Fractures of the radius and ulna in adults: An analysis of factors affecting outcome

Authors in group collected the data for fracture of the shaft of radius and ulna in 80 adult patients. Study Period: 1st October 2014-1st October 2017 The aim of the study was to determine relationship of the subjective, objective and radiographic method of treatment. The type of fractures, both open and closed, grade of communition and other injuries were assessed in patients in term of degree of pain, rotation of forearm and return to the same work following injury and the patients treated with ORIF and plate fixation were having better result in all aspect assessed than closed reduction and plaster cast. Factor most often associated with return to same work after injury are better with ORIF (Open reduction and internal fixation). Longer time for union and higher rate of infection were the only disadvantages of ORIF over closed reduction, otherwise outcomes were same for both the methods. Presence of other injuries often compromise the end result because of more pain , greater forearm rotation loss and decline in return to same work. The satisfaction and work status in assessment of outcome, concept of functional malunion, interpretation of radiographic finding should help in counselling the patient as to economic and functional impact of these injuries. © 2019 Published by Innovative Publication. This is an open access article under the CC BY-NC-ND license (https://creativecommons.org/licenses/by/4.0/)


Introduction
The union with normal anatomical restoration is critical to achieve an optimal outcome for mids haft fractures of radius and ulna in adults because radius moves around ulna in pronation and supination movements. These objectives are achieved by open reduction and plate fixation. In other studies, the outcome measures other than union have received very little attention and the inclusion of fractures of single bone with fractures of both bones (radius and ulna) cannot be compared with. [1][2][3] This study was to determine the relationship of outcome to modality of treatment, type of fractures and presence of associated injuries in adults who sustained fractures of the shafts of both radius and ulna. Measures of outcome investigated were patient satisfaction (amount of pain), rotation of forearm, radiographic findings and work status. 4

Two methods of treatment were utilized
1. Open reduction with plating (ORIF) 2. Closed reduction with square nailing The method of treatment was chosen by surgeon and the type of injury. Minimal displacement of closed fractures were the most frequent indication for closed reduction, and marked comminution was the primary reason for treatment with square nails and plaster. All reductions were performed under IVRA with c-arm machine monitoring. The definitive treatment was ORIF in 40 patients, CRIF in 40 patients. The union was defined as presence of bridging callus across the fracture site and nonunion was identified by the absence of callus within twenty-eight weeks following injury. The standards for alignment of radiographs were based on Sage's study, which defined normal as nine degrees of radial and six degrees of dorsal bowing of the radius and zero degrees in both planes for the ulna. The end result ratings were made on a 14 point scale in four Categories: (a) according the level of pain in the injured limb; (b)by the range of forearm rotation; (c) radiographic criteria of union, synostosis, and malunion; and (d) economic-impact of the injury on the patient's employment status (Table 1).

Economic outcomes
90 percent of patients with closed fractures and 97 percent of those with open fractures returned to the same work after injury. Difference may be because of the fact that nearly all patients with open fractures were treated by ORIF, while many with closed fractures were treated with CRIF. All patients treated with ORIF returned to the same work following injury more frequently than those treated with CR IF. Presence of other injuries had little effect on the ability of patients to return to the same work following injury. Pain affected the patient's ability to return to the same work following injury. The strongest correlation was with the amount of forearm rotation lost.88 percent of patients who did not return to the same work lost at least sixty one degrees of forearm rotation and only 21 percent of patients who returned to the same work lost this much rotation.

Complications
Infection: Infection rate was 9 percent in open fractures and 1.5 percent in closed fractures. Infections were not observed in open fractures treated by immediate ORIF. Infections resolved with surgical debridement and appropriate antibiotic therapy.
Nerve palsy: There were Ten palsies recorded prior to treatment. There were no post op palsy. 5,6 Synostosis: No patient had synostosis

Discussion
Present study deals with 80 cases of midshaft radius ulna fractures. Operavtive methods were compression plating (3.5mm DCP) and interamedullary nailing by square radius ulna nail. Fracture were common in male as well as in females. Right sided forearm is more involved than left. Transverse and oblique fracture were more common than middle third fracture. In this study, mode of injuries were vehicular accident and fall from height. In this comparative study of fractures of radius ulna by plating versus nailing excellent result in plating were 80.6% as comopared to nailing that is 76.2%. In complication superficial infection rate was more common in plating than nailing. None of the patients required implant removal for infection.
One each case of nailing and plating has compound fracture has comminution on admission. Delayed union cases were treated with bone grafting and slab, they finally heal by 6-7 months. Thus complication rate was less in plating (13.33%) as compared to nailing which was (26.66%). After success full closed nailing, soft tissue envelop around the fracture is well preserved with good blood supply to bone ends, because of this biologically fracture healing is rapid in closed nailing. 7 But in open nailing union will be little slow, after plate fixation union will be still more slow due to some soft tissue disturbances. The nail is straight and elastic implant often taking shape of bones, straight nail in the curved canal, but it does not alter bowing of radius 8 and final range of motion. The result was proved at the end of 36 months.

Conclusion
Out of 80 patients, at the end of 36 months end results following treatments of fractures of the shaft of radius and ulna were good to excellent regardless of the method of treatment, except for longer time to unite and high rate of infection, outcomes of open and closed fractures were also similar. Results with ORIF were better than CRIF, as ORIF minimizes malalignment and resulting loss of forearm rotation. 9 The above two factors were related to ability to return to same work following injury. The interpretation of radiological finding was associated with radiological alignment and functional limitation.

Acknowledgement
We are thankful to dept. of orthopaedics for cooperation 6. Source of Funding None.

Conflict of Interest
None.