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http://dx.doi.org/10.5704/MOJ.1607.006

Nonunion of Fractures of the Ulna and Radius Diaphyses:

Clinical and Radiological Results of Surgical Treatment

Boussakri H**, Elibrahimi A*, Bachiri M*, Elidrissi M*, Shimi M*, Elmrini A*
*Department of Orthopeadic Surgery B4, Hassan II University Hospital, Fez, Morocco
**Department of Orthopaedic and Traumatology Surgery, Midelt Hospital, Morocco

Date of submission: March 2016

Date of acceptance: June 2016

ABSTRACT and joint stiffness that is associated with long-term

immobilization 8. The goal of surgery is to achieve complete
Aseptic nonunion of the radius and ulna is a major
union of the fractures and restore the functional anatomy
complication of forearm fractures, accounting for 2% to 10%
between the radius and the ulna, so as to obtain a normal
of all forearm fractures. The aim of our study is to evaluate
hand function 9. This surgical stabilization at the nonunion
the functional and radiological results of surgical treatment
should be associated with the compression of the fracture site
of diaphyseal aseptic nonunion of the radius and ulna, with
and stimulation of bone formation by bone grafting and or
autologous bone grafting, decortication and internal plate
decortication according to Judet et al 10. Other treatment
fixation. A series of 21 patients (26 nonunions) was
options are discussed, such as bone-marrow injection, and
retrospectively reviewed, the average age was 35 years with
induced membrane technique which are not the choice of our
a mean of 31,58 years (range 12-44 years) . The fractures
surgeons.
included isolated radius (n=6) and ulna (n=10), and both
radius and ulna (n=5). The Grace and Eversmann score was
In this single-centered retrospective study, we aim to analyze
used to evaluate our results. Fifteen had very good results,
the causative factors of aseptic non union of the forearm
five good and one average. Consolidation of the two bones
fractures and evaluate the clinical and radiological results
was attained in 6.2 months. Therefore, the functional
and the operative treatment with a dynamic compression
prognosis of the upper limb imposes the need for an adequate
plate, bone grafting and decortication.
treatment. This management strategy has enabled us to have
satisfactory results. However, the best treatment of nonunion
remains the preventive treatment with an optimal management
MATERIALS AND METHODS
and care of the forearm fractures.
This is a retrospective study of 21 patients (with 26
Key Words: nonunions) treated between May 2007 and January 2013 for
Radius and ulna, diaphyseal fracture, nonunion aseptic diaphyseal nonunion of the radius and ulna. The
inclusion criteria were the existence of aseptic nonunion of
the diaphysis of the one and or both bones of the forearm
INTRODUCTION treated with compression plate and screws, and associated
with an autogenous iliac bone graft and osteomuscular
Non unions are a major complication of diaphyseal fractures
decortication. Exclusion criteria were septic nonunions and
of the forearm, with eventual variable dysfunction of the
metaphyseal-epiphyseal nonunions as well as nonunions
upper limb and hand 1. Non union is defined as absence of
restricted to the proximal or distal quarter fractures of both
radiological and clinical signs of unions after an average
forearm bones and those treated with other therapeutic
period of six months. The use of dynamic compression plate
modalities.
has totally changed the prognosis of surgical treatment of
diaphyseal fractures of the radius and ulna. Although large
We applied the classification of AO when we used the initial
series in the literature have shown that this technique is
radiographs to classify fractures of the forearm 11. Comparing
simple with a low complication rate 1,2, the incidence of
the radiographs of delayed unions and nonunion of the
aseptic nonunion of the forearm fractures remains significant
forearm fractures, we noticed the absence of bone
between 2% and 10% in various publications 1,3-7. The
consolidation in the first stage after a period going from
management of these non unions remains difficult due to the
three to six months of the initial treatment; whereas, the
poor bone mass, the existence of previous implant material
radiographs of the second stage showed a total lack of union
Corresponding Author: Hassan Boussakri, Department of Orthopaedic Surgery B4,Hassan II University Hospital, Fez, 30000, Kingdom of
Morocco
Email: [email protected]

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Malaysian Orthopaedic Journal 2016 Vol 10 No 2 Boussakri H, et al

after a period of six months. On these radiographs, we also removing the osteosynthesis implant applied previously (Fig
analyzed the level of nonunion, and its type as well as the 1a), then the nonunion focal spot was clared of the fibrosis
initial treatment of the fracture of the forearm. Furthermore, tissue and the tissue-ingrowth associated with medullary
the interpretation of this imagery also helped us search for recanalization. Besides, we obtained the routine
technical errors and factors which would have contributed to bacteriological samples and did an osteomuscular
nonunion. decortication (Fig 1b). The graft was then taken from the
anterior ipsilateral iliac crest and packed opposite the
Of these 21 patients (Table I), there were 16 men and five nonunion focal spot (Fig 2a). Fixation with dynamic plate
women, average age was 34.52 years, with extremes of 18 compression (type DCP (3.5mm)) was applied after manual
and 56, a standard deviation of 11.53 and a median of 34. compression of the nonunion focal spot. The optimum
Our center had initially taken care of six patients. We had 13 application included at least three screws on either side of
cases with fractures on the left side, and 8 cases on the right. the focal spot (Fig 2b). The upper limb was immobilized in
Among our 21 patients, 12 patients had the fractures on their a splint for 30 days and antibiotic prophylaxis instituted with
dominant side. Fifteen patients were engaged in manual first generation cephalosporin (1CG) for 48 hours.
work, four non-manual work and two had no vocations. All Functional rehabilitation (passive and active) of the
patients in our series had pain. On visual analogue scale, proximal and distal joints was carried out. All
pain was an average of 7/10 (EV: 5-10) 12. According to the bacteriological samples taken were negative.
topography of lesions: five cases had fractures of both bones
of the forearm, 10 cases an isolated fracture of the ulna shaft, The patients were followed-up to assess pain on analogue
including two Monteggia fracture dislocations, and six scale 12, the range of motion of the elbow and wrist using a
cases with an isolated fracture of the radial shaft. We noted goniometer and detect any morbidity of bone graft site. We
two cases of polytrauma (all following road traffic accidents) proceeded to an overall evaluation of our functional results
and three cases of open fracture (stage I in one case and stage through the Grace and Eversmann score 14 and the DASH
II in two cases). One case of paresthesia in the territory of questionnaire 15.
the median nerve had been recorded. However, there were
no case of radial nerve palsy. The initial fracture line The post-operative radiological evaluation included AP and
according to the AO classification of diaphyseal fractures of lateral views of the forearm. The consolidation was
the forearm were five fractures A1 and two type A2, three confirmed based on the existence of the two orthogonal
A3, eight B1, six B3 and two C2 (Table I). The nonunion evidence of bony bridges between the two ends of the
sites: 18 fractures in the middle third, six in the distal third, nonunion focal spot, and absence of pain or tenderness at the
and two fractures in the proximal third. In eleven cases, the fracture site. The radiological study was also to detect any
initial treatment of the fracture consisted of intramedullary evidence of malunion and to measure its angulation in the
pinning on by Kirschner wire, 14 plate and screws and an frontal and sagittal planes.
external fixation for the one open fracture.

The time between initial treatment and the treatment of RESULTS

nonunion was seven months (range: 5 to 16 months). Thus,
All patients were operated by two senior surgeons,
three of our patients were operated before six months, which
specialized in upper limb surgery. For diaphyseal forearm
is theoretically considered as the period for diagnosis of
aseptic nonunion with less than 3 cm of bone defect, were
nonunion. Conventionally, we differentiated between two
treated with debridement and fixation by a dynamic
types of nonunion: a viable nonunion (hypertrophic or
compression plate and iliac bone autograft. The average
oligotrophic) with a large callus or malunion that is
follow-up was 31.58 months (range: 12 to 44 months), the
mechanically incompetent, and atrophic nonunion (or
standard deviation was of 10.27, and the median was of 30.
devitalized nonunion) without callus, which required an
osteogenic treatment. In our series, 58% of nonunions were
The mean pre-operating range of elbow motion was 100°
oligotrophic (15 cases), 35% were hypertrophic (9 cases) and
(70° - 140 °) , with an average extension deficit of 10° and
7% were atrophic (2 cases) (Table I).
its average pronation 55° (0° -75°), with a supination of 50°
(0° -85°). On the wrist, the average preoperative flexion was
Surgical technique: Based on the criteria of Corrales et al.13,
48° (range: 10° - 90°), with an average extension of 60°
the operating indications relied on the existence of clinical
(range: 15° - 90°). At the last following up, the average
signs of nonunion (pain and / or mobility of the fracture) and
mobility of the wrist was 60° (20° - 90°) in flexion
radiological signs (lack of bone consolidation) after six
(postoperative improvement in comparison to the
months since the start of treatment of the initial fracture.
preoperative condition) and 70° (30° -90°) in extension;
The incision used was the classical anterior approach of
whereas, the average pronation was of 65° (0° - 80°) with
Henry for the radius and, the dorsal approach centered on the
supination of 70° (0° - 85°). The elbow average flexion was
ulnar ridge for the ulna. The first surgical step consisted of
130° (90° -140°) and the average extension deficit was 5°.

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Treatment of Radius and Ulna Diaphyseal Non-union

Table I: Clinical and anatomical data of the 21 patients

Patient Age/Sex Nonunion Type of fracture Type of nonunion Follow up

localization (AO) (in months)
MM 18 M Ulna A1 oligotrophic 44
KA 56 M Ulna A1 oligotrophic 36
SA 34 F Ulna B3 oligotrophic 44
AM 43 M Ulna B3 oligotrophic 26
AT 24 M Ulna A1 hypertrophic 42
AE 28 F Ulna B3 hypertrophic 39
HA 31 F Ulna B1 hypertrophic 30
OF 37 M Radius B1 oligotrophic 32
OF 37 M Ulna B1 oligotrophic 32
EM 38 M Radius B1 oligotrophic 36
EJ 48 M Radius B3 oligotrophic 23
EJ 48 M Ulna B3 oligotrophic 23
HE 30 F Ulna B1 oligotrophic 34
HB 50 F Radius A2 hypertrophic 26
HB 50 F Ulna A2 hypertrophic 26
JE 38 M Radius A3 oligotrophic 44
BA 46 M Radius B1 oligotrophic 30
BA 46 M Ulna B1 oligotrophic 30
EK 30 M Radius B3 hypertrophic 17
JN 19 M Radius B3 hypertrophic 28
JD 27 M Radius C1 atrophic 12
JD 27 M Ulna C1 atrophic 12
BH 31 M Ulna A1 hypertrophic 46
AM 20 M Ulna A1 hypertrophic 37
DM 32 M Radius A3 oligotrophic 19
SM 27 M Radius B1 atrophic 24

AO : Muller classification of fractures. M : male, F : female.

Table II: Preoperative and postoperative range of motion of the series

Preoperative period Postoperative period

Series (21 patients) Mobility Mobility Mobility Mobility Mobility Mobility
in pronation- in Flexion- in Flexion- in pronation- in in
supination extension extension supination Flexion- Flexion-
of the elbow of the wrist extension extension
of the elbow of the wrist
MM (Ulna) 75/80 130/0 70/90 80/80 135/0 65/80
KA(Ulna) 50/50 140/0 70/80 70/60 140/0 70/80
SA (Ulna) 40/55 135/0 70/80 40/60 130/0 70/80
AM (Ulna) 75/85 140/0 75/55 80/80 140/0 60/50
AT (Ulna) 70/55 120/0 70/80 80/50 120/-5 75/80
AE (Ulna) 75/70 110/0 50/55 80/80 140/0 75/80
HA (Ulna) 10/50 70/0 10/15 0/80 140/0 20/30
OF (Radius) 40/60 140/0 55/50 65/70 140/0 75/50
OF(Ulna) 40/60 140/0 55/50 65/70 140/0 75/50
EM(Radius) 80/80 140/0 75/90 75/50 130/0 70/80
EJ(Radius) 60/85 130/0 60 /60 70/70 140/0 70/60
EJ(Ulna) 60/85 130/0 60/60 70/70 140/0 70/60
HE (Ulna) 55/75 140/0 70/75 50/60 140/0 70/80
HB(Radius) 60/40 135/0 70/70 40/40 140/0 90/75
HB(Ulna) 60/40 135/0 70/70 40/40 140/0 90/75
JE(Radius) 70/70 140/0 60/90 75/80 120/0 70/80
BA(Radius) 0/30 90/0 55/55 55/80 140/0 80/80
BA(Ulna) 0/30 90/0 55/55 55/80 140/0 80/80
EK (Radius) 60/85 120/0 70/70 80/85 140/0 70/80
JN(Radius) 50/50 135/0 65/60 55/60 140/0 70/80
JD(Radius) 55/60 130/0 50/50 40/70 90/0 65/70
JD(Ulna) 55/60 130/0 50/50 40/70 90/0 65/70
BH( Ulna) 75/75 140/0 70/90 80/80 140/0 80/80
AM( Ulna) 60/70 130/0 80/80 70/50 120/0 75/80
DM (Radius) 40/20 140/0 50/60 50/0 140/0 55/75
SM (Radius) 75/70 135/0 70/90 80/80 130/0 70/75

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Table III: The average preoperative and postoperative range of motion

Average range Flexion Extension Pronation Supination Flexion Extension

of motion (wrist) (wrist) (forearm) (forearm) (elbow) (elbow)
Preoperative results 48° 60° 55° 50° 100° Average
[10° - 90°] [15° - 90°] [0° - 75°] [0° - 85°] [70° - 140°] deficit of 10°
Postoperative results 60° 70° 65° 70° 130° Average deficit
[20° - 90°] [30° - 90°] [0° - 80°] [0° - 85°] [90°-140°) of 5°

Table IV: Comparative results of the plate osteosynthesis in various series

Authors Number of cases Radiological Union Follow up (in months)
Kloen P 47 100% 75
(2010) [12-315]
Ring D 35 100% 43
(2004)
Baldy dos Reis F(2009) 31 30/31 patients 43,2
97 % [24-72]
Our study 21 95% 32 (31,58)
[12- 44]

a b

Fig. 1: Intraoperative appearance. (a): nonunion of the ulna with the material fracture. (b) : decortication and debridement of the
fracture site.

c d

Fig. 2: (c): corticocancellous graft. (d): final intraoperative appearance after implementation of graft and fixation by a dynamic
compression (DCP).

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Treatment of Radius and Ulna Diaphyseal Non-union

Fig. 3: Nonunion of the ulna on a screwed plate after a period Fig. 4: Functional results.
of 10 months with union of the focal spot.

Thus, we noted an improvement in postoperative mobility DISCUSSION

compared to the preoperative status (Table II-III).
Aseptic nonunion remains a significant late complication of
diaphyseal forearm fractures with reported incidences
According to Grace and Eversmann score, the therapeutic
ranging from 2% to 10%. 1, 3-7.
results were: 15 excellent (Fig. 3-4), five good and one case
of average results. This one case who presented with the
Treatment of nonunion of the forearm remains a matter of
average results, had been operated twice in another hospital.
debate. Several surgical techniques : internal fixation with
She was addicted to smoking, and she also had reflex
bridging plate, intramedullary nailing, and external fixation
sympathetic dystrophy syndrome. The overall average
have been recommended 17-22. A successful surgical treatment
DASH score was 14 (5-36). Radiological consolidation was
of nonunion of the forearm requires several considerations:
achieved in 25 nonunions (20 cases or 95.11%) within an
time to receive the appropriate care in relation to the initial
average of 6.2 months. Nine cases had fracture consolidation
injury, the number of previous surgery, the presence of
in the first quarter, 13 cases in the second quarter and three
infection, the length of the bone defect and finally the type of
cases in the third quarter, while one case had been
fixation method. The aim of the surgical treatment is to re-
consolidated in the fourth quarter. There was one case with
establish length of both the radius and ulna, restores their
radiological nonunion but was asymptomatic. The analysis
anatomy and quickly recovers the function of the upper limb
of the AP and lateral radiographs (Fig. 3) allowed us to
and hand 21. Diaphyseal fracture nonunion of upper limb,
ascertain malunion without any functional disability in one
including the forearm, must be differentiated from
case with callus on both bones of the forearm with varus of
diaphyseal nonunion of lower limb fractures because the
2° on the radius and 3° on the ulna and two calluses with
main constraints are related to rotation and distraction and
valgus of 2° on the radius. On the other hand, we did not find
not to compression 23. This fundamental constitutes the basis
any limb length discrepancy or any rotational malunion.
of diaphyseal fractures treatment of the forearm, which will
block rigidly the shearing forces and rotation.
Complications:
We encountered two hematomas which had resorbed with
In the light of the results of our study and those reported in
local treatment and an early surgical site infection with
the literature (Table IV), the treatment of nonunion of
methicillin resistant Staphylococcus aureus, which resolved
diaphyseal forearm fractures by bone graft and fixation with
with appropriate antibiotics therapy. A single case of chronic
a bridging plate gives excellent results if the principles of
regional pain syndrome had been documented at one year
this technique are adhered. These principles include
follow-up.
freshening the non-viable tissue, removal of the defective
osteosynthesis material, restoration of alignment, length and
The morbidity related the iliac crest was minimal with two
rotation. We have found in our study that oligotrophic
patients who had mild pain, which did not require painkiller,
nonunion are more common than hypertrophic or atrophic
and one unsightly scar.

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Malaysian Orthopaedic Journal 2016 Vol 10 No 2 Boussakri H, et al

nonunion, and that the high rate of nonunion for ulna is likely recommended this technique in the absence of infection and
to be explained by the use of the intramedullary pinning to the existence of a bone gap between the two fracture ends of
treat fractures of the ulna. Some authors have shown that less than 50mm 27, this does not preclude that there are
stabilization of forearm fractures with intramedullary authors who believe that osteomuscular decortication is
Kirschner wire and one-third tubular plate may have a high sufficient and can replace the bone graft since this latter can
risk of nonunion because of the fastening failure 16. On the cause morbidity of the engraftment site10. Ramoutar et al 28
other hand, no study has shown a significant difference in showed that the usual use of autologous bone graft was not
risk between ulna and radius that leads to nonunion 8-24. necessary, and in their comparative study showed that the
union ratio without the use of bone graft was 94.6% while
Some authors report the importance of the use of adding bone graft let's have a union ratio of 95%, without
intramedullary nailing in the treatment of nonunion of the any difference (p = 0.67). This standard technique using a
forearm, a technique in which we have no experience, and bone plate and an iliac graft is less effective in the treatment
we believe that this technique provides relative stability and of long defects. It is particularly less effective in bone
lack of rotation control 21,31. The locked intramedullary nail defects over 60 mm and which have operational difficulties
treatment is commonly used in the treatment of nonunions of for the management of the iliac graft so as to obtain sufficient
long bones of the lower limb 32. The authors emphasize on compression and a normal length due to the physiological
the possibility to cure nonunion of the forearm by an bowing (curvature) of the bone 27. Ring et al 26 showed that a
intramedullary nailing, profiting from closed focal spot non-vascularized autologous bone graft led to union in the
fixation which would have union rates comparable to those case of atrophic nonunion with bone loss up to 6 cm while,
using compression plates 21. We think that we need to be more Dos Reis et al 29 showed, in a series of 31 patients, that
critical and do not advise the treatment of forearm nonunion treatment with corticocancellous bone graft and fixation with
by nailing, especially as some authors propose to associate a plate for atrophic and hypertrophic nonunion led to
an intramedullary nailing to a cortico cancellous bone graft excellent radiological and functional results. However, the
with an open focal spot in order to improve anatomical treatment remains controversial for bone defects varying
results, particularly in case of atrophic nonunion 10,33. In this between 6cm and 10.5 cm 27,30. Davey et al emphasized on the
case, we lose all the advantages of closed focal spot fixation; limits of the use indications concerning non-vascularized
however, the locked nail seemed to be indicated only for bone graft for bone defects exceeding 6 cm. In order to be
hypertrophic diaphyseal nonunion without bone graft. successful, this surgical technique depends on the union and
Concerning the external fixation method, it is commonly healing of corticocancellous bone graft.
used in the treatment of septic nonunion and its effectiveness
is recognized. This type of treatment often use the Ilizarov Our results are in agreement with other reports published in
external fixator 19. Its proponents believe that through it they the literature. We had only minimal complications and a
stop septic risks and periosteal devitalization, but in reality, satisfactory consolidation rate of 95% compared to the
it suffers from some side effects such as: difficulties in literature which varies between 91% and 100% (Table IV).
blocking rotation, obtaining an anatomical reduction, poor We obtained excellent functional end results. Therefore, this
fixation and insufficient focal spot compression, as well as surgical method is, from our point of view, an excellent
complications including nerve and vascular damage during technique to treat forearm diaphyseal fracture nonunion.
the installation of sheets. Finally, the current therapeutic approach prevents the
occurrence of nonunion. This rule is especially applied to
It is important to compare between the two types of fractures involving both bones of the forearm, which are
nonunion, the one which only concerns one forearm bone conventionally treated by plate osteosynthesis. It seems clear
and the one which concerns a dual radius and ulna nonunion that the absence of bone formation around the third or the
whose impact on the function is definitely different. fourth month pushes us to take an almost early preventive
therapeutic approach with a possible bone intake and a
The choice of bone graft is still a controversial subject 25,26, change in the fixation if it seems essential.
since autologous bone graft is often performed in
orthopaedic surgery for the treatment of nonunion, and even
in the treatment of fractures of the forearm so as to accelerate CONCLUSION
healing as well as to prevent nonunion. This attitude remains
Surgical management steps for non union with decortication,
controversial in the literature 4,5. Furthermore, the iliac crest
bone autograft and stabilization with bridging plate has
is the most common donor site for obtaining an autologous
achieved satisfactory results in our series.
bone graft. These autografts have advantages, like the
absence of risk of autoimmune response and disease
Declaration of interest: The authors declare that they have
transmission. Nicoll 17 was the first to report the value of use
no conflicts of interest related to this article.
of corticocancellous autograft in nonunion of the forearm, he

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Treatment of Radius and Ulna Diaphyseal Non-union

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