Forearm Plate Fixation: Should Plates Be Removed?

Document Type : RESEARCH PAPER


1 1 Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA 2 Upper Extremity and Reconstructive Microsurgery Unit, Institute of Orthopaedics, Lerdsin Hospital, Department of Orthopaedic Surgery, College of Medicine, Rangsit University, Bangkok, Thailand

2 Department of Orthopaedic Surgery, Hand and Upper Extremity Service, Massachusetts General Hospital, Harvard Medical School, Boston, USA

3 Department of Plastic and Reconstructive Surgery, Radboud University Medical Center, Nijmegen, The Netherlands


Background: Refracture after both bone forearm fracture fixation may vary with or without plate removal. We tested
the null hypothesis that there is no difference in the rate of refracture in patients who have undergone open reduction
and internal fixation of a diaphyseal forearm bone who have retained implants versus removed implants. We also
studied factors associated with plate removal.
Methods: We retrospectively identified 645 adult patients with a total of 925 primary fractures that underwent primary
plate fixation of an ulnar or radial shaft fracture between 2002 and 2015 at a single institutional system. Patients with
nonunion, pathological fracture or infection were excluded. Independent factors associated with refracture and plate
removal were identified using multivariable analysis.
Results: Refractures occurred in 6.3% of the fractures that had forearm implant removal, compared to 2.1% of the
fractures with retained plates. Refractures were independently associated with plate removal (OR: 3.7, 95% CI: 1.2-
11.7, P=0.023) and was more frequent in the radius (OR: 2.4, 95% CI: 1.0-5.8, P=0.06). A refracture after implant
removal occurred within 3 months after removal. Ulnar plates were removed more often compared to radial plates (OR:
2.6, 95% CI: 1.4-4.7, P=0.002) as were plates used for type A fractures compared to type C fractures (OR: 3.2, 95%
CI: 1.1-9.2, P=0.032).
Conclusion: The rate of refracture is higher after plate removal compared to patients who did not have plates removed.
Although uncommon, refractures of the radius tend to be more common than a refracture of the ulna. If the implant is
symptomatic on the ulnar side, it may be preferable to remove the ulnar implant and retain the radius implant rather
than remove both plates when possible. Furthermore, limiting strenuous activity for three months after implant removal
is a consideration.
Level of evidence: III


1. Rüedi TP, Murphy WM. AO principles of fracture 
management. 2000.
2. Marcheix PS, Delclaux S, Ehlinger M, Scheibling 
B, Dalmay F, Hardy J, et al. Pre- and postoperative 
complications of adult forearm fractures treated 
with plate fixation. Orthop Traumatol Surg Res. 
3. Vos DI, Verhofstad MH. Indications for implant removal 
after fracture healing: a review of the literature. Eur J 
Trauma Emerg Surg. 2013;39(4):327-37.
4. Haseeb M, Butt MF, Altaf T, Muzaffar K, Gupta A, 
Jallu A. Indications of implant removal: A study of 
83 cases. International journal of health sciences. 
5. Yao CK, Lin KC, Tarng YW, Chang WN, Renn JH. Removal 
of forearm plate leads to a high risk of refracture: 
decision regarding implant removal after fixation of 
the forearm and analysis of risk factors of refracture. 
Arch Orthop Trauma Surg. 2014;134(12):1691-7.
6. Hidaka S, Gustilo RB. Refracture of bones of the 
forearm after plate removal. J Bone Joint Surg Am. 
7. Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones 
of the forearm after the removal of compression 
plates. J Bone Joint Surg Am. 1988;70(9):1372-6.
8. Bednar DA, Grandwilewski W. Complications of 
forearm-plate removal. Can J Surg. 1992;35(4):428-31.
9. Labosky DA, Cermak MB, Waggy CA. Forearm fracture 
plates: to remove or not to remove. J Hand Surg Am. 
10.Langkamer VG, Ackroyd CE. Removal of forearm 
plates. A review of the complications. J Bone Joint 
Surg Br. 1990;72(4):601-4.
11.Anderson LD, Sisk D, Tooms RE, Park 3rd WI. 
Compression-plate fixation in acute diaphyseal 
fractures of the radius and ulna. The Journal 
of bone and joint surgery. American volume. 
12.Chapman MW, Gordon JE, Zissimos AG. Compressionplate fixation of acute fractures of the diaphyses 
of the radius and ulna. J Bone Joint Surg Am. 
13.Rosson JW, Shearer JR. Refracture after the removal of 
plates from the forearm. An avoidable complication. J 
Bone Joint Surg Br. 1991;73(3):415-7.
14.Truntzer J, Vopat ML, Kane PM, Christino MA, Katarincic 
J, Vopat BG. Forearm diaphyseal fractures in the 
adolescent population: treatment and management. 
Eur J Orthop Surg Traumatol. 2015;25(2):201-9.
15.Uhthoff HK, Finnegan M. The effects of metal plates 
on post-traumatic remodelling and bone mass. J Bone 
Joint Surg Br. 1983;65(1):66-71.
16.Johnson CB, Fallat LM. The effect of screw holes on 
bone strength. The Journal of foot and ankle surgery. 
17.Lu Y, Thiagarajan G, Nicolella DP, Johnson ML. Load/
strain distribution between ulna and radius in the 
mouse forearm compression loading model. Med Eng 
Phys. 2012;34(3):350-6.
18.Kaufmann RA, Kozin SH, Barnes A, Kalluri P. Changes 
in strain distribution along the radius and ulna with 
loading and interosseous membrane section. J Hand 
Surg Am. 2002;27(1):93-7.
19.Zwingenberger S, Nich C, Valladares RD, Yao Z, 
Stiehler M, Goodman SB. Recommendations and 
considerations for the use of biologics in orthopedic 
surgery. BioDrugs. 2012;26(4):245-56.