Should a plate or nail be used for fracture fixation in a patient with a radius shaft fracture and ulna segmental fracture, especially in an elderly diabetic patient?

Plate Fixation for Radius Shaft and Ulna Segmental Fractures in Elderly Diabetic Patients

For a patient with radius shaft fracture and ulna segmental fracture, especially in an elderly diabetic patient, plate fixation is recommended over nailing due to superior stability and anatomical reconstruction capabilities.

Rationale for Plate Fixation

Plate fixation offers several advantages in this specific clinical scenario:

1. Anatomical Considerations

   • The radius has a critical role in forearm function requiring anatomical reconstruction in all planes and axes 1
   • Segmental fractures of the ulna require multiple points of fixation that plates provide better than nails

2. Stability Factors

   • Plates provide superior rotational stability which is crucial in forearm fractures
   • Elderly diabetic patients often have osteoporotic bone requiring stable fixation to prevent displacement
   • Comminution and segmental patterns are better addressed with plates that can span the entire fracture zone

Technical Considerations for Radius Fixation

• Approach: Volar Henry approach is preferred as it allows exposure of almost the entire radius with minimal risk to the deep branch of the radial nerve 1
• Plate Selection: 3.5mm DCP or LC-DCP plates are recommended over locking plates in many cases due to:
  • More physiological rigidity
  • Better ability to contour to the radius curvature
  • Avoiding the excessive stiffness of locking plates that may suppress bone healing 1
• Plate Placement: Lateral surface placement is biomechanically advantageous:
  • Lateral surface is a tension site
  • Allows better control of rotational position
  • Provides longer screw trajectory increasing rotational stability 1

Technical Considerations for Segmental Ulna Fracture

• Fixation Method: A longer plate spanning the entire segmental fracture is necessary
• Screw Configuration: At least 3 screws proximal and distal to the fracture, with additional fixation at the segmental fragment when possible
• Bone Grafting: Consider bone grafting for comminuted and segmental fractures to promote union 2

Special Considerations for Elderly Diabetic Patients

• Bone Quality: Osteoporosis may necessitate additional fixation points and careful screw placement
• Soft Tissue: Diabetic patients require close monitoring of skin to prevent pressure points and breakdown 3
• Rehabilitation: Early mobilization is crucial but must be balanced with fracture stability
• Metabolic Optimization: Ensure proper glucose control perioperatively to reduce infection risk and promote healing

Potential Complications and Mitigation

• Infection: Higher risk in diabetic patients; meticulous surgical technique and appropriate prophylactic antibiotics are essential
• Non-union: Consider primary bone grafting for segmental fractures 2
• Hardware Irritation: Proper plate contouring and positioning can minimize soft tissue irritation
• Stiffness: Early protected range of motion exercises once fracture stability allows

Follow-up Protocol

• Regular wound and radiographic assessments
• Monitor for hardware-related complications
• Implement a directed home exercise program to prevent stiffness 3
• Consider secondary fracture prevention strategies for osteoporotic patients

While both plate and nail fixation are options for forearm fractures, the complex nature of a radius shaft fracture combined with a segmental ulna fracture in an elderly diabetic patient makes plate fixation the superior choice for achieving anatomical reduction, stable fixation, and optimal functional outcomes.