FRCS (Tr & Orth) Oral Examination: Abbreviated Both Bones Forearm Fracture Case Presentation

The radiographs show displaced midshaft diaphyseal fractures of both bones of the left forearm.

I would make a careful patient assessment, completing the history and examination. Particularly, I would look for any open wounds, make an assessment of the soft tissues and the neurovascular status of the limb as well as any suggestion of compartment syndrome. I would ensure that the patient has adequate analgesia and would splint the forearm in an above elbow backslab in 90 degrees of flexion. In an otherwise healthy adult, I would plan to treat this injury definitively on the next routine trauma operating list with dynamic compression plating of both fractures using 3.5 mm LC-DC plates.

These radiographs show that the fracture has been treated operatively with plate fixation. The alignment appears satisfactory; however, there is a persisting delayed or non-union of the ulnar fracture. The radius seems to have united. I would complete my assessment of the patient, looking for any persisting symptoms suggestive of delayed union or non-union or infection such as pain, local swelling or erythema. I would take some blood for full blood count and inflammatory markers. I would arrange a CT scan of the forearm to confirm the degree of union of both fractures and if non-union is confirmed in the absence of infection, I would advise revision fixation of the non-union with autologous iliac crest bone grafting. I would consider the use of a bone stimulator for 6–8 weeks as an interim measure, and current guidance suggests that this is appropriate for an established non-union after 9 months. If the screening investigations are suggestive of infection, then I would send peripheral blood and wound samples for culture. I would also perform an initial debridement at which I would sample tissue taken from the non-union site so that targeted antibiotic treatment can be given before definitive grafting is undertaken.