Unstable Diaphyseal Forearm Fractures Research Articles

Randomized Controlled trial Comparing Single Bone and Both Bone Fixation for Forearm Fracture in Children

Background: Fractures of shaft of the radius and ulna are one of the commonest injuries seen in the paediatric age group. Single bone intramedullary fixation has been advocated in the treatment of unstable diaphyseal forearm fractures. We conducted this study to evaluate the radiological and functional outcome in single bone and both bone fixation in forearm fracture in children. Methods: We designed a prospective randomized trial to compare single bone and both bone fixations in forearm fracture in aged 8-15 years. Fifty patients were presented to our institution during the period from May 2016 to May 2017 and randomly assigned a group with 25 patients in each group. Patients in Group A (SBF) were fixed with intramedullary Rush pin in ulna and those in Group B (DBF) were both radius and ulna were fixed. The patients were followed up for a period of twelve weeks. A radiological and functional outcome was evaluated and was compared and graded using Price et al. (1) criteria. Results: Among the 50 patients analyzed, randomization was successful. ROM of elbow at the final follow up was not statistically significant differences between two Groups. There were no statistically significant differences of radiological parameters at the final follow-up. Final assessment with Price et al. (1) criteria showed no statistically significant differences between two groups (P value- 0.1). Conclusion: Single bone ulna intramedullary fixation was comparable in terms of function and radiological parameter for both-bone forearm diaphyseal fracture in children.

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.

Single Bone Intramedullary Fixation of the Ulna in Pediatric Both Bone Forearm Fractures: Analysis of Short-term Clinical and Radiographic Results

Although single bone intramedullary (IM) fixation has been advocated in the treatment of unstable diaphyseal forearm fractures, some reports have questioned the ability of single bone fixation to maintain adequate reduction. The purpose of this investigation is to report the radiographic and early clinical results of single bone IM fixation for diaphyseal forearm fractures and to identify factors leading to loss of reduction of the radius after ulnar fixation. A retrospective analysis of 38 children who underwent single bone IM fixation of the ulna for both bone forearm fractures was performed. Mean age was 9 years (range: 4-14 y). Preoperative, postoperative, and final follow-up radiographs were examined for radiographic alignment. Patient data (including age, fracture type, delay to fixation, open vs. percutaneous reduction and fixation, and time to implant removal) was collected to identify predictors for loss of reduction of the radius. Loss of reduction of the radius was defined as 10 degrees or greater change of angulation in either the frontal or lateral plane from initial postoperative radiographs to final follow-up. Multivariate analysis was used to determine associations between patient factors and loss of reduction. All patients went on to bony union with restoration of forearm rotation. Twenty-five patients (66%) healed with <10 degrees of angulation of the radius, whereas 11 patients (29%) had between 10 and 20 degrees of angulation at final follow-up. Two patients demonstrated greater than 20 degrees of radial angulation requiring additional surgical care. There was no statistically significant association between any patient factors and loss of radial reduction, though there was a trend for increased radial angulation in patients who had sustained open fractures. Single-bone IM fixation of the ulna is a safe and efficacious option for the treatment of unstable diaphyseal forearm fractures in children. Owing to the increased risk of loss of radial reduction, however, consideration should be made for IM fixation of both bones in older children and cases of open fractures. IV, therapeutic.

Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures

We compared the clinical results of open reduction with a mini incision and closed reduction in pediatric unstable diaphyseal forearm fractures treated with intramedullary nailing. We retrospectively evaluated 45 children who were treated with intramedullary nailing for unstable middle third diaphyseal forearm fractures. Before intramedullary nailing, 24 patients (group 1; 5 girls, 19 boys; mean age 10 years; range 5 to 14 years) underwent open reduction with a mini incision, and 21 patients (group 2; 5 girls, 16 boys; mean age 11.5 years; range 8 to 13 years) underwent closed reduction. There were 16 closed, seven Gustilo-Anderson type 1, and one type 2 open fractures in group 1, and 15 closed and six type 1 open fractures in group 2. The mean time to surgery was 5 days (range 1 to 20 days) in group 1, and 3.1 days (range 1 to 5 days) in group 2. Rush rods or Kirschner wires were used for fixation. In group 1, both radius and ulna were fixed in all the patients, whereas fixation involved both bones in 18 patients, and only ulna in three patients in group 2. Functional results were evaluated according to the criteria of Price et al. The mean follow-up period was 33 months (range 12 to 89 months) in group 1, and 37 months (range 14 to 52 months) in group 2. Union was obtained in a mean of 7.1+/-1.0 weeks (range 6 to 9 weeks) in group 1, and 6.5+/-1.0 weeks (range 6 to 10 weeks) in group 2. The implants were removed after a mean of 7.2+/-1.7 weeks (range 6 to 10 weeks) in group 1, and 8.1+/-0.4 weeks (range 8 to 10 weeks) in group 2. The two groups differed significantly with respect to union and implant removal times (p=0.036 and p=0.002, respectively). According to the criteria of Price et al., the results were excellent in 19 patients (79.2%) and 18 patients (85.7%), and good in five patients (20.8%) and three patients (14.3%) in group 1 and 2, respectively. There was no significant difference between the functional results of the two groups (p>0.05). Complications showed a similar profile in the two groups, being one major (4.2%) and seven minor (29.2%) in group 1, one major (4.8%) and eight minor (38.1%) in group 2. None of the patients had complications such as limb-length discrepancy, epiphyseal damage, angular or rotational deformity, synostosis, or limited elbow or forearm range of motion. Closed reduction or open reduction with a mini incision before intramedullary nailing yield similar functional results, with a similar complication profile in the treatment of pediatric unstable diaphyseal forearm fractures.

Use of Elastic Stable Intramedullary Nailing for Treating Unstable Forearm Fractures in Children

The majority of the pediatric diaphyseal forearm fractures are treated with closed reduction and the application of an above elbow cast for a varying period, depending on the age of the child. Some forearm diaphyseal fractures require osteosynthesis mainly because of the presence of an unacceptable angular deformity, fracture instability, presence of an open injury or failure of conservative management in the form of redisplacement in the cast after manipulation. We present our experience with elastic stable intramedullary nailing (ESIN) for displaced and unstable pediatric diaphyseal fractures. A consecutive series of 21 patients treated with ESIN between 1997 and 2005 have been reviewed retrospectively. There were 14 boys and 7 girls with a median age of 11.8 years. All fixations were protected in an above elbow plaster cast. Patients were followed up for an average of 12.8 months (Range, 12-21.5 months). Clinical and radiologic union was achieved within 13 weeks after the procedure in 19 children. One patient had delayed union of the ulna which finally united at 9 months after operation without any further intervention. Another patient had nonunion of ulna that required autologous bone marrow injection after 1 year before full consolidation occurred. Complications were all modest and transient and eventually all patients achieved a good functional clinical outcome. We think that the technique has many merits over a more traditional plating technique including a minimally invasive technique, a less time consuming procedure and easier metal work removal. We think that cosmesis is perhaps the most important to our patients because the wounds are small and less conspicuous than the traditional Henry approach for plating which leaves a long unsightly volar forearm scar. We think that ESIN is an attractive treatment option for displaced and unstable diaphyseal forearm fractures in children.

Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children

This study analyses the results of 50 displaced diaphyseal forearm fractures in children treated with flexible intramedullary nailing. Between 1999 and 2002 we treated 50 children aged between 5 and 15 years, with diaphyseal fractures of the forearm using Flexible intramedullary nailing (FIN). Both bones were fractures in 45 patients, radius only in 4 and ulna only in 1. The indications for fixation were instability (26), re-displacement (20), and open fractures (4). 24 patients were reduced closed, followed by nailing, while 26 fractures required open reduction of either one bone(16 cases) or both bones(10 cases) prior to nailing. Bony union of all fractures was achieved by an average of 7 weeks (range 6 weeks to 4 months) with one delayed union. Pronation was restricted by an average of 20 degrees in 9 patients. Two patients developed post operative compartment syndrome requiring fasciotomy. Three patients were lost to follow-up. FIN led to early bony union with acceptable bony alignment in all 47 patients available at final follow-up. We therefore recommend FIN for the treatment of unstable diaphyseal forearm fractures in children.

小児前腕骨骨折に対する経皮的髄内固定症例の検討

Both-bone forearm fractures in children are usually treated conservatively, but numerous incidences of redisplacement, residual angulation, and loss of range of motion have been reported.We reviewed the clinical results of 24 children (18 boys and 6 girls) with unstable diaphyseal forearm fractures treated by intramedurally Kirschner-wire fixation from 1995 to 2003. The average age of the patients was 8.3 years (range : 2 to 15 years) and average follow-up time was 11.6 months (range : 3 to 32 months). All fractures healed with less than 10 angulations. One case had sustained internal rotation loss.

Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius

We retrospectively reviewed the result from 50 children (5 to 14 years; mean age 11 years) with unstable diaphyseal forearm fractures involving both the radius and ulna, for which closed reduction has been unsuccessful, and so were treated with open reduction and internal fixation of the radius only. The rationale of this treatment is to stabilize the radius as it is this bone which has the more complicated function of the two forearm bones. After anatomical reduction and fixation of the radius the ulnar fracture had a better alignment. In this series the functional and the anatomical results in all children at a mean follow up of 4 years (range 1 to 10 years) were excellent.

Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children.

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20 degrees, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.

Intramedullary Kirschner Wire Fixation of Open or Unstable Forearm Fractures in Children

This retrospective review evaluates the efficacy of standard intramedullary Kirschner wires (K-wires) for the treatment of open or unstable diaphyseal forearm fractures in 32 children with a mean follow-up of 13 months. Thirty-one patients had an excellent result, and one patient had a good result. Average time to bridging cortex was 3 months. Four patients lacked full pronation and supination, with none lacking >20°, and no patients had evidence of growth-plate arrest. Nine complications occurred in eight patients: lost reduction after K-wire removal (three), refracture (two), deep infection (one), pin-site infection (one), transient anterior interosseous nerve palsy (one), and skin ulcer over buried K-wire (one). Both infections occurred in cases in which the K-wire ends were left outside the skin. Each case of lost reduction occurred in single-bone fixation cases when the K-wires were removed before 4 weeks. In children, intramedullary fixation by using standard K-wires plus cast immobilization provides effective treatment for the problematic open or unstable diaphyseal forearm fracture when closed management has failed. Refinement of the technique may help to avoid complications. We now recommend burying the K-wires under the skin for 3-5 months and stabilizing both the radius and ulna with an intramedullary K-wire.