What management is recommended prior to surgery for a nonunion ulnar fracture?

Preoperative Management of Nonunion Ulnar Fracture

Prior to surgery for nonunion ulnar fracture, assess and optimize nutritional status (particularly serum albumin), evaluate for underlying osteoporosis, ensure adequate vitamin D and calcium levels, and implement comprehensive medical optimization including correction of anemia and electrolyte abnormalities.

Nutritional Assessment and Optimization

Preoperative serum albumin is a critical modifiable risk factor that independently predicts nonunion and surgical site infection. 1

• Check serum albumin preoperatively - hypoalbuminemia is independently predictive of nonunion (OR 0.028, P = .015) and increases risk of surgical site infection 1
• Low preoperative total protein and albumin independently predict increased surgical site infection (P = .003 and P = .009, respectively) 1
• Consider nutritional supplementation if albumin is low, though specific protocols have insufficient evidence for formal recommendation 1

Hematologic Evaluation

Correct preoperative anemia to reduce risk of postoperative complications and optimize bone healing. 1

• Obtain complete blood count - anemia occurs in approximately 40% of patients and can result from fracture-related hemorrhage, poor nutrition, or chronic disease 1
• Consider preoperative transfusion if hemoglobin < 9 g/dL, or < 10 g/dL with history of ischemic heart disease 1
• If hemoglobin is 10-12 g/dL, crossmatch two units of blood 1
• Expect perioperative hemoglobin drop of approximately 2.5 g/dL 1

Metabolic and Bone Health Assessment

Evaluate for underlying osteoporosis and metabolic bone disease, as nonunion may reflect compromised bone metabolism. 1, 2, 3, 4

• Check vitamin D, calcium, and parathyroid hormone levels during initial evaluation 4
• In elderly patients with typical fragility fracture patterns, consider initiating anti-osteoporotic therapy even before DEXA scan results 2, 3, 4
• Ensure adequate calcium intake (1000-1200 mg/day) and vitamin D supplementation (800 IU/day) 1
• Vitamin D deficiency is endemic in patients with fractures and should be corrected preoperatively 1

Electrolyte and Metabolic Panel

Obtain urea and electrolytes routinely before surgery. 1

• Correct hypokalaemia - associated with new onset rapid ventricular rate atrial fibrillation perioperatively 1
• Evaluate for hyperkalaemia which may indicate rhabdomyolysis if patient was immobilized after injury 1
• Address hyponatraemia (common in 17% of patients), which may indicate infection or result from medications 1

Cardiovascular Assessment

• Obtain electrocardiogram in all elderly patients 1
• If atrial fibrillation present, ensure ventricular rate < 100/min by treating underlying causes (hypokalaemia, hypomagnesaemia, hypovolemia, sepsis, pain, hypoxemia) 1

Infection Screening

• Leukocytosis > 17 × 10⁹/L may indicate infection (commonly chest or urine) and should be investigated 1
• Address any active infection prior to surgery to reduce risk of surgical site infection 1

Medication Review and Optimization

Review all medications for inappropriate dosing and potential interactions. 1

• Polypharmacy increases likelihood of adverse drug reactions (80% potentially avoidable) 1
• Pay particular attention to anticoagulation status and timing of discontinuation 1
• Smoking cessation is critical - smoking is a well-known risk factor for nonunion 1, 5
• Limit alcohol intake as it negatively affects bone quality 1

Special Considerations for Bisphosphonate-Associated Fractures

In elderly women on long-term bisphosphonate therapy, suspect atypical ulnar fracture requiring specialized surgical approach. 6

• Standard open reduction and internal fixation will fail in atypical fractures due to compromised bone metabolism 6
• These cases require revision osteosynthesis with locking plate, callus resection, and strut/cancellous bone graft 6
• Evaluate contralateral limb for incomplete fractures 6

Orthogeriatric Co-Management

Implement orthogeriatric co-management for frail elderly patients with multiple comorbidities. 1, 2, 3, 4

• This approach improves functional outcomes, reduces hospital stay, and decreases mortality 1, 4
• Assess for pressure sores, cognitive function, and overall frailty 4

Common Pitfalls to Avoid

• Do not proceed to surgery without addressing nutritional deficiencies - low albumin independently predicts nonunion 1
• Do not ignore underlying osteoporosis - failure to address bone health leaves patient at risk for subsequent fractures 4
• Do not use NSAIDs for pain control in elderly patients due to renal and gastrointestinal risks 4
• In proximal third ulnar fractures with displacement ≥5mm, recognize higher nonunion risk and plan accordingly 7