Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

Refracture Following Operative Treatment of Pediatric Both Bone Forearm Fractures

INTRODUCTION

Both bone forearm fractures are common injuries in children. Most can be treated with reduction and casting. Those that fail nonoperative management can be treated with a plate or intramedullary fixation; however, refracture remains a problem. The goal of this study is to evaluate the refracture rate in both bone forearm fractures based on the mode of fixation.

METHODS

Institutional board review approval was obtained. A retrospective chart review from 2010 to 2021 at a single tertiary care institution was conducted for all operative patients <18 years who sustained a both bone forearm fracture. Groups were stratified based on initial operative fixation type: both bones fixated using nails, 1 bone fixated with a nail; both bones plated, and 1 bone plated. Further review was conducted to identify refractures following initial operative treatment. Statistical analyses were conducted using the χ 2 test of independence and Fisher's exact test.

RESULTS

In all, 402 operatively treated both bone forearm fracture patients were identified. Two hundred fifty-six of these patients underwent intramedullary fixation (average age 10.3y/o), while 146 patients received plate fixation (average age 13.8y/o). Fracture location was similar across the nailing and plating cohorts, most often occurring in the mid-shaft region. Patients aged ≤10 years refractured at a significantly higher rate than patients aged >10 years across all operative fixation cohorts (12.5% vs. 2.5%, P <0.001). Among the 256 patients who underwent intramedullary fixation, 61.3% had both bones treated (n=157/256), whereas 38.7% received single bone fixation (n=99/256). Of the 146 plate fixations, 84.4% had both bones fixed (n=123/146), and only 15.8% were treated with single bone fixation (n=23/146). In the intramedullary group, 15 patients sustained refractures, 11 of whom were treated with single bone fixation (11.1%, n=11/99) versus 4 with both both fixation (2.5%, n=4/157). Among the plating group, 7 patients sustained refractures, 6 with both bone fixation (4.9%, n=6/123) and 1 in single bone fixation (4.3%, n=1/23). Refractures were found to be significantly more prevalent among patients treated with single bone compared with both bone intramedullary nail fixation (11.1% vs. 2.5%, P =0.006). By fixated bone, single bone ulna fixations had a higher refracture rate compared with both bone fixations (12.1% vs. 3.6%, P =0.003).

CONCLUSION

The overall refracture rate following operative treatment of both bone fractures is 5.5% and is similar between intramedullary and plate fixations. Overall, patients ≤10 years of age had a higher rate of refracture. Among single bone fixations, higher refracture was seen with intramedullary fixations, and when the radius was treated nonoperatively. Surgeons may be able to reduce the refracture rate by performing intramedullary fixation of both bones instead of only one bone. Effective postoperative counseling among younger patients may also decrease refracture rates.

To Bury or Not to Bury the K-wires After Fixation of Both Bone Forearm Fractures in Patients Younger Than 11 Years Old: A Randomized Controlled Trial

PURPOSE

The primary objective was to compare the re-fracture incidence of both radius and ulna fracture in 2 groups treated using intramedullary Kirschner wires (K-wires) where the wires were exposed in group I and buried in group II. The secondary objective was to compare the final functional outcomes and complications incidence.

METHODS

Between March 2019 and February 2021, 60 pediatric patients with unstable radius and ulna fractures amenable to surgical intervention using intramedullary K-wires were randomized into group I (K-wires were exposed above the skin by 2 cm) or group II (K-wires were buried under the skin). In group I, K-wires were removed in the outpatient clinic, while in group II, they were removed under general anesthesia as a day-case procedure. Functional outcome per Price criteria was reported at 1-year follow-up.

RESULTS

Included patients had a mean age of 7.6 years (range: 5 to 10 y). The mean operative time was significantly higher in group II (32.33±7.51 vs. 36.77±8.70 min, P =0.03), with no difference regarding intraoperative x-ray exposure (43.12±15.52 vs. 41.6±11.96 s, P =0.67). Fracture union was achieved after a mean of 44±2.6 days in group I and 43±1.87 days in group II, with no difference between both groups ( P =0.34). One patient had re-fracture in group I and no patients in group II; however, the difference was insignificant ( P =0.12). Infection occurred in 2 patients in each group. All patients reported excellent scores per Price criteria and achieved full wrist and elbow range of motion compared with the contralateral noninjured side.

CONCLUSIONS

Exposed implants are a safe option when dealing with forearm fractures in patients younger than 11 years old, with the added advantage of fewer hospital admissions. Furthermore, it had a similar complication rate and functional outcomes compared with buried implants.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov, NCT03906929.

LEVEL OF EVIDENCE

Level II.

Single-bone versus both-bone plating of unstable paediatric both-bone forearm fractures. A randomized controlled clinical trial

PURPOSE

This clinical trial compares the functional and radiological outcomes of single-bone fixation to both-bone fixation of unstable paediatric both-bone forearm fractures.

METHODS

This individually randomized two-group parallel clinical trial was performed following the Consolidated Standards of Reporting Trials (CONSORT) statement at a single academic tertiary medical centre with an established paediatric orthopaedics unit. All children aged between nine and 15 years who presented to the emergency department at Assiut university with unstable diaphyseal, both-bone forearm fractures requiring surgical intervention between November 1, 2018, and February 28, 2020, were screened for eligibility against the inclusion and exclusion criteria. Inclusion criteria were diaphyseal unstable fractures defined as shaft fractures between the distal and proximal metaphyses with an angulation of > 10°, and/or malrotation of > 30°, and/or displacement > 10 mm after attempted closed reduction. Exclusion criteria included open fractures, Galeazzi fractures, Monteggia fractures, radial head fractures, and associated neurovascular injuries. Patients who met the inclusion criteria were randomized to either the single-bone fixation group (intervention) or the both-bone fixation group (control). Primary outcomes were forearm range of motion and fracture union, while secondary outcomes were forearm function (price criteria), radius re-angulation, wrist and elbow range of motion, and surgical time RESULTS: A total of 50 children were included. Out of these 50 children, 25 were randomized to either arm of the study. All children in either group received the treatment assigned by randomization. Fifty (100%) children were available for final follow-up at six months post-operatively. The mean age of single-bone and both-bone fixation groups was 11.48 ± 1.93 and 13 ± 1.75 years, respectively, with a statistically significant difference (p = 0.006). There were no statistically significant differences in gender, laterality, affection of the dominant hand, or mode of trauma between single-bone and both-bone fixation groups. All patients in both groups achieved fracture union. There mean radius re-angulation of the single-bone fixation groups was 5.36 ± 4.39 (0-20) degrees, while there was no radius re-angulation in the both-bone fixation group, with a statistically significant difference (p < 0.001). The time to union in the single-bone group was 6.28 ± 1.51 weeks, while the time to union in the both-bone fixation group was 6.64 ± 1.75 weeks, with no statistically significant difference (p = 0.44). There were no infections or refractures in either group. In the single-bone fixation group, 24 (96%) patients have regained their full forearm ROM (loss of ROM < 15°), while only one (4%) patient lost between 15 and 30° of ROM. In the both-bone fixation group, 23 (92%) patients have regained their full forearm ROM (loss of ROM < 15°), while only two (8%) patients lost between 15 and 30° of ROM. There was no statistically significant difference between groups in loss of forearm ROM (p = 0.55). All patients in both groups regained full ROM of their elbow and wrist joints. On price grading, 24 (96%) and 23 (92%) patients who underwent single bone fixation and both-bone fixation scored excellent, respectively. Only one (4%) patient in the single-bone fixation group and two (8%) patients in the both-bone fixation group scored good, with no statistically significant difference in price score between groups (p = 0.49). The majority of the patients from both groups had no pain on the numerical pain scale; 22 (88%) patients in the single-bone fixation group and 21 (84%) patients in the both-bone fixation groups, with no statistically significant difference between groups (p = 0.38). The single-bone fixation group had a significantly shorter mean operative time in comparison to both-bones plating (43.60 ± 6.21 vs. 88.60 ± 10.56 (min); p < 0.001).

CONCLUSION

Single-bone ulna open reduction and plate fixation and casting are safe and had a significantly shorter operative time than both-bone fixation. However, single-bone ORIF had a higher risk radius re-angulation, alas clinically acceptable. Both groups had equally excellent functional outcomes, forearm ROM, and union rates with no complications or refractures. Long-term studies are required.

Locked wires fixator for fractures of the distal third of the radius and ulna in children

BACKGROUND

Prevention of redisplacement is an issue after the treatment of fractures of the distal third of the radius in children. In this study, we used a locked wires fixator for this type of fracture and achieved favorable treatment outcomes.

METHODS

The subjects were 8 children with fractures of the distal third of the radius (male: 7, female: 1, mean age: 9.0 years old) who underwent surgery with locked wires fixators and were able to be evaluated 12 months after surgery. Immobilization was not applied after surgery. The locked wires fixator or K-wire was removed when the bridging callus was observed on plain radiography 4-6 (mean 5.5) weeks after surgery in all patients. The presence of bone union, functional outcomes, and complications were investigated postoperatively.

RESULTS

All patients achieved bone union without redisplacement excellent function. The pin site infection was observed in two patients.

CONCLUSIONS

The locked wires fixator may be a new useful treatment method for fractures likely to cause postoperative redisplacement.

Hybrid fixation for adolescent both-bones diaphyseal forearm fractures: Preliminary results of a prospective cohort study

INTRODUCTION

Both-bone forearm fractures account for 3.4% of all pediatric fractures and 26% of all pediatric upper extremity fractures. Although non-operative management remains a feasible treatment option for children older than 10 years, they have a higher incidence for malunion due to their limited bone remodelling potential. Therefore, surgical intervention could be advocated for this age group, however the optimal method of surgical fixation in this age group remains controversial.Authors wanted to evaluate hybrid fixation (plating of ulna & elastic nail for radius) of adolescent both-bone forearm fractures in a large single-institution cohort of patients.

METHODS

A single-center, prospective cohort study was conducted at an academic Level 1 Trauma Center from February 2016 to February 2019.A total of 60 patients (age 10-16 years) with both-bones forearm fracture were enrolled. Patients were assessed radiographically for union as well as clinically using the "Outcome Grading System" developed by Martus et al. for functional assessment of surgical management of pediatric forearm fractures using forearm rotation range of motion & complications rate.

RESULTS

At final follow up for each patient (24 months) Union was achieved in all cases. Delayed union occurred in 4 patients (2 radii & 2 ulnae) with no case of combined radius & ulnar delayed union. At final follow up, the mean supination range was 81.27° ± 4.1°, while the mean pronation range was 68.17° ± 3.03°. The "Outcome Grading System" results were: 48 cases (80%) scored excellent, 10 cases (16.7%) scored good & 2 cases (3.3%) scored fair.

CONCLUSION

Hybrid fixation method in adolescent both-bones forearm fracture could be a viable option in managing these injuries & may reduce the problem of ulnar non-union encountered when using elastic stable intramedullary nail (ESIN) in that age group.

LEVEL OF EVIDENCE

Level II, Therapeutic study.

A novel hybrid fixation versus dual plating for both-bone forearm fractures in older children: A prospective comparative study

OBJECTIVE

The aim of the present study was to compare the clinical outcomes of hybrid fixation using elastic stable intramedullary nailing (ESIN) for the ulna and plate screw fixation for the radius (Hybrid group) with dual plating fixation for both-bone forearm fractures in children between 10 and 16 years of age.

METHODS

Twenty-six patients were treated using a hybrid fixation struct and 30 patients were treated with dual plating fixation. The two groups were compared prospectively according to perioperative data and patient outcome measures.

RESULT

The hybrid fixation construct group had 26 patients, with a mean age of 13.27 years (range, 10-16 years) and the dual plate group had 30 patients, with a mean age of 13.33 years (range, 10-16 years). The groups were similar for sex, arm injured, fracture location. Incision length of ulna, duration of surgery and hospital costs were significantly different between the two groups (P < 0.05). There was no significant difference in either time to union or Price scores for function evaluation between the 2 groups (P < 0.05). Complication rates were also similar between the groups.

CONCLUSION

Hybrid fixation, using open reduction and internal fixation with a plate-and-screw construct on the radius and closed reduction and elastic intramedullary fixation of the ulna, is an acceptable method for treating both-bone diaphyseal forearm fractures in skeletally immature patients 10-16 years old. The small incision and less cost are the characteristics of this hybrid fixation.

Single Versus Double Intramedullary Fixation of Paediatric Both Bone Forearm Fractures: Radiological Outcomes

Introduction Both bone diaphyseal forearm fractures are common in children. If the reduction is unstable, intramedullary fixation using elastic intramedullary nails (EIN) is an option. Intramedullary fixation may be either of single (S-EIN) or both (double) bones (D-EIN). Some reports have shown poorer outcomes with S-EIN. Our aim was to critically analyse the radiological features of EIN cases, comparing results for single and both bone fixation. Method Retrospective review (two years: November 2014-November 2016) of EIN forearm procedures. Radiological reduction of the radius/ ulna (AP/lateral) was measured on theatre fluoroscopy and six week radiographs. The results were categorised by angulation: (i) <10°, (ii) 10-20°, and (iii) >20°. Results Of 36 patients (19 boys, 17 girls), 13 had S-EIN (mean age 9.6 years, range 7-14) and 23 had D-EIN (mean age 10 years, range 7-14). In the S-EIN group, two and 11 had the ulna and radius fixed, respectively. Intraoperatively, of the 13 S-EIN patients, nine had <10° angulation of the radius or ulna, two had 10-20°and two had >20°. All 23 D-EIN patients had intraoperative radiology showing <10° angulation of both bones and maintenance of reduction of <10° angulation at six weeks post surgery. However, some S-EIN patients had increased deformation: at six weeks, four patients had 10-20° and three patients >20°. No patient in either group had revisional treatment. Time in cast postoperatively was similar in both groups: S-EIN, 6.15 weeks (4-12) and D-EIN, 5.5 weeks (3-8). Operative time was 64 mins (43-82) and 76 mins (45-86) in S-EIN and D-EIN groups, respectively. No other complications were recorded. Conclusion Though there may be particular reasons for selecting single bone fixation, this series shows a propensity to increased angulation of fractures fixed by S-EIN (7/13 in this group). We advise caution in the use of single bone fixation for both bone forearm fractures.

Definition of infection after fracture fixation: A systematic review of randomized controlled trials to evaluate current practice

INTRODUCTION

One of the most challenging musculoskeletal complications in modern trauma surgery is infection after fracture fixation (IAFF). Although infections are clinically obvious in many cases, a clear definition of the term IAFF is crucial, not only for the evaluation of published research data but also for the establishment of uniform treatment concepts. The aim of this systematic review was to identify the definitions used in the scientific literature to describe infectious complications after internal fixation of fractures. The hypothesis of this study was that the majority of fracture-related literature do not define IAFF.

MATERIAL AND METHODS

A comprehensive search was performed in Embase, Cochrane, Google Scholar, Medline (OvidSP), PubMed publisher and Web-of-Science for randomized controlled trials (RCTs) on fracture fixation. Data were collected on the definition of infectious complications after fracture fixation used in each study. Study selection was accomplished through two phases. During the first phase, titles and abstracts were reviewed for relevance, and the full texts of relevant articles were obtained. During the second phase, full-text articles were reviewed. All definitions were literally extracted and collected in a database. Then, a classification was designed to rate the quality of the description of IAFF.

RESULTS

A total of 100 RCT's were identified in the search. Of 100 studies, only two (2%) cited a validated definition to describe IAFF. In 28 (28%) RCTs, the authors used a self-designed definition. In the other 70 RCTs, (70%) there was no description of a definition in the Methods section, although all of the articles described infections as an outcome parameter in the Results section.

CONCLUSION

This systematic review shows that IAFF is not defined in a large majority of the fracture-related literature. To our knowledge, this is the first study conducted with the objective to explore this important issue. The lack of a consensus definition remains a problem in current orthopedic trauma research and treatment and this void should be addressed in the near future.

Single Bone Fixation versus Both Bone Fixation for Pediatric Unstable Forearm Fractures: A Systematic Review and Metaanalysis

BACKGROUND

It is uncertain whether single bone fixation is comparable to both bone fixation in the treatment of unstable both bone forearm fractures in children.

MATERIALS AND METHODS

A systematic review using PubMed, Embase, and Cochrane Library database searches was performed on October 1, 2015 on English language scientific literature only. Clinical study designs comparing single bone fixation with both bone fixation of pediatric both bone forearm fractures were included. Studies of only one treatment modality were excluded from the study. Studies eligible for inclusion were assessed using the risk of bias tool for nonrandomized studies.

RESULTS

Metaanalysis points to no significant differences in re-angulation, loss of rotation, union time and complications between single bone and both bone fixation. However, the published research lacks quality.

CONCLUSIONS

Despite scattered evidence and small sample sizes, the metaanalysis suggests single bone fixation can be considered a suitable alternative for both bone forearm fractures in children, as it carries less time in surgery and less cost without compromise in final functional outcome compared to double-bone fixation.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

Comparison of Hybrid Fixation to Dual Plating for Both-Bone Forearm Fractures in Older Children

When operative stabilization of forearm fractures in older children is necessary, the optimal method of fixation is controversial. This study compared the radiographic and functional outcomes of dual plating to a hybrid fixation construct with elastic intramedullary nailing of the radius and plate fixation of the ulna of forearm fractures in children aged between 10 and 16 years. Nineteen patients were treated using a hybrid fixation construct and 13 patients were treated with dual plating fixation. The 2 groups were compared retrospectively according to perioperative data and patient outcome measures. The hybrid fixation construct group had 19, with a mean age of 13.3 years (range, 10-16 years) and the dual plate group had 13 patients, with a mean age of 12.9 years (range, 10-16 years). Groups were similar for sex, arm injured, and fracture location. Duration of surgery and tourniquet use was significantly shorter in the hybrid fixation construct group. There was no significant difference in either time to union or Price scores for function evaluation between the 2 groups. Complication rates were also similar between groups, with 1 ulna delayed unions, 1 superficial infection at entry of nail in hybrid fixation construct group, and 1 ulna delayed unions in the dual plating group. Hybrid fixation, using open reduction and internal fixation with a plate-and-screw construct on the ulna and closed reduction and elastic intramedullary fixation of the ulna, is an acceptable method for treating both-bone diaphyseal forearm fractures in skeletally immature patients aged 10-16 years.

Comparison of Pediatric Forearm Fracture Fixation Between Single- and Double-Elastic Stable Intramedullary Nailing

The purpose of this study was to evaluate and compare the outcome of single- and double-elastic stable intramedullary nailing (ESIN) for the treatment of pediatric both-bone forearm fractures. We retrospectively analyzed 49 children with both-bone forearm fractures treated with ESIN. Twenty-four patients were treated with single-ESIN (S-ESIN) to fixate the radius only, and the other 25 patients were treated with double-ESIN (D-ESIN) to fixate the radius and ulna. The duration of surgery, times of fluoroscopy, cost of hospitalization, period of castoff, union time, radiographic outcomes, clinical results, and postoperative complications were compared. The duration of surgery, times of fluoroscopy, and cost of hospitalization were significantly lower in the S-ESIN group; however, the average period of castoff was longer in the S-ESIN group. The incidence of delayed union of the ulna was significantly higher in the D-ESIN than in the S-ESIN group. Although the mean angulation deformity of the ulna in the S-ESIN group was significantly larger than in the D-ESIN group, both of them were acceptable (<10 degrees). Despite this, there was no difference in the loss of forearm motion and complication rates between the 2 groups. In conclusion, our data suggest that S-ESIN to fixate the radius alone remains an equally effective fixation method in the pediatric population compared with both-bone fixation and is our treatment of choice.

The shaft fractures of the radius and ulna in children: current concepts

The incidence of forearm shaft fractures in children has increased in recent years. They are challenging to treat and they can result in several long-lasting complications. The treatment of children's fractures needs to be individualized to their needs. Nonoperative care will be satisfactory for young, preschool children and it is primarily treatment in stable fractures of children at every age. Injury mechanism must be understood to perform appropriate closed reduction. Immobilization using a long-arm cast needs to be focused against the deforming muscle forces - in particular those that rotate - in the forearm, keeping the bones in alignment until bone healing. Operative stabilization by elastic stable intramedullary nailing is the primarily method of treatment in cases of unstable fractures, in particular, in children between preschool age and adolescence. For older children near to skeletal maturity, a rigid plate and screw fixation will be justified. The most common complication after closed treatment is worsening of the alignment and need for repetitive interventions. elastic stable intramedullary nailing results usually in good outcome, and range of forearm rotation is the main feature determining the clinical result. In this article, we report the current concept of paediatric shaft fractures in the radius and ulna.

Three-dimensional imaging of children with severe limitation of pronation/supination after a both-bone forearm fracture

INTRODUCTION

Although both-bone forearm fractures in children may result in severe limitation of forearm rotation, finding the cause remains a diagnostic challenge. This study tries to evaluate the role of rotational malunion, bony impingement and contractures of the interosseous membrane.

PATIENTS AND METHODS

Children (5-16 years) who suffered from a both-bone forearm fracture in diaphysis or distal metaphysis with a limitation of pronation/supination ≥40° at ≥6 months after trauma were included for analysis with conventional radiographs, computed tomography (CT) and magnetic resonance imaging (MRI).

RESULTS

A total of 410 children with a both-bone forearm fracture were prospectively followed in four Dutch hospitals. At a median of 205 days, 7.3 % suffered from a limitation of pronation/supination ≥40°. 14 children were included (median limitation of 40°) and the radiographs revealed a median maximum angular malunion of 16°. CT analysis showed rotational malunion of both radius (median 19°) and ulna (median 9°). MRI analysis revealed neither bony impingement nor contractures of the interosseous membrane.

CONCLUSIONS

Three-dimensional imaging of children with a severe limitation of pronation/supination after a both-bone forearm fracture revealed rotational malunions of both radius and ulna without bony impingement or soft tissue contractures.

LEVEL OF EVIDENCE

Prospective multicenter study, Level 2.