The removal of forearm plates in children

Routine removal of forearm plates in children remains controversial. The aim of the study was to assess if risks of complications associated with removal of forearm plates in children warrant routine removal of these plates. A total of 43 children (mean age 10.6 years old at time of fracture fixation) who had forearm plates removed after fracture fixation in our unit over a 10-year period were reviewed. There were three cases of re-fractures (two in the same child), all of which occurred following an episode of trauma and the use of Dynamic Compression Plates (DCP). One case of superficial infection was successfully treated with oral antibiotics. Low rates of complications from routine removal of metalwork after forearm plating in children may be achieved.     

High Irritation and Removal Rates After Plate or Nail Fixation in Patients With Displaced Midshaft Clavicle Fractures

Background

Studies comparing plate with intramedullary nail fixation of displaced midshaft clavicle fractures show faster recovery in the plate group and implant-related complications in both groups after short-term followup (6 or 12 months). Knowledge of disability, complications, and removal rates beyond the first postoperative year will help surgeons in making a decision regarding optimal implant choice. However, comparative studies with followup beyond the first year or two are scarce.

Questions/purposes

We asked: (1) Does plate fixation or intramedullary nail fixation for displaced midshaft clavicle fractures result in less disability? (2) Which type of fixation, plate or intramedullary, is more frequently associated with implant-related irritation and implant removal? (3) Is plate or intramedullary fixation associated with postoperative complications beyond the first postoperative year?

Methods

Between January 2011 and August 2012, patients with displaced midshaft clavicle fractures were enrolled and randomized to plate or intramedullary nail fixation. A total of 58 patients with plate and 62 patients with intramedullary nails initially were enrolled. Minimum followup was 30 months (mean, 39 months; range, 30–51 months). Two patients (3%) with plate fixation and two patients (3%) with intramedullary nails were lost to followup. The QuickDASH was obtained at final followup and compared between patients who had plate fixation and those who had intramedullary nail fixation. Postoperative complications measured include infection, implant-related irritation, implant failure, nonunion, and refracture after implant removal. Indications for implant removal included implant-related irritation, implant failure, nonunion, patient’s wish, or surgeon’s preference.

Results

Between patients with plate versus intramedullary nail fixation, there were no differences in QuickDASH scores (plate, 1.8 ± 3.6; intramedullary nail, 1.8 ± 7.2; mean difference, −0.7; 95% CI, −2.2 to 2.04; p = 0.95). The proportion of patients having implant-related irritation was not different (39 of 56 [70%] versus 41 of 62 [66%]; relative risk, 1.05; 95% CI, 0.82–1.35; p = 0.683). Intramedullary fixation was associated with a higher likelihood of implant removal (51 of 62 [82%] versus 28 of 56 [50%]; relative risk, 1.65; 95% CI, 1.24–2.19; p < 0.001). Among the removed implants more plates than intramedullary nails were removed after the 1-year followup (12 of 28 [43%] versus six of 51 [12%]; p = 0.002). There were no infections, implant breakage, nonunions, or refractures between the 1-year and final followup in either group.

Conclusions

After a mean followup of 39 months, disability scores were excellent. Major complications did not occur after the 1-year followup. A frequent and bothersome problem after both surgical treatments is implant-related irritation, resulting in high rates of implant removal, after 1 year. Future research could focus on analyzing risk factors for implant irritation or removal.

Level of Evidence

Level II, therapeutic study.

     

Risk factors for implant-related fractures after proximal femoral osteotomy in children with developmental dysplasia of the hip: a case-control study

Background and purpose — Proximal femoral osteotomy (PFO) is commonly performed to treat children with developmental dysplasia of the hip (DDH). Implant-related femoral fractures after osteotomy are sometimes reported, but the potential risk factors for these fractures remain unclear. We investigated the association of implant-related fractures with PFO and potential risk factors for these fractures.Patients and methods — We retrospectively reviewed 1,385 children undergoing PFO for DDH in our institution from 2009 to 2016 after obtaining institutional review board (IRB) approval and identified 27 children (28 hips, fracture group) with implant-related femoral fractures after PFO. We selected 137 children (218 hips, control group) without fractures who matched the children in the fracture group by age, weight, surgeon, and surgical period. Relevant clinical data were collected and compared between the 2 groups. Multiple analyses of risk factors for implant-related fractures were conducted by logistic regression with the stepwise regression method.Results — The occurrence rate of implant-related fractures was 1.9% (27/1,385). Compared with the control group, the fracture group more commonly exhibited bilateral involvement (74% vs. 53%, p = 0.04), used a spica orthosis for immobilization after osteotomy (43% vs 21%, p = 0.01) and exhibited mild remodeling at the osteotomy site (46% vs. 19%, p = 0.003), and less commonly required capsulotomy during osteotomy (61% vs. 79%, p = 0.03). According to the multiple regression analysis, the only factor identified as an independent risk factor for implant-related fractures was mild remodeling at the osteotomy site (OR = 3.2, 95% CI 1.4–7.5). Remodeling at the osteotomy site was significantly associated with varus osteotomy (coefficient = 1.4, CI 1.03–1.8). The fracture occurred at a mean of 12 months (2.2–25) after osteotomy or 3.3 months (0–12) after implant removal. In children undergoing implant removal, the fractures mostly occurred at the osteotomy site (n = 13/15), while in those with the implant remaining, the fractures mostly occurred in the screw hole (n = 8/13).Interpretation — The type of PFO performed is not associated with implant-related fractures in children with DDH. Children with mild remodeling at the osteotomy site should be closely followed up, regardless of whether the hardware is removed, and high-intensity activity should not be permitted until moderate or extensive remodeling is confirmed. After PFO, the implants should be removed when solid union is achieved at the osteotomy site.

Proximal femoral osteotomy (PFO) is commonly performed to correct proximal femoral deformities in individuals with developmental dysplasia of the hip (DDH), and types of PFO include femoral shortening, varus osteotomy, and derotation osteotomy. Internal fixation implants, such as a blade plate or locking compress plate, are used to maintain the stability of the osteotomy site (Papavasiliou and Papavasiliou 2005, Sharpe et al. 2006, Shaw et al. 2016). Implant-related complications or fractures after osteotomy have been reported, with a prevalence rate of 0.3% to 3.6% (Jain et al. 2012, 2016). Although the rate is low, these complications or fractures prolong immobilization in children and sometimes require additional surgery. Few studies have investigated relations between implant-related fractures and sites of fractures or types of plates (Becker et al. 2012, Jain et al. 2012, 2016, Chung et al. 2018). Jain et al. (2012) reported that the femur is more likely to incur an implant-related fracture than are other bones, and suggested that the level of stress exerted by an implant can be high over short anatomic distances in the proximal femur. However, the authors did not stratify the results by the indications for PFO, such as DDH, Perthes disease, and cerebral palsy. Varus in PFO may increase the level of stress on the implant, which in turn leads to stress shielding at the osteotomy site; therefore, it is presumable that changes in both the anatomy of the proximal femur and stress on the implant and osteotomy site may increase the probability of implant-related fractures. However, the relation of PFO itself to implant-related fractures after DDH has not been clarified, and the potential risk factors for implant-related fractures remain unclear. Therefore, we investigated the association of implant-related fractures with PFO and possible risk factors for these fractures.     

Fate of rigid fixation in pediatric craniofacial surgery.

The advantages of rigid fixation in adult craniofacial surgery are well documented, and implanted hardware is not routinely removed unless specifically indicated. There is a tendency, however, to remove hardware in children because of concerns with growth restriction, plate migration, and the lack of information on the fate of miniplates when used in pediatric craniofacial surgery. It has been our practice during the past decade not to remove hardware in children unless specifically indicated. Our study included a total of 121 procedures in 96 children, with an average age of 3.9 years and an average follow-up of 5 years. We placed 375 titanium plates and 1944 screws from 3 manufacturers. Complications encountered in children with titanium plates were as follows: 5 cases of delayed growth and 1 instance of restricted growth, 4 screw migrations (none intracranial), 9 palpable plates causing pain, 3 fluid accumulations over plates, 2 cases of meningitis, and 8 instances of plate and screw removal from the above complications. Twenty-two of 96 patients (23%) had a total of 27 complications from 121 procedures (22%). There were 6 cases in which pain precipitated removal of hardware, 1 case of an excessively mobile plate, and 1 case of documented growth restriction requiring removal; therefore our overall reoperation rate for plate removal was 8%, with no intracranial plate or screw migration.     

Fixation of fractures of the shaft of the humerus by dynamic compression plate or intramedullary nail. A prospective, randomised trial

We randomised prospectively 44 patients with fractures of the shaft of the humerus to open reduction and internal fixation by either an intramedullary nail (IMN) or a dynamic compression plate (DCP). Patients were followed up for a minimum of six months. There were no significant differences in the function of the shoulder and elbow, as determined by the American Shoulder and Elbow Surgeons' score, the visual analogue pain score, range of movement, or the time taken to return to normal activity. There was a single case of shoulder impingement in the DCP group and six in the IMN group. Of these six, five occurred after antegrade insertion of an IMN. In the DCP group three patients developed complications, compared with 13 in the IMN group. We had to perform secondary surgery on seven patients in the IMN group, but on only one in the DCP group (p = 0.016). Our findings suggest that open reduction and internal fixation with a DCP remains the best treatment for unstable fractures of the shaft of the humerus. Fixation by IMN may be indicated for specific situations, but is technically more demanding and has a higher rate of complications.     

三种内固定方式治疗大龄儿童尺桡骨双骨折的前瞻性对比研究

目的 对应用尺骨加压钢板与桡骨弹性髓内钉、双弹性髓内钉、双钢板三种不同内固定方式治疗大龄(10～16岁)儿童尺桡骨双骨折的疗效进行对比分析.方法 对2004年2月-2008年6月收治的45例手法复位失败或不稳定型的大龄儿童尺桡骨双骨折进行前瞻性随机对照研究.分为尺骨加压钢板与桡骨弹性髓内钉固定组(A组)、双弹性髓内钉固定组(B组)、双钢板固定组(C组)3组,每组15例.分别对3组患者术中及住院期间的各项指标,术后的影像学结果、临床疗效结果及并发症进行对比分析.结果 三组相比,A、B两组手术时间相对较短、术中出血量较少,与C组相比差异均有统计学意义,而A、B两组之间差异无统计学意义;B组术中上止血带时间最短,A组次之,C组最长,三组间两两比较差异均有统计学意义;A、B、C三组在术后5d疼痛评分两两比较,差异均无统计学意义.A组3个月骨折愈合率高于B组,差异有统计学意义;而B组与C组、A组与C组间差异均无统计学意义.三组在术后6个月骨折愈合率比较差异无统计学意义.在前臂旋转受限及并发症发生率上,A组最低,B组次之,C组最高,但三组间两两比较差异无统计学意义.结论 从手术创伤、骨折愈合率、临床疗效及并发症等方面进行综合比较,采用尺骨加压钢板与桡骨弹性髓内钉的内固定方式有优越性,是治疗大龄儿童尺桡骨双骨折的一种有效方法.而双弹性髓内钉内固定具有更能体现微创化、二期取出内固定方便的优点.     

Refracture of bones of the forearm after plate removal

Thirty-two plates originally used for fracture fixation in the ulna and radius in twenty-three patients were removed at Hennepin County Medical Center in Minneapolis between 1977 and 1982. The plate was on the ulna in eighteen arms and on the radius in fourteen. Removal of twenty-one plates was elective, and eleven were removed because of slight pain or discomfort. The interval between plate application and plate removal ranged from eight to sixty-two months. The average duration of cast immobilization used for protection after removal of the plate was six weeks. There were seven refractures, which occurred between two and forty weeks after plate removal. Three refractures occurred at the former fracture site; three, through the fracture site, extending into an adjacent screw-hole; and one, at one screw-hole. No refracture occurred more than forty weeks after removal of the plate.     

Complications of forearm-plate removal.

Reconstruction of long-bone fractures with compression plates may give rise to stress shielding under the metal plate, which may be associated with late clinical problems due to insufficiency fractures around the implants. Therefore, it is common practice to remove forearm plates after fracture healing is completed. Increasing concern has been expressed recently about the complications and morbidity associated with forearm-implant removal. A retrospective review of the management of 111 forearm diaphyseal fractures at a major Canadian centre confirmed a substantial complication rate in elective forearm-plate removal. Because the true incidence of late insufficiency fracture is not well defined, elective forearm-plate removal may be contraindicated in the asymptomatic patient.     

Plate fixation of clavicle fractures: a comparative study between Reconstruction Plate and Dynamic Compression Plate

This study aimed at comparing the results of clavicular fracture fixation with AO Reconstruction (Recon) plate and Dynamic Compression Plate (DCP). The case notes of 39 patients with 40 acute and chronic clavicular fractures were retrospectively reviewed. The indications for fixation for acute cases comprised open fractures, the presence of sufficient skin tenting to risk skin integrity, neurovascular compromise and severe lateral displacement or comminution. Cases of symptomatic atrophic non-union after at least 12 months conservative management or previous failed 1/3 tubular plate fixation were also included in the study. In total 24 fractures were fixed with Recon Plate and 16 with DCP. Mean time to union was 4.2 months for the Recon plate group and 5.4 months for the DCP group. Eight of the DCP group complained of plate prominence requiring plate removal. Recon plates should be used in preference to DCP whenever clavicular fracture fixation is indicated.     

Plate osteosynthesis of simple forearm fractures: LCP versus DC plates

The aim of this study was to compare the time to radiological bony union of simple A-type fractures of the forearm, treated with either a locking compression plate (LCP) or a dynamic compression plate (DCP). For each fracture, the relation between the use of compression and radiological healing time was studied. Nine fractures were treated with LCP and 10 fractures with DC plates. The mean time to definite radiological bony union in the LCP group was 33 weeks and in the DCP group 22 weeks. Compression was used in 7 fractures in the DCP group and in 3 fractures in the LCP group. The compressed fractures, irrespective of the type of plate, healed 10 weeks faster than the non-compressed fractures. Time to definite radiological bony union of simple A-type fractures does not depend on the type of plate used, but on the application of axial or interfragmentary compression.     

Single or double plating for nonunion of the clavicle.

Between January 1982 and January 1999, 684 patients presented with a fracture of the clavicle to the accident and emergency departments of the Tamside and Bury District General Hospitals. Twenty patients (3%) subsequently developed symptomatic nonunion of the clavicle. The original injury resulted from a road traffic accident in 13 patients, from a fall on an outstretched hand in five patients, and two patients had sports related injuries. Mean age of the patients was 39 years (range, 17 to 76 years). Mean time from injury to surgery was 2.5 years (range, 6 months to 8 years). Fifteen patients underwent open reduction and internal fixation of the nonunion of the clavicle with a single plate (DCP or AO plate) and in the remaining five patients two plates were used. The clavicle went on to unite both clinically and radiographically in all patients. Mean time for clinical recovery of symptoms was 4 weeks (range, 3 to 15 weeks) and mean time for radiological union was 17 weeks (range, 15 to 35 weeks). The Constant score component for pain rose from a preoperative score of 0.71 to 13.8 +/- 3.5 (p < 0.0001, paired t-test). There was significant improvement for the level of activity of daily living from a preoperative score of 2.95 +/- 1.63 to 19.0 +/- 3.9. (p < 0.0001, paired t-test). The Imatani score for shoulder function rose from a preoperative score of 56.75 +/- 5.9, to a postoperative score of 98.39 +/- 4.0. No complications related to surgery were noted in the immediate postoperative period. Three patients required removal of the metal work. After removal of the plates there were no refractures of the clavicle. In conclusion, single or double plating of the clavicle is an effective technique in dealing with nonunions of both middle and distal thirds of the clavicle.     

Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate?

Unstable fractures of the forearm in children present problems in management and in the indications for operative treatment. In children, unlike adults, the fractures nearly always unite, and up to 10 degrees of angulation is usually considered to be acceptable. If surgical intervention is required the usual practice in the UK is to plate both bones as in an adult. We studied, retrospectively, 32 unstable fractures of the forearm in children treated by compression plating. Group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only. The mean age was 11 years in both groups and 23 (71%) of the fractures were in the midshaft. In group B an acceptable position of the radius was regarded as less than 10 degrees of angulation in both anteroposterior (AP) and lateral planes, and with the bone ends hitched. This was achieved by closed means in all except two cases, which were therefore included in group A. Union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B. After a mean interval of at least 12 months, 14 children in group A and nine in group B had their fixation devices removed. We analysed the results after the initial operation in all 32 children. The 23 who had the plate removed were assessed at final review. The results were graded on the ability to undertake physical activities and an objective assessment of loss of rotation of the forearm. In group A, complications were noted in eight patients (40%) after fixation and in six (42%) in relation to removal of the radial plate. No complications occurred in group B. The final range of movement and radiological appearance were compared in the two groups. There was a greater loss of pronation than supination in both. There was, however, no limitation of function in any patient and no difference in the degree of rotational loss between the two groups. The mean radiological angulation in both was less than 10 degrees in both AP and lateral views, which was consistent with satisfactory function. The final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%). If reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm, operation on the radius can be avoided.     

Removal of painful orthopaedic implants after fracture union

BACKGROUND: Persistent pain in the region of implanted hardware following fracture fixation commonly leads to implant removal. This prospective study evaluated patient outcomes and pain reduction following removal of orthopaedic hardware implanted for fracture fixation. METHODS: Sixty patients who had been treated previously for a fracture and complained of pain in the region of the fracture fixation hardware constituted the study cohort. Patients were carefully examined by the treating physician to rule out other causes of pain such as infection and nonunion. Baseline data were recorded preoperatively. Data obtained postoperatively at three, six, and twelve months included a visual analog pain scale score and results on the Short Musculoskeletal Function Assessment Questionnaire and the Medical Outcomes Study Short Form-36. At the one-year interval, a patient satisfaction questionnaire was completed and outcomes were analyzed. RESULTS: There were no complications associated with implant removal surgery. Three patients did not have complete follow-up, leaving a total of fifty-seven patients with complete follow-up. At one year, all patients indicated that they were satisfied, that they would have the procedure done again, and that their overall function had improved. The scores for pain on the visual analog scale decreased from a mean (and standard deviation) of 5.5 +/- 2.5 before hardware removal to 1.3 +/- 1.8 after hardware removal, with an overall improvement at one year of 76% (p = 0.00001). At one year, thirty (53%) of the fifty-seven patients had complete resolution of pain. In addition, the results on the Short Musculoskeletal Function Assessment Questionnaire showed a 43% improvement from baseline (p = 0.0001), and the results on the physical component of the Short Form-36 showed a similar improvement of 40% (p = 0.0001). CONCLUSIONS: Following fracture-healing, removal of hardware is safe with minimal risk. Improvement in pain relief and function can be expected.     

Simple Bone Cyst as a Sequel of Forearm Plate Osteosynthesis

This report presents the long-term effect of plate osteosynthesis to repair a right forearm fracture in an 11-year old patient, who 6 years later requested removal of her plates because of the pain she was experiencing in the area. The 17 year-old female had developed simple bone cysts around the implanted plates for her radius and ulnar fracture. Circulatory disturbances might have a role in the development of the simple bone cysts in this case.     

Plate removal after ulnar-shortening osteotomy

PURPOSE: Ulnar-shortening osteotomy using plate and screw fixation is a reliable method for treating various wrist disorders. In some patients the plate remains as a source of discomfort even after the osteotomy has healed and the preoperative complaints have resolved. There is not a large body of information to guide the surgeon in the timing of plate removal should it be needed to address persistent forearm complaints caused by prominent hardware. This study investigated the outcome of patients who had removal of the plate because of persistent symptoms after undergoing ulnar-shortening osteotomy once radiographic healing was apparent. METHODS: A consecutive series of 40 ulnar shaft-shortening osteotomies was performed in which 14 patients requested removal of the plate because of persistent tenderness despite nonsurgical management. There were 12 Rayhack (11 titanium, 1 stainless steel) and 2 Synthes 3.5-mm dynamic compression titanium plates used. Before removal radiographic union was documented by 2 sets of films taken in multiple planes at least 4 weeks apart. The average time to plate removal was 6.6 months. RESULTS: All patients had resolution of the ulnar forearm pain after hardware removal. There were no repeated surgeries and all patients returned to their prior levels of activity or employment. Patients were followed-up for an average of 17 months after plate removal. There was 1 refracture in an osteoporotic patient when she fell down a flight of stairs 7 months after plate removal. CONCLUSIONS: When used for fixation after ulnar shaft-shortening for ulnar-sided wrist pain of various causes 3.5-mm compression plates seem to be removable at 6 to 9 months in symptomatic patients with a low risk for refracture when sequential sets of x-rays confirm healing of the osteotomy site according to this small series of patients.     

Osteosynthesis of irreducible fractures of the clavicle with 2.7-MM ASIF plates.

Thirty-six patients with Allman group-2 fractures of the clavicle were treated by ORIF with 2.7-mm ASIF dynamic compression plates. The indications for surgery were an open fracture in one patient, ipsilateral fractures of the arm or the ribs in five patients, bilateral clavicular fractures in one patient, and an inability to reduce the fracture in all other patients. There were no instances of deep infection. One patient suffered a refracture after plate removal; three patients developed pseudarthrosis because plates that were too short were used. The total failure rate was 12%. It is concluded that the 2.7-mm DCP is the method of choice for internal fixation of midshaft clavicular fractures and that a minimum of three screws should be placed in each fragment.     

Symptomatic plate removal in maxillofacial trauma: a review of 76 cases

This study reviewed the fate of titanium plates used to correct maxillofacial trauma in 76 patients to define risk factors for plate removal. Medical records of 76 consecutive patients at a single institution, over a 10-year period, were retrospectively reviewed. Variables included age, sex, trauma type, diagnosis, fracture type, fracture diagnosis, plate location, surgical approach, and reasons for plate removal. Fracture diagnosis was described as panfacial (42%), blowout (3%), midface (28%), zygoma (26%), mandible angle (6%), ramus (7%), and symphysis (9%). All plate removals according to fracture diagnosis were in the mandible angle (30%) and symphysis (20%). When plate location was reviewed, 68% of the plates were placed in the upper and midface and 32% were placed in the mandible. Specifically, plates were placed in the frontozygomatic suture (18%), zygomaticomaxillary suture (19%), infraorbital rim (14%) and mandible symphysis (15%), mandible angle (9%), piriform (6%), nasal (5%), mandible ramus (4%) and body (4%), zygoma (2%), and frontal (2%). Of 163 plates that were placed, 6 plates (3.7%) were removed. Three (12%) of the symphysis plates and 3 (20%) of the angle plates were removed. Among all variables, only fracture diagnosis (P = 0.01) and plate location (P = 0.01) were statistically significant in plate removal. Five plates were removed for abscess/infection; 1 plate was removed for osteomyelitis. Further review revealed that 4 out of 6 plates removed involved synchronous mandible fractures. Most infections after maxillofacial trauma occur in the mandible, and often these infections are the main reason for plate removal. More vigilance is needed in the treatment of mandible angle and symphyseal fractures, especially if there are synchronous fractures, to prevent infection, plate removal and subsequent malunion.     

Complications following the treatment of trochanteric fractures with the gamma nail

Introduction The treatment of trochanteric fractures with the use of gamma nails has become an established method. Despite the good and reliable results, some typical failures and complications may occur. It was our purpose to analyse the most common complications and their treatment options.Materials and methods A total of 498 patients were treated with a gamma nail from January 1992 until December 2001. There were 77% pertrochanteric, 10% subtrochanteric, 11% reversed pertrochanteric and 2% lateral femoral neck fractures. The patients mean age was 78.6 years (ranging from 29 to 98 years).Results There were a total of 78 general complications (16%) and implant-related complications in 8% (n=42). The most common complication was trochanteric pain necessitating removal of the gamma nail (n=30). Four patients fell after removal of the nail and sustained a neck fracture on the same side. Cut-out of the screw occurred in 19 patients. Sixteen of them had to be converted to a total hip replacement. Another 5 patients were converted to a total hip replacement because of pseudoarthrosis. During conversion to total hip replacements, the trochanter major refixation and length adjustment were the most problematic steps (intra- or postoperative dislocations necessitating anti-dislocation rings in three cases). Furthermore, cement extrusion at the femur and acetabulum occurred in 13 cases. Infections occurred in 3 patients. Five patients with a short gamma nail needed a conversion to a long gamma nail due to pseudoarthrosis (n=2) or femur fracture at the distal interlocking bolt (n=3). In addition, 7 patients sustained a distal femur fracture through the distal bolt, necessitating a plate osteosynthesis.Conclusion Most complications after gamma nail fixation can be prevented by following certain rules. The other inevitable problems can be dealt with either through a conversion to a total hip replacement, a re-osteosynthesis with a long gamma nail or an additional condylar plate. Conversion to total hip replacement may be a demanding operation with a higher than normal complication rate. Removal of the gamma nail should be performed cautiously as re-fractures can occur.     

Bone mineral density after removal of rigid plates from forearm fractures: preliminary report

Bone mineral density (BMD) was measured on three occasions following removal of metal plates used to fixate diaphyseal forearm fractures in eight patients (mean age 38.5 years). At plate removal the mean BMD of the distal radius/ulna and the ulnar shaft sites were, respectively, 10.2% and 2.1% lower than on the nonfractured side. The apparent volumetric BMD (BMDvol) at the ulnar fracture site was 4.3% lower. At 6 months follow-up (n = 5) the mean ulnar shaft BMD had increased by 6.4% (P = 0.04), resulting in complete recovery of BMD, whereas the increase in BMDvol did not reach the BMDvol of the control side. No recovery was found at the distal radius/ulna site. We conclude that there is a small, partially reversible bone density deficit in the ulnar shaft that has been underneath the plate. Although the decreased bone density may in part be responsible for increased refracture risk at the fracture site immediately after plate removal, it is negligible after 6 months. The cessation of the effects of stress shielding is probably responsible for the increased bone density after plate removal.     

Open fractures of the forearm in children

OBJECTIVE: To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children. DESIGN: Retrospective review of patients treated according to protocol. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records. INTERVENTION: All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast. MAIN OUTCOME MEASUREMENTS: Time to union, angular alignment at union, and incidence of complications. RESULTS: The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously. CONCLUSIONS: Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.