[Kirschner wire osteosynthesis for fractures in childhood: bury wires or not? : Results of a survey on care reality in Germany]

Infection after buried or exposed K-wire fixation of distal radial fractures: a randomized clinical trial

We treated 220 extra-articular distal radial fractures with closed reduction and percutaneous K-wire fixation and randomized K-wire placement to buried or exposed. We analysed the incidence and severity of infection and the mobility of the metacarpophalangeal joints. At 6 weeks postoperatively, 12 patients in the exposed group had infections versus two in the buried group, which was a statistically significant difference. Mobility was statistically but not clinically better in the buried group. One patient in each group had wires removed before fracture healing due to infection, which resulted in malunion. From this study we conclude that, in the treatment of distal radial fractures, it is better to bury the K-wires under the skin, especially when geographical conditions make it difficult to control the patients' adherence to hygiene and postoperative care despite the higher costs incurred with removal of buried K-wires.Level of evidence: II.

[Technique and biomechanics of Kirschner wire osteosynthesis in children]

OBJECTIVE

Safe and stable fixation of metaphyseal and epiphyseal fractures by Kirschner (K-)wire osteosynthesis. Use of various K‑wire configurations depending on the fracture morphology.

INDICATIONS

In accordance with the AO Pediatric Comprehensive Classification of Long-Bone Fractures (PCCF), all Salter-Harris (SH) and metaphyseal fractures as well as fractures of the foot and hand independent of the reduction technique, closed or open, provided that adaptation osteosynthesis allows sufficient stability. Fixation/immobilization in a plaster cast is mandatory after K‑wire osteosynthesis.

CONTRAINDICATIONS

All diaphyseal fractures, if a K-wire is not used as an intramedullary nail. Fractures that can not be correctly reduced or are nonreducible fractures.

SURGICAL TECHNIQUE

After closed or open, as anatomical reduction as possible, one, two, occasionally three K‑wires per fragment are inserted under fluoroscopic control. Care must be taken that the K‑wires optimally capture the fragment to be fixed as well as the main fragment (metaphysis). It must therefore be possible to make a strictly lateral and correct anteroposterior x‑ray by image intensifier. It is important that the C‑arm can be positioned at the appropriate level. Rotating the limb should be minimized, as prior to fixation the previously reduced fragments may shift again, resulting in poor K‑wire fixation. Depending on the morphology of the fracture, size of the fragments and location of the fracture (humerus, forearm, femur or tibia, hand or foot), the K‑wiring technique must be adapted, e.g., mono-laterally crossed, mono-laterally divergent, in an ascending or descending direction, or the most commonly used ascending crossed technique. In most cases, the K‑wires protrude through the sin and the exposed ends are bent. This allows removal without renewed anesthesia in the outpatient setting. K‑wire osteosynthesis is neither a compression osteosynthesis (OS) nor a neutralization OS, but is always an adaptation and fixation of the fragments. Therefore, K‑wire OS always needs additional immobilization using a plaster or prefabricated splint.

POSTOPERATIVE MANAGEMENT

Immobilization in plaster cast for 4-5 weeks, depending on the age; care must be taken to avoid interference between the cast and the skin/K-wires.

RESULTS

With technically and optimally performed fixation and correct indication for K‑wire OS, as well as adequate posttreatment, very good to good results are achieved.