|Year : 2014 | Volume
| Issue : 3 | Page : 167-172
Rush nail and management of fracture both bone forearm
Soumya Ghosh1, Arnad Chowdhury1, Arunima Chaudhuri2, Soma Datta3, Debasis Singha Roy1, Abhinay Singh1
1 Department of Orthopedics, BMCH, Burdwan, West Bengal, India
2 Department of Physiology, BMCH, Burdwan, West Bengal, India
3 Department of Pathology, BMCH, Burdwan, West Bengal, India
|Date of Web Publication||19-Sep-2014|
Krishnasayar South, Borehat, Burdwan - 713 102, West Bengal
Source of Support: None, Conflict of Interest: None
Background: The failure of the conventional nailing of both bone of the forearm poses a potential problem of nail migration and rotational instability, despite the best reduction. Objectives: Rush nail is a very handy, low cost easily available implant. In the present study, we have tried to find out its applicability if used in the closed manner under C-arm control without injurying soft tissues and preserving the periosteal vascularity. Materials and Methods: This prospective study was conducted on thirty adult subjects. Skeletally mature subjects with Gustilo type 1 open and closed fractures without the neurovascular deficit were included. Stainless steel rush nails were used for all patients for both radius and ulnar repair. Patients were followed-up for a minimum of 4 months and maximum of 1.5 years. Results: The mean age of study participants was 37.43 years. Mean time of the union was 14.32 weeks. Average operative time was 67.16 min. No intraoperative complication occurred nor was any nailing converted to some other form of fixation, except in three cases radial nail was introduced by open method through anterior Henry's approach. Cast support was maintained for a mean of 7.43 weeks, after that forearm brace was applied for a mean period of 6.26 weeks and continued until radiographic union was seen. Three patients showed non-union of radius mostly distal third. They were treated with open reduction and internal fixation with locking plate and bone grafting. One patient had extensor tendon injury. Two patients have superficial infection which cured with antibiotics. One case had delayed union of radius which required bone grafting. Two patients had gross restrictions of wrist movements and pronation-supination movement. Using Anderson criteria 22 patients had satisfactory results (71.33%), three patients had excellent result. Three patients had non-unions (10%). Implant removal was performed in two cases about 14 months post-operatively and no refracture has been reported until date (after 4 months). Conclusion: Use of rush nail continues to have predictable and good results. Complication rates are lower when compared to plate osteosynthesis and even in locked intramedullary nails although application of above elbow cast after nailing is a downside of this procedure. The rush nail has still a future in repair of forearm fractures considering its low complications rates, cost and acceptable results in a developing country where financial matters are to be considered.
Keywords: Facture both bone forearm, rush nail, management in a developing country
|How to cite this article:|
Ghosh S, Chowdhury A, Chaudhuri A, Datta S, Roy DS, Singh A. Rush nail and management of fracture both bone forearm. J Sci Soc 2014;41:167-72
| Introduction|| |
Forearm skeleton in humans is adapted more for mobility than stability and plays an important role in upper extremity function. The presence of proximal and distal radio-ulnar joints allow pronation and supination movements. Moreover, forearm serves as the origin of muscles inserting on the hand, therefore fracture of forearm bones significantly affect a function of whole upper limb. Diaphyseal fractures of the radius and the ulna present specific problems in addition to problems common to all fractures of shafts of long bones. In addition to regaining length, apposition, axial alignment achieving normal rotational alignment is necessary for restoration of good range of pronation and supination movement. ,,
Malunion and non-union occur more frequently because of difficulty in reducing and maintaining the reduction of two parallel bones in the presence of pronating and supinating muscles having the power to angulate and rotate. The biceps and the supinator muscles exert rotational forces in proximal third of radius. In the mid and distal radius pronator teres and pronator quadratus come into play. ,,,
Singh and Sharma in a study of 40 patients each with diaphyseal fractures of both bones forearm treated by square nail showed intramedullary nailing is a simple method of treating forearm fractures with better results than conservative methods. Unstable fractures of radius and ulna with subluxation or dislocation of superior or inferior radio-ulnar joints and open fractures with skin loss needs internal fixation. 
With the unacceptable results of closed methods and with the less than excellent results of a variety of intramedullary appliances, numerous investigators sought more rigid fixation by means of plates and screws. ,,
The development of locked intramedullary nail systems has expanded the role of forearm nails in the management of diaphyseal forearm fractures. Interference fit nails generally cannot maintain bone length if bone loss occurs. Rotational control in fractures near the metaphyseal-diaphyseal junction is difficult with interference fit nails. Closed reduction and internal fixation of forearm fractures by screw intramedullary nails reestablishes the near normal relationship of the fractured fragments. Screw intramedullary nail effectively controls both rotatory forces and the migration of the nail. ,,,,, The failure of the conventional nailing of both forearm bones or isolated fractures of radius and ulna pose a potential problem of nail migration and rotational instability, despite the best reduction. When intramedullary fixation is used for any fracture, errors in selecting the proper length or diameter of the nail, operative technique and after treatment contribute to poor results. Intramedullary fixation of the forearm is no exception. In this case, errors in measuring the length of the nail are unusual, but disproportion between the size of the nail and the medullary canal often occurs and allows side-to-side and rotary movements if the nail is too small and further comminution or additional fracture if it is too large. Complication rates associated with the use of square nails were lower when compared to plate osteosynthesis and locked intramedullary nails. ,,,,,
Rush nail is a very handy, low cost easily available implant. In the present study, we have tried to find out its applicability if used in the closed manner under C-arm control without injurying soft tissues and preserving the periosteal vascularity. The objectives were to evaluate the results of closed intramedullary fixation of fractures of both bone forearm in terms of fracture union, range of movement complications and functional outcome.
| Materials and methods|| |
This case series prospective study was conducted on 30 adult subjects, attending a tertiary care hospital in West Bengal during the period between April 2012 and March 2013 after getting clearance from the institutional ethics committee. Written informed consent was taken from all the study participants for participation in this study.
Skeletally mature subjects with Gustilo type 1 open and closed fractures without neurovascular deficit attending Orthopaedics Department of Burdwan Medical College were included.
Comprised of skeletal immaturity; very narrow medullary canal; fractures older than 14 days before treatment; single bone fractures; presence of neurovascular deficit; fractures in proximal and distal metaphysis; presence of associated injuries such as distal radio-ulnar joint subluxation; patient with head injuries; Gustilo type 2 or 3 open fractures.
Stainless steel rush nails were used for all patients for both radius and ulnar repair. Nail diameters were 2.0 mm, 2.5 mm, 3.0 mm, or 3.5 mm, with nail lengths from 16 to 36 cm for all surgical procedures.
On admission of the patient, careful history was elicited followed by physical examination. Radiographs were evaluated for each patient for type and location of fractures. The size of the nails was estimated on the normal limb radiograph. An ulnar nail was placed along the ulnar border of the uninjured forearm to estimate nail size. Alternatively, the length of the ulnar nail was measured from the tip of then olecranon to the ulnar styloid −1 cm. The radius nail was measured from the Lister's tubercle to the lateral epicondyle −3 cm. The length of the radius nail is usually 2 cm shorter than the ulnar nail. The diameter of the nail is also estimated on the pre-operative X-ray and verified intraoperatively under the C-arm.
After thorough clinical evaluation X-ray [Figure 1] of the affected forearm was taken in both anteroposterior and lateral view including wrist and elbow joints. The limb was immobilized in above the elbow (AE) slab with positioning the forearm according to the site of fracture with sling. The patients were taken up for surgery after routine investigations and pre-anesthetic check-up.
Pre-operative implant assessment was done. Nail size was determined. The required nail was determined by measuring the normal limb. The ulna was measured with a tape from the tip of the olecranon to the ulnar styloid. The radius nail size is difficult to measure clinically; it is approximately 2 cm shorter than the ulna. One cm is subtracted from the measurement to avoid the risk of driving the nail through the end of bone. Nail diameter was determined by measuring the medullary canal size using X-ray. We routinely used thinner diameter nails (2-2.5 mm) during the procedure. All sizes were kept available at the time of surgery.
The patient was laid in supine position with forearm resting on the chest. Manual traction and counter traction with elbow flexed to right angle and manipulation at fracture site was done under C-arm guidance before positioning.
Surgical technique for intramedullary nailing
Under aseptic precautions radial nail was inserted from the distal end, either through radial styloid process or lateral to Lister's tubercle. About 1-1.6 cm incision was made over the radial styloid between the abductor pollicis longus and extensor pollicis brevis holding the wrist in palmar flexion and ulnar deviation. Entry portal was made over radial styloid about 5 mm from its articular surface on its lateral aspect with the help of bone awl [Figure 2]. Bone awl was inserted at 45° angle to the distal radius, after entering the bone for 1-1.5 cm taking care not go through the volar cortex. Angle of bone awl insertion was dropped to the axis of the bone and continued for another 2-4 cm. Entry portal was checked under C-arm guidance.
The nail was driven from distal to proximal fragment after reducing the fracture by manual traction and manipulation at the fracture site under C-arm guidance.
The nail was driven until the tip of the nail impinges against the bone. While driving the nail care was taken to avoid rotation and wrist was held in palmar flexion and ulnar deviation.
The nail for ulna was inserted from the olceranon process at a point 5 to 8 mm from the dorsal cortex (to avoid entering to trochlear notch) and 5 mm from the lateral cortex (to compensate for the lateral bow). An incision about 1 cm made over the end of olecranon splitting the insertion of triceps tendon. Nail was inserted into the proximal fragment after making entry portal with bone awl. Ulnar fracture was reduced by manual traction, counter traction and manipulation at the fracture site under C-arm guidance and the nail was passed. Ulnar nailing was done first, thereby providing a more stable forearm for nailing of the radius. The ulna was approached from the radial side of the olecranon tip an ulnar nail of appropriate size was selected and loaded over a T-handle. The nail was pushed free hand into the medullary canal of the ulna while the assistant applied traction in the position favoring reduction, depending on the type of fracture. If the nail did get jammed, it was hammered lightly so that it made its way into the medullary canal. The position was checked using the C-arm. The distal end of the nail was usually within 1 cm of the tip of ulna. The end of the nail was buried inside the olecranon. A radius nail of appropriate size was selected and pre-bent to match the radial contour. The radius nail was loaded over the T-handle with a Jacob's chuck and pushed with the beveled edge of the radius nail sliding over the volar surface of the radius.
The assistant assisted in reducing of the fracture. The position of the nail was checked repeatedly under C-arm in both planes during the procedure. The radial nail was inserted up to the proximal border of the bicipital tuberosity of the radius. Distally the nail was buried flush with the bone. In cases where reduction was difficult to achieve, a mini open reduction was performed.
All patients were immobilized with an AE slab and asked to perform active finger movements. Movement of the thumb was especially checked for any injury to the extensor pollicis longus tendon during surgery. Patients were discharged on the 3 rd to 4 th day post-operatively. Suture removal was done in 2 weeks and another AE cast was applied with the elbow in 90° of flexion and the forearm in neutral rotation. Patients were evaluated weekly and radiographically at 4 weekly intervals till union and then at 3 monthly intervals. When there is sufficient amount of callus usually at 8-10 weeks post-operatively, we removed cast and forearm was supported with forearm brace and patient was advised to perform elbow and wrist movement to avoid stiffness [Figure 3]. External support was removed 8-12 weeks post-operatively. The nails should be removed once union is secured but not before 1 year.
Results were assessed on the basis of the time to union, functional recovery and complications. Union was defined as the presence of bridging bone or trabeculae spanning the fracture site. The patients were also evaluated clinically for fracture site tenderness and pain on rotation. All patients were prescribed physiotherapy for range of motion and strengthening exercises. At the last assessment, the degree of forearm rotation was measured with a goniometer.
Functional outcome was calculated using the system described by Anderson et al [Figure 4], [Figure 5], [Figure 6], [Figure 7]. [Table 1]  shows criteria for functional assessment.
| Results|| |
During the study period, 30 cases were selected in this study following inclusion criteria mentioned earlier. Patients were followed-up for a minimum of 4 months and maximum of 1.5 years. The mean age of study participants was 37.43 years (range: 16-60 years), with a mean age in males of 38.05 years and mean age in females of 36.2 years (range: 16-51 year). Males are predominantly affected (70%). The right limb was fractured in 17 subjects (56.67%) and left limb was fractured in 13 subjects (43.33%). The most common mode of injury was road traffic accidents (63.33), followed by household falls (20%), fall from bicycle (13.33%). Short oblique fractures were the most common type of fracture in the present study. Mean time of the union is 14.32 weeks (range: 12-18 weeks) with standard deviation 2.091 weeks.
Average operative time was 67.16 min. No intraoperative complication occurred nor was any nailing converted to some other form of fixation. Except in three cases radial nail was introduced by an open method through Ant. Henry approach. Cast support was maintained for a mean of 7.43 weeks (range: 6-10 weeks) after that forearm brace was applied for a mean period of 6.26 weeks and continued until the radiographic union was seen. Three patients showed a non-union of radius mostly distal third. They were treated with open reduction and internal fixation with locking plate and bone grafting. One patient had an extensor tendon injury. Two patients have superficial infection which cured with antibiotics. One case had delayed union of radius which required bone grafting. Two patients had gross restrictions of wrist movements and pronation-supination movement. Using Anderson criteria 22 patients had satisfactory results (71.33%), three patients had excellent result. Three patients had non-unions (10%). Implant removal was performed in two cases about 14 months post-operatively and no refracture has been reported until date (after 4 months).
| Discussion|| |
Plate fixation has been considered the gold standard for fixation of both bone forearm fractures. Several studies have shown good results.  Total cost of rush nail instruments amounts to nearly 5000 rupees, while cost of plate and instruments varies from 15000 to 25000 and this should be kept in mind while treating poor patients in a developing country like India.
Possible complications include compartmental syndrome, delayed union or non-union and re-fractures after extraction of the plate.  A high frequency of intraoperative nerve injuries has also been reported. The reported incidence of transient dorsal nerve palsy is 7-10% of all patients with radius fracture treated by plating. Incidence of radio-ulnar synostosis of the plate fixation is reported in the literature is 2-9%. , Though plating for both forearm bones fracture is a sound practice and adheres to the principles of osteosynthesis, a straight plate is unable to maintain and preserve the radial bow, essential for normal rotational movements of the forearm. 
A study by Droll et al.  compared injured arms to uninjured arms, following internal fixation of the forearm fractures, and found that injured arms had reduced strength of forearm pronation (70%) of that of the normal arm, forearm supination (68%), wrist flexion (84%), wrist extension (63%) and grip (75%). In addition, the injured arms had a significantly reduced active range of forearm supination (90%), forearm pronation (91%) and wrist flexion (82%).
Closed nailing has many advantages, including early union, low incidence of infection, small scars, less blood loss, no periosteal stripping, minimal compromise to bone vascularity and frequently a relatively short operating time with minimal surgical trauma. In our experience, the main complications during surgery were due to improper nail size. Another important advantage of intramedullary implants is their stress-sharing behavior, which facilitates secondary periosteal callus formation. ,,,
Lil et al. prospectively evaluated 34 patients with both bone forearm fractures. 316 L stainless steel Talwarkar square nails were used for all patients for repair. The average time to the union was 12.8 weeks with cast support for a mean of 8.2 weeks. To control rotation post-operatively an AE cast after nailing was used. Union was achieved in 31 out of 34 patients. Using the Grace and Eversmann rating system, 17 patients had excellent, 10 had good and 4 had an acceptable results. Three patients had non-unions, 2 for the radius and one for ulna. There were two cases of superficial infection, one subject had olecranon bursitis, and one case of radio-ulnar synostosis. Complication rates associated with the use of square nails were lower as compared to plate osteosynthesis and locked intramedullary nails. 
In the present case series, the average operating time for fixation of both forearm fractures was comparable to other studies. We achieved union in 27 out of 30 patients (90%). The cause of the non-union in our study was a distraction at the fracture site in three cases, in radius, due to inadequate immobilization in all subjects who were not cooperative and inadequate nail size and length. Cast support was given to patients for a mean 7.43 weeks (range: 6-10 weeks). As most cases were closed procedures and an AE cast with forearm in midprone position followed by functional bracing was used post-operatively, final functional outcomes were improved. Implant removal was performed in two patients at mean 14 months post-operatively and no re-fractures were reported even after an average of 4 months post-removal which is lower than those associated with plate removal.
| Conclusion|| |
Use of rush nail continues to have predictable and good results. Complication rates are lower when compared to plate osteosynthesis and even in locked intramedullary nails although application of AE cast after nailing is a downside of this procedure. The rush nail has still a future in repair of forearm fractures considering its low complications rates, cost and acceptable results in a developing country where financial matters are to be considered.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]