“FUNCTIONAL OUTCOME OF INTRA MEDULLARY TITANIUM

ELASTIC NAILING IN OSTEOPOROTIC DIAPHYSEAL FRACTURE

OF BOTH BONE FOREARM”

DISSERTATION SUBMITTED FOR MS (ORTHOPAEDICS)

MADURAI MEDICAL COLLEGE
MADURAI

REG.NO. 221712107

THE TAMILNADU

Dr.M.G.R. MEDICAL UNIVERSITY

CHENNAI–600032.

MAY 2020
 CERTIFICATE

This is to certify that the work “FUNCTIONAL OUTCOME OF

INTRA MEDULLARY TITANIUM ELASTIC NAILING IN

OSTEOPOROTIC DIAPHYSEAL FRACTURE OF BOTH BONE

FOREARM” which is being submitted for M.S. Orthopaedics, is a bonafide

work of DR.N.SATHIYA PRAKASH, Post Graduate Student at

Department of Orthopaedics, Madurai Medical College

The Dean,

Madurai Medical College

Madurai.
 CERTIFICATE

This is to certify that this dissertation “FUNCTIONAL OUTCOME

OF INTRA MEDULLARY TITANIUM ELASTIC NAILING IN

OSTEOPOROTIC DIAPHYSEAL FRACTURE OF BOTH BONE

FOREARM” is the bonafide work done by DR.N.SATHIYA PRAKASH

under my direct guidance and supervision in the Department of Orthopaedic

Surgery, Madurai Medical College, Madurai-20.

Prof.Dr.R.ARIVASAN, M.S Ortho.D.Ortho ,

Professor and Head,
Department of Orthopaedics & Traumatology
Madurai Medical College,
Madurai
 CERTIFICATE

This is to certify that this dissertation “FUNCTIONAL OUTCOME

OF INTRA MEDULLARY TITANIUM ELASTIC NAILING IN

OSTEOPOROTIC DIAPHYSEAL FRACTURE OF BOTH BONE

FOREARM” is the bonafide work done by DR.N.SATHIYA PRAKASH

under my direct guidance and supervision in the Department of Orthopaedic

Surgery, Madurai Medical College, Madurai-20.

Prof. DR.B.SIVAKUMAR, M.S Ortho.,

Professor and Chief of spine unit
Department of Orthopaedics & Traumatology
Madurai Medical College,
Madurai.
 ACKNOWLEDGEMENT

At the very outset I would like to thank . Dr.J.SANGUMANI M.D,

the Dean, Madurai Medical College and Govt. Rajaji Hospital, Madurai for

permitting me to carry out this study in this hospital.

I am greatly indebted and thankful to my beloved chief, and my

guide Prof.DR.B.SIVAKUMAR M.S.ortho ortho-spine unit and

Head of department, Prof.Dr.R.ARIVASN M.S.,Ortho, D.Ortho.,

Ortho-I unit, Department of Orthopaedic Surgery and Traumatology,

Madurai Medical College for his invaluable help, encouragement and

guidance rendered to me in preparing this dissertation.

I am most indebted and take immense pleasure in expressing

my deep sense of gratitude to., Prof.Dr.V.R.GANESAN, M.S., Ortho

D.Ortho, Prof.Dr.N.THANAPPAN, M.S., Ortho.,

Prof.Dr.THIRUMALAIMURUGAN, MS. Ortho., for their easy

accessibility and timely suggestion, which enabled me to bring out this

dissertation. I take immense pleasure to thank my co-guide

Dr.TC.PREMKUMAR M.S Ortho, D Ortho., for his timely help and

encouragement.

I also take this opportunity to thank Dr.M.N.Karthi, M.S. Ortho.,

Dr.J.Maheswaran, M.S.Ortho., Dr.T.Saravana Muthu, M.S.Ortho.,

Dr.Premkumar, M.S., Ortho. Dr.V.A.Prabhu, M.S.Ortho.,

Dr. R.Karthick Raja, M.S. Ortho, Dr.SenthilKumar.,M.S.Ortho.,

Dr.Karthikeyan M.S Ortho, Dr.Singaravel M.S.,Ortho,

Dr.Gokulnath, M.S Ortho, Dr.Anbarasan, M.S., Ortho,

DR.Saravanan M.S. Ortho., Assistant Professors, Department of

Orthopaedics, Madurai Medical College, for their timely help and

guidance given to me during all stages of the study.

Last but not the least, I express my gratitude to the patients for their

kind co-operation.
 DECLARATION

I, DR.N.SATHIYA PRAKASH, solemnly declare that the dissertation

titled “FUNCTIONAL OUTCOME OF INTRA MEDULLARY

TITANIUM ELASTIC NAILING IN OSTEOPOROTIC DIAPHYSEAL

FRACTURE OF BOTH BONE FOREARM” has been prepared by me.

This is submitted to “The Tamil Nadu Dr. M.G.R. Medical University,

Chennai, in partial fulfillment of the regulations for the award of M S degree

branch II Orthopaedics.

Place : DR.N.SATHIYA PRAKASH,

Date : Post Graduate in Orthopaedics,

Madurai Medical College,

Madurai.
 CONTENTS

PART A

CONTENTS Page No.

Introduction 1

Epidemiology 3

Review of Literature 4

Anatomy 7

Biomechanics of forearm 20

Classification 22

Mechanism of injury 24

Investigations 25

Principles of management 26

Methods of management 27

Conservative management 28

Surgical management 30

Implant profile & removal 33

Complications 35

Evaluation of outcome 39
 PART -B

CONTENTS Page No.

Aim and Objective 41

Materials & methods 42

Operative procedure 45

Statistical analysis 48

Analysis of functional outcome 61

Case illustrations 64

Observation & Results 71

Discussion 73

Conclusion 75

ANNEXURES :

a. BIBLIOGRAPHY

b. PATIENT PROFORMA

c. CONSENT FORM

d. MASTER CHART

e. ETHICAL COMMITTEE APPROVAL

f. PLAGIARISM FIRST PAGE & DIGITAL RECEIPT

 INTRODUCTION

The forearm plays an important role in positioning of the hand in space

by flexion and extension of the elbow and wrist as well as pronation and

supination through the proximal and distal radioulnar joints. Fractures of the

ulnar and radial shaft can therefore result in significant dysfunction if treated

inadequately.

Motor vehicle accidents account for an important fraction of forearm

shaft fractures. It is estimated that 4% of restrained front seat passengers

involved in a motor vehicle collision suffer a fracture of the upper extremity.

In this setting, forearm fractures account for one quarter of upper extremity

fractures, a fraction that is equal to that of wrist and hand fractures. The goal

of treatment of diaphyseal fractures of both bones of forearm in adults is to

regain length , axial and rotational stability.

Open reduction and internal fixation using plates achieve a high

percentage of union in about 96-98% of cases. However, extensive surgical

exposure and periosteal stripping during open reduction surgery may increase

the risks of neurovascular injuries, soft tissue injuries, intraoperative fractures,

muscle swelling, and even postoperative compartment syndrome. There is a

high chance of secondary fractures or implant failure with plating in

osteoporotic individuals [19]

The locked intramedullary nailing technique offers the advantages of

preventing shortening and rotation in metaphyseal, comminuted, and

segmental diaphyseal forearm fractures. However, CRIF with the radial

1
interlocking nails requires screws which lock at both ends, and there is the

possible risk of PIN injury during the proximal locking procedure and the risk

of extensor pollicis longus and/or superficial radial nerve injuries while

performing distal locking.

Intramedullary nailing with kirschner wires, rush pins and Steinmann

pins have been tried with disappointing results and a high rate of non union

have been reported. To avoid iatrogenic injuries, non-locked intramedullary

nailing treatment for forearm fractures has been tried recently.

Recently intramedullary titanium elastic nails have been tried in elderly

osteoporotic individuals & have been superior compared to plating in elderly

individuals. TENS is the choice of implant in osteoporotic individuals where

plate fixation may lead to secondary fractures or screw pullout. Open plating

have more chance of neurovascular injuries, high risk of infections when

compared to closed nailing.

In case of osteoporotic individuals, the medullary canal is narrow with

thin cortices & bones are fragile where plate fixation may lead to cortical

breakage. Plate fixation in osteoporotic comminuted fractures lead to implant

failure & pathological fracture.

TENS is ideal in cases of implant failure, compound, segmental,

comminuted fractures where open plate fixation may lead to disruption of the

fracture hematoma, or implant failure in elderly individuals. When compared

to open plating, closed TENS nailing has advantage of preserving fracture

hematoma, less operative time, early mobilization, no periosteal stripping,

smaller incision.
2
 EPIDEMIOLOGY

The incidence of forearm fractures has increased over the past decades.

However, the frequency of forearm shaft fractures appears to be stable over

time. The average yearly incidence in adults has been reported to be 1.45 per

10,000 population, ranging from 0 to 5 per 10,000 population depending on

age and gender.

This is relatively infrequent compared to that of humerus shaft (0 to 9),

femur (0 to 36), and tibia (0 to 20). Four-fifths of forearm shaft fractures occur

in children. Above the age of 20, the yearly incidence of forearm shaft

fractures remains below 2 per 10,000 people, predominating in males

throughout all age groups.

Clinical studies on forearm fractures, without exception, show that

forearm fractures predominantly occur in male patients. The proportion of

males ranges from 63% to 91%. The mean age ranges from 24 to 37 years, and

the vast majority of forearm fractures occur during the first four decades of

life.

Over half of all forearm shaft fractures occur in males within the ages

of 15 and 39 years. This age group accounts for 80% of forearm fractures in

males. As for femur and tibia shaft fractures, forearm shaft fractures have the

highest incidence in males aged 15 to 40 years. In females, a lower incidence

of forearm shaft fractures can be observed throughout life. A peak incidence

has been reported in the seventh decade of life.[20]

3
 REVIEW OF LITERATURE

Intramedullary fixation method using Titanium Elastic Nail has

advantages, such as closed application, short surgery period, good cosmetic

results and early return to movement.

Ghagan khanna et al in 2016 in his study observed that intramedullary

fixation method may be used as an alternative treatment method to plate

osteosynthesis in surgical treatment of radius and ulna diaphyseal fractures

where there is potential risk of plate loosening in elderly osteoporotic

fractures.

In his study 30 elderly patients with forearm fractures were studied.

Average follow-up period was 6 months to 1 year. According to Grace-

Eversman criteria, results were excellent in 17(56.64 %) patients, good in 9

(29.67 %) ,acceptable in 3 (10 %) and unacceptable in 1(3.33 %). Average

DASH questionnaire score was 15.21. There was no iatrogenic vascular,

neural and bone injury during surgery.

J Moerman, A Lenaert, DE Coninck, [17] in 1996 in his study of acute

fractures of diaphysis of ulna and radius in adults were treated with

intramedullary nailing. A modification of rush pin was used. 70 diaphyseal

fractures in 38 patients were treated by intramedullary fixation. The mean age

of the patients was 31.5 years. Union occurred in 66 fractures (94%).

The average union time was 73 days.. Non-union was seen in 4 cases

(6%) No postoperative infection was noted. The overall success rate was 83%.

4
No failure of fixation or material breakage was seen in the study. They

concluded that closed nailing does have many advantages, including early

union, low incidence of infection, small scars, less blood loss and short

operating time with minimal surgical trauma.

Haider Mohammed, Fareed Salloom et al, 2009 conducted a

retrospective Study Between May 2004 and April 2006, twenty one elderly

patients with displaced forearm fractures were treated with flexible

intramedullary nails. Closed reduction and percutaneous introduction of

nails was tried in all patients. In 8 patients, a mini incision was needed for

either the radius or the ulna.

The patients were followed- up for a period between 6 to 36 weeks

(mean 18 weeks). All fractures were united in acceptable alignment in an

average of 20 weeks. The two complications occurred were delayed union and

mild limitation of forearm motion. However, the functional outcome was

excellent.

Ayhan KILIC, Umit OZDOGAN IN 2002, evaluated the results of two

different surgical methods (locked intramedullary nailing and plate

osteosynthesis) for the treatment of adult diaphyseal fractures of both forearm

bones. Forty-two adult patients with forearm fractures were retrospectively

evaluated. Of these, 22 patients underwent open reduction and platescrew

fixation, and 20 patients underwent closed reduction and locked

intramedullary nail fixation.

5
 The patients were assessed using the Grace-Eversmann criteria and the

DASH (Disability of the Arm, Shoulder and Hand) questionnaire. According

to the Grace-Eversmann criteria, the results were excellent or good in 18

patients (81.8%) and acceptable in four patients (18.2%) treated with plate-

screw fixation, compared to 18 patients (90%) and two patients (10%),

respectively, treated with intramedullary nailing.. Postoperative complications

were seen in three patients (13.6%) and two patients (10%) with plates crew

fixation and intramedullary nailing, respectively. They concluded that two

fixation methods yield similar results in terms of functional healing and patient

satisfaction in the management of adult forearm fractures.

6
 ANATOMY

Osseous Plane

The osseous component of the forearm separates the anterior from the

posterior aspect and is composed of the radius, ulna, and interosseous

membrane

THE BONES:

A) THE RADIUS:

The radius is the lateral bone of the forearm, and is homologous with the

tibia of the lower limb. It has an upper end, a lower end and a shaft. The adult

radius measures on average 25 cm in length. The proximal radius comprises

the radial head, neck, and biceps tuberosity. The radial head articulates with

the radial notch (lesser sigmoid notch) of the proximal ulna. The shaft of the

radius extends distal to the biceps tuberosity. The neck is the constriction

distal to the head, which overhangs it especially on the lateral side. The

tuberosity is distal to the medial part of the neck which is extra articular and

has a rough posterior portion for the insertion of biceps tendon.[5]

It has two curvatures, one medial, the major radial bow, and one lesser

anterior curvature.

Distally, the radius broadens to articulate with the carpus. Medially, the

distal radius articulates with the ulnar head through the sigmoid notch. It is

located on the lateral aspect of the forearm in supination and dorsally in

pronation.
7
 The long narrow medullary cavity is enclosed in a strong wall of

compact bone. It is thickest along the interosseous border and thinnest at the

extremities, same over the cup-shaped articular surface (fovea) of the head.

Ossification: The shaft ossifies from a primary centre which appears during

the 8th week of development [28]. The lower end ossifies from a secondary

centre which appears during the first year and fuses at 20 years; it is the

growing end of the bone. The upper end (head) ossifies from a secondary

centre which appears during the 4th year and fuses at 18 years.

8
THE ULNA :

The ulna is the medial bone of the forearm, and is homologous with the

fibula of the lower limb. It has upper end, lower end, and a shaft. The upper

end consists of olecranon and coronoid processes and trochlea and radial

notches articulating with the humerus and radius respectively. The olecranon,

more proximal is bent forwards at its summit like a beak, which enters the

humeral olecranon fossa in extension. The posterior surface of olecranon is

smooth, triangular and subcutaneous, its proximal border being the elbow’s

point. In extension it can be in the same line the humeral epicondyles, the

three osseous forming an isosceles triangle. The anterior surface of olecranon

is the surface which forms the proximal part of trochlear notch. The base of

olecranon is slightly constricted where it joins the shaft.

The long narrow medullary cavity of the ulna is enclosed in a strong

wall of cortical tissue which is thickest along the interosseous border and

dorsal surface.

Ossification: The shaft and most of the upper end ossify from a primary centre

which appears during the 8th week of development. The superior part of the

olecranon ossifies from a secondary centre which appears during the 10th year.

It forms a scale-like epiphysis which joins the rest of the bone by 16 years.

The lower end ossifies from a secondary centre which appears during the 5th

year, and joins with the shaft by 18 years. This is the growing end of the

bone.

9
INTEROSSEOUS MEMBRANE:

The ulna and radius create a space between their proximal and distal

articulations that is somewhat oval in shape. The greatest distance between the

two bones is seen in full supination. The space is occupied mainly by the

interosseous membrane that establishes a distinct barrier between the anterior

and posterior compartments. The interosseous membrane has a marked

thickening with fibers running obliquely from proximal radial to distal ulnar

known as the interosseous ligament or central band of the interosseous

membrane.

10
THE RADIO ULNAR ARTICULATIONS:[5]

The radius and ulna are joined each other at the superior and interior

radio ulnar joints. The two bones are also connected by the interosseous

membrane which is said to constitute a middle radioulnar joint.

THE SUPERIOR RADIO-ULNAR JOINT :

This is a uni-axial pivot between the circumference of the radial head

and osseo-fibrous ring made by the ulnar radial notch and annular ligament.

The annular ligament is a strong band that encircles the radial head holding it

against the ulnar radial notch. It forms about four-fifths of the ring and is

attached anteriorly behind the posterior margin of radial notch. The proximal

annular border blends with the cubital capsule reflected synovial membrane to

attach loosely on the radial neck.

THE INFERIOR RADIOULNAR JOINT:

The distal radio-ulnar joint is a uniaxial pivot joint. The articulating

surfaces are between the convex distal head of the ulna & the concave ulnar

notch of the radius. These surfaces are connected by an articular disc. It is

closed distally by a triangular fibrocartilage which is attached at its base to the

ulnar notch of radius and by its apex to fossa at the base of ulnar styloid.[5]

11
MOVEMENTS :

Movements of the radio-ulnar joint complex are pronation and

supination of the hand. In pronation the radius is carried antero-medially

obliquely its proximal end remaining lateral and distal end becoming medial. In

supination the radius returns to a position lateral & parallel to ulna. The hand

can be turned thus through 140° -150° and with the elbow extended this can be

increased to nearly 360° by rotation humeral and scapular movements.

MUSCLES PRODUCING THE MOVEMENTS :

Pronation : Pronator Quadratus, Pronator Teres and Flexor Carpi Radialis.

Supination : Biceps Brachii and Supinator .

MUSCLES OF FOREARM [5]

The various muscles attached to radius are

Proximal third

(1)Biceps brachiaii(insertion)

(2)Supinator (insertion)

(3)Pronator teres(insertion)

(4)Flexor digitorumsuperficialis(origin)

Middle third

(1) Flexor pollicislongus (origin)

(2)Abductor pollicislongus (origin)

12
Distal third

(1)Pronator quadratus(insertion)

(2) Branchioradialis(insertion)

(3)Extensor pollicisbrevis(origin)

The various muscles attached to ulna are

Proximal third

1) Brachialis (insertion)

2) Pronator teres (origin)

3) Flexor pollicis longus (origin)

4) Triceps (insertion)

5) Anconeus (insertion)

6) Supinator (origin)

7) Abductor pollicislongus (origin)

Middle third

1) Flexor digitorum profundus (origin)

2) Flexor carpi ulnaris (origin)

3) Extensor carpi ulnaris (origin)

4) Extensor pollicislongus (origin)

Distal third

1) Extensor indices (origin)

2) Pronator quadratus (origin)

13
 Ossification centre Appearance Fusion
Capitulum 1 Year 14-16 Yrs
Head of Radius 4 Year 16-18 Yrs
4 Years (Female) 16-18 Yrs
Medial Epicondyle
6 Years (Male)
9 Years (Female) 14-16 Yrs
Trochlea
10 Years(Male)
Olecranon 10 Years 14-16 Yrs
Lateral Epicondyle 12 Years 14-16 Yrs

Table 1: Ossification centers around the Elbow

VASCULAR SUPPLY OF FOREARM

Radial artery

originates from brachial artery at about 1 cm distal to the flexion crease

of the elbow. It descends along the lateral side of the forearm, me artery is

medial to the radial shaft proximally, and anterior to it distally. Runs

inferolaterally under cover of brachioradialis and distally lateral to flexor

cafpiradialis tendon Its posterior relations in the forearm are successively the

tendon of biceps, supinator, the distal attachment of pronator teres, the radial

head of flexor digitorum superficialis, flexor pollicis longus, pronator

quadratus and the lower end of the Radius (where its pulsation is most

accessible). winds around lateral aspect of radius and crosses floor of

anatomical snuffbox to pierce fascia ends by forming deep palmar arch with

deep branch of ulnar artery.

14
Branches in the forearm

· Radial recurrent artery

· Cutaneous branches & Muscular branches.

Ulnar artery

The ulnar artery is the larger terminal branch of the brachial artery. It starts

1cm distal to the flexion crease of the elbow and reaches the medial side of

the forearm midway between elbow and wrist. Passes inferomedially and then

directly, deep to pronator teres, Palmaris longus, and flexor

digitorumsuperficialis to reach medial side of forearm. The ulnar artery

crosses the flexor retinaculum lateral to the ulnar nerve and pisiform bone to

enter the hand and gives a deep palmar branch to deep arch and continues as

superficial palmar arch. The ulnar nerve lies medial to the distal two-thirds of

the artery.

Branches in the forearm

· Anterior and posterior ulnar recurrent arteries

· Common interosseous artery

· Anterior interosseous artery

· Muscular and nutrient branches

15
Radial recurrent artery

Originates on the lateral side of radial artery, just distal to its

origin.Ascends on supinator and then passes between brachioradialis and

brachialis. It supplies these muscles and the elbow joint, anastomosing with

the radial collateral branch of the profundabrachii.

Anterior ulnar recurrent and posterior ulnar recurrent artery.

Originates fiom ulnar artery, just distal to elbow joint. AUR artery

ascends between brachialis and pronator teres, supplies them and anastomoses

with the inferior ulnar collateral artery anterior to the medial epicondyle.

16
 PUR artery passes dorsomedially between flexor digitorumprofundus

and superficialis, ascending behind the medial epicondyle ; it supplies adjacent

muscles, nerve, bone and elbowjoint, and anastomoses with the ulnar collateral

andinterosseous recurrent arteries.

Common interosseous artery

The common interosseous artery is a short branch of the ulnar artery.

After a short course, terminates by dividing into anterior and posterior

intersosseous artery.

Anterior interosseous artery

The anterior interosseous artery descends on the anterior aspect of the

interosseous membrane with the anterior interosseous branch of the median

nerve. the anterior interosseous artery proper leaves the anterior compartment

by piercing the interosseous membrane proximal to pronator quadratus. It

anastomoses with the posterior interosseous artery in the posterior

compartment of the forearm.

Posteriorinterosseous Artery

It passes dorsally between the oblique cord and proximal border of the

interosseous membrane. It descends deep in the groove between extensor carpi

ulnaris and the extensor digiti minimi part of extensor digitorum. While in the

groove it gives rise to multiple muscular branches. The posterior interosseous

artery accompanies the deep branch of the radial nerve (posterior interosseous

nerve) on abductor pollicislongus. Distally it anastomoses with the terminal

part of the anterior interosseous artery and the dorsal carpal arch.
17
NERVES OF FLEXOR COMPARTMENT

The lateral cutaneous nerve of the forearm, the cutaneous continuation

of the musculocutaneous nerve, pierces the deep fascia above the elbow lateral

to the tendon of biceps and supplies the anterolateral surface of the forearm.

The medial cutaneous nerve of the forearm supplies front and back of

the medial part of the forearm.

The posterior cutaneous nerve of the forearm passes along the dorsum

of the forearm to the wrist. It supplies the skin along its course.

Median Nerve

Enters the forearm between the heads of pronator teres. It passes behind

a tendinous bridge between the humero-ulnar and radial heads of the flexor

digitorum superficialis, and descends through the forearm posterior and

adherent to flexor digitorumsuperficialis and anterior to flexor digitorum

profundus. About 5 cm proximal to the wrist it becomes superficial, It then

passes deep to the flexor retinaculum into the palm.

Branches in the forearm

· Anterior interosseous nerve

·Muscular branches to pronator teres, flexor carpiradialis, palmarislongus

and flexor digitorumsuperficialis. · Articular branches.

18
Ulnar Nerve

The ulnar nerve enters the forearm from the extensor compartment of

arm by passing between the two heads of flexor carpi ulnaris. The ulnar nerve

descends on the medial side of the forearm, lying on flexor digitorum

profundus with the ulnar artery to its radial side.

It supplies flexor carpi ulnaris and ulnar half of flexor

digitorumprofundus also gives palmar cutaneous branch

Superficial terminal branch

The superficial terminal branch of the radial nerve, the cutaneous

continuation of the main nerve, runs from the cubital fossa on the surface of

supinator, pronator teres tendon and flexor digitorumsuperficialis, on the

lateral side of forearm under cover of brachioradialis. In the middle third of the

forearm it lies beside and lateral to radial artery. It then leaves the flexor

compartment of the forearm by passing backwards deep to the tendon of

brachioradialis and breaks into two or three branches.

Nerve of extensor compartment

Posterior interosseous nerve

The posterior interosseous nerve is the deep terminal branch of the

radial nerve. It reaches the back of the forearm by passing round the lateral

aspect of the radius between the two heads of supinator. It passes downwards

over the abductor pollicis longus origin and dips down to reach the

interosseous membrane were it passes between the muscles as far as the wrist

joint. Here it ends in a small nodule from which branches supply the wrist

joint.

19
 BIOMECHANICS OF FOREARM
The longitudinal axis of rotation of the forearm passes through the

articular surface of the radial head, the interosseous membrane, and the

articular surface of the ulna at the distal radio-ulnar joint.

Diaphyseal fractures of the radius and ulna present specific problems in

addition to those common to all fractures of the shafts of long bones. In

addition to regaining length, apposition and axial alignment, achieving normal

rotational alignment is necessary if a good range of pronation and supination

are to be restored.

The movements of supination and pronation of the forearm involve a

rotatory movement around a vertical axis at the proximal & distal radio ulnar

joints. The axis passes through the head of radius above and the attachment of

apex of the triangular articular disc below. During pronation, the entire radius

moves around the ulna through the longitudinal axis of forearm.

Pronation is performed by pronator teres and pronator quadratus.

Supination is performed by biceps brachii. and supinator. Supination is the

powerful of the two movements, because of the strength of biceps muscle.

Maintenance of the interosseous space is essential for pronation and

supination. The biceps and the supinator exert rolational forces on fractures of

the proximal third of radius. Distally, the pronator teres at the level of mid

shaft and the pronator quadratus on the distal fourth of shaft of radius exert

both rotational and angulatory forces. Fractures of distal radius tend to

20
angulate toward the ulna by the action of the pronator quadratus and the pull

of long forearm muscles.

Rotational deformity will limit radioulnar movement. The supinator

muscles are inserted proximally and the pronators distally. Consequently in a

fracture of mid shaft of radius the proximal fragment supinates and the distal

fragment pronates, resulting in 90 ° of rotational displacement. Shortening of

the two bones following overriding may also occur. Both angular and

rotational deformities are compounded by the presence of comminution.

Hence, in addition to regaining length, bony apposition, axial alignment and

achieving normal rotational alignment is necessary, if a good range of

pronation and supination are to be restored.

21
 CLASSIFICATION

Fractures of forearm are classified according to the level of fracture, the

pattern of fracture, the degree of displacement, the presence or absence of

communication or segmental bone loss and whether they are open of closed.

Each of these factors may have some bearing on the type of treatment to be

selected and the ultimate prognosis. For descriptive purposes, it is useful to

divide the forearm into thirds, based on the linear dimensions of radius and

ulna. Disruption of proximal or distal radioulnar joints is of great significance

to the treatment and prognosis. It is imperative to determine whether the

fracture is associated with joint injury because effective treatment demands

that both the fracture and joint injuries are treated in an integrated fashion.

AO CLASSIFICATION"

Type 22 A Simple fractures of one or both bones

A1 Simple fracture of ulna

A2 Simple fracture of radius

A3 Simple fracture of both radius & ulna

Type 22 B Wedge fractures of one or both bones

B1 Wedge fracture of ulna

B2 Wedge fracture of radius

B3 Wedge fracture of both radius & ulna

22
Type

22 C Complex fracture of one or both bones

C1 Grossly comminuted fracture of ulna with simple fracture of radius

C2 Grossly comminuted segmental fracture of Radius with simple fracture of

ulna

C3 Grossly comminuted fractures of both bones

23
 MECHANISM OF INJURY

Most forearm fractures occur as the result of high-energy Mechanisms.

Sporting activities as well as motor vehicle higher-energy fractures occur with

greater displacement and a higher incidence of concomitant injuries. The force

applied by trauma can be applied either directly or indirectly onto the diaphysis

of the radius and/or ulna. Direct injury frequently results from gunshot injuries

or from blunt injury to the forearm.

Indirect trauma on the other hand occurs either as bending or torsional

forces. Bending forces can result in both-bone forearm fractures that are

located at similar segments along the diaphysis of the ulna and radius. bending

forces can result in Monteggia fracture dislocation, in which the proximal ulna

is fractured and the radiocapitellar and proximal radioulnar joints (PRUJs)

dislocate in the direction of the ulnar deformity.

Torsional forces with axial loading, such as those occurring during a

fall with a hyperpronated forearm and wrist extension, can lead to both-bone

forearm fractures at different levels or to Galeazzi fractures. With this

mechanism a fracture is generated through the radial shaft and progresses

distally rupturing the interosseous membrane and finally injuring the

triangular fibrocartilage complex (TFCC), thereby rendering the distal

radioulnar joint unstable.

24
 INVESTIGATIONS

A minimum of two views-anteroposterior and lateral-are mandatory in

all suspected forearm fractures. Additional oblique views may be required.

The following features are noted in the radiographs.

1) Degree of offset

2) Degree of angulation

3) Amount of shortening

4) Presence of communication

Additional visualization is needed to rule out involvement of wrist,

elbow and both radio ulnar joints. A line drawn through the radial shaft, neck

and head should pass through the center of the capitellum on any projection.

The rotational aligunent of the forearm is difficult to determine in

routine antero posterior and lateral views. The bicipital tuberosity view

recommended by Evans is helpful in those instances. since the proximal radial

fragment could not be controlled with closed methods, the distal radial

fragment must be brought into correct relationship with the proximal fragment.

Ascertaining the rotation of the proximal fragment from the tuberosity view

before reduction, gives some idea of how much pronation or supination of

distal fragment is needed. The tuberosity view is made with the x-ray tube

tilted 20 ° towards the olecranon, with the subcutaneous border of ulna flat on

the cassette. The x-ray can then be compared with the diagram showing the

prominence of the tubercle in various degree of pronation and supination. As

an alternative, a film of the opposite elbow can be made in a given degree of

rotation for comparison.

25
 PRINCIPLES OF MANAGEMENT

There are a number of factors which play a dynamic role in determining

the type of management, thereby influencing the prognosis. They include

1) Amount of overriding of fracture fragments

2) Degree of Communication

3) Extent of soft tissue injuries

4) Associated neuro vascular injuries

5) Magnitude of joint involvement

6) Presence of multiple trauma

7) The width of medullary canal

8) Degree of osteoporosis

9) Complex ipsilateral injuries (side swipe injury)

So the objectives of treatment of diaphyseal fractures of both bones in adults

are

1) To obtain and maintain satisfactory reduction and rigid fixation.

2) To regain functional range of movement of elbow joint.

3) To regain adequate pronation and supination

4) To treat associated injuries.

The absence of pronation and supination is a permanent disability since they

cannot be regained by physiotherapy or rehabilitation

26
 METHODS OF MANAGEMENT

There are a variety of options for treating an adult with a fracture of

both bones of forearm. It is fair to say that that vast majority of fractures of

both bones of the forearm can bc most effectively treated by accurate

anatomical reduction, rigid plate fixation, and early mobilization. The various

modalities of treatment available for treating adult diaphyseal fractures of both

bones of forearm are

1)conservative management

a) Cast Immobilization

b) Closed reduction and cast immobilization

2)surgical Management

a) Open reduction and internal fixation with plate osteosynthesis

b) Closed reduction and Intramedullary fixation

c) External fixator application

27
 CONSERVATIVE MANAGEMENT

a)Cast immobilisation

The rare non displaced fracture of both bones of the forearm in adults

can usually be treated by immobilization in above elbow cast with elbow in 90

° flexion and forearm in midprone position. Angulation can be prevented by

incorporating a plaster loop on the radial side of the cast proximal to the level

of fractures. Despite good technique, an initially non displaced fracture can

become displaced while being immobilized in plaster.

b) Closed reduction & Cast immobilization

It is difficult to reduce and maintain satisfactory position of the

fragments by closed methods due the various deforming forces acting on the

fragments and due to the role of supinators and pronators leading to rotatory

instability. Closed reduction is most successful for fractures of both radius and

ulna when the fractures are located in distal third. Functional cast bracing of

forearm fractures following 6 weeks of immobilization in arm cast helps in

starting early elbow mobilization exercises leading to lesser incidence of

elbow stiffness.

Before closed reduction is undertaken, the patient must be advised that,

surgical fixation may be necessary at any time to ensure solid union in

acceptable position.

Technique of closed reduction

Relaxation of muscles is mandatory for closed reduction and general

anesthesia is preferred. Traction and counter traction are applied and ulna is

28
reduced under direct palpation. The radius could not be palpated in the

proximal half. The forearm is placed under appropriate supination. when the

fractures seem reduced and the alignment of forearm-appears satisfactory, an

above elbow plaster slab is applied and check X-rays are taken. Above elbow

cast conversion is done after week and radiographs in two planes are taken at

weekly intervals through the cast for the first month and every two weeks

thereafter until solid union is obtained.

There are only a few indications available for conservative treatment in adult

forearm fractures. These include

1) Undisplaced/incomplete fractures

2) Associated life threatening trauma like head injury, chest injury etc.

29
 SURGICAL MANAGEMENT

INTRODUCTION

During the last century, surgical management of diaphyseal fractures of

both bones forearm in adults has gained widespread acceptance as operative

techniques and the quality of implants have improved. The combination of

properly designed implants, better understanding of the personality of the

fracture, minimal soft tissue handling techniques, preoperative antibiotics have

made surgical fixation safe and practical while treating these fractures.

The goals of operative treatment for diaphyseal forearm bones fractures

in adults include

a) Anatomical alignment

b) Stable fixation

c) Early mobilization

d) Early functional rehabilitation of upper limb.

Indications for operative management include virtually all diaphyseal fractures

of both bones of forearm in adults.

30
 CLOSED INTRAMEDULLARY NAIL FIXATION

While selecting an intramedullary device, it is mandatory to select a

nail of appropriate diameter for fixation. If the size of the nail is small, there is

side to side and rotatory movement leading to instability. If the size of the nail

is large, further communication or additional fracture may occur.

The nail diameter should be selected to be between 30% & 40% of the

narrowest medullary space diameter. Both bones are considered as a unit &

nails should occupy 60% of the bony canal. The nails must be of same

thickness & similarly prebent

Principle :

-Since the fractures of both radius and ulna are fixed in closed manner,

fracture hematoma is preserved leading to early union and consolidation.

Moreover, the chance of infection is minimized.

-The ulna is fixed first

-· An appropriate sized nail is selected, so that the nail fits snuggly inside the

medullary canal.

- Titanium elastic nail offers three point fixation thereby stabilizing the

fracture fragments.

Technique of fixation

-C arm is mandatory

-Closed reduction of the bones is achieved with traction, counter traction and

manipulation

31
-The reduction is checked with C arm.

-For the ulna, entry point in made over the olecranon with an awl and the

position is confirmed.

A nail is introduced through the olecranon and passed across the fracture site

under image control.

For the radius-the entry point is from distal aspect and just medial to Lister

tubercle

-The nail is passed, across the fracture site under C arm control.

-Both the radius and ulnar nails are cut at their ends and buried

32
 IMPLANT PROFILE & REMOVAL

TITANIUM ELASTIC NAIL

These nails are made of alloys such as Ti-6Al-7Nb. They offer

outstanding corrosion resistance, excellent biocompatibility and higher

strength. Titanium alloy implants may be ceramic shot coated & either

chemically panivated in nitric acid or anodized as a final surface treatment.

The lower modulus of elasticity of titanium allow easy insertion & provide

more load sharing with the bone.

Length: 44cm

Width: 2mm – 5mm

Colour coded for different sizes

End: beak shaped for curved insertion & used as a reduction tool.

33
Intramedullary nails placed on forearm bones are not removed usually unless

they cause symptoms. Routinely they should not be removed before 2 years,

even though the fracture will have appeared solid on radiographs much

earlier. The limb has to be protected in above elbow slab for minimum 6

weeks after removal, if there is local pain or tenderness.

NAIL DIAMETER

The nail diameter should be selected to be between 30% & 40% of the

narrowest medullary space diameter. Both bones are considered as a unit &

nails should occupy 60% of the bony canal. The nails must be of same

thickness & similarly prebent.

34
 COMPLICATIONS

The complications following operative treatment for diaphyseal

fractures of both bones forearm in adults are relatively less common because

of 'better surgical techniques and improved implants.

Complication of fractures

(a) Infection

(b) Malunion

(c) Non union

(d) Cross union

(e) Associated vascular and nerve injuries

(9 Post traumatic Stiffness

Complication of operative treatment

(a) Incomplete reduction

(b) Incongruous reduction

(c) Unstable fixation

(d) Inadequate implant

(e) Infection.

The use of state of the art implants and instrumentation for diaphyseal

fractures of both bones forearm does not always guarantee a favourable.

The surgeon must have a thorough understanding of local anatomy, of fracture

fixation and patterns of fracture healing after internal consistently good results

are to be achieved.

35
1)Infection.

The major drawback of operative fixation is infection. It is less common with

closed intramedullary fixation than with open reduction techniques. If

postoperative infection develops, appropriate antibiotics are given for 3 to 6

weeks intravenously. Even in the presence of infection, every effort should be

made to retain the implants since stable infected fractures are easy to manage

than unstable infected fractures. However if the infection is severe, the implant

has to be removed.

2)Malunion

This is relatively more common in conservatively treated cases than in

surgically treated cases, since it is difficult to maintain the fracture fragments

in alignment when treated conservatively. The varying pull of supinators and

pronators on the fracture fragments lead to malunion.

3) Non union

The varying causes of nonunion are inadequate immobilization,

improper fixation, implant failure and the presence of underlying infection.

Gross osteoporosis of the bones is also an important cause for nonunion.

Inadequate internal fixation, with plates which are too small, nails which are

of inappropriate size is a potent cause of nonunion. Loss of substance of radius

or ulna following gun shot injuries also lead to nonunion. Repeated

manipulation by traditional bone setters may also lead to nonunion. In a case

36
of non union, open reduction and internal fixation with autologous bone

grafting is the treatment of choice.

4) cross union

Cross union of the radius and ulna results from a continuous hematoma

between the two fractures. The important cause of cross union following

conservative treatment is improper reduction with bony fragments encroaching

the interosseus space.

Cross union may also occur if the fractures are stabilized by open

methods and bone grafting with bone grafts kept in the interosseous border of

either bones. If cross union occurs there is loss of pronation and supination

due to a bridge of bone between radius and ulna. This bridge of bone has to be

excised for pronation and supination to occur. synostosis is relatively

uncommon. Seen frequently in patients with either a crushing injury of

forearm or a head injury. The highest risk for synostosis is in proximal

fractures treated through single incision. If synostosis develops and position of

forearm is relatively functional, it is best to do nothing. if rotational alignment

of forearm is poor, an osteotomy to position the hand in more functional

position can be considered.

5) post traumatic stiffness

This is more common is patients managed conservatively than by

surgical fixation. Elbow joint is notorious for developing stiffness immobilized

too long. The main advantage of surgical fixation is that, since the fracture

37
fragments are stable after fixation, active mobilization exercises of wrist,

elbow and hand can be started early.

6) Nerve injuries

Injury to posterior interosseous nerve can occur in Henry's approach

during plating of radius. Also, there are chances of injury to recurrent radial

artery and superficial branch of radial nerve through this approach. These can

be prevented by knowing the proper anatomy of forearm and gentle handling

of soft tissues.

7) Compartment syndrome

This can occur either after trauma or after surgery on the forearm

bones. they are usually due to faulty hemostasis of closure of the deep fascia.

They can usually be avoided by releasing the tourniquet before wound closure

to make sure hemostasis is adequate, by closing only the subcutaneous tissue

and skin.

Complications of intramedullary nail fixation

Most complications result from improper selection of nail size. A nail

that is too long may be driven through the bone end. One that is too short may

not adequately stabilize the fracture. A nail with too large a diameter may split

the cortex and one with a smaller diameter may not adequately control

rotational alignment resulting in non-union.

38
 EVALUATION OF OUTCOME

For evaluating the functional outcome of fracture fixation, we used the

MODIFIED GRACE & EVERSMANN SCORING SYSTEM. This scoring

includes the following parameters:

1) SUPINATION AND PRONATION [6]

(normal- pronation & supination 80 degrees)

RATING RANGE OF MOVEMENT SCORE

EXCELLENT >80 4

GOOD 60 – 80 3

FAIR 40 – 60 2

POOR <40 1

2) RADIOLOGICAL UNION (End of 6th week)

RADIOLOGICAL UNION SCORE

UNION PRESENT
2
(good callus)

NON UNION 1

39
 3. RANGE OF MOVEMENT- ELBOW [6]

RANGE RESULT SCORE

Flexion > 120 Excellent 4

Flexion 100 – 120 Good 3

Flexion 80 – 100 Fair 2

Flexion <80 Poor 1

FINAL ANALYSIS

RESULT SCORE

EXCELLENT >10

GOOD 8-9

FAIR 6-7

POOR <5

40
 PART-B

AIMS AND OBJECTIVES

AIM:

To analyse the outcome using minimally invasive tens nail in

osteoporotic diaphyseal # of forearm fractures.

OBJECTIVES

To analyse the functional outcome in forearm fractures using titanium

elastic nails in osteoporotic diaphyseal # of forearm fractures To assess the

range of movements, functional outcome at 6 weeks, 12weeks, 18weeks, 6

months & at 1 year.

41
 MATERIALS AND METHODS

The present study includes 30 cases of diaphyseal fractures of both bone

forearm admitted in GOVERNMENT RAJAJI HOSPITAL, attached to

Madurai medical college , between november 2017 to october 2020.

Study design: prospective study

Method of collection of Data (including sampling procedure if any): Collection

of data for patients presenting with fracture of forearn are as follows :-

• History by Verbal communication

• Clinical examination, both local and systemic.

• Radiological examination routine and other imaging modalities.

• Investigations- Baseline and others.

• Fracture anatomy assessed with X-rays.

• Diagnosis – Clinical and Radiological.

• Informed written consent will be taken for Surgical procedure.

• Surgery – CRIF WITH TENS NAILING

• Complications :-

• Follow up :-

Assessment at 6 weeks

- Clinical assessment of pain and stiffness

- Radiological assessment

42
 Assessment at 12 weeks

- Clinical assessment of stiffness & range of movements

- Radiological assessment

Assessment at 18 weeks

- assessment of range of movements(supination & pronation)

Assessment at 6 months

- Assessment of Radiological and Functional ability of the forearm

Assessment at 1 year

- Assessment of Radiological and Functional ability of the

forearm.

- Assessment of any complications.

- Assessment of function using Grace & eversmann scoring system.

- Inclusion and exclusion criteria :

Inclusion criteria :

1. Osteoporotic fractures of forearm

2. Elderly forearm fractures > 60 years

3. Segmental Osteoporotic fractures of radius & ulna

4. Compound grade I & II fractures

5. Immunocompromised individuals with forearm fractures

43
Exclusion criteria :

1. Paediatric Forearm Fractures

2. Compound Fractures type III

3. Adult # < 60 with co morbidities

4. Severe co morbidities- terminally ill

. The patients were then assessed clinically to evaluate their general condition

and the local injury.

 Radiographic study was done taking anteroposterior and lateral xray of

the involved forearm. The limb was then immobilized in above elbow

plaster of paris slab with sling.

Preoperative planning :

• Consent of the patient or relative was taken prior to the surgery.

• A dose of tetanus toxoid and antibiotic were given preoperatively.

• Preparation of the part was done a day before the surgery.

• The injured limb was immobilised in an above elbow slab with

sling during preoperative period.

• Instruments to be used were checked be and sterilised.

Position :

• Patient in supine position on operating table ,with affected arm

positioned with pronation

44
 OPERATIVE PROCEDURE

Closed Reduction and Fixation with Intra medullary nailing

Titanium elastic Nail fixation:

The patient is placed supine and the forearm is kept in a hand table

compatible with C arm. Tourniquet was not used. The width of the medullary

canal of radius was measured and an appropriate sized nail was selected such

that, the nail should occupy at least 60% of the medullary space. The entry was

made on the distal radius just medial to Lister tubercle, beneath the extensor

pollicis longus tendon 5 mm proximal to wrist joint. The medullary canal was

entered with a curved awl and the position was confirmed with C arm. The

selected titanium elastic nail was introduced and passed into the medullary

canal of radius and gently pushed till it reaches the fracture site. The fracture

fragments were reduced by gentle manipulation and the nail was entered into

the distal fragment by gently rotating the tip. The position of the nail was

continuously confirmed with C arm. The nail was passed till it reached the

radial neck. The nail was then slightly withdrawn and cut. The cut end of the

nail was gently hammered so that the tip lies flush with the bone.

The ulna was entered from the olecranon and an appropriate nail was

inserted, fracture fragments reduced and the nail gently manipulated into distal

fragment. The tip of the nail was cut and buried. The wounds were sutured.

45
a) Ulna entry point b)radius entry point

c-arm fluoroscopy image

Post operative protocol

All cases were immobilized in an above elbow slab after surgery.

Wound inspection was done after 48 hours. Suture removal was done on Xth

POD, and above elbow cast was applied. After 3 weeks the cast was removed

and a below elbow cast was applied, after obtaining check X rays. Active

elbow mobilization exercises were started at the end of 3rd week after removal

of cast. By the end of 6 weeks, active pronation and supination exercises were

started.

The functional assessment of the patient was done according to

modified grace & eversmann Performance Score.

46
 GRADING OF RESULTS

In this Study, we have used the modified grace & eversmann

Performance Score to evaluate the functional outcome.

The cases were analysed as per the following criteria

1) Age distribution

2) Sex distribution

3) Side of injury

4) Mode of injury

5) Classification of fracture

6) Time interval between injury & surgery.

7) Associated injuries.

8) Complications

47
 STATISTICAL ANALYLSIS

1. AGE INCIDENCE

AGE No. of Cases %

60 13 43.33
> 60 17 56.67
TOTAL 30 100.00
Mean 62.5
SD 3.472

AGE

18 17
16
14 13
12
10
8
6
4
2
0
60 > 60

No. of Cases

48
 2) SEX INCIDENCE

SEX No. of Cases %

MALE 17 56.67

FEMALE 13 43.33

TOTAL 30 100.00

SEX

20
17
15 13

10

0
MALE FEMALE

No. of Cases

49
 3) SIDE DISTRIBUTION

SIDE No. of Cases %

LEFT 18 60.00

RIGHT 12 40.00

TOTAL 30 100.00

SIDE

20 18
18
16
14 12
12
10
8
6
4
2
0
LEFT RIGHT

No. of Cases

50
 4) MODE OF INJURY

Mode of Injury No. of Cases %

Accidental fall 10 33.33

Assault 5 16.67

RTA 15 50.00

TOTAL 30 100.00

MODE OF INJURY

16 15
14
12 10
10
8
6 5
4
2
0
Accidental fall Assault RTA

Accidental fall Assault RTA

51
 5) TYPE

Type No. of Cases %

A1 1 3.33

A2 1 3.33

A3 17 56.67

B2 1 3.33

B3 10 33.33

TOTAL 30 100.00

52
 6) TIMING OF SURGERY

Timing of Surgery No. of Cases %

<2 2 6.67

3-5 22 73.33

>5 6 20.00

TOTAL 30 100.00

TIME OF SURGERY

25 22
20
15
10
6
5 2
0
<2 3-5 >5

No. of Cases

53
7 ) ASSOCIATED INJURIES

Associated Injuries No. of Cases %

#Shaft of humerus 1 3.33

Chest injury 2 6.67

Head injury 4 13.33

Supracondylar humerus 1 3.33

Nil 22 73.33

TOTAL 30 100.00

ASSOCIATED INJURIES

25 22

20

15

10
4
5 1 2 1
0
#Shaft of Chest injury Head injury Supracondylar Nil
humerus humerus

#Shaft of humerus Chest injury Head injury Supracondylar humerus Nil

54
 8) COMPLICATIONS

Complications No. of Cases

deformity 1
Malunion 1
Nail breakage 1
Nail pullout 1
Non union 1
Skin irritation 1
Stiffness 1

COMPLICATIONS

1 1 1 1 1 1 1
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
deformity Malunion Nail Nail pullout Non union Skin irritation Stiffness
breakage

deformity Malunion Nail breakage Nail pullout

Non union Skin irritation Stiffness

55
9) SCORE AT 6 WEEKS

Score at 6 weeks
6 WEEKS No. of Cases %
0 0.00
Excellent(> 10)
0 0.00
Good(8 - 9)
10 33.33
Fair(6 - 7)
20 66.67
Poor(< 5)
30 100.00
TOTAL
4.7
Mean
1.264
SD

SCORE - 6 WEEKS

20
20

15
10
10

5
0 0
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7) Poor(< 5)

No. of Cases

56
 10) SCORE AT 12 WEEKS

Score at 12 weeks
12 WEEKS No. of Cases %
0 0.00
Excellent(> 10)
1 3.33
Good(8 - 9)
19 63.33
Fair(6 - 7)
10 33.33
Poor(< 5)
30 100.00
TOTAL
5.833
Mean
1.177
SD

SCORE AT 12 WEEKS

20 19
18
16
14
12
10
10
8
6
4
2 0 1
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7) Poor(< 5)

No. of Cases

57
 11) SCORE AT 18 WEEKS

Score at 18 weeks
18 WEEKS No. of Cases %
0 0.00
Excellent(> 10)
11 36.67
Good(8 - 9)
14 46.67
Fair(6 - 7)
5 16.67
Poor(< 5)
30 100.00
TOTAL
6.867
Mean
1.167
SD

SCORE AT 18 WEEKS

14
14

12 11

10

6 5

2
0
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7) Poor(< 5)

No. of Cases

58
 12 )SCORE AT 6 MONTHS:

Score at 6 months
6 MONTHS No. of Cases %
1 3.33
Excellent(> 10)
18 60.00
Good(8 - 9)
8 26.67
Fair(6 - 7)
3 10.00
Poor(< 5)
30 100.00
TOTAL
7.7
Mean
1.368
SD

SCORE - 6 MONTHS

18
18
16
14
12
10 8
8
6
3
4
1
2
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7) Poor(< 5)

No. of Cases

59
 13) SCORE AT 1 YEAR:

Score at 1 year
1 YEAR No. of Cases %
Excellent(> 10) 17 56.67
Good(8 - 9) 11 36.67
Fair(6 - 7) 2 6.67
Poor(< 5) 0 0.00

TOTAL 30 100.00
Mean 9.567
SD 1.478

SCORE - 1 YEAR

17
18
16
14 11
12
10
8
6
2
4
2
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7)

No. of Cases

60
 ANALYSIS OF FUNCTIONAL OUTCOME

The analysis was done using modified GRACE AND EVERSMANN

RATING SYSTEM & the following results were obtained.

1) OVERALL RESULTS:

6 1
6 WEEKS 12 weeks 18 weeks MONTHS YEAR
Excellent(> 10) 0 0 0 1 17
Good(8 - 9) 0 1 11 18 11
Fair(6 - 7) 10 19 14 8 2
Poor(< 5) 20 10 5 3 0
TOTAL 30 30 30 30 30
P VALUE < 0.001 Significant
chi square 138.36

ANALYSIS OF OUTCOME

20
20
19
18
18
17

16

14
14

12
11 11
10 10
10

8
8

6
5

4
3
2
2
1 1
0 0 0 0 0
0
Excellent(> 10) Good(8 - 9) Fair(6 - 7) Poor(< 5)

6 WEEKS 12 weeks 18 weeks 6 MONTHS 1 YEAR

61
ANALYSIS OF OUTCOME – MEAN SCORE COMPARISON

Score Mean SD
6 weeks 4.7 1.264
12 weeks 5.83 1.177
18 weeks 6.87 1.167
6 months 7.7 1.368
1 year 9.57 1.478
p value < 0.001 Significant

Mean score comparison

9.57
10
9 7.7

8 6.87
5.83
7
4.7
6
5
4 W3
3
2
1
0
6 WEEKS 12 weeks 18 weeks 6 MONTHS 1 YEAR

Mean

62
Statistical analysis:

The mean value of modified grace and eversmann score for 30 patients who

underwent nailing is 4.5, 5.83, 6.87, 7.7 & 9.57 at 6 weeks, 12 weeks, 18 weeks, 6

months & 1 year respectively. Standard deviation being 1.26, 1.16, 1.17, 1.36 & 1.47

at 6 weeks, 12weeks, 18weeks, 6 months & 1 year respectively. The p value was

found to be less than 0.001 and hence the results were satisfactory at the end of 1 year

follow up.

63
 CASE ILLUSTRATIONS

CASE NO : 1 S. No 4 SEEMAN 70/M

PRE OP INTRAO 6WEEKS 6months

Grace & eversmann score =10

EXCELLENT

64
CASE NO : 2 S.No. 1 ANGUSAMY 60/M

PRE OP INTRAOP 6 WEEKS 6 MONTHS

Grace & eversmann score =12

EXCELLENT

65
CASE 3 S.NO 17 INDIRA 66/F

PRE OP 6 WEEKS

6 MONTHS

Grace & eversmann score =11

EXCELLENT

66
 CASE NO : 4. S.NO:5 VELU 62/M

PRE OP INTRAOP 6WEEKS

EXTENSION PRONATION FLEXION

Grace & eversmann score -12

EXCELLENT

67
CASE 5 S NO 16 VAIRAM 64/F

PRE OP INTRAOP 6WEEKS

Grace & eversmann score -11

EXCELLENT

68
CASE NO :6 S.NO 29 KARUPASAMY 60/M

INTRAOP 18 WEEKS

Grace & eversmann score =9

GOOD

69
 COMPLICATIONS

NAIL BREAKGE NAIL PROMINENCE NON UNION RADIUS

70
 OBSERVATION AND RESULTS
The following observations were made in our study. From November 2017 to

October 2019, 30 elderly patients >60 years with forearm fractures were operated

using TENS nail in closed manner in our institution.. Of the 30 cases who fulfilled

the inclusion criteria no one denied to take part in the study leaving 30 cases for the

study. 30 patients of forearm fractures were treated surgically with TENS nail and

analysed with an average follow up of 12 months. The mean age of the cases was 60

years (range >60 years). 60% of the patients were more than 65 years. There were 17

males & 13 females. Males dominated our study.

18 fractures affected left side & 12 on right upper limb 15 fractures were

due to RTA. 10 were due to accidental fall & 5 due to assault. Motor Vehicle

accidents was a major form of injury. All types of fractures were simple (closed)

fractures. The fractures were labelled according to AO-OTA fracture classification.

55 % fractures wereA3 type, 40 % fractures contributed to B3 type (A3>B3) 8

patients had associated injuries . 3 had other skeletal injuries with two of them

having # humerus & 4 with head injuries & 2 with chest injuries.

None of them had fracture related pre-operative nerve injuries. Fractures were

managed within a week( 3 to 8) days after injury. All of the patients were operated

by closed reduction method. The average surgical time was 60 minutes. The duration

of surgery was minimal compared to plating.

During the period of follow up. Only 7 patients had mild pain. .

71
The Mean grace & eversmann score was 9.565. Based on that score, 56.6% (n=17 )

patients score was > 10 & were rated as excellent, 36.67% (n=11 )were rated as

good, 6.6 % (n=2) as fair and no cases had poor functional outcome.

Seven Patients developed complications of which one had stiffness of elbow

joint which were managed by regular physiotherapy. one had superficial wound

infection which was treated with intravenous broad spectrum antibiotics for 3 weeks.

One patients had nail breakage & one had skin irritation over radial aspect with

prominence at radial styloid post operatively for which nail was removed later. One

patient had nail pullout.

Three patients were lost for follow up.

In our study, solid radiologic union was achieved in a mean duration of 18

weeks(16 to 24 weeks) for all patients. Time taken for union was similar to plating.

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 DISCUSSION
Plate fixation has been considered the gold standard for fixation of both bone

forearm fixation. However, Closed nailing offers many advantages, including early

union, low incidence of infection, small scars, less blood loss, and, frequently a

relatively short operating time with minimal surgical trauma.

The main aim of this study is to analyse the outcome of treating forearm

fractures using TENS nail in elderly individuals. We selected 30 cases of diaphyseal

both bone forearm fractures in elderly individuals. The period of study was between

November 2017 and October 2019. They were operated by closed reduction using

tens nail. They were followed up at 6weeks, 12 weeks, 18 weeks, 6months & 1 year.

Overall final outcome was assessed by Grace and Eversman scoring system. In

2016 ghagan khanna in his study 30 elderly patients with forearm fractures were

studied. Average follow-up period was 6 months to 1 year. According to Grace-

Eversman criteria, results were excellent in 17(56.64 %) patients, good in 9 (29.67 %)

,acceptable in 3 (10 %) and unacceptable in 1(3.33 %). In his study, Time taken for

union was 18-24 weeks.

In my study According to Grace-Eversmann criteria, results were excellent in

17(56.67) patients, good in 11(36.67) patients, fair in 2(6.67) patients and no cases

had poor functional outcome. In our study, solid radiologic union was achieved in a

mean duration of 18 weeks for all patients.

Open reduction and internal fixation using plates achieve a high percentage of

union because of good anatomical reduction, proper alignment of fragments, rigid

fixation. Early mobilization and Range of movements (supination & pronation) are

73
 good in plating as it is a stable fixation. It gives both axial & rotational stability

compared to nailing. TENS lack axial and rotational stability. So postoperative

immobilization is necessary.

Plating has less chance of malalignment as it provides good anatomic

reduction but 1 case of malalignment was reported in closed nailing radiologically

but functionally it was acceptable.

However plating produces extentive soft tissue damage and the fracture

haematoma is disturbed. complications like compartment syndrome, infection,

nonunion, cross union, malunion, nerve injuries and Refractures after extraction of

the plate are also common in plating.

TENS is the choice of implant in osteoporotic individuals where plate fixation

may lead to secondary fractures or implant failure. TENS is ideal in cases of implant

failure, compound, segmental, comminuted fractures where plate fixation may lead to

infection, disruption of the fracture hematoma, or implant failure in some cases.[27]

74
 CONCLUSION
The conclusion of this study are closed intramedullary titanium elastic nailing

is the choice of implant for elderly osteoporotic individuals. The advantages are

 Closed Minimally invasive technique with Preservation of fracture

hematoma

 Less chance of infection

 Less post operative morbidity

 Smaller incision-hence better cosmesis

 chances of implant failure is very less

 Can be done as a day care procedure

 No neurovascular injury

To conclude:

Intramedullary TENS nailing is the choice of implant for elderly osteoporotic

individuals as it is a less invasive technique with preservation of fracture hematoma

that allows restoring function more quickly with less pain and less risk of

complications.

75
 BIBLIOGRAPHY

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children. J Bone Joint Surg Br.2004;86:947–953.

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415pp.(p6,9,11,13,14,17,20,21)

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9. Hadden WA, Reschauer R, Seggi W. Results of AO plate fixation of

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17. Moerman J, Lenaert A, De Coninck D, Haeck L, Verbeke S, Uyttendaele

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26. Screw elastic intramedullary nail for the management of adult forearm

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79
 PATIENT PROFORMA

Consent form

FOR OPERATION/ANAESTHESIA

I_________ Hosp. No.______ in my full senses hereby give my

full consent for ______ or any other procedure deemed fit which is a

diagnostic procedure / biopsy / transfusion / operation to be performed on me /

my son / my daughter / my ward _____age under any anaesthesia deemed fit.

The nature, risks and complications involved in the procedure have been

explained to me in my own language and to my satisfaction. For academic and

scientific purpose the operation/procedure may be photographed or televised.

Date: Signature/Thumb Impression of Patient/

Guardian Name:

Designation Guardian Relation ship

80
PATIENT PROFORMA

 Name :

 IP No:

 Age : Sex:

 Occupation:

 Diagnosis :

 Associated injuries :

 Date of surgery:

 Procedure :

 Complications :

 Secondary procedure :

 Follow up period :

81
 MASTER CHART
s.n modeof typ timing of associated
o name age sex side injury e surgery injuries complications score
6 6 1
WEEK 12 18 MONTH YEA
S WEEKS WEEKS S R
1 Angusamy 75 M Left RTA B3 4 NIL 6 7 8 9 12
Supracondylar
2 Alagupilai 62 F Left Assault A3 6 humerus 3 4 5 5 8
3 Maheswaran 60 M Left RTA A3 5 NIL malunion 5 6 7 7 9
4 Seeman 70 M Left Assault A3 4 Head injury skin irritation 6 7 8 9 10
5 Velu 62 M Left RTA A2 4 NIL 7 8 9 10 12
6 Alagar 65 M Left RTA B2 5 Chest injury 6 7 8 9 10
7 Balasubramanian 60 M Left RTA A3 6 Chest injury Nail breakage 3 4 5 5 7
Accidental
8 Irulakkal 65 F Left fall A3 5 NIL 3 5 6 6 8
Rig
9 Maheshwari 61 F ht RTA A3 5 NIL 6 7 7 8 10
Rig Accidental
10 Thottichi 62 F ht fall A3 3 NIL 6 7 8 9 11
Accidental
11 Santhakumari 62 F Left fall A3 4 NIL 5 7 8 8 10
Rig
12 Shanmugam 65 M ht RTA B3 4 Head injury 5 5 6 8 10
Rig Accidental
13 Usha 60 F ht fall B3 3 NIL 6 7 7 8 12

14 Shanthi 60 F Left Assault A3 4 NIL 5 6 7 8 10

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15 Balan 60 M Left RTA A3 2 NIL 6 7 8 9 12
Accidental
16 Vairam 64 F Left fall A3 2 NIL nail pullout 6 7 8 9 11
Accidental
17 Indhira 66 F Left fall A3 3 NIL 5 6 8 9 11
Rig
18 Veerayee 60 M ht RTA A1 5 NIL 3 4 5 5 8
Rig
19 Sankar 60 M ht Assault A3 7 NIL 4 6 7 7 9
Rig
20 Pandian 60 M ht RTA B3 6 Head injury deformity 3 4 5 6 8
#Shaft of
21 Gurunathan 61 M Left RTA B3 4 humerus 6 6 7 8 10
Rig
22 Vellaiyan 65 M ht Assault B3 5 NIL stiffness 3 5 5 6 7
Accidental
23 Subbamal 65 F Left fall A3 5 NIL 5 6 8 9 10
Rig
24 Ganesan 60 M ht RTA A3 6 Head injury Non union 4 6 7 8 8
25 Tamilarasi 60 F Left RTA B3 5 NIL 5 6 6 8 10
26 Muthiah 61 M Left RTA A3 6 NIL 3 4 6 7 8
Accidental
27 Rakkamal 60 F Left fall B3 4 NIL 3 4 6 7 8
Rig
28 Shanmugavalli 60 F ht RTA A3 3 NIL 4 6 8 9 10
Rig Accidental
29 Karupasamy 60 M ht fall B3 4 NIL 4 5 6 7 9
Rig Accidental
30 Sangaiah 64 M ht fall B3 3 NIL 5 6 7 8 9

83
84
 CERTIFICATE

This is to certify that this dissertation titled “FUNCTIONAL OUTCOME

OF INTRA MEDULLARY TITANIUM ELASTIC NAILING IN

OSTEOPOROTIC DIAPHYSEAL FRACTURE OF BOTH BONE

FOREARM” of the candidate Dr.N.SATHIYA PRAKASH with registration

number 221712107 for the award of M.S. degree in the branch of

ORTHOPAEDICS. I personally verified the urkund.com website for the purpose

of plagiarism check. I found that the uploaded thesis file containing from introduction

to conclusion pages and result shows 18 percentage of plagiarism in the dissertation.

Prof. DR.B.SIVAKUMAR, M.S Ortho.,

Professor and Chief of spine unit
Department of Orthopaedics & Traumatology
Madurai Medical College,
Madurai.

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86