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

Therapeutic approaches of diametaphyseal radius fractures in children

BACKGROUND

There are clear standards for when to operate on both distal epiphyseal and diaphyseal forearm fractures in children. However, paediatric surgeons are often faced with fractures in the transition zone between metaphysis and diaphysis. This aim of the study is to compare different treatment approaches for diametaphyseal forearm fractures, to classify different types of these fractures, and to define further assessment parameters and treatment recommendations.

METHODS

This retrospective study included all patients with diametaphyseal radial fractures who were seen at a paediatric surgery clinic between 01.01.2010 and 31.12.2013. Patients were treated either non-surgically (C) or surgically using bicortical Kirschner wire (BC-KW), intramedullary K-wire (IM-KW), elastic stable intramedullary nailing (ESIN), or combined bicortical and intramedullary K-wire (BCIM-KW).

RESULTS

During the study period, 547 patients presented with forearm fractures of which 88 patients (16%) had a fracture in the diametaphyseal region. The majority of diametaphyseal fractures were greenstick fractures (54.4%) followed by transverse fractures (44.3%). Distal fractures were predominantly treated with bicortical K-wiring (BC-KW, 40.5%) or non-surgically (C, 26.2%). Proximal fractures were treated by ESIN osteosynthesis (50%), followed by IM-KW (30%). Intermediate fractures were just as likely to be treated with one out of the 5 above-mentioned techniques. The ulna was involved in 64 of 88 cases. Depending on the type of fracture, it was treated either by ESIN osteosynthesis or non-surgically. No superior operative technique was identified.

CONCLUSIONS

The description of diametaphyseal fractures as a separate entity is important, because the therapy of these fractures is heterogeneous and challenging. A classification into proximal, intermediate, and distal may be useful in clinical decision-making. Despite the retrospective nature of this study, our data suggest that the use of a K-wire or combined technique BCIM-KW-technique, whenever technically feasible, achieves better radiological results without secondary dislocation. Further prospective studies are needed to provide better guidance to trauma surgeons.

The use of flexible nails in the treatment of paediatric long bone fractures: Experience at a level one paediatric trauma centre, a cohort study

Introduction

Fractures occur in children at an incidence only surpassed by women >85 years and account for 25 % of paediatric injuries. Over the last three decades, there has been a trend towards operative management of children's fractures including utilisation of flexible nails as popularised by the Nancy group in the 1980s. Between 5 and 11 % of paediatric forearm fractures are now fixed in this manner with complication rates of 12-42 %. This study shares the experience of a paediatric level one major trauma centre using this technique in managing long bone fractures in children.

Methods and materials

This retrospective cohort study comprises a sequential series of 109 cases (71 children) of upper and lower limb fractures in children (aged 16 years and below) who underwent fracture fixation using flexible intramedullary nails between 1st April 2015 and 31st March 2019. Radiological and clinical outcomes and complications were assessed.

Results

Ninety-three cases (10 in the lower limb, 83 in the upper limb) satisfied the inclusion criteria in 57 children with a mean age of 8.6 years. All cases were successfully reduced intra-operatively and 92 (98.9 %) achieved union. Taking into account all complications in the upper and lower limb, the overall complication rate is 30.1 % (28 cases) with the vast majority (13 cases, 46.4 %) occurring in the upper limb due to prominence of metalwork prompting early removal.

Conclusions

This study has shown flexible intramedullary nailing to perform well with good stabilisation of a wide variety of paediatric long bone fractures with restoration of bone alignment, satisfactory outcomes with good union rates and a return to normal function. The technique is also safe and in the upper limb can be performed as day-case surgery by a generalist orthopaedic surgeon. Although the overall complication rate is not insignificant, major complications are rare.

Reliability of radiographic union scale in tibial fractures and modified radiographic union scale in tibial fractures scores in the evaluation of pediatric forearm fracture union

Objectives

This study aims to evaluate the reliability of the radiographic union scale in tibial (RUST) fractures and modified RUST (mRUST) fractures in pediatric forearm fractures treated with elastic stable intramedullary nail (ESIN) and to investigate the effect of the experience of surgeon, thresholds for union, and delayed union decisions.

Patients and methods

In this retrospective study, radiographic images of 20 patients (10 males, 10 females; mean age 8.6±4.3; range, 4 to 11 years) with forearm fractures treated using ESIN between January 2013 and December 2018 were scored by 20 observers based on the RUST and mRUST scores. The observers scored the radiographs at immediate postoperative period, and at 4-, 8-, and 12-week follow-up. Intra- and interobserver agreement for each cortex, RUST, and mRUST were evaluated using intraclass correlation coefficient (ICC). The Fleiss’ kappa (k) coefficient was used in the agreement between evaluators regarding union decision. Receiver operating curves were created to determine the thresholds for radiographic union and delayed union.

Results

Intra- and interobserver reliability of the mRUST score (ICC: 0.84 and 0.79) were slightly higher than that of the RUST score (ICC: 0.80 and 0.72). Pediatric orthopedic and trauma surgeons had slightly higher agreement than the residents and general orthopedists for the total mRUST and RUST scores of the eight-week radiographs. Mean RUST and mRUST scores at the union for all fractures were 10.2±3.4 and 13.0±2.1, respectively. Kappa value for union was moderate (0.74). The total mRUST score had a higher predictive value for union than the total RUST score (area under the curve: 0.986 vs. 0.889). A mRUST score of ≥12 and RUST score of ≥9 were considered as the predictors of union. In addition, a mRUST score of ≤7 and RUST score of <9 were considered as the predictors of delayed union.

Conclusion

A moderate agreement for both RUST and mRUST scores was found. However, the agreement for mRUST was found to be slightly higher. Healing and union of forearm fractures treated with ESIN can be reliably assessed using RUST and mRUST.

Biomechanical and Clinical Comparative Study of the New Elastic Stable Intramedullary Nailing "MJ-FLEX Orthofix"

BACKGROUND

The objectives of this study were first to compare the results of osteosynthesis with standard Metaizeau (MS) nails versus Metaizeau Junior Flex or MJF Orthofix (MJF) in terms of the stability of long-bone fractures in children, and to study the preoperative and postoperative safety of these new nails. We also carried out an analysis by computer modeling of a femur, in order to compare the biomechanical stability of the 2 nails. The interest in the MJF nails lies in the improvements they bring in terms of stability for long-bone fractures in pediatric patients, as well as the simplification of the surgical procedure.

METHODS

A study by numerical computer modeling of a femur was conducted to compare the biomechanical stability of the 2 assemblies with MS versus MJF nails. A retrospective single-center study of 137 fractures treated with MS and MJF was added to this biomechanical study. The onset of angular misalignment during follow-up was identified by radiographic measurements.

RESULTS

The biomechanical study showed greater stiffness of MJF in the frontal and sagittal plane and in torsion for modeled comminuted and simple transverse fractures. Use of MJF nails significantly reduced the risk of frontal and sagittal misalignment, by a factor of 5 and 12, respectively. The amplitude of this misalignment was also significantly reduced by 30% in the frontal plane with the MJF nail. The use of MJF compared with MS significantly diminished not only the quantity of preoperative radiation by 66% but also operative time by 30%. The complication rate in our population was 33.4% with a 6-fold lower risk of complications with MJF.

CONCLUSIONS

MJF nails provide greater stability in the frontal and sagittal plane with regard to both the onset and amplitude of misalignment in the treatment of long-bone fractures in children. This improvement was confirmed by the biomechanical study. Preoperative and postoperative safety was also better with these new nails, and surgery was easier.

Treatment of Unstable Pediatric Tibial Shaft Fractures with Titanium Elastic Nails

Background and objectives: Pediatric tibial shaft fractures often have satisfactory outcomes after closed reduction and casting. However, surgical treatment may be required in unstable or open fractures. Titanium elastic nails (TENs) are a good option for the surgical treatment of pediatric tibial fractures due to their advantages such as short hospitalization periods, easy applicability, early weight bearing, and early union. In this study, we evaluated radiological and functional outcomes in pediatric patients with tibial shaft fractures that underwent fixation with TENs. Materials and methods: A total of twenty tibial shaft fractures that were treated with TENs in our clinic between 2013 and 2017 were retrospectively reviewed. The mean age at injury was 8.9 ± 2.78 (range of 3–14) years. Seven (35%) out of 20 fractures were open fractures, of which one fracture was classified as Grade I and six fractures were classified as Grade II. In each patient, antegrade nailing was performed by inserting a TEN in the medial and another TEN in the lateral side of the proximal metaphysis. Clinical outcomes including union, alignment, leg-length inequality, and complications were evaluated using modified Flynn’s criteria. Results: The mean time to union was 10.85 ± 3.39 (range of 6–20) weeks. No patient had a sagittal or coronal angulation of over 10°. One patient had a leg-length inequality of 10 mm. Among three patients with open fractures, two of them had superficial wound infections and the other patient had a deep wound infection. All the infections were successfully treated with appropriate antibiotic therapies. Four other patients had pin tract irritation that required no intervention. No significant difference was observed between patients with open and closed fractures with regard to the clinical and radiological findings although patients with open fractures had a significantly higher complication rate compared to patients with closed fractures (p < 0.05). No patient had a restricted range of motion of the ankle and knee joints. Twelve (60%) patients had an excellent outcome, and eight (40%) patients had a satisfactory outcome. Conclusions: Intramedullary fixation with TENs provides favorable outcomes and reduced complication rates in the treatment of unstable pediatric tibial shaft fractures that cannot be reduced with conservative treatment modalities or cannot be casted due to the presence of an edema or open wound.

Update on leg fractures in paediatric patients

Leg fractures are common and further increasing in prevalence in paediatric patients. The diagnosis is readily made in most cases. Choosing the best treatment is the main issue. Non-operative treatment is the reference standard for non-displaced or reducible and stable fractures but requires considerable expertise and close monitoring, as well as an immobilisation period that far exceeds 3 months in many cases. Some surgical teams therefore offer elastic stable intra-medullary nailing (ESIN) as an alternative to children who do not want to be immobilised for several months. Internal fixation is required for unstable or irreducible leg fractures. ESIN is often used as the first-line method, based on its very good risk/benefit ratio. For fractures that do not lend themselves to ESIN, optimal stabilisation can be achieved by choosing among the other available options (screw-plate fixation, rigid intra-medullary nailing or external fixation) on a case-by-case basis. Close monitoring during the first few days is crucial to ensure the early detection of compartment syndrome. The other complications and sequelae are non-specific.

Slow Recovery of Weight Bearing After Stabilization of Long-Bone Fractures Using Elastic Stable Intramedullary Nails in Children

Stabilization of diaphyseal long-bone fractures using elastic stable intramedullary nails (ESIN) in children promises early mobilization and rapid resumption of full weight bearing. We evaluated the duration of postoperative functional rehabilitation after ESIN, measured by the time from stabilization until first partial weight bearing, full weight bearing, and resumption of school sports. Fifty children with unstable, displaced fractures of the femur or lower leg treated with ESIN between 2002 and 2012 were included in this retrospective analysis. We classified fractures according to the pediatric comprehensive classification of fractures (PCCF). Thirty-five children sustained a femur fracture, and 15 children had a fracture of the lower leg or tibia. The surgeons in charge applied an additional plaster cast in 7 of 15 children who suffered a lower leg fracture. The postoperative time interval until full weight bearing in the group of children who had suffered transverse or short oblique femur fractures was significantly shorter (median: 4.4 weeks; range: 0.1-9.1 weeks) than that in the group who had sustained more complex fracture patterns (median: 6.8 weeks; range: 2.9-13.9 weeks; P = 0.04). Similarly, transverse and short oblique lower leg and tibia fractures required less time until full weight bearing (median: 4.1 weeks; range 2.7-6.0 weeks) than complex lower leg fractures (median: 6.1 weeks; range: 1.3-12.9 weeks; P = 0.04). ESIN proved fairly effective in restoring full weight bearing in transverse or short oblique fractures of the lower extremities but was less effective in complex fractures.

Open unstable metaphyseo-diaphyseal fractures of the tibia in adolescents: treatment by flexible intramedullary nails augmented by external fixator

INTRODUCTION

The treatment of open and unstable metaphyseo-diaphyseal fractures of the tibia in adolescents is challenging. It is important to choose a fixation method that can maintain alignment, allow wound care and not violate the growth plate. The aim of this work was to evaluate the efficacy of using flexible intramedullary nails (FIN) augmented by external fixator (EF) in the management of such fractures.

PATIENTS AND METHODS

A total of 26 males, with a mean age of 14.08 years and average body weight of 49.8 kg, presented with open metaphyseo-diaphyseal tibial fractures. All cases were treated using FIN augmented by mono-lateral EF. The fractures were located at the upper third in 17 cases and at the lower third in nine cases. The fracture pattern was spiral in eight cases, oblique in seven and multi-fragmentary in 11. The results were evaluated according to the scoring system for femoral TENs.

RESULTS

All fractures united primarily after an average eight to 12 weeks with no evident angular deformity or limb-length discrepancy. None of the cases required cast immobilization or revision procedure. Twenty patients had excellent results, six patients showed good results and none had poor results. Fracture characteristics as well as patients' characteristics had no statistically significant effect (p > 0.005) on the final end results.

CONCLUSIONS

The use of FIN augmented by EF is a good alternative in the management of open metaphyseo-diaphyseal tibial fractures in adolescents. This fixation provides more stability, allows easy access to the wound and early patients' ambulation.

Elastic Stable Intramedullary Nailing for Fractures in Children - Specific Applications

Elastic stable intramedullary nailing (ESIN) is a new minimally invasive technique for the treatment of pediatric fractures. It approximates the physiological healing process of bone, without opening the fracture site. Also, the operative stress is minimal because of the minimally invasive nature of the procedure, and the volume of implants is small, offering a very good stability without plaster cast immobilization.

Elastic Stable Intramedullary Nailing for Fractures in Children - Principles, Indications, Surgical Technique

Elastic stable intramedullary nailing (ESIN) is a minimally invasive technique. According to this technique, two elastic nails are introduced through the metaphysis into the medullary canal, advanced through the fracture site and impacted into the opposite metaphysis. These nails are preformed in a C-shaped manner, which allows for their precise orientation and the creation of an elastic system that resists deformation.

Complications and technical pitfalls of titanium elastic nail fixation for midclavicular fractures

Intramedullary titanium elastic nails have been reported to fix displaced midclavicular fractures with excellent functional outcomes and minor complications. This study reports and analyzes the complications and technical pitfalls associated with titanium elastic nail fixation of displaced midclavicular fractures and describes how to prevent these problems. The authors operated on 27 patients (17 men, 10 women; mean age, 45.8 years; range, 16.5-66.9 years) with marked displaced midclavicular fractures using intramedullary titanium elastic nail fixation. The mean Constant score and Disability of the Arm, Shoulder, and Hand score were 93.58 (range, 66.5-100) and 6.22 (range, 0-35), respectively. The mean length difference compared with the contralateral clavicle was a shortening of 0.3 cm (range, -1.5 to 1 cm). Eight patients (30%) had different levels of difficulty at the medial entry point. Clavicular length shortening of more than 1 cm occurred in 5 patients (19%), and all of these patients experienced medial nail tip prominence/protrusion. One patient had 1-cm lengthening of the injured clavicle caused by distraction of the fracture site during titanium elastic nail insertion. Iatrogenic perforation of the posterolateral cortex occurred in 3 patients. Initial misplaced nail insertion occurred in 1 woman who underwent revision with the mini-open method. In 2 patients it was impossible to remove the full nail under general anesthesia. In conclusion, high patient satisfaction and functional outcomes were achieved after titanium elastic nail fixation of displaced midclavicular fractures. However, some complications and technical pitfalls must be considered before titanium elastic nails are used to fix displaced midclavicular fractures.

A new mini-invasive technique in treating pediatric diaphyseal forearm fractures by bioabsorbable elastic stable intramedullary nailing: a preliminary technical report

BACKGROUND AND AIM

Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing.

MATERIAL AND METHODS

We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial.

RESULTS

The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture.

CONCLUSIONS

We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.

Delayed union in pediatric forearm fractures

BACKGROUND

The aim of this study was to assess the predictive factors of delayed union in pediatric forearm fractures. Few previous reports have approached this complication, but contrary to these studies we excluded cases with known pathogenic factors and included in the sample cases treated with conservative methods.

METHODS

This is a case-control study of all pediatric shaft forearm fractures presenting delayed union in a minimum follow-up period of 12 months, from 2003 through 2009, in a hospital covering a health area. Exclusion criteria were fracture dislocations, infection, suboptimal osteosynthesis, greenstick, open, pathologic, and associated radial head fractures. Statistical assessment included bivariate and multivariate linear regression analysis.

RESULTS

Four hundred and forty-one complete, both-bone forearm fractures were treated during the study period: 14 of them (3.2%) were identified as suffering delayed union; and 63 controls fulfilling inclusion criteria were randomly selected. Bivariate analysis showed significant differences between "union delay" and "control" groups in age, need of surgical treatment, open versus closed reduction, and mean time to hardware removal. However, open reduction of the fracture, more frequent in the "union delay" group, was the only variable that remained associated with time to consolidation in the multivariate analysis.

CONCLUSIONS

The strongest predictor of union delay in pediatric forearm fractures is open reduction. Based on our results, we recommend to avoid when possible the open reduction of the fracture in patients undergoing surgery and to use instead closed reduction and internal fixation.

LEVEL OF EVIDENCE

A case-control study. Therapeutic level III.

Treatment of femur fractures in school-aged children using elastic stable intramedullary nailing: a systematic review

Femur fractures are common long-bone injuries in school-aged children (6-12 years). Among the various acceptable treatment options, elastic stable intramedullary nailing (ESIN) has gained popularity over recent years although the level of evidence for ESIN is low. This study was a systematic review of the literature to examine the outcomes and complications of ESIN in school-aged children and to critically evaluate the quality of the available literature. Although most complications were minor, some series report complication rates of more than 50%. Union rates are high. Malunion or mechanical axis malalignment, on the other hand, is common, and leg length discrepancy and overgrowth are also not unusual. Symptomatic implants are common, particularly if the distal ends of the nail are left long and prominent. Refracture was noted to be uncommon in this population. ESIN is a well-accepted and reliable option for treatment of femur fractures in school-aged children. Advantages are decreased length of hospital stay, early return to function, and high union rates. Care must be taken to obtain and maintain reduction, and caution is advised in older and heavier children.

The treatment of upper limb fractures in children and adolescents

BACKGROUND

The treatment of fractures in children and adolescents must be based on an adequate knowledge of the physiology of the growing skeleton. Treatment failures usually do not result from technical deficiencies, but rather from a misunderstanding of the special considerations applying to the treatment of fractures in this age group.

METHODS

We selectively reviewed recent publications on the main types of long bone fracture occurring in the period of skeletal development.

RESULTS

Alleviating pain is the first step in fracture management, and due attention must be paid to any evidence of child abuse. The goals of treatment are to bring about healing of the fracture and to preserve the function of the wounded limb. The growth that has yet to take place over the remaining period of skeletal development also has to be considered. Predicting the growth pattern of fractured bones is a basic task of the pediatric traumatologist. During the period of skeletal development, conservative and surgical treatments are used in complementary fashion. Particular expertise is needed to deal with fractures around the elbow, especially supracondylar humeral fractures, displaced fractures of the radial condyle of the humerus, radial neck fractures, and radial head dislocations (Monteggia lesions). These problems account for a large fraction of the avoidable cases of faulty fracture healing leading to functional impairment in children and adolescents.

CONCLUSION

The main requirements for the proper treatment of fractures in children and adolescents are the immediate alleviation of pain and the provision of effective treatment (either in the hospital or on an outpatient basis) to ensure the best possible outcome, while the associated costs and effort is kept to a minimum. Further important goals are a rapid recovery of mobility and the avoidance of late complications, such as restriction of the range of motion or growth disorders of the fractured bone. To achieve these goals, the treating physician should have the necessary expertise in all of the applicable conservative and surgical treatment methods and should be able to apply them for the proper indications.

Elastic intramedullary nailing in unstable fractures of the paediatric tibial diaphysis: a systematic review

PURPOSE

The majority of paediatric tibial fractures can be managed conservatively. However, there is a small but significant group of patients that require surgical intervention for several indications, most notably, unstable fractures. There are various surgical options, each with its own advantages and risks. This review establishes the current available evidence for the use of elastic intramedullary nails in this group.

METHODS

A systematic review of the currently available literature was performed. The relevant studies were then critically appraised.

RESULTS

Seven applicable retrospective case series were identified, with the outcomes from a total of 210 (range 16-60) patients considered. The mean time to union ranged from 7 to 21 weeks. Reported complications included small numbers each of delayed union, non-union, malunion, leg length discrepancy and infection.

CONCLUSIONS

There is only a small body of evidence currently published on this topic. The evidence published so far concludes that elastic intramedullary nailing represents an effective and reliable method to treat an unstable fracture of the tibial diaphysis in the paediatric patient, where conservative management is not appropriate.

Tratamento das fraturas da diáfise dos ossos do antebraço em crianças e adolescentes

OBJETIVO: O tratamento e os desvios angulares tolerados nas fraturas diafisárias do antebraço em crianças evoca opiniões divergentes na literatura. Frente a esta indefinição, idealizamos este trabalho com o objetivo de avaliar transversalmente os métodos terapêuticos preferenciais para esta lesão durante o 39º Congresso Brasileiro de Ortopedia e Traumatologia. MÉTODO: Foram respondidos 759 questionários (13% do total de inscritos). Abordamos os aspectos gerais da amostra estudada para traçar o perfil do ortopedista questionado. Foram expostas duas situações clínicas em indivíduos de 12 (CASO 1) e 5 anos (CASO 2), sendo apresentadas radiografias com fraturas do antebraço destes pacientes. Os dados obtidos foram compilados e submetidos à análise estatística. RESULTADO: O tratamento mais indicado no CASO 1 foi redução incruenta e fixação com fios de Kirschner (26%), enquanto no CASO 2 foi redução incruenta seguida de aparelho gessado (46%). CONCLUSÃO: Entre os ortopedistas com menos de 30 anos, a escolha por tratamentos menos invasivos e aceitação de maiores angulações prevaleceu para ambos os casos. Os traumatologistas aceitam menor angulação e tendem aos tratamentos invasivos, particularmente para o CASO 2. Já o ortopedista pediátrico opta por tratamentos menos invasivos e aceita maiores desvios angulares.

Nonunion of forearm shaft fractures in children after intramedullary nailing

The elastic stable intramedullary nailing (ESIN) is the current treatment of choice for unstable forearm shaft fractures in children. There is no large study on paediatric nonunion of forearm shaft fractures in children after intramedullary nailing. There are only sporadic reports on nonunions after ESIN in children. The aim of this study was to define predisposing factors of nonunions in paediatric forearm fractures. All children who had been treated for forearm fractures by ESIN in our hospital from 1990 to 2006, and all children treated elsewhere surgically and being followed up at our institution were included in the study. In these children, we identified all patients who did not show bony consolidation of the fracture after 6 months from ESIN. Over a period of 16 years, 537 patients were primarily treated in our hospital and 55 children had been initially treated in a different institution. Six children were identified to fulfill the criteria of having developed a pseudarthrosis. Of these six children, three patients had been primarily treated in another hospital and three were our original patients. The average age was 11.1 years (9-14 years). There were only pseudarthroses of the ulna to be observed. In five children, the pseudarthrosis was in the middle third and in one patient in the distal third of the ulna. There were five closed fractures and one first-degree open fracture. Five times an open reduction of the ulna had been performed because closed reduction and insertion of the ESIN was impossible, whereas the radius had been treated closed in five cases and open in one case for intramedullary stabilization. Three cases were refractures, in one child it was a second refracture. In one case, we identified a technical error as cause of the development of the pseudarthrosis. Four children needed a revision surgery. In these children, the ulna was plated. Two patients showed spontaneous healing of the pseudarthrosis. In five patients, there was a hypertrophic pseudarthrosis present and in one case was hypotrophic pseudarthrosis. The reintervention was necessary because of increasing deformity in four patients and implant failure in one case. In conclusion, Non-unions after forearm fractures are observed in children and adolescents mainly in the middle third of the ulna. With the need of initial open reduction or the presence of an open fracture in the first instance, the risk of developing a pseudarthrosis. It may also be higher in such cases, which represent a refracture. Despite the small risk of developing a pseudarthrosis after forearm fracture, the indication for ESIN is clear. The surgical trauma needs to be as minimal as possible in cases with open reduction with as little as possible compromise of the blood circulation of the affected bone.

Intramedullary nailing of clavicular midshaft fractures with the titanium elastic nail: problems and complications

BACKGROUND

Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail has been described as a technically easy, minimally invasive operation with few complications and an early return to competitive sports.

HYPOTHESIS

The results reported thus far have been positive. The titanium elastic nail is associated with multiple intraoperative and postoperative problems.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

From April 2004 to March 2007, 34 patients at our institution were treated with intramedullary nailing. A standard titanium elastic nail was used in 19 cases and a titanium elastic nail with an end cap in 15 cases. The titanium elastic nail was inserted and advanced under fluoroscopic control. A short incision at the fracture site was made for open reduction if needed. Postoperatively, free range of motion was allowed.

RESULTS

In 62% of patients, open reduction was necessary independent of fracture type, flattening of the titanium elastic nail, or transverse fragments. Operating time was 44 minutes (range, 10-105 minutes) and fluoroscopy time 9 minutes (range, 2-25 minutes). In 70% of patients, problems or complications occurred (7 medial perforations, 7 lateral penetrations, 1 titanium elastic nail breakage, 1 titanium elastic nail dislocation, 7 hardware irritations). The reoperation rate was 36%. Medial migration and pain were significantly reduced by using an end cap.

CONCLUSION

Intramedullary nailing of clavicular midshaft fractures using the titanium elastic nail is a technically demanding operation with various complications in the postoperative phase. This study might explain why the implant has not yet achieved widespread application, despite the fact that other authors have reported good results. Amending the operative technique and postoperative treatment might improve the outcome in the future.

Open Gustilo 1 and 2 midshaft fractures of the radius and ulna in children: is there a role for cast immobilization after wound debridement?

INTRODUCTION

Open fractures of the forearm in children are one of the indications for open reduction and internal fixation. Fixation allows for soft tissue management and maintenance of reduction. This study compares the outcome of open Gustilo 1 and 2 midshaft forearm fractures treated with cast immobilization versus the outcome of those treated with internal fixation after wound debridement.

METHODS

This is a retrospective study of the cases of 31 children treated in Kandang Kerbau Women's and Children's Hospital from 1998 to 2005. All had wound debridement, followed by cast immobilization in 15 patients and implant stabilization in 16 others, using plates and screws or intramedullary K-wires. The patients were assessed at final follow-up using the classification by Price.

RESULTS

Both treatment groups had 100% excellent or good results. There was no significant difference in time to union. However, there was a higher incidence rate of delayed union and infection when treated with implant stabilization. The main complication associated with cast immobilization was loss of reduction (4 cases), of which 1 case required a second manipulation.

DISCUSSION

Despite the trend toward implant stabilization of all open forearm fractures, this study shows that there is still a role for cast immobilization in its treatment of Gustilo 1 and 2 open forearm fractures as long as proper casting technique and close follow-up is achieved. However, internal fixation should be considered in cases where the fracture is noted intraoperatively to be unstable or if attempted reduction fails, bearing in mind the possible complications associated with internal fixation.