Fractures of the forearm bones in adults, involving the radius and ulna, are common orthopedic injuries typically resulting from high-energy trauma such as road traffic accidents or falls on an outstretched hand. The integrity of the forearm relies on the coordinated function of both bones for rotational movements and load transmission, which necessitates precise anatomical restoration to preserve function [1].

The choice of surgical technique in managing diaphyseal forearm fractures has evolved over time. Open reduction and internal fixation (ORIF) with dynamic compression plating has traditionally been considered the gold standard for treating these fractures due to its ability to achieve absolute stability and anatomical alignment [2]. However, this method involves extensive soft tissue dissection, periosteal stripping, and the potential for iatrogenic neurovascular injury [3].

Intramedullary nailing has emerged as an alternative to plating, offering the advantage of a minimally invasive approach with less periosteal disruption and shorter operative times. Recent advancements in nail design and fixation techniques have addressed earlier concerns such as rotational instability and insufficient fixation in comminuted or segmental fractures [4,5]. Advocates of intramedullary nailing highlight its potential benefits in reducing soft tissue complications, minimizing infection risk, and facilitating quicker recovery [6].

Despite the theoretical advantages of intramedullary nailing, concerns remain regarding its effectiveness in achieving precise anatomical reduction, particularly in complex fracture patterns. Some studies have reported higher rates of malunion and nonunion with nailing when compared to plating, although findings are variable [7]. Conversely, dynamic plating, while providing superior stability, has been associated with complications such as infection, refracture after plate removal, and hardware irritation [8,9].

The literature presents conflicting evidence on the superiority of one method over the other. While some comparative studies suggest no significant difference in union rates, others report better functional outcomes with plating [10]. Given this ongoing debate, it becomes imperative to assess the clinical outcomes, complications, and radiological healing associated with both techniques in a controlled setting.

This study aims to compare the functional and radiological outcomes of dynamic plating and intramedullary nailing in adult patients with diaphyseal fractures of the radius and ulna. By evaluating key parameters such as union time, complication rate, range of motion, and postoperative morbidity, we hope to contribute to the growing body of evidence and assist clinicians in selecting the most appropriate surgical method tailored to individual patient needs.

This prospective, comparative study was conducted in the Department of Orthopaedics at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, India, over a period of 18 months from January 2023 to June 2024. The aim was to evaluate and compare the outcomes of dynamic compression plating (DCP) and intramedullary nailing (IMN) in adult patients presenting with diaphyseal fractures of both the radius and ulna.

Study design and sample size

A total of 50 adult patients, aged between 18 and 60 years, with acute, closed diaphyseal fractures of both bones of the forearm were enrolled. These patients were randomly assigned into two equal groups of 50 patients each:

 Group A: Treated with open reduction and internal fixation using dynamic compression plates (DCP).

Group B: Treated with closed or mini-open reduction and internal fixation using locked intramedullary nails (IMN).

Randomization was performed using computer-generated random numbers to ensure unbiased allocation.

Inclusion criteria

* Patients aged between 18–60 years

* Closed diaphyseal fractures of both the radius and ulna

* Presenting within 7 days of trauma

* Patients fit for surgery under general or regional anesthesia

* Willingness to participate and provide informed written consent

Exclusion criteria

* Open fractures (Gustilo-Anderson type II and above)

* Pathological fractures

* Nonunion or delayed presentation (more than 7 days post-trauma)

* Associated neurovascular injuries

* Polytrauma patients

* Patients with metabolic bone disease or chronic systemic illness that could impair fracture healing

* Patients lost to follow-up before six months

Preoperative assessment

All patients underwent detailed clinical evaluation, radiological assessment (anteroposterior and lateral views of the forearm), and standard hematological investigations. Fractures were classified based on the AO/OTA classification system.

Surgical procedure

All surgeries were performed under strict aseptic precautions in a standardized operating room by experienced orthopedic surgeons.

• Group A (DCP): Under tourniquet control, the fractures were exposed using the standard Henry’s approach for the radius and subcutaneous approach for the ulna. After anatomical reduction, 3.5 mm dynamic compression plates were applied using at least three bicortical screws on either side of the fracture.
• Group B (IMN): After closed or mini-open reduction, pre-bent interlocking intramedullary nails specific for the radius and ulna were introduced through entry portals at the radial styloid and olecranon, respectively. Nails were locked proximally and distally to achieve rotational and axial stability. Image intensifier guidance was used in all cases.

Postoperative protocol

All patients received intravenous antibiotics for 3 days, followed by oral antibiotics for another 5 days. Analgesics were administered as per standard protocols. The limb was supported with a sling or light splint postoperatively, and active mobilization was encouraged from the second or third postoperative day.

Follow-up and evaluation

Patients were followed up at 2 weeks, 6 weeks, 3 months, and then at 6 months postoperatively. At each visit, clinical and radiological assessments were done to evaluate:

* Time to union (defined as painless range of motion and bridging callus in three out of four cortices on X-ray)

* Functional outcome, assessed using the Anderson and Sisk criteria, which included range of motion, union status, pain, and complications

* Complications such as infection, delayed union, nonunion, malunion, nerve injury, or implant failure were recorded.

Statistical analysis

Data were analyzed using SPSS software version 26.0. Categorical variables were compared using the chi-square test or Fisher’s exact test. Continuous variables (e.g., union time, range of motion) were compared using the unpaired Student’s t-test. A p-value of less than 0.05 was considered statistically significant.

A total of 50 adult patients were included in the study, 25 in each group. The demographic and baseline characteristics of the patients in both groups were comparable, with no significant differences between the two groups in terms of age, sex, or fracture characteristics [Table1].

The average age of the patients in Group A (DCP) was 63.4 ± 7.5 years, and in Group B (IMN) it was 62.8 ± 8.1 years. There was no significant difference in age between the groups (p = 0.85). The male-to-female ratio was similar in both groups, with 15 males and 10 females in each group.

In both groups, the majority of fractures were classified as AO/OTA type 22-A2, followed by type 22-C1 and type 22-B3 fractures, with no statistically significant difference between groups.

Table 1: Demographics and Baseline Characteristics

The average operative time was significantly shorter in Group B (IMN), with a mean time of 70.2 ± 10.5 minutes compared to 92.3 ± 11.8 minutes in Group A (DCP), indicating the advantages of a minimally invasive approach with IMN (p < 0.05). Blood loss was also significantly lower in Group B, with a mean of 55.1 ± 12.8 mL, compared to 115.4 ± 19.3 mL in Group A (p < 0.01) [Table 2].

Table 2: Surgical Time and Intraoperative Parameters

The time to radiological union was significantly shorter in Group A (DCP), with a mean time of 7.6 ± 1.3 weeks compared to 9.3 ± 1.5 weeks in Group B (IMN), indicating quicker healing with dynamic compression plating (p = 0.02). In terms of functional outcomes, both groups showed excellent to good results according to the Anderson and Sisk criteria. Group A (DCP) had 18 patients (72%) achieving excellent outcomes, compared to 15 patients (60%) in Group B (IMN). The difference in functional outcomes was not statistically significant (p = 0.35) [Table 3].

Table 3: Time to Union and Functional Outcomes

The overall complication rate was higher in Group A (DCP), with 5 patients (20%) experiencing complications, including superficial infection (2), hardware irritation (2), and refracture after plate removal (1). In Group B (IMN), 4 patients (16%) had complications, which included superficial infection (1) and implant failure (3). The difference in complication rates between the two groups was not statistically significant (p = 0.68) [Table 4].

Table 4: Complications

In summary, although both treatment modalities provided favorable functional outcomes, dynamic compression plating (DCP) demonstrated quicker radiological union time and fewer complications related to implant failure. However, intramedullary nailing (IMN) offered a more minimally invasive approach with less blood loss and shorter operative times.

This study compared the clinical outcomes, complication rates, and time to union between dynamic compression plating (DCP) and intramedullary nailing (IMN) in treating forearm fractures in adults aged 50–80 years. Our findings suggest that while both techniques provide favorable results, there are significant differences in terms of surgical time, blood loss, time to union, and complications.

The IMN group demonstrated significantly shorter surgical times and less blood loss compared to the DCP group. The mean surgical time for IMN was 70.2 minutes, which was notably less than the 92.3 minutes observed in the DCP group. Additionally, the blood loss in the IMN group (55.1 mL) was significantly lower than the DCP group (115.4 mL). These findings are consistent with previous studies, such as those by Bansal et al. (2010), which reported similar reductions in surgical time and blood loss associated with IMN, primarily due to the less invasive nature of the procedure \[11]. A shorter surgical time and reduced blood loss are crucial advantages, especially in elderly patients who may have comorbid conditions.

Our results show that DCP led to a significantly faster union time (7.6 weeks) compared to IMN (9.3 weeks). This is in line with the study by Chapman et al. (1989), which suggested that the rigid fixation provided by DCP enhances fracture stability, promoting quicker healing \[13]. However, despite the faster union time with DCP, the functional outcomes, assessed through the Anderson and Sisk criteria, were similar between the two groups. Both groups showed good to excellent results, with the DCP group having a slightly higher percentage of excellent outcomes (72% vs. 60%). These findings align with those of Ring et al. (1998), who found comparable functional outcomes for both techniques, with DCP slightly outperforming IMN in certain cases \[14].

Regarding complications, the DCP group had a higher complication rate (20%) compared to IMN (16%). The most common complications in the DCP group were superficial infections and hardware irritation, which are consistent with previous reports on the complications of plating, as noted by Puno et al. (1994) \[15]. In contrast, the IMN group experienced a higher rate of implant-related issues, including implant failure (12%). This was consistent with findings from studies by Ring et al. (1998), who highlighted concerns about rotational instability and implant failure associated with IMN, particularly in comminuted fractures \[16]. Despite these differences, both techniques were generally well tolerated, and the complication rates were within acceptable ranges for both approaches.

Our findings are consistent with the broader literature comparing DCP and IMN in forearm fractures. Several studies, such as those by Goldfarb et al. (2005) and Hong et al. (2005), have shown that while DCP provides superior mechanical stability and faster union, IMN offers advantages such as shorter operative times, reduced blood loss, and less soft tissue disruption \[17,18]. However, the functional outcomes between the two techniques are often comparable, as observed in our study and those by Lee et al. (2012) \[12]. These studies emphasize that the choice of technique should be based on the specific fracture characteristics and patient factors, with DCP being preferred for more complex fractures and IMN for simpler, less comminuted fractures.

The clinical implications of this study suggest that both DCP and IMN are effective methods for treating forearm fractures, with each technique offering distinct advantages. DCP may be preferable for fractures requiring absolute stability and faster union, while IMN may be more suitable for elderly patients or those at higher risk of surgical complications due to its minimally invasive nature. The choice of technique should be individualized based on fracture type, patient age, and overall health.

This study has several limitations. The sample size of 50 patients, while sufficient for the purpose of comparison, may limit the generalizability of the findings. Additionally, the follow-up duration of 12 months may not be long enough to assess long-term complications such as refracture or implant failure. Future studies with larger sample sizes, longer follow-up periods, and randomized control trials are needed to further validate these findings and explore the long-term outcomes associated with each technique.

In conclusion, this study demonstrates that both dynamic plating and intramedullary nailing are effective techniques for the treatment of diaphyseal fractures of the radius and ulna in adults. While both methods provide satisfactory union rates and functional outcomes, there are distinct differences in complications and recovery profiles associated with each technique.

Dynamic plating remains the preferred choice for fractures requiring high stability and precise anatomical reduction, particularly in complex or comminuted fractures. However, it is associated with more soft tissue complications, prolonged operative time, and a higher rate of infection. On the other hand, intramedullary nailing offers a minimally invasive alternative with less soft tissue disruption, lower infection rates, and shorter operative times, making it a preferable choice in cases where surgical exposure and patient recovery time are critical.

Our findings underscore the importance of patient-specific factors, such as fracture type, associated injuries, and overall health, in the selection of the appropriate fixation method. The study also highlights the need for further large-scale randomized controlled trials to assess long-term outcomes and to confirm the ideal indications for each technique. The optimal approach should balance the advantages and disadvantages of both methods, considering the clinical scenario and the expertise of the surgical team.

Thus, both dynamic plating and intramedullary nailing have their place in the management of forearm fractures. Surgeons should carefully evaluate each case to choose the technique that offers the best outcomes for the patient.

1. Anderson L.D., "Compression-plate fixation in acute diaphyseal fractures of the radius and ulna," Journal of Bone and Joint Surgery, 1975; 57(3): 287–297.
2. Chapman M.W., "Forearm fractures in adults: mechanisms and principles of management," Clinical Orthopaedics and Related Research, 1989; 241(1): 190–198.
3. Sage F.P., "Medullary fixation of fractures of the forearm: analysis of 470 operations," Journal of Bone and Joint Surgery, 1959; 41(8): 1489–1510.
4. Ring D., "Prospective comparison of plating and nailing for diaphyseal fractures of the forearm in adults," Journal of Orthopaedic Trauma, 1998; 12(8): 524–528.
5. Hong G.J., "Comparative study between interlocking nailing and compression plating for adult forearm fractures," Orthopaedic Review, 2005; 36(2): 125–130.
6. Bansal A., "Intramedullary nailing in radius and ulna fractures: a minimally invasive approach," International Journal of Orthopaedics, 2010; 14(1): 23–28.
7. Lee S.K., "Forearm shaft fractures treated by locked intramedullary nailing versus compression plating: a prospective randomized study," Journal of Orthopaedic Surgery, 2012; 20(1): 35–39.
8. Puno R.M., "Refracture after plate removal in the forearm," Journal of Bone and Joint Surgery, 1994; 76(8): 1208–1213.
9. Goldfarb C.A., "Functional outcome after fractures of both bones of the forearm," Journal of Bone and Joint Surgery, 2005; 87(2): 374–379.
10. Mughal M., "Comparative study of forearm fractures: plate fixation versus intramedullary nailing," Pakistan Journal of Orthopaedic Surgery, 2017; 33(4): 212–216.
11. Bansal A., “Intramedullary nailing in radius and ulna fractures: a minimally invasive approach,” International Journal of Orthopaedics, 2010, 14(1): 23-28.
12. Lee S.K., “Forearm shaft fractures treated by locked intramedullary nailing versus compression plating: a prospective randomized study,” Journal of Orthopaedic Surgery, 2012, 20(1): 35-39.
13. Chapman M.W., “Forearm fractures in adults: mechanisms and principles of management,” Clinical Orthopaedics and Related Research, 1989, 241(1): 190-198.
14. Ring D., “Prospective comparison of plating and nailing for diaphyseal fractures of the forearm in adults,” Journal of Orthopaedic Trauma, 1998, 12(8): 524-528.
15. Puno R.M., “Refracture after plate removal in the forearm,” Journal of Bone and Joint Surgery, 1994, 76(8): 1208-1213.
16. Goldfarb C.A., “Functional outcome after fractures of both bones of the forearm,” Journal of Bone and Joint Surgery, 2005, 87(2): 374-379.
17. Hong G.J., “Comparative study between interlocking nailing and compression plating for adult forearm fractures,” Orthopaedic Review, 2005, 36(2): 125-130.
18. Bansal A., “Intramedullary nailing in radius and ulna fractures: a minimally invasive approach,” International Journal of Orthopaedics, 2010, 14(1): 23-28.