertrophic scar
and posterior interosseous nerve palsy were observed in the
dual plating group. ese complications might not affect the
long term outcomes but can pose major functional limitations
and psychological burdens to the patient for the short period
of their affection.
e complication of dorsal tendon rupture or irritation,
especially the extensor pollicis longus tendon, has not been
observed in our study. e entry point of titanium elastic nail
was created over lister tubercle under direct vision, thus
avoiding injury to surrounding tendons. However, the risk of
delayed tendon rupture could not be assessed owing to the
limited follow up of 6 months. A long term followup would be
needed to comment on the same.
is study compares the outcomes of hybrid xation of
forearm fractures involving the proximal half of radius sha
with dual plate xation in similar fractures. e functional
outcomes were found to be comparable in both these groups.
e complications were fewer with hybrid xation group.
Conclusion
Hybrid xation using plate osteosynthesis for ulnar fracture
and TENs for radial fracture is a valid option for treatment of
adult both bone forearm fractures involving the proximal half
of radial sha with a shorter surgical duration and less so
tissue complications when compared to open reduction and
plate osteosynthesis for both the fractures.
Clinical relevance
Hybrid xation of adult both bone forearm fractures involving
proximal half of radial sha, using plate xation for ulnar sha
fracture and TENs for radial sha fracture, is a potential
alternative to conventional plating with comparable
functional and radiological outcomes and a lesser risk of
complications.
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Kumar A et al www.jbjdonline.com
24 | | | | | Journal of Bone and Joint Diseases Volume 35 Issue 2 May-Aug 2020 Page 19-24
Conict of Interest: Nil.
Source of Support: None
How to Cite this Article
Kumar A, Khan R, Chouhan D, Arora R, Kumar S, Jameel J Comparative |
study between hybrid xation and dual plating in the management of both
bone forearm fractures involving proximal half of radial sha in adult patients.
| | Journal of Bone and Joint Diseases May-Aug 2020;35(2):19-24.