Comparison of the clinical and radiographic outcomes of plate fixation versus new-generation locked intramedullary nail in the management of adult forearm diaphyseal fractures

Abstract

Objective:
This study aimed to compare functional and radiographical outcomes following intramedullary nailing (IMN) versus plate and screw osteosynthesis in managing patients with diaphyseal forearm fractures.

Methods:
Forty-six patients (27 male, 19 female) were included in this retrospective study. Of these, 25 were treated with plate osteosynthesis and 21 with IMN. The mean age was 32.4 (range, 19-67) years in the plate group and 28.8 (range, 18-64) years in the IMN group. The mean follow-up was 22.3 (range, 12-36) months in the IMN group and 24.8 (range, 12-48) months in the plate group. Functional outcomes were evaluated based on the forearm pronation/supination range of motion, grip strength, Disabilities of the Arm, Shoulder, and Hand (DASH) score, and Grace-Eversmann scoring criteria.

Results:
The median time to union was 13.6 weeks in the plate group and 10.9 weeks in the IMN group (p<0.05). Union was achieved in 24 of 25 patients in the plate group (96%) and all patients in the IMN group (100%). The mean operative time was 69.7 (range, 45-110) minutes in the IMN group and 88.2 (range, 50-130) minutes in the plate group. The mean fluoroscopy time was 2.7 seconds in the plate group and 21.3 seconds in the IMN group. The mean length of hospital stay was five (range, 3-9) days in the plate group and four (range, 3-10) days in the IMN group. The mean operative time was significantly shorter in the IMN group (p < 0.05), while the mean fluoroscopy time was longer in the IMN group (p < 0.05). There was no significant difference between the groups in forearm pronation and supination, grip strength, DASH score, and Grace-Eversmann scoring criteria.

Conclusion:
Locked IMNs seem a viable alternative to ORIF with plate osteosynthesis for adult diaphyseal forearm fractures with similar healing rates, functional scores, and shorter operative times.

Level of evidence:
Level III, Therapeutic Study.

Full text

ACTA ORTHOPAEDICA et TRAUMATOLOGICA TURCICA
www.aott.org.tr
321
ABS TR ACT
Objective: This study aimed to compare funct ional and radiographical outcomes following intramedullary nailing (IMN) versus plate and
screw osteosynthesis in managing patients wit h diaphyseal forearm fractures.
Methods: Forty-six patients (27 male, 19 female) were included in this retrospect ive study. Of these, 25 were treated with plate osteosyn-
thesis and 21 with IMN. The mean age was 32.4 (range, 19–67) years in the plate group and 28.8 (range, 18–64) years in the IMN group.
The mean follow-up was 22.3 (range, 12–36) months in the IMN group and 24.8 (range, 12–48) months in the plate group. Functional
outcomes were evaluated based on the forearm pronation/supination range of motion, grip strength, Disabilit ies of the Arm, Shoulder,
and Hand (DASH) score, and Grace-Eversmann scoring criteria.
Results: The median time to union was 13.6 weeks in the plate group and 10.9 weeks in the IMN group (p<0.05). Union was achieved in
24 of 25 patients in the plate group (96%) and all patients in the IMN group (100%). The mean operative time was 69.7 (range, 45–110)
minutes in the IMN group and 88.2 (range, 50–130) minutes in the plate group. The mean fluoroscopy time was 2.7 seconds in the plate
group and 21.3 seconds in the IMN group. The mean length of hospital stay was five (range, 3–9) days in the plate group and four (range,
3–10) days in the IMN group. The mean operative time was significantly shorter in the IMN group (p < 0.05), while the mean fluoroscopy
time was longer in the IMN group (p < 0.05). There was no significant difference bet ween the groups in forearm pronation and supination,
grip strength, DASH score, and Grace-Eversmann scoring criteria.
Conclusion: Locked IMNs seem a viable alternative to OR IF with plate osteosynthesis for adult diaphyseal forearm fractures with similar
healing rates, functional scores, and shorter operative times.
Level of Evidence: Level III, Therapeutic Study
Introduction
Forearm fractures are common in young adults
after direct trauma, such as traffic accidents, falls
from height, and sports activities. The kinematics
between the proximal radioulnar joint, forearm, and
distal radioulnar joint is critical in hand placement
in 3-dimensional space and load transfer along the
upper extremity.1 The proximal radius and distal ulna
form an axis around which the forearm rotates.2,3
Because of the functional and anatomical character-
istics of the forearm bones, diaphyseal fractures of
the forearm should be considered as intra-articular
fractures.4,5 Surgical interventions are performed to
restore anatomic alignment and preserve the function
of the forearm complex.
Plaster casting, osteosynthesis with a plate, intramed-
ullary K-wire, and intramedullary locking nails are
used to treat forearm fractures in adults. The plas-
ter cast is used only in rare cases.6-8 The main chal-
lenge in the surgical treatment of forearm fractures is
achieving uniform axial and rotational reduction and
fixation. The axial angle should be <10° to attain sat-
isfactory results.6
Open reduction and internal fixation (ORIF) with
plate osteosynthesis is generally accepted as the
standard treatment method for diaphyseal forearm
fractures in adults. This method provides adequate
reduction, high union rates, and satisfactory func-
tional results. However, ORIF with plate osteosynthe-
sis has many disadvantages. Problems such as large
skin incisions, impaired blood supply, risk of soft tis-
sue and periosteal injury, interruption of periosteal
circulation due to the contact pressure of the plate,
skin irritation from the implants, refracture after
plate removal, and drainage of the fracture hematoma
can lead to delayed union, nonunion, and infection.7-11
In 1913, a study on fracture fixation with K-wires and
Steinmann nails (first generation) was conducted.
However, it showed high nonunion rates due to rota-
tional instability.12 Nails (second generation) adapted
to the forearm anatomy were introduced by Sage in
1959.13 The second-generation nails did not have a
locking mechanism or compression function, and
union with plate fixation could not be performed
because they did not provide rotational stability.14
For this reason, intramedullary nails (IMNs) have not
been used in the treatment of forearm fractures for
many years.
Polat and Toy.
Plate fixation versus new-generation locked intramedullary nail
Research Article
Comparison of the clinical and radiographic outcomes of plate fixation versus
new-generation locked intramedullary nail in the management of adult forearm
diaphyseal fractures
Oktay Polat1, Serdar Toy2
1Clinic of Orthopedics and Traumatology, Sultanbeyli State Hospital, İstanbul, Turkey
2Clinic of Orthopedics and Traumatology, Basakşehir Çam and Sakura City Hospital, İstanbul, Turkey
Corresponding author:
Se rda r Toy
serda rtoy7 37@gm ail.c om
Cite th is article as: Polat O, Toy S. Comparison of the cl inical and ra diogr aphic outcome s of plate fi xation ve rsus new-generation l ocked intram edul lary n ail in t he
management of adu lt forearm di aphyseal fra ctur es. Acta Orthop Traumato l Turc. 2022;56(5):321-326.
5
56
DOI: 10.5152/j.aott.2022.21190
ARTICLE IN FO
Article history:
Submitted May 8, 2021
Received in revised form
March12, 2022
Last revision received
September4, 2022
Accepted October 2, 2022
Publication Date October 19, 2022
Keywords:
Forearm
Internal fixation
Intramedullary nail
Open reduction
ORCID iDs of the authors:
O.P. 0000-0001-7130-2434;
S.T. 0000-0001-8074-4672.
Content of this journal is licensed
under a Creative Commons
Attribution-NonCommercial 4.0
International License.

Polat and Toy. / Acta Orthop Traumatol Turc 2022; 56(5): 321-326
322
Recently, IMNs with locking and compression functions have
become available for the treatment of diaphyseal forearm fractures.
This method offers shorter operative time, less dissection of soft tis-
sues, better cosmetic appearance, satisfactory functional results,
higher union rates similar to ORIF, and lower fracture risk.15-19 We
believe that the new-generation intramedullary locking nail could
be used as an alternative fixation method to plate osteosynthesis in
thetreatment of forearm fractures.
This study retrospectively evaluated patients who underwent ORIF
with plate osteosynthesis and IMN for diaphyseal forearm fractures
and compared the radiologic and functional outcomes and patient
satisfaction of these 2 methods.
Materials and Methods
Patients who underwent ORIF with plate osteosynthesis and IMNs
for diaphyseal forearm fractures between 2014 and 2018 were
retrospectively evaluated. Written informed consent was obtained
from all patients, and ethics committee approval was obtained
(IRB date/number: November 19, 2018/HNEAH-KAEK 2018/45). This
study conforms to the Strengthening the Reporting of Observational
Studies in Epidemiology criteria.
Patients were included in this study based on the following criteria:
the bony maturation was complete. Fractures were treated while
they were still in the acute phase. Fractures of the radius and ulna
were simultaneously treated. Both radial and ulnar fractures were
treated with either plate and screw osteosynthesis or IMN. Patients
were followed for at least 1 year.
Patients with open epiphysis and additional injuries to the same
limb, isolated diaphyseal forearm single-bone fractures (radius or
ulna only), Monteggia and Galeazzi fractures, pathologic fractures,
proximal and distal metaphyseal fractures, open type 3 fractures, or
head trauma were excluded from the study.
Patient demographics
In this study, 46 patients who met the criteria were included. Of
these, 25 were treated with plate osteosynthesis and 21 with IMNs.
Fractures were categorized according to the Association for Osteo
synth esis/ Ortho pedic Trauma Association classification (AO/OTA).
Radiography of the forearm was performed in the posterior-anterior
(PA) and lateral views upon admission to the emergency department.
Long-arm splints were used in all patients until surgery. Twenty-
nine fractures were closed (63%), and according to the Gustilo and
Anderson classification, 8 patients had open type 1 fractures and
9patients had open type 2 fractures.
Patient preparation
Surgeons selected implants based on their personal preferences
before surgery. Seven different surgeons performed the surgeries;
5surgeons performed plate and screw osteosynthesis and 2 surgeons
applied IMN.
All patients underwent surgery either under general anesthesia or
with an axillary block. All patients received 1 g of intravenous cefazo-
lin 30 minutes preoperatively. Surgeons performed the procedures
using a pneumatic tourniquet with a pressure of 250 mmHg. Surgery
was started in the less-fragmented bone to facilitate reduction and
restore length. Patients with open fractures were transferred to the
operating room for irrigation and debridement on admission. After
debridement, osteosynthesis and primary wound closure were per-
formed. No graft was used in any of the patients.
Surgical technique
In the plate group, surgical treatment for radius and ulna fractures
was performed with separate incisions. Patients in the plate group
underwent surgery with 3.5-mm limited contact dynamic compres-
sion plates (TST Rakor Medical Instruments Industry and Trade
Limited Company, Istanbul, Turkey). For radius, the volar Henry
approach was used for mid and distal diaphyseal fractures, and the
dorsal Thompson approach was used for mid and proximal diaphy-
seal fractures. Ulnar shaft fractures were accessed through an inci-
sion at the subcutaneous margin. Only the area where the plate was
to be inserted was prepared subperiosteally. The soft tissue con-
nections of the fragments were preserved when possible. After the
blood, clots, and soft tissues in the fracture line were removed, reduc-
tion was achieved and then, the plates were inserted. The distal and
proximal parts of the fracture line were fixed with at least 3 screws
(6 cortices). In osteoporotic and comminuted fractures, additional
screws were used. In 7 cases, lag screws were also used (Figure 1).
The tourniquet was opened, hemostasis was achieved, and a drain
was placed. The drain was removed 48 hours postoperatively.
In the IMN group, radial fractures were treated with a single type of
IMN (TST Rakor Medical Instruments Industry and Trade Limited
Company, Istanbul, Turkey). The radial nail, which is coated with a
titanium alloy, is firm, and round and is inserted without reaming.
The radial nail body is parabolic, and the proximal 3 cm has a 10°
angle, while the distal 3 cm has a 15° angle and static locking hole.
Digital radiography in the PA and lateral views was performed preop-
eratively to select appropriate nails. Nail length was calculated by sub-
tracting 2-3 cm from the distance between the radial styloid process
and radial neck. Surgeons used the distance between the 2 cortices at
the narrowest point of the medulla on the PA and lateral radiographs
to calculate nail size. This approach has a 10% margin of error.
A 2-cm incision was made over Lister’s tubercle. The second com-
partment was opened, the extensor carpi radialis longus and bre-
vis tendons were pulled laterally, and an awl was used to provide
vertical access to the radius. The entry point was extended to the
medullary canal with a curved drill bit. A nail of appropriate size
and diameter was advanced proximally with rotational movements
using a nail holder. When the nail tip reached the fracture line, the
nail was advanced intramedullary after closed reduction or, if this
was not possible, a mini-open incision was made. The nail was fixed
to the radius with the final penetrator. A distal locking hole at the
distal end of the nail had a 17° angle in the volar and proximal direc-
tions and was designed for a 2.7-mm locking screw. The drill sleeve
was inserted into the distal hole of the nail, the distal radius was
HIGHLIGHTS
• Open reduction and internal fixation (ORIF) with plates is generally accepted
as the standard treatment for diaphyseal forearm fractures in adults. Newer
intramedullary nails with locking and compression functions may offer an
alternative to ORIF with plates. This study aimed to compare these two fixa-
tion methods.
• The results showed that the operation time and union t ime are shorter in new-
generation distal locking forearm nails however, osteosynthesis wit h the plate
for forearm fractures has less fluoroscopy time.
• This study indicates that especially due to the new-generation distal locking
forearm nails’ ability to allow early movement and mobilization they may be
considered as viable alternatives to open reduct ion and internal fixation for
adult diaphyseal forearm fractures.

Polat and Toy. / Acta Orthop Traumatol Turc 2022; 56(5): 321-326
323
bicortically reamed with a 2.00-mm drill bit, and a locking screw of
appropriate length was inserted.
One type of ulnar nail was used for all patients in t he IMN group (TST
Rakor Medical Instruments Industry and Trade Limited Company).
Digital radiographs were obtained preoperatively at the PA and lat-
eral views to select the appropriate ulnar nail. The length of the ulnar
nail was calculated by subtracting 2 cm from the distance between
the ulnar styloid process and olecranon. The nail diameter was calcu-
lated by measuring the distance between the 2 cortices at the narrow-
est point of the medulla in the PA and lateral radiographs. However,
a 10% margin of error may exist with this method. Ulnar IMNs were
fixed by a non-stretching approach. Distal locking was performed
by inserting 1 or more locking screws into the 8 transverse clefts in
the distal 3 cm portion of the nail; proximal locking was performed
with an external guide t hrough the round, oval, and proximal oblique
holes. A 1.5-2.0 cm incision was made from the olecranon tip at the
elbow at 90° flexion, and a 2 mm Kirchner (K) wire was inserted
into the bone marrow from the olecranon tip. After a 3 cm zone was
drilled over the K-wire with a cannulated drill, nails of appropri-
ate size and diameter were advanced distally with rotation. Closed
reduction or mini-open incisions were used to cross the fracture line.
Distal locking was achieved by inserting 3 mm screws through the
double cortex. Depending on the surgeon’s choice, proximal locking
was performed as static, dynamic, or oblique locking (Figure 2).
Postoperative rehabilitation
Patients were hospitalized for follow-up, pain control, and rehabili-
tation in the early postoperative period. During the postoperative
period, patients did not have regular visits. We examined the dates of
patient’s visits and made assessments accordingly. While all patients
were called in the 2nd and 3rd postoperative weeks, follow-up was
mainly in the 1st, 3rd, and 12th postoperative months.
Active and passive movements of the wrist, elbow, and forearm
were observed on the first day in the IMN group. The reason for
the early onset of motion in patients undergoing IMN was that sur-
geons emphasized stability. Elbow, forearm, and wrist motions were
observed in the plate group after applying a cast above the elbow
with 90° flexion of the elbow and neutral rotation of the forearm for
2-3 weeks. Surgeons who performed osteosynthesis with plates and
screws used a cast after surgery in all patients.
During the follow-up, fracture union was assessed by pain sensation
in the fracture line and union in 3 of 4 cortices on AP and lateral
radiographs.20-27 At 6 months, the absence of union in 3 of 4 corti-
ces on AP and lateral radiographs was considered as nonunion.28,29
Functional outcomes were evaluated using the Grace–Eversmann
scoring system and the Disabilities of the Arm, Shoulder, and Hand
(DASH) questionnaire. Forearm rotation was measured using a
goniometer while the elbow was flexed at 90°. Grip strength was
Figure1. A-D. Preoperative posterior-anterior and lateral radiographs of a 56-year-old male with a right diaphyseal forearm fracture (A, B); postoperative posterior-anterior
and lateral radiographs at 12 months (C, D).
Figure2. A-D. Preoperative posterior-anterior and lateral radiographs of a 49-year-old male with right diaphyseal forearm fracture (A, B); postoperative posterior-anterior
and lateral radiographs of 12 months (C, D).

Polat and Toy. / Acta Orthop Traumatol Turc 2022; 56(5): 321-326
324
measured using a Saehan hydraulic hand dynamometer. Intermittent
measurements were performed 3 times while the patient was in the
following positions: sitting position, shoulder adducted position,
elbow flexed at 90° position, and neutral position of the forearm and
wrist. Then, the average values were obtained.
Statistical analysis
Power analysis was performed using G*Power (G*Power version
3.1.9.4; University of Kiel, Kiel, Germany) for the Mann–Whitney
Utest with an alpha of 0.05, power of 80%, and sample size of 46,
resulting in detectable effect size of 0.8 (large effect).30
International Business Machines Statistical Package for the Social
Sciences Statistics 22 (IBM SPSS Corp., Armonk, NY, USA) was
used to analyze the results obtained in this study. The normality of
parameter distributions was assessed using the Shapiro–Wilk test.
The Mann–Whitney U test and Student’s t-test were used to com-
pare parameters between the 2 groups. Wilcoxon signed-rank tests
were used for within-group comparisons of nonnormally distributed
parameters. Pearson’s chi-square test, Fisher’s exact test, Fishe r–Fre
eman– Halto n test, and Yates correction for continuity were used to
compare qualitative data. Significance was assessed at a P-value <.05.
Results
Of 46 patients, 27 (58.7%) were men and 19 (41.3%) were women.
The mean age of the plate group was 32.4 (range, 19-67) years and
that of the IMN group was 28.8 (range, 18-64) years. The right diaph-
yseal forearm was affected in 23 patients and the left side in 23
patients. The dominant side was affected in 23 (50.0%) patients. No
patient had bilateral forearm fractures. The injury was caused by an
assault in 2 patients, traffic accident in 6 patients, work accident in
8 patients, sports in 8 patients, and fall in 22 patients. The fractures
were classified according to the AO/OTA classification: 20 were type
A (simple, 43.5%), 18 were type B (wedge-shaped, 39.1%), and 8 were
type C (complex, 17.4%). A detailed analysis of the 2 groups is pre-
sented in Table 1.
The mean length of hospital stay was 5 (range, 3-9) days in the plate
group and 4 (range, 3-10) days in the IMN group. The mean follow-
up duration was 22.3 (range, 12-36) months in the IMN group and
24.8 (range, 12-48) months in the plate group. Surgery was performed
within a mean of 3.8 (range, 1-10) days; this duration was 3.6 (range,
1-9) days in the IMN group and 4.1 (range, 1-10) days in the plate
group. The mean operative time was 69.7 (range, 45-110) minutes in
the IMN group and 88.2 (range, 50-130) minutes in the plate group.
The mean fluoroscopy time was 21.3 seconds in the IMN group and
2.7 seconds in the plate group. The mean operative time was signifi-
cantly shorter in the IMN g roup (P < .05), while the mean fluoroscopy
time was longer in the IMN group (P < .05).
The mean union time was 10.9 weeks in the IMN group and
13.2 weeks in the plate group. The difference was statistically sig-
nificant (P < .05). No nonunion was observed in the IMN group, and
union was achieved in 24 of 25 (96%) patients in the plate group. In
patients in the plate group in whom union could not be achieved by
postoperative month 12, autografts from the iliac wing and longer
plates were used; union was achieved at an additional 4 months after
revision surgery.
In the plate group, loss of extension of the elbow to 20° relative to the
other limb was observed in 1 patient, but no specific intervention was
performed to correct this problem. In all other patients, t he full range
of motion of the wrist and elbow was preserved. The differences
between the groups in terms of DASH score, Grace–Eversmann crite-
ria, grip strength, and supination and pronation of the forearm were
not statistically significant (P > .05). The summary of the results is
given in Table 2.
Fracture reduct ion was achieved by mini-open incisions in the 7 radius
fractures and 5 ulna fractures in the IMN group. Superficial infections
developed in 3 patients in the plate group, all of whom recovered with
Table 1. Evaluation of parameters between groups
IMN group
(n = 21)
Plate group
(n = 25) P
Mean age
(range)
28.8
(18-64)
32.4
(19-67)
0.465
Sex (n) Male 11 16 0.430
Female 10 9
Trauma mechanism Fall 10 12 0.359
Traffic
accident
4 2
Work
accident
4 4
Sports 3 5
Assault 0 2
Side Right 12 11 0.380
Left 9 14
Fracture classification
(AO/ASIF)
A1 4 1 0.570
A2 4 5
A3 1 5
B1 3 4
B2 4 3
B3 2 2
C1 1 3
C2 1 1
C3 1 1
Dominant extremity (n, %) 12 (57.1%) 11 (44.0%) 0.380
IMN, intramedullary nailing; AO, Association for Osteosynthesis ; ASIF, Association for the Study of Internal
Fixation.
Table 2. Evaluation of results between groups
IMN group Plate group P
Mean surgery waiting time (day)
(range)
3.6
(1-9)
4.1
(1-10)
0.416
Anesthesia type General 9 9 0.639
Axillary block 12 16
Mean operative time (minute)
(range)
69.7
(45-110)
88.2
(50-130)
0.008*
Mean follow-up time (month)
(range)
22.3
(12-36)
24.8
(12-48)
0.535
Mean pronation (degree)
(range)
81.4
(70-90)
80
(60-90)
0.517
Mean supination (degree)
(range)
81.4
(70-90)
79.8
(60-90)
0.521
Mean grip strength (kg) 38.9 39.2 0.991
Mean DASH score
(range)
6.8
(0-15)
8.4
(0-30)
0.689
Grace–Eversmann
evaluation (n)
Excellent 13 17 0.916
Good 8 5
Acceptable 0 2
Nonacceptable 0 1
Open fracture (n) Type 1 5 6 0.857
Type 2 3 3
Fluoroscopy time (second) 21.3 2.7 <0.001*
Mean union time (week) 10.9 13.2 0.028*
*P < .05.
IMN, intramedullary nailing; DASH, Disabilities of t he Arm, Shoulder, and Hand.

Polat and Toy. / Acta Orthop Traumatol Turc 2022; 56(5): 321-326
325
oral antibiotic therapy and local wound care. One patient in the plate
group had deep infection t hat recovered after debridement and 1 week
of parenteral antibiotics. Three patients in the IMN group had super-
ficial infections that completely resolved with oral antibiotic therapy
and local wound care. No deep infection was observed in the IMN
group. In the plate group, pain and implant irritation developed in 3
patients, and implants were removed after an average of 20 (range,
18-24) months. No refracture was observed after implant extraction.
In the IMN group, no implant was removed from any patient. In the
plate group, 1 patient had transient posterior interosseous nerve palsy,
but this was completely resolved without any intervent ion. In the IMN
group, 1 patient had neuropraxia of t he superficial branch of the radial
nerve, which completely resolved without intervention.
Discussion
Surgical treatment is generally accepted for forearm fractures in
adults. Many studies recommend ORIF with plate osteosynthe-
sis.10,31-33 Recently, third-generation IMNs have been introduced.
These nails have locking mechanisms and compression effects and
provide rotational stability.16,18,34-36 In our study, functional and radio-
logic outcomes were similar in the 2 patient groups. However, it was
challenging to ensure anatomic fixation and proper rotation when
using IMN. Prolonged radiation exposure during IMN was also a sig-
nificant obstacle. However, soft tissue damage and less bleeding were
observed with IMN than with ORIF with plate osteosynthesis.
There are few studies on the outcomes of plate osteosynthesis and
third-generation IMN used to treat diaphyseal forearm fractures in
adults. These studies compared the outcomes of 2 different surgical
options for diaphyseal forearm fractures in terms of operative times,
fluoroscopy times, union times, Grace–Eversmann criteria, DASH
scores, and complications.
When the studies in the literature were examined, it was found that
the operative time in patients with forearm fractures was shorter
in the patient groups in which IMN (range, 43-61 minutes) was
applied than in the patient groups in which osteosynthesis with the
plate (range, 63-74 minutes) was used.17,18,35,37 Patients in the IMN
group had a much shorter operative time (69.7 [range, 45-110] min-
utes) than patients in t he plate group (88.2 [range, 50-130] minutes) in
our study. As the incisions were small and the procedure was simple,
the surgery required less time.
In previous studies on adult forearm fractures, the fluoroscopy time
in patients who underwent IMN (1.2-7 minutes) was significantly
longer than that in patients who were treated with plate osteosyn-
thesis (0-2 minutes).14,17,18,35,37,38 In our study, which is consistent with
the literature, fluoroscopy time was significantly longer in patients
who underwent IMN (21.3 seconds) than in patients who underwent
plate osteosynthesis (2.7 seconds). The long fluoroscopy time was the
major disadvantage of using IMNs.
Lee et al17 reported that union was achieved at 10 weeks in the
plate group and 14 weeks in the IMN group. Kose etal37 found that
union was achieved at 12.3 weeks in the plate group and 12 weeks
in the IMN group. Kibar et al18 reported that union was achieved
at 12.2weeks in the plate group and 12.1 weeks in the IMN group.
Cevik etal14 noted that union was achieved at 12.3 weeks in the plate
group and 12.0 weeks in the IMN group. In our study, the mean time
to union in patients undergoing plate osteosynthesis was 13.2 weeks,
whereas the mean time to union in patients treated with IMN was
10.9 weeks. In our study, the mean time to union in patients who
underwent plate osteosynthesis was consistent with those in the lit-
erature, whereas the mean time to union in patients who underwent
IMN was significantly shorter than those in the literature.
In our study, according to the Grace–Eversmann criteria, excellent
results were obtained in 17 patients, good results in 5 patients, mod-
erate results in 2 patients, and an unacceptable result in 1 patient in
the plate group. The mean DASH score of patients who underwent
plate osteosynthesis was 8.4. In the plate group, the mean pronation
angle of patients was 80°, and the mean supination angle was 79.8°.
Based on the Grace–Eversmann criteria, in patients who underwent
IMN surgery, 13 had excellent results and 8 had good results. The
mean DASH score for patients who were treated with IMN was 6.8.
The mean pronation angle of patients in the IMN group was 81.4°,
and the mean supination angle was 81.4°. The results of this study
were consistent with those of previous studies, and there was no
significant difference in functional scores between the 2 groups as
reported in the literature.14,17,34,39
In this study, we used IMNs with elastic and parabolic structures.
These nails provide 3-point stabilization and rotational stabil-
ity, thanks to their distal screws. The radius nail also restores the
curvature of the radius. Fracture compression of up to 7 mm is also
possible with the dynamic locking approach. The ulnar nail also has
a static clamping mechanism. Lee et al17 used the new-generation
forearm nails, which did not have the distal locking mechanism.
Therefore, they could not initiate early mobilization in the patients
they treated postoperatively with IMN and applied a long-arm
splintto these patients for 6 weeks. Many authors had used long-arm
splints to monitor forearm fractures treated with ORIF for a period
after surgery, as we did in our study.8,40 Because the IMN we used
in our study provided distal locking mechanism and increased rota-
tional stability, we encouraged patients to undergo treatment with
IMN to mobilize them early. Thus, our study found that the time to
union was shorter and the functional outcomes were better in our
patients who underwent treatment with IMN than in other studies.
Lee et al34 found that only 1 bone was fractured in 16 patients
(radius in 7 and ulna in 9), and both forearm bones were fractured in
11patients. Gradl etal39 investigated isolated radius fractures in their
study. Saka etal15 investigated 43 patients wit h 59 forearm fractures in
their study. Their study reported that 14 patients had isolated radius
fractures, 17 patients had isolated ulna fractures, and 28 patients
had both radius and ulna fractures. Kose etal37 considered both iso-
lated radius and ulna fractures and fractures of both forearms. Kibar
etal18,35 considered isolated radius and isolated ulna fractures in their
studies. Azboy etal32,33 included isolated radius or isolated ulna frac-
tures in their studies. After reviewing the literature, most studies on
diaphyseal forearm fractures were heterogeneous. The heterogeneity
could affect the results of the studies. Our study included patients
who had both radius and ulna fractures in both patient groups. Thus,
unlike other studies, our study achieved homogeneity in both groups.
Complications such as posterior interosseous nerve injury, infection,
fractures after implant removal, synostosis, tendon rupture, and vas-
cular injury have been reported after forearm fracture surgery.17,34,41-43
In our study, no patient had fractures, tendon damage, and vascular
complications after implant removal surgery.
This study had some limitations. Major limitations were the small
number of patients and retrospective design. Because this was a

Polat and Toy. / Acta Orthop Traumatol Turc 2022; 56(5): 321-326
326
retrospective study, the patient groups did not include equal num-
bers of patients, different surgeons performed the surgeries, and the
number of screws placed and the number of cortices was not uni-
form. Patient follow-up periods were also not standardized. Future
prospective studies performed on more patients in multiple centers
would contribute significantly to the literature.
In conclusion, the mean operative time and mean union time were
shorter in the IMN g roup because of the minimal incision, intact peri-
osteum, and lack of opportunit y to evacuate the hematoma. However,
a significant disadvantage of IMNs was the prolonged use of fluo-
roscopy. Because the interlocking IMNs provided relative stability,
patients could be mobilized early, thus increasing the union rate and
shortening the union time. To the best of our knowledge, this is the
only study that compared the new-generation distal locking forearm
nails in the treatment of forearm double fractures and plate osteo-
synthesis, where only both bone fractures (isolated radius or ulna
fractures) were not taken alone. Thus, locked IMNs are a viable alter-
native to ORIF with plate osteosynthesis for adult diaphyseal fore-
arm fractures with similar union rates, functional scores, and shorter
operative times.
Ethics Committee Approval: Ethical approval (IRB date/No: November 19, 2018/
HNEAH-KAEK 2018/45) was obtained from t he Local Ethical Committee of
Haydarpaşa Numune Training and Research Hospital.
Informed Consent: Written informed consent was obtained from all patients.
Author Contributions : Concept - O.P., S.T.; Design - O.P., S.T.; Supervision - S.T.; Mate-
rials - O.P., S.T.; Data Collection and/or Processing - O.P.; Analysis and/or Interpreta-
tion - S.T.; Literature Review - O.P.; Writing - O.P., S.T.; Critical Review - S.T.
Acknowledgments: The authors thank Birkan Kibar, MD., for his crucial suggestions
and contributions.
Declaration of Interests: The aut hors have no conflicts of interest to declare.
Funding: The authors declared t hat this study has received no financial support.
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