Review Question - QID 8980

The patient has a comminuted, relatively high-energy open fracture of the right radius and ulna, which is best treated with irrigation and debridement of the gunshot wounds followed by early internal fixation if possible using a 3.5 mm LC-DCP plate placed with a bridging technique.

Diaphyseal forearm fractures are best treated with open reduction and internal fixation to restore anatomic alignment and absolute stability. Typically this is achieved by the use of 3.5 mm plates, placed in such a manner to produce interfragmentary compression. Due to the comminution in this case, bridge plating will provide a superior outcome as it will minimize interfragmentary strain and preserve the local bone biology. Multiple studies have demonstrated that open reduction and internal fixation at the initial encounter is appropriate, even if there is comminution, bone loss, or an open injury requiring multiple debridements.

Anderson et al. performed a retrospective study of 87 patients with 129 diaphyseal forearm fractures treated with dynamic compression plates. Open fractures were fixed primarily and the overall union rate was 98%. Refracture occurred in 2 patients after removal of 4.5 mm plates, whereas there were no refractures after removal of the 3.5 mm plates.

Moed et al. reviewed 57 patients that underwent immediate internal fixation of a diaphyseal forearm fracture. Functional results were good to excellent in 85% of patients and there were 2 deep infections and 6 non-unions overall. The authors conclude immediate plate fixation is an appropriate treatment method for open diaphyseal forearm fractures and recommend autogenous grafting at the time of wound closure.

Jones et al. analyzed a retrospective case series of 18 patients with grade 3 open diaphyseal forearm fractures treated with irrigation and debridement and immediate open reduction and internal fixation followed by aggressive soft tissue management over the following weeks. Their treatment protocol provided good to excellent results in 66% of patients, indicating immediate reduction and fixation may be an acceptable treatment for some patients.

Figure A demonstrates comminuted radius and ulna shaft fractures with retained bullet fragments.

Incorrect answers:
Answer 2: The patient has an open fracture which requires urgent debridement
Answer 3: Compression plating will not work for this comminuted fracture pattern.
Answer 4: While bridge plating is appropriate, 4.5mm plates are too large and have an increased risk of refracture if later removal is required
Answer 5: External fixation is not necessary, this fracture can be treated with immediate open reduction and internal fixation.