The forearm is an important anatomical unit of the upper limb and it plays a crucial role in upper limb function by performing multiaxial activities required for living. The proximal and distal radioulnar joints are essential for facilitating pronation and supination movements of the forearm [1-4] Because of these unique anatomical and functional characteristics, the diaphyseal fractures of the forearm are complex and they differ significantly from the fractures of long bones and they may be managed similar to that of intra-articular fractures [5, 6] Based on the complex nature of injuries there are various modalities of treatment evolved for management of these injuries each offering its specific advantage. Forearm fractures if not treated promptly will result in considerable functional impairment. The incidence of these fractures is increasing due to increased road traffic accidents, industrialization, falls, and sports-related injuries [7]. One of the widely accepted procedures for the management of this type of injury is open reduction and internal fixation (ORIF) using a dynamic compression plate (DCP) [8]. Despite the introduction of newer plate osteosynthesis techniques, such as locking plates and limited contact plates, the DCP remains the preferred choice for many orthopedic surgeons (9).

The specific problems in relation to diaphyseal fractures of the radius and ulna are the chances of malunion and non-union are greater because of the difficulty of reducing and maintaining the reduction of two parallel bones in the presence of axial movements and rotator movements. Loss of forearm pronation commonly occurs with radius/ulna diaphyseal fractures which may or may not be functionally significant. Open reduction offers the best outcomes and therefore they are commonly preferred for treatment [10, 11]. The average undisplaced fractures of long bone take 6-8 weeks before they heal and displaced fractures take 3 -5 months for healing. Various authors have reported excellent results with plate fixation in displaced diaphyseal fractures of bones of the forearm and few authors have focused on plate fixation in the management of open diaphyseal fractures of both the radius and ulna [12-16]. The advantages of operative management are early mobilization and patient comfort but operative management carries the risk of technical errors and post-operative complications like infections and nerve injuries etc [17, 18]. Generally, non-specific intramedullary (IM) implants have been used as an alternative treatment method. Because they do not have locking and compression features, these materials cause high rates of nonunion; therefore, their use has been abandoned. Current IM forearm nails have emerged with locking and compression features. The use of this method in treatment is increasing with union rates similar to those of ORIF and very good functional results [19-22] with this background we in the present study tried to evaluate the outcomes of the dynamic compression plates and IM square nail in the treatment of the diaphyseal fractures of radius and ulna.

This prospective clinical study was conducted at the Department of Orthopaedics, Rajiv Gandhi Institute of Medical Sciences (RIMS), Adilabad. Institutional Ethical approval was obtained for the study from the institutional Ethical committee. Written consent was obtained from all the participants of the study and possible outcomes after explaining the nature of the study in vernacular language. Only those patients who were willing to participate in the study voluntarily were included in the study. 

Inclusion Criteria

1. Patients aged 18 to 60 years both males and females
2. Acute, closed, or Grade I open diaphyseal fractures of both the radius and ulna
3. Fractures located in the middle third (midshaft) of both bones
4. Fractures amenable to both dynamic compression plating (DCP) and intramedullary (IM) nailing
5. Willingness to comply with follow-up protocol

Exclusion Criteria

1. Pathological fractures
2. Segmental, comminuted Grade II or III open fractures
3. Fractures involving the proximal or distal third of the radius or ulna
4. Associated neurovascular injury
5. Systemic illness contraindicating surgery

A total of 40 patients were enrolled and randomly allocated into two groups based on the clinical evaluation and preoperative assessment.

Group A (DCP Group) N=20: Treated with open reduction and internal fixation using dynamic compression plates. Group B (IM Nail Group) N=20: Treated with closed or mini-open reduction and fixation using square intramedullary nails with locking features

Surgical Technique in brief: All procedures were performed under general or regional anesthesia. Group A: Open reduction was done using standard volar (Henry) and dorsal (Thompson) approaches. Anatomical reduction was achieved, followed by fixation with 3.5 mm dynamic compression plates and cortical screws. Group B: A small incision was made over the olecranon for the ulna and the distal radius for radial entry. Closed or mini-open reduction was followed by the insertion of pre-contoured square intramedullary nails with distal locking to enhance rotational stability.

Postoperative antibiotics and analgesia were administered according to hospital protocol. Early mobilization was encouraged as tolerated.

Follow-up and Evaluation: Patients were followed up at 2, 6, 12, and 24 weeks postoperatively. Clinical and radiological assessments were done at each visit. The following parameters were evaluated:

• Union Time: Defined as the presence of bridging callus across three cortices on radiographs and absence of pain or tenderness at the fracture site
• Functional Outcome: Assessed using the Disabilities of the Arm, Shoulder, and Hand (DASH) score and Mayo Elbow Performance Score (MEPS)
• Complications: Including infection, implant failure, nonunion, malunion, and restricted range of motion

Statistical Analysis: Data were analyzed using SPSS software version 23. Continuous variables were expressed as mean ± standard deviation and categorical variables as frequencies and percentages. Student's t-test and chi-square test were used for comparison between groups. A p-value <0.05 was considered statistically significant.

A total of n=40 cases were included in the study. The demographic characteristics of the cohort are presented in Table 1. The most frequently affected age group was 21 – 40 years with 26/40 (65%) of all the cases in this age group. The mean age was 34.2 years in the DCP group and 35.6 years in the IM nail group, with no statistically significant difference (p = 0.63). Similarly, the groups were comparable in terms of gender distribution, minimizing demographic bias in outcome comparisons. Both groups had a male predominance (13 males and 14 males in Groups A and B, respectively), and the gender difference was not statistically significant (p = 0.74).  

The assessment of the mechanism of injury in the cases of the study is presented in Table 2. The frequent cause of such injury was road traffic accidents (RTA), accounting for 60% of cases (12 in Group A and 13 in Group B). The second most frequent cause of injury was falls from height 6 in Group A and 5 in Group B), while sports-related injuries were the least common (2 in each group). Since the distribution of injury mechanisms was similar in distribution in both groups it shows that the type of trauma is not a confounding variable in comparing treatment outcomes.

The mean time to radiological union in our cohort is presented in Table 3. A critical analysis of the table shows that fracture union confirmed based on radiographs in group A was significantly faster mean union time of 11.2 weeks, compared to 12.5 weeks in Group B (IM Nail), with a statistically significant p-value of 0.04.  This indicates that dynamic compression plating allowed earlier healing of bones than intramedullary nailing, possibly attributed to stiffer anatomical reduction and compression at the area of fracture.

*Significant

The functional assessment of the cases was done at 24 weeks postoperatively given in Table 4. The Disabilities of the Arm, Shoulder, and Hand (DASH) score and the Mayo Elbow Performance Score (MEPS) were used for assessment. The mean DASH score was slightly better in the DCP group (11.6 vs. 13.2), but the difference was not statistically significant (p = 0.23). Similarly, MEPS scores favored the DCP group (91.4 vs. 88.6), though again, not significantly (p = 0.19). Minor restriction in range of motion was observed in 2 patients in the DCP group and 4 in the IM Nail group. These findings indicate that both treatment methods yield comparable long-term functional results.

Table 5 highlights the complications that were experienced in these two treatment groups. The complication rate was 40% in Group B (IM Nail) as opposed to Group A (DCP) which was 20%. Malunion (2 cases), implant irritation (3 cases), and two reoperations were considered common complications in the IM Nail group. The DCP group experienced fewer problems as there was only one instance of nonunion and two instances of superficial infection. The rate of complications was greater in the IM Nail group, but this did not quite achieve statistical significance (p = 0.07).

Midshaft radius and ulna fractures are special because these bones work together to promote forearm rotation. Anatomical reduction and stable fixation are essential to the restoration of forearm biomechanics and to avoid long term functional deficits [23, 24]. The results of dynamic compression plating (DCP) and intramedullary (IM) nailing in the treatment of midshaft forearm fractures were compared in this study. This study found that DCP led to faster union of the fracture as compared to IM nailing. The mean time to union in the DCP group was 11.2 weeks and in the IM nailing group, it was 12.5 weeks (p = 0.04) and significant. The results are in agreement with the findings of Anderson et al. [25] showed a better union rate and quicker healing time using plate osteosynthesis. The reason behind the enhanced healing of the DCP group could be the compression and rigid anatomical fixation offered by the plate which allows direct bone healing. In our study, we found the two groups had similar functional outcomes as measured by DASH and MEPS scores at 24 weeks. The results however slightly favored the DCP group. These findings agree with the studies of Sage et al. [26] and Chapman et al. [27] who stated that both techniques can restore function when appropriate reduction and fixation is obtained. The slightly lower results of the IM nailing group can be explained by less precise rotational control that is vital to sustain forearm pronation and supination.

The incidence of complications was higher in the IM nailing group (40%) as compared to the DCP group (20%) but the distinction was not found to be significant. Implant-related irritation and malunion occurred more often with IM nails, which might be explained by less rigid fixation and the impossibility of obtaining perfect alignment using closed techniques. All these complications have been previously reported in the literature. This cautions that the earlier generation of the IM nails without the locking capabilities led to inferior rotational stability and increased the nonunion rate [28, 29]. However, the contemporary nails that have locking mechanisms like the ones used in the current study have demonstrated better results [30]. Despite these advantages, plating necessitates greater dissection of soft tissues and is associated with infection and neurovascular risks, whereas only two instances of superficial infection and one of reoperation were seen in our DCP group. Compared to it, IM nailing is less invasive and has a shorter operation time and less blood loss, which makes it a better choice for polytrauma patients or those who are not candidates to undergo long surgical procedures.  Overall, both modalities demonstrate good results, but DCP seems to have more predictable results regarding union time and fewer complications. IM nailing can still represent an option in chosen cases, particularly with the development of locked IM nails. These results should be confirmed by further research involving larger samples and extended follow-ups.

This study demonstrates that both dynamic compression plating (DCP) and intramedullary (IM) nailing are effective in managing midshaft fractures of the radius and ulna. However, DCP offers a faster union rate, fewer complications, and slightly better functional outcomes. IM nailing, while less invasive, is associated with a higher rate of implant-related issues and malunion. Therefore, DCP remains the preferred method, especially when anatomical reduction is crucial. IM nailing may still be suitable in selected cases, particularly in polytrauma patients or when minimally invasive techniques are required. Further long-term studies are recommended to confirm these findings.

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