Refracture of the Pediatric Forearm with Intramedullary Nails in situ

INTRODUCTION

There are few described cases in literature describing the management of refracture of both bone forearm fractures with elastic stable intramedullary nails (ESIN) in situ. We describe our experience and discuss it in the context of existing reports.

CASE REPORT

A 6-year-old girl presented to our unit with a refracture of her forearm with ESIN in situ following a trauma, 5 months post her index injury and ESIN procedure. She was managed with closed reduction under general anesthesia with a good outcome.

DISCUSSION

Treatment of this unusual injury is challenging given the paucity of evidence to inform management. Many existing case series fail to report this complication. We echo those studies that have employed similar strategies and note potential complications associated with this management including altered biomechanics of the ESIN.

CONCLUSION

Closed reduction of a refracture of pediatric forearm with ESIN in situ is an acceptable approach to this unusual injury. Caution must be taken intraoperatively and postoperatively to account for any biomechanical deficiencies in the ESIN resulting from the forces applied to cause the refracture and forces applied to the in situ nails to achieve correction intraoperatively.

Galeazzi fractures: Is DRUJ instability predicted by current guidelines?

INTRODUCTION

Clinically significant distal radioulnar joint (DRUJ) injuries can occur with radial shaft fractures. Several radiographic methods of diagnosis, such as radial shortening of >5mm or fracture line within 7.5cm from the lunate facet, have been proposed but not clinically validated. The purpose of this study was to compare radiographic measurements of radial shaft fractures associated with and without clinically significant DRUJ injury (i.e., true Galeazzi fracture-dislocation) in order to evaluate the predictive value of reported parameters of DRUJ injury.

PATIENTS AND METHODS

A retrospective record and radiographic review was performed of 66 consecutive skeletally mature patients with isolated radial shaft fractures from 2004 to 2014 treated at one level 1 academic trauma center. Intraoperatively determined DRUJ instability after radial shaft fixation was used as the gold standard for diagnosis of a Galeazzi fracture-dislocation.

RESULTS

Average age was 34 years old (range: 18-90). By thirds, there were 10 proximal (15%), 27 middle (41%), and 29 distal (44%) fractures. 13 (20%) had an associated ulnar styloid fracture. 7 (11%) patients had DRUJ instability after radial fixation. Radial shortening averaged 4.4±5.2mm (-2.6-22), and 21 had shortening of >5mm. Twenty-six (39%) fractures were within 7.5cm of the wrist joint. Previous guidelines were only moderately accurate. Even greater shortening did not predict instability (3/7 patients with >10mm shortening had a true injury). Four out of 7 cases with instability had ulnar styloid fractures (p=0.02).

DISCUSSION AND CONCLUSIONS

Using a larger data set than has historically been evaluated, previously reported radiographic guidelines are only moderately accurate. The presence of an ulnar styloid fracture can be helpful. Surgeons should be aware of these associations but rely primarily on intraoperative assessment of the DRUJ after radial fixation to determine treatment.

Isolated radial shaft fracture with unreducable posterior dislocation of the radial head and rupture of the lateral collateral ligament: A case report

Combined injuries associated with forearm shaft fractures and elbow dislocations are well recognized. We describe an uncommon case of an isolated radial shaft fracture with an unreducable posterior dislocation of the radial head and associated rupture of the lateral collateral ligament of the elbow.