The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures

Surgical treatment of pediatric forearm fractures with intramedullary nails: is it a disadvantage to leave the tip exposed?

Elastic intramedullary nailing is the main treatment method in the surgical treatment of pediatric forearm fractures. In this study, we compared the clinical outcomes of intramedullary nailing of forearm fractures with leaving the tips exposed and with placing the tip of the nails under the skin. We aimed to present the clinical outcomes of intramedullary nailing and determine the advantages and disadvantages of leaving the tips of the nails exposed. One hundred and ninety-two children with both-bone forearm fracture who were treated with titanium elastic nailing (TEN) in the Department of Orthopedics at Erzurum Regional Training and Research Hospital between January 2009 and December 2016 were included in the study. All cases had been followed up for at least 1 year. The tips of the TENs were left exposed in 74 and buried subcutaneously in 118 children. Union was achieved in all cases. Delayed union was observed in just one case. Skin irritation was observed in 11 (5.7%) of the exposed TEN cases. Superficial infection developed in two (1%) cases with exposed TEN tips. Migration developed during the follow-up of 11 (5.7%) cases with buried tips. The mean time to removal of TEN was 7.9 weeks in cases with exposed and 26.2 weeks in cases with buried cases. Refracture was observed in six buried (3.1%) cases and four exposed TEN (2.1%) cases in the first year after the removal of the nails. Perfect outcomes were achieved in 146 (76%) cases and good outcomes in 36 (19%) cases in our study. On comparing the rate of complications and clinicaloutcomes, leaving the TEN exposed seems to be safe.

Intramedullary Fixation of Both Bone Forearm Fractures in Children and Adolescents: Healing Correlates With Development of the Olecranon Apophysis

BACKGROUND

The purpose of this study was to determine whether healing of both bone forearm (BBFA) fractures in children and adolescents is associated with the stage of the olecranon apophysis development as described by the Diméglio modification of the Sauvegrain method.

METHODS

Records were reviewed from 2 children's hospitals from 1997 to 2008 to identify all patients younger than 18 years of age who had BBFA fractures treated with intramedullary nail fixation. Sixty-three patients were identified meeting inclusion and exclusion criteria. The stage of the olecranon apophysis was noted on the lateral radiograph at the time of the injury. Data were statistically analyzed to assess the olecranon stage at which the increased rate of delayed union becomes more prevalent using the receiver operating characteristic curve. Time to union, complications, and need for reoperation were recorded for each group.

RESULTS

One thousand three hundred ninety-eight patient records were reviewed with 63 patients meeting the inclusion criteria. Using a receiver operating characteristic curve, a cutoff of olecranon stage > 3 (stages 4 to 7) was a significant predictor of the increased rate of delayed union time compared with olecranon stages 0 to 3 (P=0.004). Non-healing-related complication rates for each group were 2/28 (7.1%) for olecranon stages and 0 to 3 and 6/35 (17.1%) for olecranon stages 4 to 7.

CONCLUSIONS

The rate of delayed union for BBFA fractures that have been treated with intramedullary nail fixation is increased in children with more mature olecranon apophyses as compared with those with younger olecranon stages. We propose the use of the stage of olecranon apophysis development when choosing the surgical approach and implant for when treating operative BBFA fractures in children.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Evaluation of Clinical Outcomes of Management of Paediatric Bone Forearm Fractures using Titanium Elastic Nailing System: A Prospective Study of 50 Cases

INTRODUCTION

Forearm fractures are common injuries in children. In older children, there management is difficult due to increased chances of re-displacement after closed reduction.

AIM

The aim of this prospective study was to evaluate the clinical outcome of managing paediatric forearm fractures using Titanium Elastic Nailing System (TENS).

MATERIALS AND METHODS

A total of 50 patients in the age group 6 to 14 years with fractures in both bones of forearm were managed by internal fixation using TENS and prospective follow-up were done for six months.

RESULTS

On final evaluation in terms of symptoms and range of motion of adjacent joints using Price CT et al., criteria for results, we had excellent outcomes in 92% patients and good in 8%. There were no significant complications except for superficial pin tract infections at entry site of nail in only 6% of patients.

CONCLUSION

We conclude that TENS is an effective and minimally invasive method of fixation of forearm fractures with excellent results in terms of bony union and functional outcomes with minimal complications and without jeopardizing the integrity of the physis.

Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations

Pediatric and adolescent forearm fractures continue to present treatment challenges. Despite high-level evidence to the contrary, traditional guidelines for nonsurgical treatment have been challenged in favor of surgical intervention, but it is unclear if this results in improved outcomes. Recent evidence suggests that certain open fractures in children may be successfully treated nonsurgically. Good results have been achieved with closed reduction and appropriate casting and clinical follow-up. Further research investigating functional outcomes into adulthood is needed.

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.

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

INTRODUCTION

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture.

MATERIALS AND METHODS

In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs.

RESULTS

Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°-10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail.

CONCLUSIONS

These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.

Surgical interventions for diaphyseal fractures of the radius and ulna in children

BACKGROUND

Diaphyseal forearm fractures in children are a common injury usually resulting from a fall. The treatment options include non-surgical intervention (manipulation and application of cast) and surgical options such as internal fixation with intramedullary nails or with plate and screws.

OBJECTIVES

To assess the effects (benefits and harms) of a) surgical versus non-surgical interventions, and b) different surgical interventions for the fixation of diaphyseal fractures of the forearm bones in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to February week 4 2011), EMBASE (1980 to 2011 week 09), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared surgical with non-surgical intervention, or different types of surgical intervention for the fixation of diaphyseal forearm fractures in children.

DATA COLLECTION AND ANALYSIS

All review authors independently examined the search results to identify trials for inclusion.

MAIN RESULTS

After screening of 163 citations, we identified 15 potentially eligible studies of which 14 were excluded and one is an ongoing trial. There were thus no studies suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

There is a lack of evidence from randomised controlled trials to inform on when surgery is required and what type of surgery is best for treating children with fractures of the shafts of the radius, ulna or both bones.

Stabilization of adolescent both-bone forearm fractures: a comparison of intramedullary nailing versus open reduction and internal fixation

OBJECTIVES

To compare flexible intramedullary (IM) nailing with open reduction and internal fixation (ORIF) with plates and screws in the treatment of adolescent both-bone forearm fractures.

DESIGN

Retrospective comparative study.

SETTING

Level I trauma center.

PATIENTS/PARTICIPANTS

Sixty-one skeletally immature adolescents (mean age, 13.9 years; range, 11.5-16.9 years) treated operatively for both-bone forearm fractures from 1997 to 2007. Patients with Monteggia, Galeazzi, intra-articular, and pathologic fractures were excluded.

INTERVENTION

Forty-six patients (mean age, 14.1 years) underwent ORIF and 15 patients (mean age, 13.3 years) underwent flexible IM nailing.

MAIN OUTCOME MEASURES

Time to fracture union, forearm rotation, magnitude and location of maximal radial bow, and complications.

RESULTS

There was no difference in mean time to union between the IM nailing (8.5 weeks) and ORIF (8.9 weeks) groups, although the study did not have sufficient power to detect a difference. Eighty-three percent of patients in both groups regained full forearm rotation. Although radial bow magnitude was comparably restored in both groups, the mean location of maximal radial bow was translated distally in the IM nailing group (67.2%) compared with the ORIF group (60.1%, P < 0.001) and a previously reported normal value (60.4%, P < 0.001). There were no major complications in the IM nailing group and five major complications in the ORIF group.

CONCLUSIONS

Flexible IM nailing of both-bone form fractures in adolescents was safe and effective in our small series; we had less complications when compared with conventional ORIF. Although flexible IM nailing results in distal translation of the radial bow, forearm rotation is not compromised.

Eleven years experience in the operative management of pediatric forearm fractures

BACKGROUND

There has been a trend toward operative management of pediatric diaphyseal forearm fractures (DFFx). We studied our experience with surgical management of these injuries to assess indications, frequency, outcome, and complications.

METHODS

One hundred forty-four consecutive children had surgical management of 149 DFFx over 11 years at our Level 1 pediatric trauma center. A chart/radiographic review established perioperative events, intraoperative findings, time-to-union, range-of-motion, and complications. We developed the Children's Hospital of Philadelphia Forearm Fracture Fixation Outcome Classification to assess postoperative outcomes.

RESULTS

Over 11 years, we treated 2297 DFFx; 155 of 2297 (6.7%) had surgical management. Six were lost to follow-up and excluded. A 7-fold increase in operative management was observed over the study period [2 of 143 (1.4%) vs. 28 of 270 (10.4%), P<0.001]. One hundred and three of 149 (69.1%) were treated with intramedullary nailing (IMN); 44 of 149 (29.5%) with plates; and 2 of 149 (1.3%) had combined plate/nail fixation. Thirty of 103 (29.1%) had the fracture site opened to pass the IMN; in 23 cases, open fractures were exploited to assist nail passage. When managed with IMN, open fracture sites showed slowed healing: union was 8.6 weeks for those opened intraoperatively and 6.9 weeks for those remaining closed (P<0.001). Fractures opened secondary to injury achieved union at 9.75 weeks which was significantly longer than those opened intraoperatively (8.6 wk, P=0.04) and those remaining closed (6.9 wk, P=0.001). Compartment syndrome occurred in 6.7% (2 of 30) treated with IMN within 24 hours of injury versus 0 of 73 treated later (P=0.026). Delayed union after IMN occurred in 6 children 10 years of age versus none less than 10 years of age. Poor/fair outcome of IMN increased with age [6 of 47 (13%) < or =10 y of age, vs. 17 of 56 (30%)>10 y of age, P=0.03]. Overall complication rate for IMN was 14.6% (15 of 103).

CONCLUSIONS

Our center has operatively managed DFFx with increased frequency over the past decade. IMN had a complication rate of 14.6% and was frequently not "minimally invasive." An open fracture site delayed healing. Compartment syndrome was more frequent when IMN was used the day of injury and older children had poorer outcomes and higher rates of delayed union.

LEVEL OF EVIDENCE

Level III, Retrospective Comparative Study.

Tratamento das fraturas da diáfise dos ossos do antebraço em crianças e adolescentes

OBJETIVO: O tratamento e os desvios angulares tolerados nas fraturas diafisárias do antebraço em crianças evoca opiniões divergentes na literatura. Frente a esta indefinição, idealizamos este trabalho com o objetivo de avaliar transversalmente os métodos terapêuticos preferenciais para esta lesão durante o 39º Congresso Brasileiro de Ortopedia e Traumatologia. MÉTODO: Foram respondidos 759 questionários (13% do total de inscritos). Abordamos os aspectos gerais da amostra estudada para traçar o perfil do ortopedista questionado. Foram expostas duas situações clínicas em indivíduos de 12 (CASO 1) e 5 anos (CASO 2), sendo apresentadas radiografias com fraturas do antebraço destes pacientes. Os dados obtidos foram compilados e submetidos à análise estatística. RESULTADO: O tratamento mais indicado no CASO 1 foi redução incruenta e fixação com fios de Kirschner (26%), enquanto no CASO 2 foi redução incruenta seguida de aparelho gessado (46%). CONCLUSÃO: Entre os ortopedistas com menos de 30 anos, a escolha por tratamentos menos invasivos e aceitação de maiores angulações prevaleceu para ambos os casos. Os traumatologistas aceitam menor angulação e tendem aos tratamentos invasivos, particularmente para o CASO 2. Já o ortopedista pediátrico opta por tratamentos menos invasivos e aceita maiores desvios angulares.

Open intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children

PURPOSE

To compare the outcomes of intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children aged older than 10 years.

METHODS

Records of 32 children aged 10 to 15 (mean, 12) years with displaced fractures of the radius and ulna were retrospectively reviewed. 17 boys and 4 girls underwent intramedullary Kirschner wiring, whereas 10 boys and one girl underwent plating. All patients had been initially treated with closed reduction and casting. Indications for surgical intervention were fractures with angulation of >10 degrees and total displacement. Patients were followed up for a mean of 24 (range, 13-40) months. Angulation and range of movements of the elbow, wrist, and forearm, as well as clinical and cosmetic results were compared.

RESULTS

Both treatments achieved excellent clinical outcomes, but intramedullary Kirschner wiring resulted in better cosmesis, shorter operating times, easier hardware removal, and lower implant costs.

CONCLUSION

Intramedullary Kirschner wiring is a better option than plating for the treatment of unstable forearm fractures in older children.

Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children

BACKGROUND

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 intramedullary nailing to plating of forearm fractures in children between 10 and 16 years of age.

METHODS

Thirty-one patients who underwent operative fixation of midshaft radius and ulna fractures were divided into nailing and plating groups and were compared retrospectively according to perioperative data and patient outcome measures (fracture union at 3 and 6 months, loss of forearm rotation, restoration of radial bow magnitude and location, and complication rates).

RESULTS

The nailing group had 19 patients, with a mean age of 12.5 years (range, 10-14.6 years), and the plating group had 12, with a mean age of 14.5 years (range, 11.9-16 years). Groups were similar for sex, arm injured, fracture location, Arbeitsgemeinschaft fur Osteosynthesefragen/Orthopaedic Trauma Association classification, and number of open fractures. Duration of surgery and tourniquet use were significantly shorter in the nailing group (P = 0.037 and 0.001, respectively). No differences were found between the groups for fracture union at 3 or 6 months. At latest follow-up, radial bow magnitude was similar for the 2 groups and restored to normal in both. Radial bow location in the nailing group was significantly different from the reported normal values (P = 0.001). Despite this, there was no difference in loss of forearm rotation between groups. Complication rates were also similar between groups, with 1 ulna nonunion, 1 compartment syndrome, and 2 refractures in the nailing group and 1 radius and ulna nonunion, 1 broken plate, and 2 refractures in the plating group.

CONCLUSIONS AND SIGNIFICANCE

Based on similar functional and radiographic outcomes, nailing of length-stable forearm fractures remains an equally effective method of fixation in skeletally immature patients 10 to 16 years of age when compared with plating and is our treatment of choice.

LEVEL OF EVIDENCE

Therapeutic level III--retrospective comparative study.

Intramedullary wire fixation for unstable forearm fractures in children

Displaced fractures of the diaphyseal forearm in children are often treated conservatively, but there is relatively high incidence of redisplacement, malunion and consequent limitation of function. This retrospective study was performed to determine means for minimalising the complications of intramedullary Kirschner (K)-wire fixation used in the treatment of unstable, diaphyseal forearm fractures by pointing out those which most frequently occur with this treatment choice. This treatment method was applied in 48 children with a mean age of 10.3 (range, 5-14) years. A limited open reduction to one or both bones was necessary for insertion of the intramedullary wire in 20 (40%) patients. Although 24 complications, such as pin site infection, loss of forearm rotation, superficial branch of radial nerve palsy, delayed union, nonunion, hardware migration, and K-wire penetration to the opposite cortex, were recorded in 18 patients, 46 patients (96%) had excellent or good, 1 patient (2%) had fair and 1 patient (2%) had poor outcome using the grading scheme adapted by Price. Except for the patient in whom the fracture was not united, the average union time was 6.3 weeks in children less than 10 years and 7.8 weeks in those above 10 years of age. Despite these minor complications, percutaneous intramedullary fixation with K-wires and proper technique is an appropriate, effective and safe operation for unstable diaphyseal fractures of the forearm in children who cannot be treated by closed manipulation.

Moment arms of forearm rotators

BACKGROUND

Rotation about a longitudinal axis of the forearm has been a matter of investigation for over 100 years. However, most studies were limited to only a few muscles and to their action in specific set positions of elbow and forearm rotation. This investigation aims at determining the moment arms of muscles that contribute to pronation and supination at three different angles of elbow flexion throughout the entire range of forearm rotation.

METHODS

Muscle moment arms were derived from tendon excursions that were recorded on a full-size epoxy model of the radioulnar complex. The results were verified on a fresh cadaver specimen.

FINDINGS

Moment arms of all major supinators exhibit peak values in 40-50 degrees of pronation, for all three positions of the elbow. These peak values vary with elbow position, the biceps muscle showing the highest dependency with its greatest moment arm in 90 degrees of elbow flexion. The pronators show a maximum of moment arm about the neutral position, with little dependency on elbow flexion. Brachioradialis brings the pronated, or supinated forearm into the neutral position. The bow of the radius is in function comparable to the 'throw' of a crankshaft, forming a greater lever arm between the point of insertion of the muscles and the axis of rotation of the radius.

INTERPRETATION

The observations drawn from this study could be of eminent value in planning rotator muscle transplantation, in understanding functional disorders after injury, and in the physical treatment of forearm rotator muscle deficiency. Reconstruction of the physiological anatomical arrangement in the treatment of injuries is strongly recommended for restoration of function.

Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases

We present our experience with elastic stable intramedullary nailing (ESIN) used in the single bone fixation of both bones forearm fractures in children. From May 2002 to July 2004, 20 children (14 boys and 6 girls), median age of 10 years (range 6-15 years) were treated with ESIN for 16 closed and 4 grade I open forearm fractures. All patients were reviewed clinically at a median follow-up of 20 months (range 6-30 months). All fractures were radiologically united at a median of 6.7 weeks (6-9 weeks). The median operating time was 35min (range 25-60min). The median hospital stay was 2 days (range 1-3 days). Removal of the nails was undertaken in all 20 children at a median of 19 weeks (range 16-24 weeks) post-operatively. At follow-up, a full range of elbow and wrist movements were found in all cases. There was no clinically significant rotational deformity in any case. ESIN seems to be a safe method in the treatment of single bone fixation of both bones forearm fractures in children between 6 and 15 years of age.

Outcomes of intramedullary nail fixation through the olecranon apophysis in skeletally immature forearm fractures

The objective of this study was to quantitatively investigate the long-term radiologic and functional outcomes of antegrade intramedullary (IM) nailing through the olecranon apophysis for ulnar fractures in skeletally immature patients. A retrospective review was conducted of skeletally immature patients with ulnar fractures that had antegrade IM nail fixation through the olecranon apophysis. Patients were excluded if they had a previous forearm fracture or a fracture of the contralateral forearm. Functional measures included the Activities Scale for Kids (ASK) questionnaire for patients younger than 15 years of age and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire for patients older than 15 years of age. Forearm range-of-motion measurements were collected from the fractured forearm and the contralateral control forearm. Radiologic outcomes were evaluated for ulnar, olecranon, coronoid, and trochlear notch proportions. Nineteen patients were evaluated. The average age at operation was 10.8 years (range 1.6-15.9) and the mean follow-up time was 3.4 years (range 1.2-7.2). Nine patients completed the ASK questionnaire, with a mean score of 93.9 (range 68.9-100), and 10 patients completed the DASH questionnaire, with a mean score of 6.0 (range 0-35). The mean fractured forearm supination was 103.2 degrees compared with 109.2 degrees on the control forearm (P < 0.05). Furthermore, the mean fractured forearm trochlear notch width was 17.7 mm compared with 17.1 mm on the control forearm (P < 0.05). Similarly, the mean fractured forearm trochlear notch height was 16.5 mm compared with 17.0 mm on the control forearm (P < 0.05). This retrospective review suggests that antegrade IM nail fixation through the olecranon apophysis for ulnar fractures in skeletally immature patients is a safe procedure. There is no significant ulnar length disruption or functional limitations, despite the differences in trochlear notch measurements and supination between the fractured and control forearms. Overall, IM nail fixation through the olecranon apophysis for surgically indicated ulnar fractures has minimal outcome limitations, with no evidence of prospective growth disruption. A larger randomized prospective trial should be conducted to strengthen the evidence of this study.

Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents

The management of adolescent radius and ulna diaphyseal fractures is controversial. The purpose of this study was to address the residual deformity and functional outcome following closed treatment of these fractures. Twenty-five older children and adolescents (mean age 13.3 years, range 8.8-15.5) with displaced diaphyseal both-bone forearm fractures underwent closed treatment and were followed for a mean of 49.6 weeks. All fractures united. On the final AP radiograph, the mean angulation was 9 degrees (range 0-18 degrees) for the radius and 8 degrees (0-20 degrees) for the ulna. All patients achieved full elbow and wrist range of motion. Loss of forearm supination and pronation averaged 4 degrees (range 0 to 20 degrees) and 6.8 degrees (0 to 40 degrees), respectively. Closed reduction and casting of displaced both-bone diaphyseal forearm fractures, despite the residual angulation, results in satisfactory functional outcome and should remain a viable treatment option in the management of this injury.

Compartment syndrome following intramedullary fixation of pediatric forearm fractures

This study was designed to evaluate the incidence of compartment syndrome (CS) resulting from the treatment of both-bone forearm fractures in children. A retrospective analysis of 285 consecutive children who presented with both-bone forearm fractures was performed. Of 235 closed injuries, 205 were treated with closed reduction and casting; none of these patients developed CS. Thirty of the closed injuries were treated with closed reduction and intramedullary fixation; three of these patients (10%) developed CS. Fifty patients sustained open fractures and were treated with debridement and open reduction with intramedullary pinning; CS developed in three of these patients (6%). The eighty patients treated with intramedullary fixation had an increased incidence of CS compared with the 205 patients treated with closed reduction and casting (P < 0.001). Within the group of patients who had surgery, patients with longer operative times and more use of intraoperative fluoroscopy were at higher risk of developing CS.