Management of forearm nonunions: current concepts

Abstract

Forearm nonunions are uncommon but severely disabling and challenging to treat. Multiple factors have been associated with the establishment of forearm nonunions such as fracture location and complexity, patient characteristics and surgical technique. Treatment of diaphyseal forearm nonunions differs from that of other type of diaphyseal nonunions because of the intimate relationship between the radius and ulna and their reciprocal movement. There is a wide variation of surgical techniques, and the optimal choice of management remains subject to debate. In this review, we aim to summarize the available evidence in the literature on forearm nonunions and combine it with practical recommendations based on our clinical experience to help guide the management of this complex problem.

Fig. 1

AP and lateral radiograph showing a nonunion after plate fixation of a Monteggia fracture. The plate is not on the tension (=dorsal) side but rather on the medial side. The apex posterior deformity recurred with subluxation of the radial head

Fig. 2

a Plain film could not clearly explain symptoms of pain and limited motion after radial head resection and plating of a Monteggia injury; b The CT-scan provided much more insight showing a nonunion of the proximal ulna and subluxation of the ulno-humeral joint. Case courtesy Peter Kloen (Source: Marti and Kloen [26])

Fig. 3

Nonunion after internal fixation of a posterior Monteggia fracture dislocation. a, b Loosening of the plate and screws and instability; c, d After hardware removal, debridement, a posterior plate is contoured to cradle the proximal ulna; e Using the femoral distractor alignment was obtained; f Final appearance intra-operatively after plating and bone grafting; g Postoperative radiograph. Case courtesy Jesse B. Jupiter (Source: Marti and Kloen [26]) (Copyright owned by David Ring, MD, PhD)

Fig. 4

If good bone contact is present, compression of the nonunion and orthogonal screw position will suffice (patient also shown in Fig. 2)

Fig. 5

A persistent nonunion of the radial neck can be relatively asymptomatic. a–c Patient sustained an ulna shaft refracture after plate ulna removal from a previous Monteggia injury. He chose refixation of the ulna and only partial removal of the radial fixation; d–g: He has no complaints and almost full range of motion. Case courtesy Peter Kloen (Source: Marti and Kloen [26])

Fig. 6

Nonunion of the radial neck treated with revision ORIF (2.7 mm T-plate) and autologous bone grafting. Case courtesy Rene K. Marti (Source: Marti and Kloen [26])

Fig. 7

Technical errors in fixation of fracture and nonunion. a Plate too short; b Lack of rotational control and “biology” by IM fixation without bone graft of an atrophic radial shaft nonunion

Fig. 8

Wide exposure and debridement of a radial shaft nonunion. The intraoperative ex-fix helps alignment and obtaining length

Fig. 9

a A bridging plate and autologous cancellous bone grafting for an atrophic radial shaft nonunion; b Consolidation—with slow remodeling—was seen after 1 year. She had no symptoms and near full ROM

Fig. 10

Bone grafting for diaphyseal forearm nonunion. a For atrophic nonunion, we prefer autologous cancellous bone graft for defects up to 6 cm; b Others have used autologous nonvascularized bone blocks; c hypertrophic nonunion only need compression; d A vascularized bone grafter (or osteoseptocutaneous flap) requires microsurgical expertize with donor-site morbidity

Fig. 11

a, b Ideally use standard AO-techniques using compression, lag screws and relatively high plate/screw ratio

Fig. 12

a, b Plain AP radiograph and CT of a distal radius nonunion. Detail proved by CT facilitates pre-operative planning; c Placement of a tricortical graft allow for some correction of radial length. Intrinsic stability provided by the soft tissue tensioning increased stability in the nonlocking era; d–j Wrist and forearm function at 7 years follow up

Fig. 13

a, b A nonunion after a Gustillo Grade 2 open complex distal ulna and radius fracture was treated with revision ORIF and bone graft of the distal radius (c). The ulna plus deformity was later salvaged with ulna head prosthesis by a plastic surgeon (d)

Fig. 14

a, b A modified DCP was used to stabilize and infected ulna nonunion. Case courtesy Chris van der Werken (Source: Marti and Kloen [26])