# Upper Limb Orthotics/Ulna Shaft Fracture/Nightstick Fracture
## Describe your case study

The patient is a 21 year old male who suffered a transverse fracture of the ulna shaft. He suffered this injury by raising his hand to protect his face from an assailant and there are also some abrasions in the area from the attack. The ulna has a transverse break with no rotation and <5mm of angulation. There is pain and swelling of the area with localised abrasions that will need to be monitored. The patient currently has bandages for the abrasions and is in need of an orthotic device for the injury. The patient would like to retain as much range of motion as possible while wearing the orthosis.

## Written information
### Orthotic Treatment of Ulna shaft fracture/Nightstick fracture

A fracture of the ulna shaft is often called a nightstick fracture as this certain type of fracture is usually obtained by raising your arm to protect the head from a blunt force as you would if you were attacked with a nightstick. Other causes of the nightstick fracture are motor vehicle accidents and falls. Symptoms of a nightstick fracture include pain, swelling, tenderness and inflammation (Orthopaedicsone, 2009) A nightstick fracture can be transverse or oblique and have a variety of angulations. A fracture with a higher degree of angulation is usually defined as more severe compared to those with a lower degree of angulation. The position of the fracture along the ulna will also change the severity, if the fracture is in the proximal 3rd of the ulna or has >10 degrees of angulation (Zych, Latta, & Zagorski, 1987, Gebuhr et al., 1992,, Mackay, Wood, & Rangan, 2000) it is usually considered too severe for a non-surgical treatment. The fracture will result in a loss of pronation, supination, permanent angulation and possibly some shortening of the forearm (Handoll & Pearce, 2012, Zych, Latta, & Zagorski, 1987, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998, Mackay, Wood, & Rangan, 2000). The amount of shortening and loss of pronation varies and can be reduced by high quality management of the fracture during healing. The goal when treating a nightstick fracture is to keep 90% or more of the original range of motion (Zych, Latta, & Zagorski, 1987) but as Stern & Drury (1983) mention “The ulna remains the most difficult bone in which to achieve primary healing. This may be due to torsional stresses incurred during pronation and supination.” It has been shown that there are a variety of options to treat a nightstick fracture both surgical and non-surgical. All of these options are viable but some are better suited to achieve certain goals (Handoll & Pearce, 2012, Mackay, Wood, & Rangan, 2000). The role of an orthosis in treating a nightstick fracture is to be rigid and provide appropriate support, pressure and protection for the site of injury while it can heal. The recommended orthosis for a nightstick fracture encompasses the wrist joint to restrict pronation, supination, and flexion/extension of the joint as to avoid misalignment of the fracture but allow some movement to increase the strength of the ulna once the fracture has healed (Sarmiento, Latta, Zych, McKeever, & Joseph, 1998).

### Orthotic treatment options

Orthotic treatment of a nightstick fracture can include a short arm below elbow brace or a long arm plaster cast. Each has been shown to be effective, but have minor differences in there outcome. A short arm brace can be pre-manufactured or custom made for the client. Both pre-manufactured and custom braces have the same function, to restrict the movement of the fracture while healing by providing different forces to different areas of the forearm. The long arm plaster cast serves the same purpose as the short arm brace but provides a larger surface area by encompassing the elbow joint for extra stability. The downside of the long arm plaster cast is it greatly restricts movement of the elbow joint which has been deemed un-necessary restriction of movement (Mackay, Wood, & Rangan, 2000) and therefore the short arm brace has been found to be a more viable treatment option for those who wish to keep active while healing. Gebuhr et al. (1992) compared using the short arm brace and long arm cast and found that the short arm brace allowed patients to get back to work while healing. The short arm brace was also found to be more popular than the long arm cast, the same result was found in a study by (Handoll & Pearce, 2012). The long arm cast was found to heal the fracture an average of 6 days earlier than the short arm brace. The results of the study also showed there was no significant change in pronation, supination and elbow range of motion between the two interventions.

### Orthotic treatment vs Surgical intervention

“Widely displaced or unstable fractures should be treated by open reduction and internal fixation using a compression plate.”(Mackay, Wood, & Rangan, 2000) The surgical intervention options for a nightstick fracture are external fixation and compression plating. External fixation is commonly used in modern day medicine to treat most fractures as it can provide great control over the pressure of the fracture site and allow limited mobility. External fixation is the use of pins and wires attached to the bone on either side of the fracture site and an external scaffolding to remove pressure from the fracture site and support the limb (Fragomen & Rozbruch, 2007). External fixation is rarely used on nightstick fractures as the ulna is rarely under enough pressure to justify the excessive procedure. External fixation comes with some complications such as infection at pin sites, malunion and adverse fractures of the ulna(Fragomen & Rozbruch, 2007). If the pin sites aren’t monitored and kept sterile then infection can easily set in. There is a possibility that the fracture unify using this form of treatment, though modern fracture management approaches have minimalized this problem (Fragomen & Rozbruch, 2007). The ulna may fracture after it has healed due to stress fractures of the pin sites or re-fracturing the original fracture site due to a lack of movement during the healing process (Fragomen & Rozbruch, 2007, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998). Compression plating is a less used form of surgical intervention used for fractures as it requires a large surgical area to operate. Compression plating is a surgical treatment option where a thick heavy plate is placed alongside the broken long bone and attached via screws (Harvey, 1971). This provides a stable backing to remove pressure from the fracture and allow healing. This method has been shown to have been a great method of achieving bone union in the fracture but has many complications. The complications of using compression plating are that it leaves the ulna weakened and brittle (Harvey, 1971). This is caused by the bone not moving during the healing phase and then suffering from atrophy (Harvey, 1971). The ulna may re-fracture after healing due to the holes left in the bone by the screws used to hold the metal plate to the bone. There is also a possibility of infection during the initial treatment or when removing the plate. (Harvey, 1971, Sarmiento, Latta, Zych, McKeever, & Joseph, 1998) Depending on the severity of the fracture orthotic treatment may be preferable over any form of surgical intervention. Nightstick fractures with an angulation of less than 10 degrees and if the fracture is in the distal 2/3 of the ulna are seen to be not as severe (Gebuhr et al., 1992, Zych, Latta, & Zagorski, 1987, Mackay, Wood, & Rangan, 2000) and it is more efficient to treat them non-surgically via orthosis.