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| ORIGINAL ARTICLE |
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| Year : 2022 | Volume
: 19
| Issue : 2 | Page : 70-74 |
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Locking compression plate in the management of fracture both bones' forearms: A prospective study
Shameez Muhammed Salim1, S Sujai2, Mohammed Junied3, Ganesh Harikumar4
1 Yenepoya Medical College, Deralakatte, Karnataka, India
2 Department of Orthopedics, MVJ Medical College and Research Hospital, Bengaluru, Karnataka, India
3 Department of Orthopedics, Jyothis Sky Speciality Hospital, Kannur, Kerala, India
4 RMO, Government General Hospital, Kasaragode, Kerala, India
| Date of Submission | 09-Jul-2022 |
| Date of Acceptance | 13-Aug-2022 |
| Date of Web Publication | 09-Feb-2023 |
Correspondence Address:
Shameez Muhammed Salim
Flat 304, Meridiyen Apartments, Yenepoya Medical College, Deralakatte, Karnataka
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/joasis.joasis_27_22
Background: The fractures of both bones' forearms are the most common fractures seen. It can be managed by various methods. Open reduction and internal fixation is the procedure of choice for displaced forearm fractures involving the radius and ulna in adults using a locking compression plate (LCP). The study is undertaken to verify the claims made by the authors of the plate (LCP) and to learn the techniques, functional outcomes, and complications of this method of internal fixation. Objectives: To study the functional outcome of treating diaphyseal fractures in both bones' forearm with LCPs. To study the duration of union with LCP. To study the complications of LCPs. Materials and Methods: It is a prospective study which was carried out from August 2015 to January 2017 at MVJ Medical College and Research Hospital, Bengaluru. In this study period, 30 cases of fractures in both bones of the forearm were treated by open reduction and internal fixation using LCP. Results: In our study, the majority of the patients were male, middle aged, with road traffic accidents being the most common mode of injury, involving the middle third. Transverse or short oblique fractures were the most common. The fractures united in all 30 patients. Excellent or full range of mobility of elbow and wrist joints was present in 25 patients (83%), with 5 (17%) patients having good range of movements. Interpretation and Conclusion: The LCP of forearm fractures produces excellent results, the advantage being early mobilization, and early union but the complication, duration of surgery, and surgical techniques remain unchanged.
Keywords: Locking compression plate, open reduction and internal fixation, shaft of both bones of forearm fractures
How to cite this article:
Salim SM, Sujai S, Junied M, Harikumar G. Locking compression plate in the management of fracture both bones' forearms: A prospective study. J Orthop Assoc South Indian States 2022;19:70-4 |
How to cite this URL:
Salim SM, Sujai S, Junied M, Harikumar G. Locking compression plate in the management of fracture both bones' forearms: A prospective study. J Orthop Assoc South Indian States [serial online] 2022 [cited 2023 Mar 27];19:70-4. Available from: https://www.joasis.org/text.asp?2022/19/2/70/369402 |
| Introduction | |  |
Both bone forearm fractures are commonly encountered in today's industrial era.[1] Restoration of forearm rotation, elbow and wrist motion, and grip strength is facilitated by anatomic reduction and internal fixation of these fractures.[2] A locking compression plate (LCP) is a product of these combinations and is in line with the latest plating techniques, the aim of which is to achieve the smallest surgical incision and to preserve blood supply to the bone and adjacent soft tissues and stability at the fracture site.[3]
The present study includes the treatment of 30 cases of fractures in both bones of the forearm by open reduction and internal fixation with 3.5 mm LCP between August 2015 and January 2017 at MVJ Medical College and Research Hospital, Bengaluru.
Inclusion and exclusion criteria
Inclusion criteria:
- Patients with closed diaphyseal fractures of both bones of the forearm
- Patients above the age of 18 years
- Patients fit for surgery
- Patients with fractures including osteoporotic, segmental, and comminuted fractures.
Exclusion criteria:
- Open fractures of forearm bones
- Patients not willing for surgery
- Patients with neurovascular damage
- Patients are medically unfit for surgery.
On admission of the patient, a careful history was taken from the patient and/or attendants to reveal the mechanism of injury and the severity of the trauma. Then, the patients were assessed clinically to evaluate their general condition and the local injury. In general, the condition of the patient and the vital signs were recorded. The examination was done methodically to rule out fractures at other sites. A local examination of the injured forearm revealed swelling, deformity, and loss of function. Nerve injury was looked for and noted. On palpation, abnormal mobility, crepitus, and shortening of the forearm were noticed and noted. Distal vascularity was of importance and was assessed by radial artery pulsations, capillary filling, pallor, and paresthesia at the fingertips. Radiographs of the radius and ulna, i.e., anteroposterior and lateral views of the forearm (full length), were obtained. The elbow and wrist joints were included in each view. The limb after initial assessment was then immobilized in the above elbow plaster of Paris slab with a sling. The patient was taken for surgery after routine investigations and after obtaining fitness for surgery. The investigations are as follows: hemoglobin %, urine for sugar, fasting blood sugar, blood urea, serum creatinine, HIV, HBSAg, and electrocardiogram.
The fracture radius was approached volar Henry approach. A narrow 3.5 mm LCP was used and a minimum of six cortices were engaged with screw fixation in each fragment. The fracture ulna was approached by a subcutaneous approach. A narrow 3.5 mm LCP was used and a minimum of six cortices were engaged with screw fixation in each fragment.
| Materials and Methods | | |
Preoperative planning
If there is any evidence of compartment syndrome, surgery has to be done as soon as possible. The injured forearm was immobilized in an above-elbow plaster of Paris slab during the preoperative period after the initial assessment. Consent of the patient or relative was taken before the surgery according to the pro forma. An appropriate length of the LCP to be used was assessed with the help of radiographs. A dose of tetanus toxoid and antibiotic was given preoperatively. Preparation of the part was done before the day of surgery. The instruments to be used were checked beforehand and sterilized.
Position
A pneumatic tourniquet is used. The patient was positioned supine on the operation table. Henry's approach – the arm is placed on an arm board with the elbow straight and the forearm in supination.
Type of anesthesia: general anesthesia was used in 20 cases and brachial block in 10 cases.
Incision
Ulnar shaft: parallel and slightly volar to the subcutaneous crest of the ulna.
Radial shaft: volar Henry's approach.
The bone which was stable and less comminuted was fixed first and later the other bone was fixed. Identify the fracture ends, it is freshened and periosteum is not elevated. Fracture ends cleaned. With reduction clamps, the fracture was reduced and held in position and the plate was applied. A plate of at least six holes was chosen and longer plates were used in spiral, segmental, and comminuted fractures. A drill sleeve for the locking screw is fixed in the hole, near the fracture site, and with 2.7 mm drill bit is used to drill both the cortices of the bone are drilled and the sleeve is removed and the screw length is measured with a depth gauge. 3.5 mm locking screws are then inserted, as the locking screws are of self-tapping, tapping of the screw hole is not done. After adaptation of the fragments, a screw hole for axial compression is drilled in the fragment which forms an acute angle near the plate. Here, the load guide is used with the arrow pointing toward the fracture line to be compressed. At this position, a lag screw will be inserted for axial compression. The lag screw is applied by subsequently over-drilling (3.5 mm) the near cortex to create a gliding hole. The lag screw and remaining screws are inserted. Once stable fixation is achieved and hemostasis secured meticulously, the wound is closed in layers.
After treatment
Postoperatively, an arm pouch was given. The patient was instructed to keep the limb elevated and move their fingers and elbow joint. The wound was inspected after 3–4 days postoperatively. Antibiotics and analgesics were given to the patient till the 10th postoperative day when the sutures are removed. Check X-ray in anteroposterior and lateral views were obtained. Later, the patient was discharged after suture removal with the forearm in the arm pouch and advised to perform shoulder, elbow, wrist, and finger movements. Patients were advised not to lift heavy weights or exert the affected forearm.
Follow-up
All the patients were followed up at monthly intervals for the first 3 months and evaluation was done based on “Anderson et al.” scoring system. Elbow movements and wrist movements were noted and the union was assessed radiologically. The fracture was considered to be united when there was the presence of periosteal bridging callus and the trabeculation was extending across the fracture line.
| Results | | |
Age distribution
The age of these patients ranged from 19 to 72 years with fractures being most common in the second and third decades and an average age of 35.1 years.
Sex distribution
Out of 30 patients, 20 (67%) patients were male and 10 (33%) patients were female showing male preponderance due to working in factories, fields, traveling, and sports.]
Preoperative and postoperative X-ray of both bone fracture fore arm-1
Preoperative and postoperative X-ray of both bone fracture fore arm-2
Preoperative and postoperative X-ray of both bone fracture fore arm-3
Side affected
There were 13 (43%) patients with left forearm fractures and 17 (57%) patients with right forearm fractures.
Mode of injury
In our study, there were 23 (76%) patients with road traffic accidents (RTAs), 6 (20%) patients with falls, and only 1 (4%) patient with assault.
Fracture characteristics
All the fractures were closed injuries. The majority of the fractures were seen in the mid-diaphysis of both bones of the forearm. About 20 (67%) patients had mid-diaphysial fractures, 4 (13%) had proximal third fractures, and 6 (20%) patients had a lower third fracture of both bones of the forearm.
Type of the fracture
The majority 75% of the fractures were transverse/short oblique. About 25% of fractures were comminuted.
Statistics of surgery
Twenty of the 30 cases were operated on under general anesthesia, and in the other 10 patients, a brachial block was used. A pneumatic tourniquet was used in all the cases. Follow-up ranged from 5 months to 18 months.
Duration of fracture union
All patients (100%) had a sound union in <6 months, and none of the patients had delayed union or nonunion.
| Criteria for evaluation of results | | |
Using the Anderson et al.[4] scoring system, we had 25 (83%) patients with excellent results and 5 (17%) patients with satisfactory results.
Intraoperative complications
- There were no cases of intraoperative complications.
Postoperative complications
Superficial infection: one patient developed a superficial infection. Infection was controlled with appropriate antibiotics after culture and sensitivity report.
Duration of surgery and tourniquet time
In our study, we noted the duration of surgery for the fixation of both bones' forearms ranged from 60 to 90 min, with an average time of 67.3 min. The tourniquet time ranged from 50 to 80 min, with an average time of 54 min.
| Discussion | | |
Both bone fracture of the forearm presents a formidable challenge to the orthopedicians as the various muscle forces acting on the fracture tend to displace it. Hence, to provide functional rehabilitation of the upper limb, anatomic reduction and rigid fixation are mandatory. This is achieved by open reduction and internal fixation with dynamic compression plates and screws.[5]
The present study was undertaken to determine the efficacy of LCP in the treatment of fractures of both bones of the forearm. A total of 30 patients with fractures of both bones of the forearm were treated with open reduction and internal fixation using 3.5 mm LCP. We evaluated our results and compared them with those obtained by various other studies utilizing different modalities of treatment. Our analysis is as follows
Age distribution
In our study, the fracture was more common in the second and third decades, with an average age of 35.1 years (19–72 years). Our findings are comparable to the study made by Frankle Leung (2003). H. Nevile Burwell and A. D. Charnley in 1964 witnessed 50% of the patients between the second and third decades and an average of 44.8 years.[6] 1n 1972, Herbert S. Dodge and Gerald W. Cady found 24 years as the average age in their series. Moed et al. found the average age was 22 years.[7]
Sex distribution
Our series had male preponderance with 67% male patients and 33% female patients which were comparable to previous studies. H. Dodge in his study noted about 89% of males and 11% of females.[3] Michael Chapman noted about 78% of males and 22% of females.[8] William in his series had 67% of males and 33% of females.[9] Frankie Leung series showed 82.6% of males and 17.4% of females.
Mode of injury
Moed et al., accounted for 50% of his cases in RTA, 20% due to an industrial accident, 14% due to falls, 12% due to a direct blow, and 4% due to gunshot injuries.[8] Grace and Eversmann noted about 29 (45%) patients with automobile or motorcycle accidents, 14 (22%) in falls, 2 (3%) had gunshot wounds and the remainder had other miscellaneous types of injuries.[10] Smith noted about 45% of his cases were due to RTA, 36% were due to falls and 19% were due to industrial accidents.[11] In our series, 76% of cases had RTAs, 20% had falls and 4% had direct blows (assault). Our series is comparable to Moed et al. series.
Extremity affected
H. N. Burwell and A. D. Charnley reported about 50% incidence of fractures in both bones in the right arm.[6] M. W. Chapman reported about 55% incidence of fractures of both bones in the right extremity.[8] We accounted for about 57% incidence of fractures in both bones in the right extremity.
Time of union
Anderson's criteria for the evaluation of the union were taken into account. In our series, we had an average union time of 11.83 weeks with a range of 9–18 weeks. We had 100% union of both radius and ulna.
| Functional results | | |
The range of motion was determined and Anderson et al.'s scoring system was used as a measure for the functional outcome.[4] Anderson et al. reported about 54 (50.9%) cases as excellent, 37 (34.9%) as satisfactory, 12 (11.3%) as unsatisfactory, and 2 (2.9%) as failure.[4] Chapman et al. reported 36 (86%) cases as excellent, 3 (7%) as satisfactory, 1 (2%) as unsatisfactory, and 2 (5%) as failure.[8] Frankie Leung reported 98% of cases as excellent and 2% as satisfactory results.[3] In our series, we had 25 (83%) cases with excellent results and 5 (17%) satisfactory results. Our series had 100% of excellent/satisfactory results which is comparable to the previous studies. We had a follow-up which ranged from 5 months to 24 months with an average mean of 12 months, which is comparable to the Chapman series but other series had longer follow-up The duration of surgery ranged between 60 and 90 min, with an average of 67.3 min. The tourniquet time ranged from 50 to 80 min, with an average of 57.1 min. These findings could not be compared to the previous studies as there was no data available.
| Conclusion | | |
The present study was conducted to assess the functional outcome and complications of LCP plating in fractures of both bones' forearms.
We conclude both bone fractures of the forearm in adults are more common in the second and third decades of life. Males are predominant in the high incidence of fractures due to manual working and outdoor activities. The majority of the fractures were transverse/short oblique in the middle shafts of both bones' forearms and were due to vehicle accidents/falls. The 3.5 mm LCP, if properly applied, is an excellent method for internal fixation of both bone fractures of the forearm. The use of a tourniquet and preservation of the natural curves of the radius, minimal soft-tissue dissection, strict asepsis, and proper rehabilitation will lessen the rate of complications. Both bone fractures of the forearm have to be fixed as early as possible and it is important to achieve anatomical reduction and stable internal fixation for excellent functional outcomes. A minimum of six cortices has to be fixed on each fracture fragment. After LCP fixation, postoperative support, given in the form of an arm pouch in most instances, can be discontinued after the soft tissues have healed and a rapid return to full, painless motion can be anticipated. Most of the fractures united within 12 weeks. LCP plating of both bones' forearms produces excellent results when applied properly. To obtain excellent results, proper preoperative planning, minimal soft-tissue dissection, adherence to AO principles, strict asepsis, proper postoperative rehabilitation, and patient education are mandatory.
Ethical statement
The institutional ethical committee, MVJ Medical College and Research Hospital has approved the study.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
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| 9. | Teipner WA, Mast JW. Internal fixation of forearm diaphyseal fractures: Double plating versus single compression (tension band) plating – A comparative study. Orthop Clin North Am 1980;11:381-91. |
| 10. | Grace TG, Eversmann WW Jr. Forearm fractures: Treatment by rigid fixation with early motion. J Bone Joint Surg Am 1980;62:433-8. |
| 11. | Smith JE. Internal fixation in the treatment of fractures of the shafts of the radius and ulna in adults; the value of delayed operation in the prevention of non-union. J Bone Joint Surg Br 1959;41-B: 122-31. |
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