Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children

Both-bones diaphyseal forearm fractures are common injuries in the paediatric age group and are potentially unstable. Both-bones intramedullary nailing for these fractures is a minimally invasive procedure that maintains alignment, and promotes rapid bony healing. Good results have also been shown with single-bone fixation. We report our experience in treating these common injuries with radius-only intramedullary nailing in 29 children. The clinical notes and radiographs were reviewed retrospectively. There were 9 girls and 20 boys; the mean age at the time of operation was 9 years (range: 5 to 17 years). Closed reduction was achieved in 21 patients, while eight patients required open reduction. Mean duration of follow-up was 6.8 months (range: 4 to 12 months). All fractures achieved clinical and radiological union at 6-8 weeks. Radius-only intramedullary nailing is a sufficient and effective option in treating both bones paediatric forearm displaced unstable type AO 22-A3 fractures, with excellent functional outcome and union rates.     

Internal fixation of diaphyseal fractures of the forearm by interlocking intramedullary nail: short-term results in eighteen patients

OBJECTIVE: This study was designed to evaluate the efficacy of the treatment of diaphyseal fractures of the forearm using the ForeSight forearm interlocking intramedullary nail. DESIGN: Retrospective study. SETTING: University-affiliated teaching hospital. PATIENTS: Eighteen patients with 32 displaced diaphyseal forearm fractures were identified. INTERVENTION: All fractures were treated with the ForeSight forearm interlocking intramedullary nail. Eighteen fractures were stabilized with static interlocking technique. MAIN OUTCOME MEASURES: The assessment of patients was based on the time to union, the functional recovery, and the incidence of complications. Physical capability was evaluated by using the rating system of Grace and Eversmann. Patient-rated outcome was assessed by completion of the Disability of Arm Shoulder Hand questionnaire (DASH). RESULTS: All fractures healed with the index procedure. The average time to union for fractures utilizing a closed technique was 10 weeks; for fractures using an open reduction technique, 15 weeks. The mean pronation was 62 (range, 0-96) degrees, and the mean supination was 80 (range, 0-105) degrees. Compared with the normal arm, the mean loss of rotation of the forearm was 32 (range, 5-162) degrees. Using the rating system of Grace and Eversmann, 13 patients had an excellent or good result, 3 had an acceptable result, and 2 had an unacceptable result. Using the patient-rated functional questionnaire, the mean DASH of 19 (range, 4-72) points at the time of the most recent follow-up indicated a mild-to-moderate impairment. There were 7 postoperative complications. The incidence of complications was 22% (7/32). One cross-union between forearm bones occurred in a patient with a closed head injury and high-energy trauma. Two nondriving end screws of the ulna nail backed out causing wrist pain and had to be removed. There were 4 superficial infections occurring all in the fractures that necessitated an open reduction technique. The overall rate of infection was 12.5% (4/32). Three patients who presented with an open fracture needed a skin graft to cover the open wound. CONCLUSIONS: Forearm interlocking intramedullary nailing is an acceptable method to stabilize displaced diaphyseal forearm fractures in adult.     

Screw elastic intramedullary nail for the management of adult forearm fractures

Background:

The failure of the conventional nailing of both forearm bones or isolated fractures of radius and ulna pose a potential problem of nail migration and rotational instability, despite the best reduction. The purpose of this paper is to evaluate the results of screw elastic intramedullary nail for the treatment of adult diaphyseal fractures of both forearm bones, which effectively addresses the problems associated with the conventional nailing systems for the forearm fractures.

Materials and Methods:

Seventy-six adults with forearm fractures (radius and ulna or isolated fracture of the single bone) were retrospectively evaluated. Fifty males and 26 females with the mean age of 38 years (range, 18-70 years) underwent closed reduction and screw intramedullary nail fixation. Ten patients required limited open reduction. The fractures were classified according to the AO/OTA system. The average followup was 12 months (range, 6 to 18 months).

Results:

The mean surgical time was 45 minutes (35 to 65 minutes). The meantime to union was 14 weeks (10-21 weeks). The results were graded as excellent in 50, good in 18 patients, and acceptable in eight patients, using the criteria of Grace and Eversman. We had superficial infection in three cases, one case of delayed infection, painful bursa in two cases, delayed union in two cases, malunion with dislocation of the DRUJ in two cases, injury to the extensor tendon of the thumb in one case, and one case of incomplete radioulnar synostosis.

Conclusion:

Closed reduction and internal fixation of forearm fractures by screw intramedullary nails reestablishes the near normal relationship of the fractured fragments. Screw intramedullary nail effectively controls both rotatory forces and the migration of the nail. It produces excellent clinical results in isolated fractures of either bones, as well as both bones of the forearm in adults.     

Elastic intramedullary nailing of paediatric fractures of the forearm: a decade of experience in a teaching hospital in the United Kingdom

We present the results of 90 consecutive children with displaced fractures of the forearm treated by elastic stable intramedullary nailing with a mean follow-up of 6.6 months (2.0 to 17.6). Eight (9%) had open fractures and 77 (86%) had sustained a fracture of both bones. The operations were performed by orthopaedic trainees in 78 patients (86%). All fractures healed at a mean of 2.9 months (1.1 to 8.7). There was one case of delayed union of an ulnar fracture. An excellent or good functional outcome was achieved in 76 patients (84%). There was no statistical difference detected when the grade of operating surgeon, age of the patient and the diaphyseal level of the fracture were correlated with the outcome. A limited open reduction was required in 40 fractures (44%). Complications included seven cases of problematic wounds, two transient palsies of the superficial radial nerve and one case each of malunion and a post-operative compartment syndrome. At final follow-up, all children were pain-free and without limitation of sport and play activities. Our findings indicate that the functional outcome following paediatric fractures of the forearm treated by elastic stable intramedullary nailing is good, without the need for anatomical restoration of the radial bow.     

Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results

The current study is a retrospective clinical and radiographic review of all children treated with intramedullary Steinmann pins for fixation of diaphyseal forearm fractures at one institution. Thirty patients were reviewed. Twenty-five patients had fractures of both bones, three had Monteggia fracture-dislocations, and two had isolated radial fractures. Eight fractures were open. The average age of the patients at the time of surgery was 9 years 3 months (range, 4 years 1 month-14 years 3 months). Time to union averaged 6 weeks but a slightly longer healing time was seen in patients older than 10 years of age. Subjective, objective, and radiographic evaluation at 3 years 6 months average followup revealed no significant side to side differences. There were six complications (two pin site infections, two cases of fracture displacement after pin removal, one extensor pollicus longus tendon rupture requiring repair, and one refracture), none of which affected outcome at followup. When combined with an open reduction, one intramedullary Steinmann pin provides adequate stability in most diaphyseal forearm fractures in children with excellent results and few complications.     

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.     

Nancy nailing of diaphyseal forearm fractures. Single bone fixation for fractures of both bones

We identified 25 children (10 girls and 15 boys) who had been treated with single bone intramedullary fixation for diaphyseal fractures of both forearm bones. Their mean age was 10.75 years (4.6 to 15.9). All had a good functional outcome. We conclude that in selected children, single bone intramedullary nailing is a suitable method of treatment for diaphyseal fractures of both bones of the forearm.     

Complications after titanium elastic nailing of pediatric tibial fractures

A retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1 patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal.The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.     

前臂交锁髓内钉治疗尺桡骨粉碎骨折的临床研究

目的探讨应用前臂交锁髓内钉治疗尺桡骨粉碎性骨折的可行性及其疗效。方法应用前臂交锁髓内钉采用切开或闭合复位技术治疗尺桡骨粉碎性骨折18例,男15例,女3例;年龄32～63岁,平均42岁。骨折按AO分型,A 1型4例,A 2型1例,A 3型2例,B 2型1例,B 3型3例,C 2型3例,C 3型4例。手术均在伤后1周内进行。结果所有病例术后随访8～10个月,骨折愈合时间8～16周,平均12周。所有患者均未发生骨不连、术后感染及桡神经深支损伤病例;术后有2例前臂旋转功能恢复欠佳,1例骨折延迟愈合,其余患者功能恢复满意。根据B erton评定标准进行评价,优10例,良5例,可2例,差1例,优良率为83.3%。结论应用前臂交锁髓内钉技术治疗尺桡骨骨折,具有手术创伤小、固定牢靠、骨折愈合率高、功能恢复快等优点,是治疗前臂骨折较理想的手术方法,尤其适用于多段骨折、粉碎性骨折。     

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

OBJECTIVES: This retrospective review evaluates the efficiency of standard intramedullary Kirschner wires for the treatment of unstable diaphyseal forearm fractures in children. DESIGN: Retrospective review. SETTING: Large teaching and research hospital in Turkey. PATIENTS: Thirty-one patients with diaphyseal forearm fractures were treated by surgical method between 1988 and 1998. The mean age was 12.3 years (range 7 to 17 years). The mean follow-up period was 4.2 years (1 to 6.2 years). INTERVENTION: The method of treatment of each forearm fracture was open reduction and intramedullary Kirschner wire fixation using a mini-incision. MAIN OUTCOME MEASUREMENTS: Fracture union, growth disturbance of the forearm, and complications were evaluated. RESULTS: Union was obtained in all cases except two (6.4 percent). No forearm inequality was observed. CONCLUSIONS: Intramedullary fixation is a useful technique for unstable shaft fractures of the forearm in children that can not be treated by closed manipulation.     

Intramedullary fixation using multiple Kirschner wires for forearm fractures: a developing country perspective

PURPOSE: To evaluate treatment results of intramedullary fixation using multiple Kirschner wires for diaphyseal forearm fractures. METHODS: Between January 2001 and January 2004, 184 patients (122 men and 62 women) with 288 displaced diaphyseal forearm fractures underwent intramedullary fixation using multiple Kirschner wires. The wires were inserted by opening the fracture site because radiographic facility for closed pinning was unavailable. The time to union, functional recovery, and the complication rates were assessed. RESULTS: 11 patients were lost to follow-up, leaving 173 whose data was analysed. In 167 (97%) of the patients the fractures united, and in 14 (8%) of them union was delayed. The mean time to union for closed fractures was 13 (range, 7-16) weeks and for open fractures it was 15 (range, 12-22) weeks. The mean time in cast was 6 (range, 3-14) weeks. In all, 34/173 (20%) had complications: superficial infection (n=13), deep infection (n=4), cross-union between bones (n=4), open fracture 'needing' a skin graft (n=2), radial nerve palsy (n=3), paraesthesia (n=1), and non-union (n=7). Among the 173 analysed patients, the infection rate was 10% and the non-union rate was 4%. 130 (75%) of the patients had the wires removed; no re-fracture occurred after wire removal. Based on the Anderson criteria, 47 (27%) of the patients attained excellent, 78 (45%) satisfactory, and 39 (23%) unsatisfactory results. In 9 (5%) of the patients, union failed (7 plain non-union and 2 due to chronic osteomyelitis). CONCLUSION: Kirschner wires are much cheaper than plates and screws, and require minimal expertise for insertion and removal. They remain acceptable for stabilising displaced diaphyseal forearm fractures in developing countries.     

Intramedullary nailing of femoral fractures in children through the lateral aspect of the greater trochanter using a modified rigid humeral intramedullary nail: preliminary results of a new technique in 15 children

OBJECTIVES: To evaluate the clinical results of intramedullary nailing of femoral shaft fractures using a rigid intramedullary nail placed through the lateral aspect of the greater trochanter in older children and adolescents. DESIGN: A retrospective study was carried out evaluating all skeletally immature patients with femoral shaft fractures treated using a modified rigid humeral intramedullary nail. PATIENTS/PARTICIPANTS: Fifteen children and adolescents with displaced femoral diaphyseal fractures and open physes. INTERVENTION: Femoral shaft fractures in children and adolescents were stabilized using a modified humeral intramedullary nail placed through the lateral aspect of the greater trochanter. MAIN OUTCOME MEASUREMENTS: Patients were evaluated to determine time to union, final fracture alignment, hospital stay, complications, clinical outcome, and proximal femoral changes including avascular necrosis or proximal femoral valgus with femoral neck narrowing. RESULTS: Fifteen patients were followed for a minimum of 1 year (range 70-157 weeks). The average age of the patients was 12 years and 5 months (range 8 years and 2 months-17 years and 1 month). All fractures healed at a mean of 7 weeks (range 5-14 weeks) after fracture. The average hospital stay for patients with isolated femur fractures (8/15) was 2.8 days (range 1-5 days). At an average follow-up of 141 weeks (range 70-326 weeks), no patient had developed avascular necrosis, femoral neck valgus, femoral neck narrowing, or other complications. CONCLUSIONS: The technique of intramedullary nailing in children through the lateral aspect of the greater trochanter seems to be safe, effective, and well tolerated by patients.     

The use of elastic intramedullary nailing in the stabilisation of paediatric fractures

The treatment of paediatric long-bone fractures remains controversial. Elastic intramedullary nailing has been proposed as an alternative for the treatment of paediatric long-bone fractures. PATIENTS: We treated 68 children in a time span of 9 years with 32 fractures of the forearm, 27 fractures of the femur and nine fractures of the tibia. The mean age was 8.3 years and the mean admission time 2.6 days. RESULTS: Mean consolidation time was 7.9 weeks for the forearm fractures, 11.9 weeks for the femur fractures and 10.6 weeks for the tibial fractures. Full weight bearing for the latter two fracture types was allowed within the first week. There were no major complications. The complications encountered were three hydrops of the knee, four low-grade infections and one delayed union. Leg length discrepancy was only seen in five patients (18%) and was less than 2 cm. DISCUSSION: In femur fractures, we let the parents decide between skeletal traction and intramedullary rods. When confronted with the possible complications (operation-related complications and infection) compared to the advantages (early weight bearing and short admission time), they almost always choose the operative approach. In our opinion, elastic intramedullary nailing is an excellent treatment option for diaphyseal fractures in children with skeletal immaturity, especially of the femur.     

Treatment of unstable tibial shaft fractures by closed intramedullary nailing with flexible (Ender-type) pins.

Eighty patients with unstable tibial diaphyseal fractures were treated by closed intramedullary nailing with Ender-type flexible pins. The majority of injuries occurred from falling while snow skiing. Sixty-six fractures were closed and 14 were open. Fifty-eight fractures involved the distal, 21 fractures the middle, and one fracture the proximal one third of the tibial shaft. The average time to roentgenographic union was 15.5 weeks (range, ten to 34 weeks) for closed and open Grade I and II fractures. The time to union in Grade III fractures was 50 weeks (range, 36-64 weeks). There were two nonunions and two delayed unions. Both nonunions occurred in Grade IIIA open shaft fractures. Intramedullary stabilization with flexible, Ender-type pins provides good control of unstable tibial shaft fractures. The use of pins with a smaller diameter (3.5 or 4 mm) allows the surgeon to place more pins across the fracture site. The use of multiple pins and packing the intramedullary canal may provide better rotational stability. The use of Ender-type pins for fixation of Type IIIA open tibial shaft fractures is contraindicated.     

Interlocking Nailing of Forearm Fractures

Aim of the study : The aim of this retrospective study is to evaluate the results after treating diaphyseal fractures of the radius and ulna with an interlocking intramedullary nail.

Materials and methods : Between 2001 and 2005, 78 patients with 118 fractures were treated using the ForeSight intramedullary nail (Smith & Nephew, Memphis, USA). The average patient age was 37.02 years. In the postoperative period, early and late complications were evaluated through radiological and functional methods. The average period of follow-up was 25 months (range: 12–58 months).

Results : The average length of time to demonstrated bone healing was 14.2 weeks. Four cases of prolonged healing were observed. Pseudo-arthrosis formation did not occur. Assessment of function according to Anderson gave the following results: full range of movement in 88.6% of patients; mild restriction of movement in 10.1%; severe restriction of movement in 1.3% of patients. The implanted material was extracted from 27 patients. Refractures did not occur. Postoperative complications included: 1 superficial infection, 3 cases of incomplete radio-ulnar synostosis; one case of compartment syndrome.

Conclusions : Upon comparing the techniques of using plates with those of nailing in the treatment of forearm fractures, we have achieved comparable results with nailing. We therefore regard it as advantageous, in particular for treating open, serial and grossly comminuted fractures of the forearm bones.     

Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children

This prospective study investigated medium-term outcomes for 51 children treated from 1997 to 2001 for displaced diaphyseal forearm fractures with elastic stable intramedullary nailing. Forty-three patients included achieved excellent/good functional results at an average follow-up of 38 months. Four patients required open fracture-manipulation at surgery. Complications included eight cases of soft-tissue irritation at nail-insertion site (three required shortening procedures), two temporary radial nerve branch injuries, four minimal rotational mobility deficits, one 10 degrees elbow extension deficit after splinting, and five small keloid scars. All patients were pain-free, without limitations in activities for daily life or sport/play activities by 12 months after hardware removal. Elastic stable intramedullary nailing is appropriate therapy for these injuries.     

A critical analysis of postoperative complications of antebrachium ten-nailing in 35 children

Background: Unstable antebrachium diaphyseal fractures in children are nowadays increasingly treated operatively by elastic intramedullary nailing. Aim: Aim of the study was to critically assess both radiological and functional outcome of antebrachium fractures treated by titanium elastic nail (TEN) in a pediatric cohort. Material and Methods: This retrospective study investigated 75 consecutive children, who were treated for antebrachium shaft fractures at Tampere University Hospital during the time period from January 2001 to December 2005. All the fractures were classified according to OTA. Thirty-five children (mean age 12.3 years) were treated by TEN-nailing. Twenty four of the forearm fractures were instable, five were open, five were re-fractures and one had ulnar nerve deficit. In all but one patient both forearm bones were fractured. Twelve (34%) operations were managed by closed reduction, open reduction was needed in 23 (66%) patients. In 29 cases both bones were fixed with TEN-nail. In the four patients with re-fracture in both ulna and radius only the radius was TEN-nailed. In one case radius was fixed with TEN-nail and ulna with K-wire and in another case radius was fixed with TEN-nail and ulna with plate. Fracture pattern, mode of reduction, surgical approach, short- and long-term complications and outcome were recorded. Results: Twenty three (66%) patients achieved healing of the fractures without any limitation in range of motion. Twelve patients with postoperative complication were followed up 31-74 (median of 54) months. Eleven (31%) patients had minor postoperative complications and one (0,3%) patient had a Volkmann's ischemic contracture. Five of complicated patients had more than one problem. Immediate post-operative problems were noted in these five patients. At follow-up visits four patients complained of ulnar nail discomfort, two had neural symptoms. Additionally, three children suffered from re-fractures. Discussion: Despite various minor complications, TEN-nailing is considered suitable treatment for unstable forearm shaft fractures. Most of the problems were related to poor technical performance in nailing.     

静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合

目的 探讨静力型交锁髓内钉动力化治疗下肢骨干骨折延迟愈合的效果。方法 对27例骨折应用静力型交锁髓内钉固定后的股骨和胫骨骨干延迟愈合患者，行近侧或远侧锁钉取出术进行动力化治疗。其中股骨干延迟愈合17例，胫骨干延迟愈合10例。结果 随访7—48个月，平均19．5个月。术后3—7个月(平均3．3个月)获临床愈合。无感染、断钉、关节损伤和内固定取出后再骨折。结论 静力型改为动力型是治疗交锁髓内钉固定后股骨和胫骨骨干延迟愈合的有效方法。应用时注意选择适当的手术时机，选择取出锁钉也要得当。     

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 35 min (range 25–60 min). 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.     

Delayed union and non-union of the ulna following intramedullary nailing in children

Most studies report little or no problem with union following intramedullary nailing of fractured forearm bones in children. The bone involved in the occasional delayed union is not mentioned except for one delayed union of the ulna following an open fracture. The present paper specifically highlights problems with union of the ulna following nailing in children. It reports two cases of delayed union and one non-union following nailing of closed fractures of both forearm bones. In all cases, the radius united in good time. We discuss the anatomical reasons and surgical techniques that predispose the ulna bone to delayed union and non-union and recommend surgical precautions to avoid this.