Long-arm Cast Research Articles

Intramedullary Fixation of Unstable Both-Bone Forearm Fractures in Children

A retrospective study was performed to evaluate the results of intramedullary fixation used in the management of unstable, diaphyseal both-bone forearm fractures in skeletally immature patients. Twenty-five patients with 25 fractures were identified whose fracture management included only intramedullary fixation. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded from this analysis. Mean age at fracture was 10 + 8 years. There were 15 closed and 10 open fractures (eight grade I and two grade II). Smooth Kirschner wires or Rush rods were used for fixation. Average length of immobilization was 8 + 2 weeks; 6 + 2 in a long-arm cast and 2 + 0 weeks in a short-arm cast. All 25 regained normal elbow motion, with 17 regaining full forearm rotation. Eight patients had an average loss of 13 degrees of supination and 9 degrees of pronation. There were four minor and two major complications (one rod migration and one delayed union). No infections, malunions, or synostoses occurred in this patient group. Using the grading scheme adapted by Price there were 21 excellent results (84%), four good (16%), and no fair or poor results. In our experience, intramedullary fixation of the unstable both-bone forearm fractures is a safe, effective, and user-friendly technique when alignment jeopardizes fracture position at union and eventual forearm motion.

Both-Bone Forearm Fractures in Children

Treatment of both-bone forearm fractures remains a difficult dilemma for the orthopedist. We assessed the results of 33 children treated with closed reduction and a long-arm cast using traction with finger traps in neutral rotation. Patients were grouped according to age and analyzed for residual angulation and range of motion (ROM). Despite some residual angulation and loss of rotation, all patients were fully active with no functional restriction at follow up. For patients 10 years old or younger with less than 30 degrees of post-casting angulation, full ROM and minimal residual angulation on radiograph can be expected. For patients ages 11 to 15 years (the oldest patient in this series was 15), residual angulation is likely and approximately 60% of patients will have residual loss of less than or equal to 30 degrees of rotation. In spite of this, we found no evidence of functional loss at follow up. Our series supports the continued use of closed manipulation as an effective treatment in children with both-bone forearm fractures.

A Scaphoid Fracture Associated With a Displaced Distal Radial Fracture in a Child

A hyperextension injury to the wrist caused a transverse scaphoid fracture associated with a displaced distal radial fracture in an 11-year-old boy. Anatomic reduction and immobilization in a long-arm cast for a period of 12 weeks resulted in subsequent healing of these fractures. The coexistence of a scaphoid fracture with a distal radius fracture in a child is important to recognize because reduction maneuvers are modified to effectively treat this combination of injuries. Patients with distal radial physeal injuries should be closely evaluated for clinical and roentgenographic signs of scaphoid fractures.

Fatigue Fracture of a Forearm Plate Within a Long-Arm Cast

Open fractures of both left ulna and radius, in which a segment of the radius was found to be missing, occurred in a 27-year-old man. The fractures were treated by open reduction, internal fixation with ASIF semitubular plates, and bone graft. Because of slow radiological union, regrafting was required twice. Approximately six months after the third operation, roentgenograms showed that the bone plate was broken, even though the fractures had been protected in a long-arm cast. The fatigue fracture of the plate, positioned on the posterior surface of the ulna, was presumably caused by the force of the finger flexors, most of which originate above the fracture site, and which were still able to contract because the fingers were not immobilized.

Treatment of nonunited scaphoid fractures by pulsed electromagnetic field and cast

Thirty-five of 44 nonunited scaphoid fractures that were at least 6 months old healed in a mean time of 4.3 months during pulsed electromagnetic field (PEMF) treatment using external coils and a thumb spica cast. The mean time from the onset of the fracture to treatment was 40 months. No concurrent operation was performed. Follow-up time averaged 8.4 months. Eight of nine fractures with avascular necrosis healed. Five of eight fractures in the proximal third healed. Twelve (75%) of 16 patients treated in short-arm thumb spica casts and PEMF healed versus 22 (92%) of 24 patients treated initially in long-arm thumb spica casts and PEMF. We have found PEMF to be a reliable alternative method of treating nonunited scaphoid fractures. Because of the low risk, simplicity of use, and reliability, we recommend its consideration in the treatment of undisplaced, nonunited fractures without carpal instability less than 5 years after the injury. Treatment should initially begin with a long-arm cast.

Nonconstrained Total Elbow Arthroplasty

Thirty capitellocondylar unhinged implant arthroplasties were performed on 27 patients during the period from October 1976 through June 1981. The average patient age was 59.4 years, with a preoperative diagnosis of rheumatoid arthritis in 28 elbows and osteoarthritis in two elbows. Follow-up periods averaged 39.9 months (range, 10-62 months). The indication for elbow arthroplasty were intractable pain, joint instability, failed synovectomy, or bilateral limitation of motion. Ranged of motion evaluations showed moderate increases in flexion, pronation and supination after operation, although there was no significant improvement in extension. Ewald functional evaluation scores improved significantly from the mean of eight points prior to operation to the postoperative mean of 85 points. The significant complications occurring were deep wound infections, necessitating removal of the prosthesis (6.6%), and subluxation (13.2%), which responded to conservative treatment by long-arm casting. One patient required reconstruction of the medial collateral ligament for subluxation. Ulnar nerve paresthesia developed in 10% of the patients. One patient required neurolysis and transposition of the nerve for relief of symptoms. The posterolateral approach was adopted to reduce the incidence of ulnar nerve complications.

The Electrical Treatment of Scaphoid Nonunion

Seventy-one percent (12 out of 17) of the previously treated nonunions united within 12 weeks by a semi-invasive technique of electrical stimulation. The electrodes are stainless steel and Teflon-coated except for the 1 cm bare tip. The power source is a 7.5 volt battery in circuit with resistors and transistors such that a constant continuous current of 20 muamp is applied to each electrode. Three or four cathodes are implanted percutaneously, using local or regional anesthesia with radiographic control, usually an image intensifier. A long-arm cast is used for three weeks and then reduced to a short-arm cast which is used for nine additional weeks. The indication for this technique is failure of previous bone grafting. The contraindications are wrist arthritis and an avascular proximal pole. Patient acceptance of this electrode technique was high and morbidity was less than in those patients treated by iliac bone grafting. The treatment of nonunion of the scaphoid by this semi-invasive electrical stimulation technique is a reasonable alternative to bone grafting and provides a salvage procedure when bone grafting or other therapeutic modalities have failed.

Fractures of the Scaphoid

Fractures of the scaphoid can be classified into either undisplaced, stable fractures or displaced, unstable fractures by their roentgenographic appearance. When there is greater than 1 mm of fracture offset or an instability collapse pattern (dorsal lunate rotation) on the lateral view, an unstable, displaced fracture is present. When doubt exists after reviewing routine films, special X-rays, such as radial-ulnar deviation stress views, traction oblique views, or trispiral tomography should be obtained. In acute scaphoid fractures, where no displacement of the fracture fragments or lunate dorsal tilting can be seen, a short-arm thumb spica cast provides satisfactory support for fracture union. A wrist position of volar flexion-radial deviation is preferred to the more traditional positions of wrist extension with radial deviation or wrist extension with ulnar deviation with 100% union rate and no malunions. In displaced scaphoid fractures, a long-arm cast is recommended, with reduction of the fracture by wrist flexion and radial deviation. If accurate reduction is not obtained or is lost during the course of treatment, open reduction and internal fixation should be strongly considered. In scaphoid nonunions, undisplaced fractures can be treated satisfactorily by an inlay bone graft, using either a dorsal or a volar approach. For displaced scaphoid nonunions, either a dorsal approach with internal fixation should be done (particularly if there is evidence of radioscaphoid arthrosis), or a volar approach with internal fixation can be performed. Peg graft techniques had a higher rate of nonunion and secondary arthritis. Nonunions should be immobilized a minimum of 4 months or until roentgenographic union is present.