Systematic review: functional outcomes and complications of intramedullary nailing versus plate fixation for both-bone diaphyseal forearm fractures in children

Canal Fill of the Forearm Bones When Placing Intramedullary Nails in the Pediatric and Adolescent Populations

BACKGROUND

In the lower extremity, studies have suggested an optimal nail diameter to medullary canal diameter (ND/MCD) ratio to minimize postoperative complications. The goal of this study was to determine whether a correlation exists between the occurrence of complications, angulation, and range of motion and the ratio of the ND/MCD in the upper extremity.

METHODS

A total of 85 radius and ulna fractures treated with flexible intramedullary nails had ND/MCD ratios measured. Random-effects models were developed to determine the association between complications and ND/MCD ratio, angulation and ND/MCD ratio, and range of motion and ND/MCD ratio. The results were reported for unadjusted models and adjusted models.

RESULTS

Of the 85 forearm fractures treated with intramedullary nailing, there were 3 complications. The average follow-up was 6 months. The ND/MCD ratios were categorized as <0.50, 0.50 to 0.59, and ≥0.60. There was not a significant association between the different ratios and angulation, or risk of complication. There was an association between the ND/MCD ratio ≥0.60 and decreased pronation of -1.58° (-2.77° to -0.38°) and supination of -2.68° (-4.91° to -0.46°) (P < .05).

CONCLUSION

This study found that there was not an association between the nail to canal diameter ratio and postoperative angulation in forearm fractures treated with flexible intramedullary nails. When choosing a flexible nail for forearm fractures, there does not appear to be an optimal ratio; it is therefore reasonable to use the ND that passes more easily.

Pediatric Diaphyseal Forearm Fracture Management with Biodegradable Poly-L-Lactide-Co-Glycolide (PLGA) Intramedullary Implants: A Longitudinal Study

Background: Pediatric forearm fractures represent a substantial proportion of childhood injuries, requiring effective and minimally invasive treatments. Our study investigated the mid-term outcomes of biodegradable poly-L-lactide-co-glycolide (PLGA) intramedullary implants in managing diaphyseal forearm fractures in children. Methods: A follow-up cohort study was conducted with 38 patients treated with PLGA implants. Control examinations were performed one year post-operation, assessing bone healing through radiographic evaluations and functional outcomes using injured and uninjured limb range of motion (ROM) comparisons. Scarring was evaluated employing the Vancouver Scar Scale (VSS), and satisfaction via a questionnaire. Results: Children were predominantly female (76.4%), with a mean age of 9.71 (SD: 2.69) years. Effective fracture stabilization and bone healing were found in all patients, with a minor reduction (mean difference of -1.5°, p = 0.282) in elbow flexion on the operated side (139.3°) compared to the intact (140.8°). Elbow extension presented negligible average changes (0.2°, p = 0.098). Forearm movements were slightly reduced on the operated side (mean pronation: 80.8° vs. 83.7°, p = 0.166; average supination: 83.5° vs. 85.7°, p = 0.141). Wrist palmar flexion and dorsiflexion showed no significant differences. VSS ratings indicated minimal scarring (mean guardian and doctor scores were 1.13 and 0.55, respectively, p = 0.020), and all patients reported satisfaction with the treatment outcomes. Conclusions: Biodegradable implants are effective for pediatric forearm fractures, providing stable bone healing while preserving functional ROM with minimal scarring and high patient satisfaction. PLGA proved to be a viable alternative to traditional metal implants, eliminating secondary removal surgeries.

Intramedullary versus plate fixation of both bone forearm fractures in skeletally immature patients: a systematic review and meta-analysis

BACKGROUND

Both bone forearm fractures (BBFFs) are a common injury amongst the pediatric population. The main indications of surgical fixation are open, irreducible, or unstable fractures. The two most commonly used surgical techniques are closed or open reduction with intramedullary fixation (IMF) and open reduction with plate fixation (PF). The aim of this systematic review and meta-analysis was to determine which fixation method is superior for BBFFs.

METHODS

PubMed, Scopus, Web of Science, and CENTRAL were searched to identify studies comparing IMF and PF. We extracted data on union rates, complications, early hardware removal rates, reoperation rates, and radiographic, clinical, and perioperative outcomes.

RESULTS

Sixteen studies were included in the analysis, with a total of 922 patients (539 IMF and 383 PF). Similar union rates were achieved by both fixation technique. IMF was associated with a higher incidence of symptomatic hardware, and early hardware removal. Better restoration of the radial bow was observed with the PF group, especially in older children and adolescents. The rate of excellent function was comparable between groups, whereas better cosmesis was reported with the IMF group. Despite shorter fluoroscopy time and immobilization time, PF demonstrated longer tourniquet time, operating time, and hospital stay compared to IMF.

CONCLUSIONS

We found no significant difference between IMF and PF in terms of union rates and functional outcomes taking in consideration the merits and demerits of each technique. High-quality randomized controlled trials are, therefore, necessary to determine the superiority of one fixation technique over the other.

LEVEL OF EVIDENCE

III.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications

PURPOSE

The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults.

METHODS

Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time.

RESULTS

A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively.

CONCLUSIONS

Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

LEVEL OF EVIDENCE III

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends

BACKGROUND

Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020.

METHODS

This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period.

RESULTS

The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033).

CONCLUSION

The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

The use of flexible nails in the treatment of paediatric long bone fractures: Experience at a level one paediatric trauma centre, a cohort study

Introduction

Fractures occur in children at an incidence only surpassed by women >85 years and account for 25 % of paediatric injuries. Over the last three decades, there has been a trend towards operative management of children's fractures including utilisation of flexible nails as popularised by the Nancy group in the 1980s. Between 5 and 11 % of paediatric forearm fractures are now fixed in this manner with complication rates of 12-42 %. This study shares the experience of a paediatric level one major trauma centre using this technique in managing long bone fractures in children.

Methods and materials

This retrospective cohort study comprises a sequential series of 109 cases (71 children) of upper and lower limb fractures in children (aged 16 years and below) who underwent fracture fixation using flexible intramedullary nails between 1st April 2015 and 31st March 2019. Radiological and clinical outcomes and complications were assessed.

Results

Ninety-three cases (10 in the lower limb, 83 in the upper limb) satisfied the inclusion criteria in 57 children with a mean age of 8.6 years. All cases were successfully reduced intra-operatively and 92 (98.9 %) achieved union. Taking into account all complications in the upper and lower limb, the overall complication rate is 30.1 % (28 cases) with the vast majority (13 cases, 46.4 %) occurring in the upper limb due to prominence of metalwork prompting early removal.

Conclusions

This study has shown flexible intramedullary nailing to perform well with good stabilisation of a wide variety of paediatric long bone fractures with restoration of bone alignment, satisfactory outcomes with good union rates and a return to normal function. The technique is also safe and in the upper limb can be performed as day-case surgery by a generalist orthopaedic surgeon. Although the overall complication rate is not insignificant, major complications are rare.

An age-matched comparative study on intramedullary nailing and plate fixation of both-bone diaphyseal forearm fracture in adolescents

OBJECTIVE

This study aimed to compare radiological and functional outcomes and complication rates between intramedullary nailing (IMN) and plate fixation for diaphyseal forearm fractures in adolescents via an age-matched analysis.

METHODS

Data were collected from medical records at 11 hospitals from 2009 to 2019, and the age-matched study was conducted between IMN and plate fixation. Functional outcomes, radiographic outcomes, and postoperative complication rates were compared.

RESULTS

The IMN group (Group N) and plate fixation group (Group P) each comprised 26 patients after age matching. The mean age after matching was 13.42 years old. Bone maturities at the wrist of the radius and ulna were not significantly different between the two groups (p = 0.764 and p = 1). At the last follow-up period, functional outcomes using the Price criteria were over 90% in both groups, and the rotational range of motion was comparable to that of the healthy side. Over 70% of cases in Group N were performed by closed reduction, and operation time was half that of Group P. Postoperative neurological symptoms and refractures were more common in Group P than in Group N, although not statistically significantly so.

CONCLUSIONS

Treatment outcomes for age-matched adolescent diaphyseal forearm fractures were excellent with IMN, as well as with plate fixation in many cases despite fewer complications, better cosmesis, and shorter operative times with IMN. IMN for diaphyseal forearm fractures is a useful treatment option even in adolescents although the indications for the best procedure to perform should be considered depending on individual patient needs.

LEVEL OF EVIDENCE IV

Multicenter retrospective study.

Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children

OBJECTIVE

Although mini-plate fixation is an attractive treatment option for distal radius metaphyseal diaphysis junction (DRMDJ) fractures in children, the benefits of minimally invasive fixation (MIF) with pre-bent elastic stable intramedullary nails (MIF) remain underexplored. Therefore, this study aimed to evaluate the clinical efficacy of MIF administration in children with DRMDJ fractures.

METHODS

This retrospective study enrolled 40 patients with DRMDJ fractures who underwent MIF or mini-plate fixation from January 2016 to January 2021. Radiographic parameters, such as palmar inclination and ulnar deflection angle, were examined postoperatively to assess the anatomical reduction of the wrist joint. Clinical outcomes, including the range of wrist flexion and back extension, were examined to analyze the recovery of the wrist range of motion. Additionally, the Gartland-Werley scoring system was used to assess the recovery status of wrist function and healing condition. The student t-test and χ2 test were used to compare differences among groups.

RESULTS

All included patients successfully underwent the operation and were followed up for 12-24 months. Patients in the MIF group had a smaller surgical incision length (0.49 ± 0.06 cm) compared to those in the mini-plate fixation group (4.41 ± 0.73 cm) (t = 22.438, p = 0.000). Palmar inclination and ulnar deflection were within the normal range in patients of both groups, and the fractures were successfully anatomically reduced. Moreover, wrist flexion and back extension in the MIF group and mini-plate group were (72.50° ± 0.64° vs. 70.18° ± 0.56°) and (59.55° ± 1.75° vs. 60.04° ± 1.37°), and differences were statistically significant (t = 2.708, p = 0.010 and t = 0.885, p = 0.382, respectively). Furthermore, MIF treatment resulted in a higher proportion of excellent Gartland-Werley scores (94.44%) than mini-plate fixation (86.36%) (p = 0.390). In addition, one case in the mini-plate fixation group experienced re-fracture following the removal of the internal fixation, and the fracture healed after reduction and cast fixation. All patients achieved satisfactory bone healing without other complications.

CONCLUSION

Compared with mini-plate fixation, MIF has the advantages of small incision length, superior range of motion of thr wrist joint, and better maintenance of the physiological radian, providing a promising approach for clinical and surgical treatment of DRMDJ fractures.

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.

Outcomes and complications of Titanium elastic nailing for forearm bones fracture in children: our experience in a district general hospital in the United Kingdom

Intramedullary Titanium elastic nailing (TENS) is successfully used for irreducible and displaced forearm bone fractures in children. The purpose of this study was to report the potential complications and functional outcomes associated with paediatric forearm fractures treated with TENS nails. We retrospectively reviewed 65 children with displaced forearm bone fractures treated by TENS nailing with a mean follow-up of 5.84 months (4-12). Data detailing patient demographics, fracture characteristics, associated fractures, injury surgery interval, grade of the operating surgeon, methods of fixation, time to union, the timing of removal of the nail, and complications were collected and analysed. The mean age in our study was 9.13 years. 92% had fractures of both radius and ulna, 83.3% had fixation of both bones, and 16.7% had single bone fixation only. Open reduction was required in 38.5% of cases. The average time to fracture union was 10.34 weeks (6-20). The average time of implant removal was 20.12 weeks (9-32). We observed an overall complication rate of 41.5%. We noted a higher (56% vs 32.5%, p=0.059) complication rate in open reduction cases. According to the Price criteria, we had excellent to good results in over 98% of patients despite a slightly higher complication rate. Titanium elastic nailing is a safe, reliable method of internal fixation for irreducible or unstable fractures of both bones of the forearm in children. Open reduction of fracture was associated with higher complications. Despite higher overall complications, we noted excellent functional results in most cases.

Clinical and Radiological Outcomes of Paediatric Forearm Fractures of the Radius and Ulna Following Fixation by Intramedullary Nailing or Plating: A Systematic Review

Ipsilateral forearm fractures of both the radius and ulna in children are one of the most common forms of injuries in this population. They often result from axial loading on the hand and wrist following a fall on an outstretched hand. These injuries can often be managed either conservatively or operatively. Non-operative management involves the use of cast immobilisation after satisfactory closed reduction. Most fractures managed conservatively have been noted to have a successful outcome. Surgical options of management include the use of intramedullary nailing (IMN), plates and screws, hybrid techniques and rarely external fixators. The purpose of this systematic review is to critically analyse the functional and radiological outcomes as well as the probability of developing a complication in children that have undergone either IMN or plating of both the radius and ulna in the paediatric population. A comprehensive electronic database search from April 2014 until April 2022 was conducted. Studies from PubMed, EMBASE and Cochrane electronic databases were retrieved. A total of 260 cohort studies with children between the ages of 5 to 17 years old were identified. After the application of both inclusion and exclusion criteria, six articles with a total of 409 patients relevant to this review were identified and analysed. There were no significant inconsistencies statistically in functional and radiological outcomes. Overall complication rate and time to fracture union were similar. Intramedullary nailing was noted to have a shorter operative and anaesthetic time, longer fluoroscopic exposure, and a better cosmetic outcome. Differences in bowing, radial bow magnitude and location had no overall bearing on rotation and daily activity. Considering the methodological limitations of this study, a larger sample size and higher level of evidence such as randomized control studies will yield a more conclusive result to resolve controversies. Based on currently available evidence, both plating and intramedullary nailing are excellent treatment modalities in both-bone forearm fractures.

Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation

BACKGROUND

Pediatric forearm fractures are common injuries and can sometimes require surgical treatment. Few studies have evaluated the long-term outcomes of pediatric forearm fracture plating. We evaluated long-term functional outcomes and satisfaction in children with forearm fractures treated with plate fixation.

METHODS

We performed a single-institution case series at a pediatric level 1 trauma center. Inclusion criteria were: patients with radius and/or ulna diaphyseal fractures, index surgery at 18 years of age or younger, plate fixation, and a minimum of 2 years follow-up. We surveyed patients with the QuickDASH outcome measure and supplemented this with functional outcomes and satisfaction questions. Demographics and surgery characteristics were obtained from the electronic medical record.

RESULTS

A total of 41 patients met the eligibility criteria, of whom 17 completed the survey with a mean follow-up of 7.2 ± 1.4 years. The mean age at index surgery was 13.1 ± 3.6 years (range, 4 to 17), with 65% males. All patients reported at least one symptom, with aching (41%) and pain (35%) occurring most frequently. There were 2 complications (12%), including one infection and one compartment syndrome treated with fasciotomy. Hardware removal occurred in 29% of patients. There were no refractures. The mean QuickDASH score was 7.7 ± 11.9, with an occupation module score of 1.6 ± 3.9 and a sports/performing arts module score of 12.0 ± 19.7. The mean surgery satisfaction was 92% and scar satisfaction was 75%. All patients returned to prior activities and 88% reported a return to their preoperative baseline level of function.

CONCLUSIONS

Plate fixation for pediatric forearm fractures achieves osseous union but not without the potential for long-term sequelae. All patients reported residual symptoms 7 years later. Scar satisfaction and return to baseline function were imperfect. Patient education for long-term outcomes of surgery is essential, especially in the transition to adulthood.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Navigating Challenges and Treatment Options in Diaphyseal Forearm Fractures Among Adolescents: Case Series and Narrative Review

In this paper, we recount the medical trajectories of two male patients, both fourteen years of age, who sustained re-fractures of their radius and ulna six months post their primary diaphyseal fractures. Owing to the limited capacity for growth of the forearm bones between the ages of ten to sixteen years, many queries are engendered concerning apt treatment strategies. The pressing questions are whether these should be conservative or surgical and the precise method to be employed in surgical interventions. This discourse endeavors to demarcate preferred therapeutic options and shed light on a series of standard clinical dilemmas physicians encounter, along with an exhaustive scrutiny of existing literature.

The effects of maximal radial bowing on forearm rotation in pediatric diaphyseal forearm fractures

PURPOSE

To evaluate the effects of radial bowing on forearm rotation in forearm fractures compared with healthy children.

METHODS

A retrospective study was conducted on children aged 1-16 years old. Group 1 was children with history of diaphyseal forearm fractures, and group 2 was healthy children. Children in group 1 with ≤ 70° forearm pronation and/or ≤ 80° supination on affected side are defined as "case." In group 2, children with forearm pronation > 70° and/or supination > 80° are defined as "control." Radial bowing was measured on AP radiograph of the forearm; maximal radial bowing (MRB) and location of the maximal radial bowing (LMRB) were recorded.

RESULTS

Total of 112 children were included (group 1 = 70, group 2 = 42). In group 1, there were 28 children with ≤ 70° forearm pronation and/or ≤ 80° forearm supination (case group). In group 2, there were 33 children with > 70° forearm pronation and > 80° forearm supination (control group). Mean age of case and control group was 11.08 ± 3.02 and 7.85 ± 3.93 years, respectively. Average MRB was 6.15 ± 1.93% and LMRB was 61.94 ± 9.41% in case group. In control group, average MRB was 7.23 ± 1.03% and LMRB was 62.08 ± 4.24%. There was statistically significant correlation between children with ≤ 70° forearm pronation and MRB (P = 0.034) compared with control group. Also, there was statistically significant correlation between children with ≤ 80° forearm supination and MRB (P = 0.023) compared with control group. For ROC curve analysis, MRB ≤ 6.84% showed the association with ≤ 70° forearm pronation (72.2% sensitivity and 73.8% specificity) and MRB ≤ 5.75% associated with ≤ 80° forearm supination (54.6% sensitivity and 84.9% specificity).

CONCLUSIONS

Children with MRB ≤ 6.84% can result in ≤ 70° forearm pronation, and MRB ≤ 5.75% can be presented with ≤ 80° forearm supination.

Retrograde intramedullary nailing of the radius in children: A pilot magnetic resonance imaging study of soft-tissue findings

PURPOSE

Unstable forearm shaft fractures in children are preferably treated surgically using elastic stable intramedullary nails. The radius is nailed retrograde from the distal metaphysis. There is a risk of surgery-related soft-tissue complications during the operation. Close evaluation of occult surgery-related soft-tissue lesions has not been possible previously, due to the titanium alloy hardware used in the process. The aim of the present study was to evaluate the potential findings in the surrounding soft tissues after intramedullary nailing of the radius, by using magnetic resonance imaging.

METHODS

The study population comprised 15 pediatric patients with forearm shaft fractures treated by polylactide-co-glycolide biodegradable intramedullary nails and postoperatively evaluated via magnetic resonance imaging. The main outcome was signal abnormality in any tendon at the entry point postoperatively. Secondarily, other changes in the soft tissues related to nailing were determined. Furthermore, the precise location of the entry point and the anatomic characteristics of the soft-tissue tunnel were described.

RESULTS

In total, 5 of 15 patients (33.3%) had transient signal pathology in a tendon postoperatively. Edema around the superficial radial nerve was detected in 13 of 15 patients (86.7%). The most common surgical approach was between the extensor pollicis brevis and the extensor carpi radialis longus tendons, which was applied in 10 of 15 patients (66.7%).

CONCLUSIONS

One in three patients exhibited transient and occult surgery-related intraparenchymal signal pathology in a tendon, after forearm intramedullary nailing. Caution with surgical prepare of the soft-tissue cleavage is recommended.

LEVEL OF EVIDENCE

IV.

Radius Shaft Fractures-What Alignment is Acceptable at What Age? Plates or Flexible Nails?

INTRODUCTION

The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients.

DISCUSSION

Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists.

CONCLUSION

This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.

Functional and radiological outcome after forearm plating in children and adolescent fracture

The literature on forearm overgrowth after plating in traumatic conditions is relatively poor though this technique can be useful when intra-medullary nailing is not sufficient in pediatric cases. The goal of this study was to assess a potential overgrowth after plating and identify impact on function. We conducted a retrospective study of all pediatric patients who underwent open surgery of the radius and/or ulna diaphysis with internal fixation by plating, in our institution, between October 2013 and July 2019. At last follow-up, functional and radiological outcomes were compared between the operated and uninjured forearm. Range of motion (ROM) of the wrist and elbow, clinical scores, radial and ulnar length were measured. A positive bone length discrepancy of more than 2mm was considered as an overgrowth. Were also studied the radio-ulnar index, radial inclination and radiocarpal angle. Thirteen patients were included. The mean age was 12.1 years old (±3.0 years), they were plated on the radius (10 cases) or on the ulna (3 cases). Mean follow- up was 4.4 years (± 1.8). In two cases, the plated bone (radius) was significantly longer than the uninjured one. There was no significant difference regarding radio-ulnar index, radial inclination and radiocarpal angle. The only statistically significant difference between the operated and uninjured forearm was the pronation/supination range, which was greater in the uninjured forearm (mean 160 ±48° versus 175 ±49°, p=0.01). This study confirms the good functional and radiological outcomes after plating even in a skeletally immature forearm. Level of evidence : IV.

Radius shortening as a limiting factor for closed reduction in pediatric forearm fractures

INTRODUCTION

Diaphyseal forearm fractures in skeletally immature patients are common injuries that account for 30% of upper extremity fractures in this age group. There are cases with unstable injuries or unacceptable reductions, in which surgical resolution by reduction and stabilisation with percutaneous elastic endomedullary nailing is indicated. One of the advantages of this system is that it avoids an approach to the fracture site, allowing closed reduction in the vast majority of fractures. However, it is not always possible to achieve an acceptable closed reduction and opening of the fracture site is necessary. The aim of this study was to determine whether there are preoperative factors to predict the difficulty of performing closed reduction in these patients.

METHODS

A retrospective study of skeletally immature patients with acute diaphyseal forearm fractures treated with elastic endomedullary nailing by the same paediatric surgeon was performed. The primary outcome variable was defined as the need for open reduction; considered as a direct surgical approach to the fracture site. Demographic characteristics of the included patients and radiographic characteristics of the fracture were analysed.

RESULTS

We found that the median percentage of preoperative radial shortening in the closed reduction and open reduction groups was 1 and 5%, respectively; resulting in a statistically significant difference (p = 0.04).

CONCLUSION

Radial shortening on preoperative radiographs predicts an increased risk of requiring an open reduction of the fracture (39% association); thus we understand that this variable should be considered by the general traumatologist as a prognostic factor in defining the referral of these patients.

Randomized Controlled Trial of the Clinical Recovery and Biodegradation of Polylactide-co-glycolide Implants Used in the Intramedullary Nailing of Children's Forearm Shaft Fractures with at Least Four Years of Follow-Up

The preferred surgical fixation of forearm shaft fractures in children is Elastic Stable Intramedullary Nailing (ESIN). Due to known disadvantageous effects of metal implants, a new surgical method using biodegradable polylactide-co-glycolide (PLGA) intramedullary nails has been developed but its long-term outcomes are unclear. The aim of this study was to compare the long-term outcomes of Biodegradable Intramedullary Nailing (BIN) to ESIN and assess the biodegradation of the study implants via magnetic resonance imaging (MRI). The study population of the prospective, randomized trial consisted of paediatric patients whose forearm shaft fractures were treated with BIN (n = 19) or ESIN (n = 16). Forearm rotation at minimally four years’ follow-up was the main outcome. There was no clinically significant difference in the recovery of the patients treated with the BIN as compared to those treated with the ESIN. More than half of the implants (57.7%, n = 15/26) were completely degraded, and the rest were degraded almost completely. The PLGA intramedullary nails used in the treatment of forearm shaft fractures in this study resulted in good function and anatomy. No unexpected disadvantages were found in the degradation of the implants. However, two implant failures had occurred in three months postoperatively.

Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature

PURPOSE

This narrative review intends to summarize the most important and relevant data on diagnosis and treatment of pediatric forearm fractures and to describe the characteristics and advantage of each therapeutic option.

METHODS

We conducted a literature research considering peer-reviewed papers (mainly clinical trials or scientific reviews) using the string "forearm fracture AND epidemiology" or "forearm fracture AND diagnosis or " forearm fracture AND treatment" or "forearm fracture AND casting" or "forearm fracture AND surgery". Studies were identified by searching electronic databases (MEDLINE and PubMed) till April 2020 and reference lists of retrieved articles. Only English-language articles were included in the review.

RESULTS

Conservative management with cast immobilization is a safe and successful treatment option in pediatric forearm fractures. Surgical indication is recommended when an acceptable reduction cannot be obtained with closed reduction and casting. Surgical treatment options are intramedullary nail, plating and hybrid fixation.

CONCLUSIONS

There is not a unique consensus about fracture management and treatment. Further studies are necessary to create univocal guidelines about optimal treatment, considering new techniques and available technologies.

Iatrogenic Distal Radial Physeal Fracture During Insertion of Intramedullary Fixation for a Both Bone Forearm Fracture: A Case Report

CASE

A 12-year-old boy with an isolated both bone forearm fracture was treated with closed reduction and flexible intramedullary nailing 11 days postinjury and after the loss of initial fracture alignment. On nail insertion, an intraoperative distal radial physeal fracture was encountered, thereby warranting modification in treatment.

CONCLUSION

Physeal injury is a rare intraoperative complication of intramedullary fixation of forearm fractures. This report provides insight regarding the management and prevention of this rare complication.

Nailing of diaphyseal ulna fractures in adults-biomechanical evaluation of a novel implant in comparison with locked plating

Background

Adult forearm fractures require surgical treatment in most cases. Open reduction and internal fixation with plate osteosynthesis is the therapy of choice. Intramedullary fixation offers several advantages compared to plate fixation but is not routinely used. The aim of our study was to compare a newly designed ulna nail with angular stable plating in a biomechanical testing setup of an ulna shaft fracture with a diaphyseal defect.

Methods

Ten pairs of sawbones with a defect osteotomy of the ulna shaft (OTA 2U2C3) were fixed with an interlocked nail or locked plate osteosynthesis. The constructs were tested under four-point bending, torsional loading and axial loading in a servo-pneumatic testing machine to compare the stiffness of both stabilization methods.

Results

The nail constructs show lower yet sufficient bending stiffness (62.25 ± 6.64 N/mm) compared to the plate constructs (71.2 ± 5.98 N/mm, p = 0.005). The torsional loading test shows superior stiffness of the plate constructs (0.24 ± 0.03 Nm/deg vs. 0.1 ± 0.01 Nm/deg; p < 0.001), while the axial loading shows superior stiffness of the nail constructs (1028.9 ± 402.1 N/mm vs. 343.9 ± 112.6 N/mm; p < 0.001).

Conclusions

Intramedullary nailing of ulna shaft fractures obtains sufficient but lower stability in bending and torsional loading when compared to rigid angular stable plating and could be an alternative technique to plate fixation. The lower stability and the closed stabilization technique allow for a rapid periosteal healing, which is not present in stiffer constructs.

The Association of Metal Frame Construct of ESIN and radiographic bone healing of pediatric forearm fractures

INTRODUCTION

The gold-standard surgical procedure of both-bone forearm shaft fracture repair is elastic stable intramedullary nailing (ESIN). Disadvantages effects of ESIN have suggested to be a consequence of inappropriate surgical techniques, while recommendations are not always followed. The purpose of the study was to analyze the effect of inadequate metal frame construct on impaired fracture healing, refracture and changing alignment.

MATERIALS AND METHODS

It is a population-based study including all consecutive patients, aged less than 16 years, who had been treated for forearm shaft fracture by ESIN during the ten-year period 2009-2018. Altogether 71 patients were included. Non-union, delayed union, and re-fracture during the following 12 months were taken as the main outcome, while inferior metal frame construct of ESIN and the surgical technique characteristics were taken the explanatory factors. Radiographic loss of reduction was a secondary outcome and a change >5° in alignment at any postoperative follow-up exam was recognized.

RESULTS

Two out of 71 fractures (3%) failed to unite, and ossifying operation was needed. Five cases (7%) showed delayed bone healing, but they ossified in five months without any intervention. These seven patients (10%) had been treated more often with larger nails (> 0.7x MCD) (p = 0.027) and by open reduction (p = 0.02), compared with thinner nails and closed reduction, respectively. Two (3%) patients had a second fracture; however, they happened 2 years after the initial injury. Other surgery or fracture related factors didn't associate with impaired ossifying. Regarding the secondary outcome, altogether 24 (35%) of the analyzed 67 patients showed >5° change in alignment during the postoperative follow-up but only one patient had clinically significant instability that required re-reduction. The alignment changed more usually in distal-third fractures, compared with middle or proximal third fractures (p = 0.019).

CONCLUSIONS

ESIN resulted in good radiographic bone healing in the vast majority (90%) of the patients and completely perfect metal frame construct was not required.

A comparative study of fixation methods in adults with two-thirds distal isolated ulnar shaft fractures with a minimum of 2 year follow-up

BACKGROUND

Adult isolated ulnar shaft fractures (IUSF) are rare. There remains a need to establish the best methods to manage these fractures. The aim of this study was to compare two forms of treatment for IUSF: intramedullary stabilization by k-wire (IMF) versus Open Reduction Internal Fixation by plating (ORIF), in order to identify differences in clinical (1) and radiological outcomes (2), as well as comparative costs (3).

HYPOTHESIS

The hypothesis of this study was assessing whether intramedullary stabilization was as feasible as plating in the treatment of isolated ulnar shaft fractures in clinical practice.

PATIENTS AND METHODS

A retrospective analysis was undertaken on patients diagnosed IUSF between January 2015 and March 2017 with a minimum of 2 years follow-up. They were treated with IMF (group 1) or ORIF (group 2). Demographic information, clinical outcomes and complications were collected. Cost, including implant cost, operative time, sterilization and inpatient stay were compared. Radiographs were reviewed to evaluate axial angulation, shortening, displacement and residual deformity.

RESULTS

54 patients with a mean age of 41.2 years were treated by IMF (27/54) and ORIF (27/54). The mechanism of injury included high-energy (55%) and low-energy falls (45%). AO/OTA 2018 fracture classification was simple (39/54), wedge (14/54) and complex (1/54). The locations were 37/54 (70%) distal third and 17/54 (30%) mid-shaft fractures. There was no significant difference pre and post-operatively between the 2 groups regarding radiologic criteria. 3 cases of non-union, 4 delay-union and 1 regional complex syndrome occurred in group 2. No complication was reported in group 1. The function determined by range of motion (ROM) at wrist and elbow was excellent in 72% (group 1) and 80% (group2), 18% satisfactory in group 1 and 20% in group 2. There was no difference for QuickDASH and pain. Implant removal was necessary in 70% of patients without sequelae in nailing, 11% after plating. Average operation time was 29 ± 5 min for ORIF and 18 ± 6 min for IMF. Total estimated cost per patient was 3678.4€ for IMF and 7051.9€ for ORIF.

CONCLUSIONS

Compared with ORIF, IMF significantly reduced the operation time and cost with lower complications.

TYPE OF STUDY

Retrospective study.

TYPE OF PROOF

Level 4.

Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review

Background

Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment. The treatment modalities available include plate and screws, flexible intramedullary nailing and external fixation devices - rarely used nowadays. The aim of this systematic review is to investigate the indications of flexible intramedullary nailing in the childhood population, to compare its results with plating and to provide detailed information considering technical pitfalls and complications that may be encountered.

Materials and methods

An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation. 56 articles were considered suitable for inclusion.

Results

The indications for surgery are unstable and irreducible fractures, open and fractures with neurovascular compromise. As far as the fracture site is concerned, radius and ulna shaft fractures, radial head and Monteggia fractures are suitable for nailing.Although plates and nailing have comparable clinical outcomes and complication rates, flexible intramedullary nailing has the advantage of smaller incisions, less tissue disruption, shorter operative and hospital times and an ease in hardware removal.Controversy exists over the need of single or double nailing in both-bone fractures of the forearm. In addition, there is no consensus as to which is the preferred nail diameter. Yet, all the authors agree that open reduction must be considered after certain failed closed reductions in order compartment syndrome to be avoided.Flexible intramedullary nailing is not complication-free. Skin irritation, Extensor Pollicis Longus rupture, superficial radial nerve injury, delayed union or even nonunion, malunion and refractures are some of the complications that may be encountered.

Discussion

Flexible nails are excellent implants combining stability and elasticity. The procedure of passing the nails across radius and ulna is relatively simple, requiring a small learning curve. Flexible intramedullary nailing is an excellent treatment modality for the treatment of forearm fractures in children and adolescents.

Predictors for losing reduction after reposition in conservatively treated both-bone forearm fractures in 38 children

BACKGROUNDS

Alignment loss after reduction and cast immobilisation of angulated and/or complete displaced forearm fractures is challenging. Many authors have tried to describe risk factors and create indices (initial angulation, initial complete displacement, lack of anatomic reduction, cast and padding index) in order to identify those fractures that are prone to losing their alignment during treatment.

METHODS

This retrospective case-control study included children sustaining both-bone forearm fractures treated by closed reduction and cast immobilisation. Basic characteristics were recorded and radiographs evaluated to measure displacement and angulation before and after reduction, cast index and padding index. The primary outcome was loss of reduction during the immobilisation period.

RESULTS

Group A consisted of 22 patients in whom >5° reduction loss was seen during cast immobilisation. Group B consisted of 16 patients with <5° reduction loss. After multivariate analyses we found group A included more broken cortices, with a statistically significant higher number of initial displaced fractures (p < 0.001 and p = 0.010) and residual displacement (p = 0.022). The cast and padding index did not differ significantly between groups (p = 0.77 and 0.15 respectively).

CONCLUSIONS

Cast and padding index did not correlate well as predictor of alignment loss, although in this study cortical stability seemed more important towards predicting alignment loss.

A comparison of fixation methods in adolescent patients with diaphyseal forearm fractures

INTRODUCTION

The purpose of this study was to compare both bone diaphyseal forearm fractures in adolescent patients treated with plate fixation to patients treated with intramedullary fixation to identify differences in complications and outcomes.

MATERIALS & METHODS

A retrospective study was performed on all adolescent patients with age between 10 and16 year and treated with intramedullary fixation or plate fixation for a diaphyseal both bone forearm fracture between 2005 and 2014. Demographic information and clinical data was collected. Radiographs were reviewed to evaluate post-operative radial bow magnitude and location, time to union, and residual angulation. Complications were graded using the modified Clavien-Dindo Classification system.

RESULTS

A total of 102 patients met the inclusion criteria. Of these, 32 were treated with plate fixation and 70 with intramedullary fixation. The intramedullary nail group had 55% of complications classified as major. There were no major complications in the plate fixation group (P = 0.1). The radial bow was significantly more distal and smaller in magnitude in the intramedullary fixation group (P < 0.01). Of the patients who underwent intramedullary fixation, 76% required an open reduction of at least one forearm bone. There was increased time to radiographic union in patients treated with intramedullary fixation when compared to those treated with plates, 68 days versus 58 days (P = 0.03). A second operation was necessary for 91% of patients treated with intramedullary fixation compared to only 3% of patients treated with a plate (P < 0.01).

CONCLUSION

Diaphyseal forearm fractures in adolescent patients remain challenging injuries to treat. Forearm bony anatomy is not completely restored with intramedullary fixation. Results suggested an association towards increased complication rates and complication severity with intramedullary fixation.

LEVEL OF EVIDENCE

Level 3 retrospective comparative study.

Intramedullary nailing of forearm shaft fractures by biodegradable compared with titanium nails: Results of a prospective randomized trial in children with at least two years of follow-up

There are disadvantages in Elastic Stable Intramedullary Nailing (ESIN) of forearm-shaft fractures, such as the need of implant removal. Biodegradable Intramedullary Nailing (BIN) is a new technique developed for these fractures. We hypothesized that there is no difference in rotational ROM between the patients treated by BIN vs. ESIN. A randomized, controlled clinical trial included patients, aged 5-15 years, requiring surgery for forearm-shaft fractures. Biodegradable polylactide-co-glycolide (PLGA) nails (Activa IM-Nail™, Bioretec Ltd., Finland) were used in 19 and titanium nails (TEN^®, SynthesDePuy Ltd., USA) in 16 patients. Rotational ROM of forearm after two years was the primary outcome. Elbow and wrist ROM, pain and radiographic bone healing were secondary outcomes. Forearm rotation was mean 162° and 151° in BIN and ESIN groups, respectively (P = 0.201). No difference between the groups was found in any other ROMs. Three cases in the ESIN vs. none in the BIN group reported pain (P = 0.113). There was no clinically significant residual angulation in radiographs. Two adolescents in the BIN group vs. none in the ESIN (P = 0.245) were excluded because of implant failure; another two with complete bone union suffered from re-injury. Therefore, satisfactory implant stability among older children needs to be studied.

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.

The titanium elastic nail serves as an alternative treatment for adult proximal radial shaft fractures: a cohort study

Background

To investigate whether closed reduction and internal fixation (CRIF) with titanium elastic nails (TENs) is a viable alternative treatment in proximal radial fractures.

Methods

In Kaohsiung Veterans General Hospital, from November 2013 to April 2015, five adult male patients with forearm injuries (average age 43 years; range 35–64 years) were treated for proximal radial shaft fractures. CRIF with TENs for radial shaft fractures was performed in these five patients. Radiographs; range of motions; visual analog scale (VAS); quick disabilities of the arm, shoulder, and hand (Quick DASH) questionnaire; and time to union were evaluated in our study.

Results

Mean follow-up period was 30 months (range 28–36 months). Average time of radius union was 7.3 months (range 6–10 months). Functional outcomes 1 year after operation revealed an average Quick DASH score of 7.92 (range 4.5–25), an average VAS of 1.5 (range 1–3), and average forearm supination and pronation of 69.2° (range 45°–75°) and 82.5° (range 80°–85°). No major complication was noted.

Conclusions

CRIF with TEN for adult proximal radial fractures is a method to avoid extensive exposure or nerve injury during ORIF, especially in multiple trauma patients who require short operative time, uremia patients with ipsilateral forearm AV shunt, severe soft tissue swelling due to direct muscle contusion or strong muscularity before surgery, extensive radial fracture, and those in pursuit of cosmetic outcomes.

Plate Fixation Versus Intramedullary Nailing for Both-Bone Forearm Fractures: A Meta-analysis of Randomized Controlled Trials and Cohort Studies

OBJECTIVE

The aim of this study was to compare the radiographic and functional outcomes of operative intervention in patients with both-bone forearm fractures treated by open reduction and internal fixation (ORIF) with plates or intramedullary (IM) nailing.

METHODS

Studies published in PubMed, EMBASE, Web of Science, SinoMed (Chinese BioMedical Literature Service System, China), and CNKI (China National Knowledge Infrastructure, China) were systematically searched. The main outcomes included time to union, union rate, operation time, magnitude and location of radial bow, loss of forearm rotation, and complication rates. Results were expressed with weighted mean difference or risk ratio with 95 % confidence intervals. Pooled estimates were calculated using a fixed-effects or random-effects model according to the heterogeneity among studies.

RESULTS

A total of 13 studies met the inclusion criteria and were included in this meta-analysis. Compared with ORIF, IM nailing significantly reduced the operation time and complication rate. However, no significant differences were observed between the two surgical techniques in several outcomes, including time to union, union rate, radial bow magnitude, and loss of forearm rotation. Except in complications, these findings were consistent across the subgroup analysis of children and adult patients.

CONCLUSION

IM nailing is associated with shorter operation time and lower complication rate compared with ORIF. It is an effective and safe treatment option for children and adults with both forearm fractures. However, considering the limitations in this study, large-scale, high-quality randomized controlled trials are needed to indentify these findings.

Forearm diaphyseal fractures in children: intramedullary Kirschner's wire fixation treatment

INTRODUCTION

Diaphyseal fractures of the forearm comprise 6%-10% of all fractures in children. The treatment depends on the age and type of displacement, and conservative and surgical management with fixation of intramedullary nails, among other techniques, is valid. The aim is to show the radiological and functional outcomes, and complications of intramedullary fixation with Kirschner nails in children.

MATERIALS AND METHODS

A retrospective descriptive case series of patients treated with intramedullary fixation of forearm fractures. The radiological and functional results, and complications are correlated.

RESULTS

Of the 117 patients operated, 59 met the inclusion criteria. The average age was 10 years. Eighty-four point seven percent were males and the left side was the most affected (62.7%). In 88.1% both bones were fractured and 11 cases had open fractures. An open reduction was performed in 72.8% of the cases, the main indications for this being instability, failed reduction and refracture. There were 52 excellent outcomes, 2 good, and 4 regular and 1 bad. There were 13.5% minor complications.

DISCUSSION

This study shows that intramedullary fixation with Kirschner nails in radius and ulna diaphysis fractures in children is a safe, low-cost procedure and offers adequate short and medium term functional outcomes, with a low prevalence of serious complications with only 6 cases of non-consolidation and refracture. Larger preoperative angulations in the anteroposterior and lateral planes, and lateral postoperative angulations, could be considered predictors of less satisfactory functional results.

The Community Orthopaedic Surgeon Taking Trauma Call: Pediatric Forearm Shaft Fracture Pearls and Pitfalls

Pediatric forearm shaft fractures are the third most common fracture in children, and the forearm is the third most mobile joint in the body (with a nearly 180 degree arc of motion). The goals of treatment are aimed squarely at achieving satisfactory anatomic alignment (within defined parameters) as the consequences of malunion can be permanent forearm stiffness and deformity. Nonoperative treatment approaches still dominate care of the youngest age groups while surgical intervention has become increasingly common in older children. This article will offer evidence and experience-based tips intended to benefit the community orthopedic surgeon caring for children during the course of their on-call duties.

Intramedullary Implant Choice and Cost in the Treatment of Pediatric Diaphyseal Forearm Fractures

OBJECTIVES

To compare outcomes and costs between titanium elastic nails (TENs), stainless steel elastic nails (SENs), and Kirschner wires (K-wires) in the treatment of pediatric diaphyseal forearm fractures with intramedullary fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Pediatric Trauma Center.

PATIENTS/PARTICIPANTS

A total of 100 patients (65 male and 35 female) younger than 18 years with diaphyseal forearm fractures treated with intramedullary fixation were included in the study.

INTERVENTION

Patients received single or both bone intramedullary fixation with either TENs, SENs, or K-wires.

MAIN OUTCOME MEASUREMENTS

Time to radiographic union, complication rate, surgical time, and average cost per implant.

RESULTS

One hundred patients were included in the study. Thirty-one patients were treated with TENs, 30 with SENs, and 39 with K-wires. No significant difference in time to radiographic union, complication rate, or surgical time was found between the 3 types of fixation. Average time to union was 9.4 ± 5.4 weeks, and complication rate was 12.9% for TENs, 10.0% for SENs, and 12.8% for K-wires. There was a significant difference in cost per implant, with an average cost of $639, $172, and $24 for TENs, SENs, and K-wires, respectively (P < 0.001).

CONCLUSIONS

This study demonstrates no difference between TENs, SENs, and K-wires in the treatment of pediatric diaphyseal forearm fractures with regards to outcome, time to union, surgical time, or complication rates. Given the significant cost difference between these implants, we recommend that surgeons consider modifying their implant selection to help mitigate cost.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

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.

Stacked Flexible Nailing for Radius Ulna Fractures: Revival of a lost Technique

Introduction:

Simultaneous radius and ulna fractures are common in adults and generally osteosynthesis with plating is the treatment of choice. Nailing of such fractures is infrequently advocated. We present our unique technique of radius ulna nailing in adults to achieve closed reduction and early predictable union with minimal or no complications.

Case Report:

Case 1: 22 year old male with midshaft both bones forearm fracture was treated with stacked nailing. Two 2.5 mm steel elastic nails were used in each radius and ulna. No post-operative splintage was needed and patient was mobilized immediately. Patient was able to go back to work in 2 weeks and at one year follow up he showed excellent functional outcome.

Case 2: Fifteen year old boy presented with midshaft both bone fractures secondary to fall from height. He was also treated with stacked flexible nailing. Good stability was achieved and patient was mobilized immediately without any splints. He was able to write his exams which started on 11th day post-surgery and could complete his theory papers. At final follow up both bones united with good callus and no functional limitations.

Conclusion:

Stacked nailing technique is a good option in midshaft transverse or short oblique fractures of radius and ulna. It allows for early mobilization without brace or splint. With proper patient selection, good results can be obtained by this simple and minimally invasive technique.

Post-traumatic forearm nonunion in healthy skeletally immature children: A report on 15 cases

BACKGROUND

Nonunion is a rare but severe complication following forearm fracture in skeletally immature patients. The purpose of this study is to describe a case series of pediatric forearm nonunions treated at our Institute.

MATERIALS AND METHOD

We retrospectively reviewed medical charts and radiographs of healthy children affected by post-traumatic nonunion of the forearm, from April 1992 to July 2015. An overall series of 15 cases was included in the study. Nonunion developed at ulna in 5 cases and at radius in 10 cases, at a mean time of 9 months (range 6-12) from fracture. Surgical treatment was performed in 14 cases out of 15. Stabilization of the nonunion was achieved with Kirschner wires (5 cases), plates (4 cases), rush rods (2 cases) and unilateral external fixator (3 cases). Iliac crest bone autograft was used in 11 cases, strut cortical bone allograft was used in 2 cases while in one case no bone graft was applied. In 2 cases an additional shortening osteotomy of the ulnar shaft was necessary to obtain adequate compression of the bone fragments. Cast immobilization was maintained for 6 to 8 weeks after surgery, then a brace was applied for further 8 to 12 weeks.

RESULTS

The average follow-up was 54 months (range 12-129); nonunion healed in 14 cases (93%) at an average time of 4 months (range 2-8). One case of nonunion did not heal 12 months after surgery; other complications included: radio-ulnar fusion and radial nerve palsy (1 case), myositis ossificans at the ulna (1 case), olecranon bursitis with residual elbow stiffness (1 case). One case was treated conservatively and healed after 18 months with residual malalignment.

CONCLUSIONS

The present study describes the largest series of pediatric forearm nonunions in the current literature. Whether the surgical management of pediatric forearm nonunion provides satisfactory results in terms of bone healing, it may be accompanied by several complications, permanent sequelae and residual functional impairment. Any effort must be undertaken to avoid this serious complication.

Pediatric diaphyseal forearm fractures: epidemiology and treatment in an urban population during a 10-year period, with special attention to titanium elastic nailing and its complications

This study aims to describe the epidemiology of pediatric diaphyseal forearm fractures in an urban population and the complications of titanium elastic nailing. The medical records of 456 consecutive fractures were reviewed. The annual incidence was 0.7/1000 children. Eighty-six (19%) fractures in 83 children were titanium elastic nailed. The complication rate was 24%. Dorsal entry to the radius was associated with extensor pollicis longus rupture and radial entry was associated with sensory nerve deficit in three cases each. Seventy-eight (94%) of the operated patients recovered completely. Titanium elastic nailing is effective, but associated with a high rate of complications, most of which resolve spontaneously.

Adult diaphyseal both-bone forearm fractures: A clinical and biomechanical comparison of four different fixations

BACKGROUND

Although there have been a small number of studies reporting single bone fixation of either radius or ulna as well as hybrid fixation, the paucity of data for the hybrid fixation method still remains.

HYPOTHESIS

Hybrid fixation with plate and IM nailing would achieve good fixation and functional outcome, minimal damage to soft tissues and lower re-fracture risk.

MATERIALS AND METHODS

Forty cadavers (20 males, 20 females; mean age 68.06, SD 1.58years) were selected in biomechanical study under axial loading, bending loading, and torsional loading. Eighty-seven patients (47 males, 40 females; mean age 38.03±0.88years) were enrolled in the clinical study and randomly received different fixation: both-bone plate fixation or both-bone intramedullary nailing, plate fixation of ulna and intramedullary nailing of radius and intramedullary nailing of ulna and plate fixation of radius.

RESULTS

In the biomechanical study, intramedullary nailing of ulna and plate fixation of radius had similar results with that using both-bone plate method under axial, bending and torsional loading (All P>0.05), suggesting the more stable fixation compared with the other two groups (All P<0.05). In clinical research, both-bone intramedullary nailing was related to shortest operative time, smallest wound size and periosteal stripping area compared with other three groups (P<0.05). Patients receiving intramedullary nailing of ulna and plate fixation of radius showed the lowest incidence of postoperative complications and the best functional recovery outcome comparing with other three groups of patients (Both P<0.05).

CONCLUSION

The hybrid fixation method of intramedullary nailing of ulna and plate fixation of radius showed good stability in biomechanics, fewer complications and better functional clinical outcomes.

LEVEL OF EVIDENCE

Level II, prospective randomised study.

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.