Treatment of 1-Year-Old Radius and Ulna Nonunion in a 19-Year-Old Male
Surgical intervention with open reduction, internal fixation (plate osteosynthesis), and bone grafting is the definitive treatment for this established nonunion, as conservative management is only appropriate for asymptomatic pediatric patients, not young adults with chronic nonunion. 1, 2
Surgical Approach
The primary treatment should consist of:
- Plate osteosynthesis with bone grafting is the standard surgical approach for established forearm nonunions, particularly in adults where the nonunion has persisted for one year 1, 2
- Autograft remains the gold standard for bone grafting, though allograft is acceptable if donor site morbidity is a concern 3
- Both radius and ulna nonunions should be addressed surgically given the concomitant nature of the fractures, as combined radius-ulna fractures are associated with healing problems and instability 1
Why Conservative Management is Not Appropriate Here
- Conservative management (observation without surgery) is only successful in pediatric patients (median age 10 years) with asymptomatic hypertrophic nonunions, requiring 7-15 months of additional healing time 2
- At 19 years old with a 1-year-old nonunion, this patient has already passed the window where spontaneous healing is likely 1, 2
- Continuing pain after remobilization combined with progressing deformity are classic indicators that surgical intervention is required 1
Key Surgical Principles
Realignment and preservation of anatomy should be prioritized:
- Even small distal fragments should be preserved and attempts made to realign and heal the fracture rather than proceeding directly to wrist fusion 1
- The goal is to restore wrist motion, with fusion reserved only as a final resort after failed reconstruction attempts 1
- Assess for DRUJ instability with true lateral radiographs, as this commonly accompanies radius-ulna fractures and may require concurrent treatment 3
Common Pitfalls to Avoid
- Do not attempt prolonged conservative management in adult patients with established nonunion—this delays definitive treatment and risks progressive deformity 1, 2
- Inadequate immobilization periods and unstable fixation are the primary causes of forearm nonunions; ensure rigid fixation is achieved 1
- Technical problems during surgery (identified in 33% of pediatric nonunion cases) must be avoided through meticulous surgical technique 2
Post-Operative Management
- Initiate active finger motion exercises immediately after adequate surgical stabilization to prevent stiffness 4, 5
- Reevaluate any patient with unremitting pain during follow-up, as this may indicate fixation failure or other complications 3, 4
- A home exercise program is appropriate for rehabilitation after surgical treatment 3, 4