Treatment of a Segmental Defect in Open Radial and Ulnar Shaft Fractures Using rhBMP-2 and Iliac Crest Bone Graft: A Case Report

Abstract

Segmental defects and delayed healing of long bone fracture remains a major problem among orthopedic surgeons. Nonunion of the forearm as a result of complex open fracture can result in imbalance in the main anatomical structures, leading to impaired function [17]. Therefore, the treatment of these defects must include the restoration of length and alignment in order to restore functional forearm motion [21]. Current treatment options for segmental long bone defects includes autogenous bone grafting, bone shortening, plate fixation combined with either intercalary non-vascularized structural (corticocancellous) bone grafts, vascularized grafts, or amputation [9]. The identification of recombinant human bone morphogenetic protein-2 (rhBMP-2) has led to revolutionary treatment options in certain orthopedic procedures. Currently, rhBMP-2 is approved by the United States Food and Drug Administration (FDA) for spine fusion [7, 11, 13, 16], tibial fractures [12, 14], and oral maxillofacial [4–6] procedures. The reported use of BMP-2 in cases of forearm shaft fractures has been limited. In our case report, we describe an off-label use of rhBMP-2 used in combination with iliac crest bone graft to treat segmental defects in a man with open radius and ulna fractures. Case Report A 35-year-old right hand dominant male sustained an open ipsilateral radius and ulna fracture with significant bone loss after a motorcycle accident (Fig. 1). On the day of presentation, the patient was taken to the operating room for irrigation and debridement of the open fractures. After the wounds were copiously irrigated, a dynamic compression plate was first placed on the extensor aspect of the ulna. Next, the radius was approached through a volar Henry interval. After initial reduction with dynamic compression plate, it was noted that the ulna was 12 mm longer than the radius. Contralateral fluoroscopic images were then taken in the operating room to assess the ulnar variance, which was noted to be neutral. The radius was then brought out to the appropriate length and the plate was reapplied. This resulted in a 3-cm gap in the mid-radial shaft. The ulnar shaft fracture had an approximately 1-cm defect, but had one point of cortical contact (Fig. 2). The wound was then closed with all bone and tendon being covered. The wound healed with dressing changes over the next 2 weeks without any signs of infection. He was seen several times in the office and underwent therapy to promote forearm, wrist, and finger range of motion. The soft tissue healed completely, and the ulna and radius stayed in good alignment; however, the bony defects persisted at the fracture sights. At 10 weeks postoperatively, the ulna fracture showed some signs of partial bridging, but the radius fracture defect was persistent. He was then scheduled for revision of his hardware and bone grafting. Open in a separate window Fig. 1 Anteroposterior (a) and lateral (b) initial injury radiographs of the left forearm demonstrating comminution at the fracture sites