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CASE REPORT
Year : 2019  |  Volume : 8  |  Issue : 4  |  Page : 264-267

New simple unicortex locking intramedullary fixation of forearm shaft fracture: A Case report


Department of Orthopaedics and Traumatology, Faculty of Clinical Medicine No. 2, Pyongyang Medical College, Kim Il Sung University, Pyongyang, Democratic People's Republic of Korea

Date of Submission09-Jun-2019
Date of Decision22-Aug-2019
Date of Acceptance17-Oct-2019
Date of Web Publication16-Dec-2019

Correspondence Address:
Dr. Hyon-Chol Kim
Department of Orthopaedics and Traumatology, Faculty of Clinical Medicine No. 2, Pyongyang Medical College, Kim Il Sung University, Pyongyang
Democratic People's Republic of Korea
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JDRNTRUHS.JDRNTRUHS_67_19

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  Abstract 


We have used nonlocking nails in patients with small intramedullary canals for the fixation of segmental fractures of the radius and ulna. We report a patient with the Monteggia fracture dislocation (the ulnar shaft segmental fracture) treated by new simple unicortex locking intramedullary fixation.

Keywords: Forearm shaft segmental fracture, intramedullary fixation, minimally invasive osteosynthesis, unicortex locking


How to cite this article:
Kim HC, Kim HS. New simple unicortex locking intramedullary fixation of forearm shaft fracture: A Case report. J NTR Univ Health Sci 2019;8:264-7

How to cite this URL:
Kim HC, Kim HS. New simple unicortex locking intramedullary fixation of forearm shaft fracture: A Case report. J NTR Univ Health Sci [serial online] 2019 [cited 2020 Jul 13];8:264-7. Available from: http://www.jdrntruhs.org/text.asp?2019/8/4/264/273133




  Introduction Top


Rush, Sage,[1],[2] and others[3] popularized intramedullary nailing of forearm shaft fractures in the late 1950s and the 1960s. Although compression plating became popular in the 1970s and 1980s and achieved equally good results,[4],[5],[6] intramedullary nailing remained popular in some centers.[7],[8],[9]

Various modifications were made in the cross-sectional shape of the nail.

Sage[1] introduced a triangular-shaped nail, whereas Street[10] introduced a square design to improve stability and fracture healing.

Star-shaped nail also has been introduced.[8] (True-Flex Nail, Encore Medical, Austin, TX).

More recent interlocking nail designs such as the ForeSight nail and Stainless Steel Taper stainless steel nail were introduced.[11] The development of locked intramedullary nail systems has expanded the role of intramedullary nails in the management of forearm shaft fractures.[12],[13],[14] Most simple forearm shaft fractures are usually treated surgically with the use of intramedullary nail. It is effective for segmental fractures.[15]

However, there are some problems of locked intramedullary nailing as follows.

  • Small medullary canals may preclude intramedullary nailing or require the use of very small nails.
  • Medullary canals less than 3 mm in diameter contraindicate locked intramedullary nailing.


Here, we report a case of a traumatic ulnar shaft segmental fracture, with small intramedullary canal less than 3 mm in diameter, managed with new simple unicortex locking intramedullary fixation.


  Case History Top


A 20-year-old healthy female without significant past medical history presented to the emergency department with crush wound on the left elbow and forearm, having been brought in by ambulance. She put her left hand into the rolling machine.

The main wound was Gustilo–Anderson type IIIA locating in the anterior aspect of the left elbow joint. The anterior dislocated, and severe comminuted radial head and the humeral condylar were exposed.

Physical examination of her left upper extremity revealed the incomplete sensory radial nerve palsy. The initial radiographs of the left humerus and forearm demonstrated the humeral supracondylar fracture and Monteggia fracture-dislocation with ulnar shaft segmental fracture. Ulnar shaft medullary canal was nearly 3 mm in diameter.

The patient was taken to the operating room for first aid for soft-tissue wound, resection of the radial head, and percutaneous K-wires placement for the humeral supracondylar fracture [Figure 1].
Figure 1: Resection of the radial head and percutaneous K-wires placement for the humeral supracondylar fracture

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The left upper extremity injury was stabilized in a splint until the next day when the patient was transferred to the orthopedic department.

The patient was taken to the operating room again for a closed reduction and internal fixation of the ulnar shaft segmental fracture.

Surgical procedure

The surgical fixation was performed under the general anesthesia and the axillary block anesthesia.

After positioning of the patient and reduction of the fracture under fluoroscopic control using the longitudinal traction, a minimal incision was made over the olecranon tip.

After making an entry point with a 3.2-mm drill at the tip of the olecranon, new simple unicortex locking intramedullary nail (3 mm by 180 mm) was inserted.

The intramedullary nail was grooved on the proximal and distal end [Figure 2].
Figure 2: Locking groove of new simple unicortex locking intramedullary nail

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The groove position was confirmed with fluoroscopy and one fully-threaded unicortex locking screw was inserted proximally and another one was inserted distally [Figure 3].
Figure 3: Unicortex locking screw placement

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The patient had an uneventful postoperative recovery and was allowed to slightly move the elbow and the wrist postoperatively, and further radiographs were obtained to confirm the position [Figure 4].
Figure 4: Preoperative anterior–posterior (a) and postoperative lateral (b) fluoroscopy views of the left forearm

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On follow-up at 6 weeks in the outpatient clinic, the pain had settled well, wounds had healed satisfactorily, and she had a good range of motion in the left elbow and wrist on examination. Repeated radiographs demonstrated good callus formation around the ulnar shaft fracture sites.

At 12 weeks, the patient was allowed to fully supinate, pronate the wrist and by 16 weeks, she had returned to working and her QuickDASH score was 23 out of 24 [Figure 5].
Figure 5: Fluoroscopy views at 12 weeks

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  Discussion Top


Monteggia fracture-dislocation with the ulnar shaft segmental fracture is rare. The treatment options can be operative with the locking intramedullary nail.[6],[16],[17],[18],[19]

Historically, the locking techniques for forearm shaft fracture were specific to each appliance. Various modifications of the cross-sectional shape of the nail improved fixation due to their proximal and distal cross-locking capabilities such as a triangular-shaped Sage nail, a square-shaped Street nail, and a Star-shaped True-Flex nail.[1],[2],[10],[20] These designs (e.g. the Sage nail) often have fluted cross-sections, and these offer additional fixation and reasonable rotational stability by good cortical contact.

More recent interlocking nail designs such as the ForeSight nail and the Stainless Steel Taper stainless steel nail provide rigid fixation by interlocking screws across both cortices.[9],[11],[15],[21] Generally, medullary canals less than 3 mm in diameter contraindicate locked intramedullary nailing.

In our case, the initial radiographs demonstrated ulnar shaft segmental fracture; ulnar shaft medullary canal was nearly 3 mm in diameter. We used new simple unicortex locking intramedullary nail (3 mm by 190 mm) and unicortex locking screws.

In the literature,[8],[9],[10] the diameter of locking intramedullary nail is 4 to 5 mm and the diameter of interlocking screw is 2.7 mm.

The diameter of interlocking hole is more than 2.7 mm.

New simple unicortex locking intramedullary nail has locking grooves instead of the locking holes. The depth of the groove is 1.2 to 1.3 mm and the length is 3.1 to 3.2 mm. The threaded unicortex locking screw is placed in the groove of the nail. The diameter and the length of new simple unicortex locking screw are 3 mm each.

In the literature,[10],[15] the unicortex locking technique was applied to olecranon generally. The unicortex locking screw was transfixed through the nail. But, new simple unicortex locking screw is not transfixed through the nail and is contacted with locking groove of the nail across only one cortex.

In our opinion, new simple unicortex locking intramedullary fixation was the rational surgical approach in the management of the ulnar shaft segmental fracture with small medullary canal.

Our case demonstrates an option of using a locking intramedullary nail without the use of interlocking screws across both cortices with good clinical outcome.

The important aspect is to use a smaller drill than new simple unicortex locking screw diameter making the entry portal for interlocking.

We think new simple unicortex locking intramedullary fixation is a good surgical approach for the ulnar shaft segmental fracture with small medullary canal although the fixation is less rigid than typical interlocking technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to b'e reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sage FP. Medullary fixation of fractures of the forearm: A study of the medullary canal of the radius and a report of 50 fractures of the radius treated with a prebent triangular nail. J Bone Joint Surg Am 1959;41:1489-516.  Back to cited text no. 1
    
2.
Sage FP. Fractures of the shafts and distal ends of the radius and ulna. Instr Course Lect 1971;20:91-115.  Back to cited text no. 2
    
3.
Smith H, Sage FP. Medullary fixation of forearm fractures. J Bone Joint Surg Am 1957;39:91-8.  Back to cited text no. 3
    
4.
Anderson LD, Sisk TD, Tooms RE, Park WI 3rd. Compression-plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg 1975;57:287-97.  Back to cited text no. 4
    
5.
Chapman MW, Gordon JE, Zissimos AG. Compression-plate fixation of acute fractures of the diaphyses of the radius and ulna. J Bone Joint Surg 1989;71:159-69.  Back to cited text no. 5
    
6.
Duncan R, Geissler W, Freeland AE, Savoie FH. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma 1992;6:25-31.  Back to cited text no. 6
    
7.
Marek FM. Axial fixation of forearm fractures. J Bone Joint Surg Am 1961;43:1099–114.  Back to cited text no. 7
    
8.
McLaren AC, Hedley A, Magee F. The effect of intramedullary rod stiffness on fracture healing. Paper presented at 60th Annual Meeting of OTA, Toronto, 1990.  Back to cited text no. 8
    
9.
Weckbach A, Blattert TR, Weisser CH. Interlocking nailing of forearm fractures. Arch Orthop Trauma Surg 2006;126:309-15.  Back to cited text no. 9
    
10.
Street DM. Intramedullary forearm nailing. Clin Orthop 1986;212:219-30.  Back to cited text no. 10
    
11.
De Pedro JA, Garcia-Navarrete F, Garcia De Lucas F, Otero R, Oteo A, Lopez-Duran Stern L. Internal fixation of ulnar fractures by locking nail. Clin Orthop 1992;283:81-5.  Back to cited text no. 11
    
12.
Crenshaw AH Jr, Staton K. Intramedullary nailing of forearm fractures. Paper presented at the American Academy of Orthopaedic Surgeons, Instructional Course Lectures, Orlando, Fla, Mar 24-28, 2000.  Back to cited text no. 12
    
13.
Crenshaw AH, Zinar DM, Pickering RM. Intramedullary nailing of forearm fractures. Instr Course Lect 2002;51:279-89.  Back to cited text no. 13
    
14.
Hong G, Cong-Feng L, Hui-Peng S, Cun-Yi F, Bing-Fang Z. Treatment of diaphyseal forearm nonunions with interlocking intramedullary nails. Clin Orthop Relat Res 2006;450:186-92.  Back to cited text no. 14
    
15.
Gao H, Luo CF, Zhang CQ, Shi HP, Fan CY, Zen BF. Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: Short-term results in eighteen patients. J Orthop Trauma 2005;19:384-91.  Back to cited text no. 15
    
16.
Bado JL. The monteggia lesion. Clin Orthop Relat Res 1967;50:71-86.  Back to cited text no. 16
    
17.
Bruce HE, Harvey JP, Wilson JC Jr. Monteggia fractures. J Bone Joint Surg Am 1974;56:1563-76.  Back to cited text no. 17
    
18.
Konrad GG, Kundel K, Kreuz PC, Oberst M, Sudkamp NP.: Monteggia fractures in adults: Longterm results and prognostic factors. J Bone Joint Surg Br 2007;89:354-60.  Back to cited text no. 18
    
19.
Ring D, Jupiter JB, Simpson NS. Monteggia fractures in adults. J Bone Joint Surg Am 1998;80:1733-44.  Back to cited text no. 19
    
20.
Sage FP. Fractures of the shaft of the radius and ulna in the adult. In: Adams JP. editor. Current Practice in Orthopaedic Surgery. Vol 1. St. Louis: CV Mosby; 1963.  Back to cited text no. 20
    
21.
Lee YH, Lee SK, Chung MS, Baek GH, Gong HS, Kim KH. Interlocking contoured intramedullary nail fixation for selected diaphyseal fractures of the forearm in adults. J Bone Joint Surg Am 2008;90:1891-8.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]



 

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