A Moroni

AM Hollister

BG Weber

CH Barbieri

D Ring

EH Schemitsch

EJ Dabezies

Fernando Baldy dos Reis

Flávio Faloppa

H Tscherne

HT Ling

Hélio J Alvachian Fernandes

JB Jupiter

JR Skahen

M Saint-Cyr

MJ Rochard

MS Calkins

Philip F Stahel

PJ Stern

R Krzykawski

RC Miller

RR Richards

RR Tarr

TG Grace

W Orzechowski

Walter Manna Albertoni

WF Enneking

Y Safoury

Annals of Surgical Innovation and Research

English

PubMed

Crossref

Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating

Fernando dos Reis

Hélio Fernandes

Walter Albertoni

Springer - Publisher Connector

BioMed Central
Annals of Surgical Innovation and 
Research
ssOpen AcceResearch article
Outcome of diaphyseal forearm fracture-nonunions treated by 
autologous bone grafting and compression plating
Fernando Baldy dos Reis*1, Flávio Faloppa1, Hélio J Alvachian Fernandes1, 
Walter Manna Albertoni1 and Philip F Stahel2
Address: 1Department of Orthopaedics and Traumatology, Federal University of Sao Paulo (UNIFESP), Sao Paulo, Brazil and 2Department of 
Orthopaedic Surgery, Denver Health Medical Center, University of Colorado School of Medicine, Denver, Colorado, USA
Email: Fernando Baldy dos Reis* - fbaldy.dot@epm.br; Flávio Faloppa - faloppa.dot@epm.br; Hélio J 
Alvachian Fernandes - heliofernandes@terra.com.br; Walter Manna Albertoni - albertoniwm.dot@epm.br; 
Philip F Stahel - philip.stahel@dhha.org
* Corresponding author    
Abstract
Background: The treatment of forearm fracture-nonunions continues to represent a therapeutic
challenge, and reported outcomes are moderate at best. Limiting aspects of this particular anatomic
location include the relation between restoration of shaft length with the anatomy and long-term
functional outcome of adjacent joints, as well as the risk of elbow and wrist stiffness related to
prolonged immobilization. The present study was designed to assess the outcome of autologous
bone grafting with compression plating and early functional rehabilitation in patients with forearm
fracture non-unions.
Methods: Prospective follow-up study in 31 consecutive patients presenting with non-unions of
the forearm diaphysis (radius, n = 11; ulna, n = 9; both bones, n = 11). Surgical revision was
performed by restoring anatomic forearm length by autologous bone grafting of the resected non-
union from the iliac crest and compression plating using a 3.5 mm dynamic compression plate
(DCP) or limited-contact DCP (LC-DCP). The main outcome parameters consisted of
radiographic bony union and functional outcome, as determined by the criteria defined by Harald
Tscherne in 1978. Patients were routinely followed on a short term between 6 weeks to 6 months,
with an average long-term follow-up of 3.6 years (range 2 to 6 years).
Results: Radiographically, a bony union was achieved in 30/31 patients within a mean time of 3.5
months of revision surgery (range 2 to 5 months). Clinically, 29/31 patients showed a good
functional outcome, according to the Tscherne criteria, and 26/31 patients were able to resume
their previous work. Two postoperative infections occurred, and one patient developed a
persistent infected nonunion. No case of postoperative failure of fixation was seen in the entire
cohort.
Conclusion: Revision osteosynthesis of forearm nonunions by autologous iliac crest bone grafting
and compression plating represents a safe and efficacious modality for the treatment of these
challenging conditions.
Published: 18 May 2009
Annals of Surgical Innovation and Research 2009, 3:5 doi:10.1186/1750-1164-3-5
Received: 18 December 2008
Accepted: 18 May 2009
This article is available from: http://www.asir-journal.com/content/3/1/5
© 2009 dos Reis et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
Annals of Surgical Innovation and Research 2009, 3:5 http://www.asir-journal.com/content/3/1/5Background
The surgical treatment of diaphyseal forearm fracture-
nonunions remains a therapeutic challenge for orthopae-
dic trauma surgeons. Key to success in the management of
these demanding conditions is to develop a comprehen-
sive treatment concept which considers the forearm and
its adjacent joints, the elbow and wrist, as a complex func-
tional unit [1,2]. Nonunions of the radius and ulna shaft
cause a severe anatomic and functional impairment,
related to disturbance of the interosseous membrane and
dysfunction of the adjacent joints, elbow and wrist [3-6].
These demanding nonunions require the surgical correc-
tion to restore the anatomy of the forearm and to improve
function [1,7]. New techniques have been recently postu-
lated for the treatment of forearm nonunions, including
distraction-compression osteogenesis, locked plating, and
locked intramedullary nailing [8-10]. In addition, free fib-
ula transfer flaps have been advocated as a means to
restore anatomic length and ensure bony union [11,12].
In the present study, we evaluated the long-term radiolog-
ical and clinical outcome of 31 consecutive patients
treated by autologous bone grafting and compression
plating for fracture-nonunions of the forearm. We
hypothesized that this "classic" treatment concept would
result in excellent clinical outcome and a low incidence of
long-term functional impairment.
Methods
A retrospective analysis of a prospective database of all
consecutive patients treated for fracture-nonunions of the
forearm was performed at a single academic center (Dept.
of Orthopaedics and Traumatology, Federal University of
Sao Paulo, Brazil). The inclusion criteria consisted of all
adult patients (> 18 years) of either gender with posttrau-
matic nonunions of the radius and/or ulna shaft, in
absence of an active infection. Patients with nontraumatic
forearm pseudarthrosis, infected nonunions, or with an
associated neurological impairment of the ipspilateral
upper extremity, which may preclude from an adequate
functional assessment, were excluded from analysis. All
surgical procedures were performed by a single surgeon
(F.B.R.). Nonunions were classified according to the
standard classification by Weber and Cech [13]. The pre-
operative plan included plain X-rays of the forearm, wrist
and elbow, in antero-posterior (a.p.) and lateral views.
The presence of infection was excluded by preoperative
analysis of systemic infection parameters (WBC, sedimen-
tation rate, CRP) and by intraoperative tissue samples of
the resected nonunions which were sent for microbiology
cultures and histopathological workup. The standardized
treatment concept (Figure 1) consisted of resection of the
forearm nonunion, autologous bone grafting with a tri-
cortical graft from the iliac crest with anatomic restoration
of the foreram length, as determined by intraoperative
fluoroscopy assessment of the adjacent joints, and com-
pression plating using a stainless steel small fragment (3.5
mm) dynamic compression plate (DCP) or limited-con-
tact DCP (LC-DCP). Radiological and functional outcome
was determined at a minimum of 2 years follow-up, with
standardized intervals at 3, 6, 12, and 24 months after
revision surgery. The functional outcome was evaluated
according to the criteria defined by Tscherne et al. [14].
These criteria include the range of motion of forearm pro-
/supination, wrist and elbow flexion and extension, ulnar
shift/deviation, and positive/negative ulnar variant on
wrist X-rays. Bony union was defined in the presence of a
minimum of three bridging cortices in plain X-rays of the
forearm in a.p. and lateral views, in absence of pain at the
nonunion site.
Results and discussion
A total of 32 consecutive patients were available for pro-
spective enrollment. One patient died from a cardiovascu-
lar condition (myocardial infraction) in the postoperative
course and was therefore lost to follow-up. The remaining
31 patients (27 males and 4 females; median age 30 years)
presenting with forearm fracture-nonunions were pro-
spectively enrolled into this study. Of these, 26 patients
had their dominant arm affected, and 8 patients had a pre-
vious history of infection. Eleven patients presented with
a both bone fracture-nonunion, and 20 patients had a sin-
gle bone affected (11 radius, 9 ulna shaft). Eight patients
had a history of a previous local infection, which however
was completely healed at the time of revisions surgery, as
determined by negative intraoperative bone biopsies and
tissue cultures. The number of previous surgeries on the
affected forearm varied from 1 to 5 (median 1.5). Patients
presented with a fracture-nonunion within 5 to 24
months after the initial surgery (median of 7.5 months).
Preoperative planning scheme for nonunion resection, place-m nt of corticoca cellous iliac crest bo e graft, and com-p ssi n pla ngFigur  1
Preoperative planning scheme for nonunion resec-
tion, placement of corticocancellous iliac crest bone 
graft, and compression plating.
  
   
Page 2 of 4
(page number not for citation purposes)
Annals of Surgical Innovation and Research 2009, 3:5 http://www.asir-journal.com/content/3/1/5According to the Weber and Cech classification, 28 cases
(90%) were defined as atrophic, nonviable nonunions.
Fourteen of these 28 patients had a segmental bone defect
ranging from 1 to 5 cm (median 2.3 cm). Radiographi-
cally, a bony union was achieved in 30/31 patients within
a mean time of 3.5 months of revision surgery (range 2 to
5 months). Clinically, 29/31 patients showed a good
functional outcome, according to the Tscherne criteria,
and 26/31 patients were able to resume their previous
work. An illustrative case example of uneventful nonun-
ion healing is shown in figure 2.
Two patients developed a posteroperative infection, of
which one case was successfully managed by surgical deb-
ridement and antibiotics for two weeks. The other patient
developed a persistent infected nonunion requiring fur-
ther revision surgery. This was the only case of the entire
cohort of 31 patients which failed to achieve bony union.
No postoperative failure of fixation was seen in any
patient. One patient was lost to long-term follow-up sec-
ondary to death related to a cardiovascular event at 5
months, when the nonunion was fully healed. No associ-
ation was shown between the time of bony union and the
time elapsed between the trauma and the last surgery
prior to presentation with a nonunion (data not shown).
Residual radiological or clinical deformities were
observed in 13 patients (table 1). These radiological find-
ings did not appear to significantly influence the func-
tional outcome, based on the observed clinical outcome
in 29/31 patients, as defined by the Tscherne criteria, with
less than 10% of restricted range of motion at the wrist
and elbow (table 2). Regarding forearm rotation (pro-/
supination), 17/31 patients presented losses lower than
20 degrees, and 9/31 presented moderate results with pro/
-supination loss between 20–40 degrees. A total of 26/31
patients were able to resume their previous work.
This study demonstrates the efficacy and safety for the
treatment concept of autologous bone grafting and com-
pression plating for forearm fracture-nonunions, leading
to excellent radiological and functional long-term out-
come. Reconstruction of the anatomy of both forearm
bones is of crucial importance in the management of the
diaphyseal forearm nonunions [1-6]. The concept of cor-
ticocancellous iliac crest bone grafting and compression
plating for, was previously postulated as an early treat-
ment strategy for traumatic segmental defects of the upper
extremity, including forearm fractures [15]. Despite open
wounds in some patients which healed by secondary
intention, the exposed cortical bone graft was not shown
Clinical case example of a patient with a fracture-nonunion of the ulna shaft secondary to an unstable t ea m nt modality us g  small frag ent tubular plate, lacking adequate st bilitywith i terfragmentary compression (A)Fig re 2
Clinical case example of a patient with a fracture-
nonunion of the ulna shaft secondary to an unstable 
treatment modality using a small fragment tubular 
plate, lacking adequate stability with interfragmen-
tary compression (A). Revision surgery was performed by 
corticocancellous bone grafting and compression plating 
using a more rigid construct with a dynamic compression 
plate (B). Panel C shows the fully healed radius fracture and 
ulnar fracture-nonunion after hardware removal.



Table 1: Clinical and radiological residual deformities in 13 
patients following revision surgery for forearm fracture-
nonunions
Residual deformity Number of patients (total n = 13)
Positive ulnar variant: 1 mm 4
Positive ulnar variant: 2 mm 1
Negative ulnar variant: 1 mm 2
Ulnar head prominence 2
Ulnar head absence 1
Loss of radial bow 3
Table 2: Functional outcome in 30 patients with radiologically 
healed forearm fracture nonunions, assessed 6 months after 
revision surgery
ROM* wrist Number of patients
Normal (identical to contralateral side) 26
Flexion/extension 90°/0°/60° 3
Limited ulnar shift 1
ROM* elbow Number of patients
Normal (identical to contralateral side) 27
Extension/flexion 0°/20°/120° 1
Extension/flexion 0°/30°/120° 2
Forearm rotation Number of patients
Normal (identical to contralateral side) 17
Pro-/supination 90°/0°/60° 5
Pro-/supination 90°/0°/45° 3
Pro-/supination 80°/0°/70° 1
Pro-/supination 60°/0°/45° 1
Pro-/supination 45°/0°/30° 3
*ROM, range of motion.Page 3 of 4
(page number not for citation purposes)
Annals of Surgical Innovation and Research 2009, 3:5 http://www.asir-journal.com/content/3/1/5to be prone to infection [15]. More recently, a retrospec-
tive analysis of 41 patients with comminuted both bone
forearm fractures treated by compression plating with or
without primary bone grafting determine a nonunion rate
of 12%, and no benefit was revealed for early bone graft-
ing with regard to the rate of union [16]. Barbieri and col-
leagues reported their experience in a case series of 12
patients treated by iliac crest bone block grafting and com-
pression plating for diaphyseal defects of the forearm, sec-
ondary to infection and bone loss [17]. The authors
demonstrated a successful union in 10/12 patients, within
a mean time period of 17 weeks after the surgical revision
[17]. However, a high rate of 30% recurrent infections of
was reported in this cohort, which questions the safety of
autologous bone grafting in the setting of posttraumatic
infection and chronic osteomyelitis. Similarly, Moroni
and colleagues reported a high incidence of infection of
12.5% after intercalary bone graft fixation in patients with
isolated forearm nonunions [18]. In the present study, the
incidence of postoperative infection was much lower (2/
31 patients). One case resulted in failure by developing a
chronic infected nonunion, while the other case was suc-
cessfully managed by surgical debridement and antibiotic
therapy, resulting in a healed union and a good functional
long-term outcome. Bony union were achieved in 96.7%
of all cases (30/31) on average time of 3.5 months. The
functional outcome measured by the Tscherne's criteria
showed good results in 26/31 patients. Based on these
findings, our data confirm the safety and efficacy of autol-
ogous bone grafting and compression plate fixation of
fracture nonunions of the forearm [19].
Conclusion
Autogenous cortical bone grafts were historically
described as a successful modality for the reconstruction
of traumatic segmental skeletal defects [20-23]. While the
plate fixation of forearm fractures remains the gold stand-
ard, complications have been shown to occur in up to
28% of all patients [24]. One of the major challenges of
long-term complications are forearm nonunions with
bone loss and segmental defects. In the present study, we
demonstrate the safety and efficacy of corticocancellous
iliac crest bone grafting and compression plating for revi-
sion fixation of forearm fracture-nonunions, leading to
excellent radiological and functional long-term outcomes.
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
FBR, FF, HJAF, and WMA designed the study and were
responsible for the clinical care of the patients. FBR and
PFS wrote and edited the manuscript. All authors read and
approved the final version of this paper.
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3rd: Malunions and nonunions of the forearm. Hand Clin

A: Double-barrel free fibula flap for treatment of infected nonunion of both forearm bones.

A: The effects of angular and rotational deformities of both bones of the forearm. J Bone Joint Surg (Am)

Autogenous cortical bone grafts in the reconstruction of segmental skeletal defects. J Bone Joint Surg [Am]

Cech O: Pseudarthrosis of the forearm.

Chronic disorders of the forearm.

Comminuted diaphyseal fractures of the radius and ulna: does bone grafting affect nonunion rate? J Trauma

Deffer PA: Management of segmental defects of the radius and ulna.

Drury WJ: Complications of plate fixation of forearm fractures. Clin Orthop Relat Res

Eversmann WW Jr: The management of segmental bone loss associated with forearm fractures. J Bone Joint Surg [Am]

Fortino MD: The interosseous membrane of the forearm: anatomy and function. J Hand Surg (Am)

Free vascularized fibula for the treatment of traumatic bone defects and nonunion of the forearm bones. J Hand Surg [Br]

GS: The repair of defects of the radius with fibular bone grafts. J Bone Joint Surg [Am]

Kami&#x0144;ski A: The results of locked intramedullary nailing for non-union of forearm bones. Ortop Traumatol Rehabil.

MM: Use of a bone block graft from the iliac crest with rigid fixation to correct diaphyseal defects of the radius and ulna. J Hand Surg [Br]

RL: The relationship of the interosseous membrane to the axis of rotation of the forearm. Clin Orthop Relat Res

RR: The effects of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg (Am)

Rüedi T: Intraoperative distraction in the treatment of complex nonunions of the radius. J Hand Surg (Am)

Surgical treatment of isolated forearm nonunion with segmental bone loss. Injury

T: Treatment of non-union of the forearm using distraction-compression osteogenesis. Ortop Traumatol Rehabil.

Technique and results of rigid-plate fixation in forearm fractures. Unfallheilkunde

Traumatic segmental bone defects in the upper extremity. Treatment with exposed grafts of corticocancellous bone. J Bone Joint Surg (Am)

TS: Locking compression plate: a treatment option for diaphyseal nonunion of radius or ulna.

Ununited diaphyseal forearm fractures with segmental defects: plate fixation and autogenous cancellous bone grafting. J Bone Joint Surg [Am]

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Outcome of diaphyseal forearm fracture-nonunions treated by autologous bone grafting and compression plating

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