What is the management plan for a 72-year-old female (72Y/F) with a radius shaft fracture and ulna segmental fracture, who also has diabetes?

Management of Radius Shaft Fracture and Ulna Segmental Fracture in a 72-Year-Old Diabetic Patient

Surgical fixation with open reduction and internal fixation (ORIF) is the recommended treatment for this patient with radius shaft fracture and segmental ulna fracture to optimize functional outcomes and reduce complications.

Initial Assessment and Considerations

• Assess for:

  • Fracture displacement (>50% displacement indicates instability)
  • Angulation (>10 degrees indicates instability)
  • Neurovascular status (particularly median nerve function)
  • Soft tissue condition
  • Compartment syndrome signs

• Obtain appropriate imaging:

  • Standard radiographs in AP and lateral views
  • Consider CT scan for complex segmental fractures to better visualize fracture patterns

Management Algorithm

Surgical Management

1. Primary treatment: ORIF with plates and screws

   • Ulna should be addressed first to achieve alignment 1
   • Segmental ulna fracture requires fixation of all fragments
   • Radius shaft fracture typically requires plate fixation

2. Timing of surgery:

   • Expedited surgery is preferred, especially in elderly patients
   • Hyperglycemia alone is not a reason to delay surgery unless the patient is ketotic and/or dehydrated 2

3. Surgical technique:

   • Compression plating for unstable fractures 3
   • Consider square nails or K-wiring as alternative fixation methods for specific fracture patterns 4
   • Ensure anatomic reduction to preserve forearm rotation

Diabetes-Specific Considerations

• Glycemic control:

  • Follow hospital guidelines for perioperative management of diabetes 2
  • Monitor blood glucose levels closely
  • Target range: 90-150 mg/dL to avoid hypoglycemia 5

• Fracture healing concerns:

  • Patients with diabetes have higher fracture risk (relative risk 1.7 in type 2 diabetes) 2
  • Fracture risk increases with poor glycemic control (8% increased risk per 1% rise in A1C) 2
  • Maintain optimal glycemic control to promote healing

• Medication considerations:

  • Review current diabetes medications
  • Avoid thiazolidinediones if possible, as they increase fracture risk, especially in women 2
  • Consider the impact of sodium-glucose cotransporter 2 inhibitors on bone health 2

Post-Operative Management

1. Immobilization:

   • Short-arm cast or splint for 3-6 weeks depending on fracture stability and fixation
   • Early range of motion exercises when fracture stability permits

2. Rehabilitation:

   • Progressive physical therapy focusing on:
     • Range of motion exercises
     • Strengthening
     • Functional activities

3. Diabetes management:

   • Continue close monitoring of blood glucose levels
   • Adjust medications as needed based on activity levels and healing progress
   • Maintain adequate nutrition with sufficient protein intake for healing

4. Follow-up:

   • Regular radiographic assessment at 2,6, and 12 weeks
   • Monitor for complications including:
     • Delayed union or nonunion
     • Infection (higher risk in diabetic patients)
     • Hardware failure
     • Radioulnar synostosis

Special Considerations and Pitfalls

• Avoid conservative management for segmental or unstable fractures, as this leads to higher rates of nonunion, malunion, and poor functional outcomes 6

• Watch for median nerve injury which can complicate distal radius fractures 7

• Consider bone health assessment in this diabetic patient, as diabetes increases fracture risk despite potentially higher bone mineral density 2

• Beware of missed associated injuries such as radial head dislocation, which occurs in some forearm fractures and can be initially missed in up to 42% of cases 6

• Monitor for hypoglycemic episodes which can increase fracture risk (RR 1.52) 2

This management approach prioritizes surgical stabilization to allow for early mobilization and rehabilitation, which is particularly important in elderly patients to prevent complications of prolonged immobilization while addressing the specific concerns related to diabetes.