Antegrade elastic stable intramedullary nail fixation for paediatric distal radius diaphyseal metaphyseal junction fractures: A new operative approach

Antegrade ESIN technique via the Kocher interval reduces radiation exposure and accelerates recovery in pediatric DRDMJ fractures: A comparative study with cadaveric validation

BACKGROUND

Distal radius diaphyseal-metaphyseal junction (DRDMJ) fractures in children often require surgical intervention due to the unique anatomical characteristics and high failure rate of nonoperative treatment. However, the choice of internal fixation remains a challenge for pediatric orthopedic surgeons. Traditional fixation methods, including plate and screw fixation, crossed Kirschner wires (K-wires), and external fixators, have drawbacks such as extensive local trauma and the risk of physeal injury. This study evaluates the clinical efficacy of antegrade elastic stable intramedullary nailing (ESIN) for DRDMJ fractures in children, comparing it with the crossed K-wire technique.

METHODS

A retrospective analysis was conducted on 47 pediatric patients with DRDMJ fractures treated between June 2018 and January 2023. Patients were divided into an antegrade ESIN group (n = 20) and a crossed K-wire group (n = 27). Demographic data, perioperative parameters (operative time, radiation exposure), and postoperative recovery indicators (duration of internal/external fixation, radiographic healing time, wrist function recovery) were collected. All patients were followed up for at least 12 months, and complications were recorded. The Garland-Werley score was used to assess wrist function. Additionally, a cadaveric study was performed to validate the neurovascular safety of antegrade ESIN insertion via the middle third of the radial head-radial tuberosity axis within the Kocher interval.

RESULTS

All patients achieved radiographic union, with no cases of dorsal interosseous nerve injury, tendon rupture, or refracture. There were no significant differences between the two groups in terms of radiographic healing time or wrist function scores at 12 months postoperatively (P > 0.05). However, compared to the crossed K-wire group, the antegrade ESIN group demonstrated a significantly shorter operative time by 10.71 min (P = 0.002), reduced fluoroscopy use by 2.74 exposures (P = 0.001), and a shorter postoperative cast immobilization duration by 9.11 days (P < 0.001). Additionally, the antegrade ESIN group exhibited a higher rate of excellent wrist function scores at the 3-month follow-up. The cadaveric study confirmed that needle insertion through the middle third of the Kocher interval safely avoided the dorsal interosseous nerve, with no risk of nerve injury in either pronation or supination positions.

CONCLUSION

Antegrade ESIN and crossed K-wire fixation provide comparable long-term functional and radiographic outcomes for pediatric DRDMJ fractures. The antegrade ESIN technique, performed through the middle third of the radial head-radial tuberosity axis within the Kocher interval, effectively avoids dorsal interosseous nerve injury while significantly reducing operative time, minimizing intraoperative radiation exposure, and promoting early functional recovery. This technique may serve as a valuable surgical option for treating DRDMJ fractures in children.

[Treatment of diametaphyseal forearm fractures in children and adolescents : Antegrade intramedullary nail osteosynthesis and its alternatives]

OBJECTIVE

Osteosynthesis in dislocated diametaphyseal forearm fractures is intended to restore anatomy and function. Antegrade intramedullary nailing in the radius is used to restore length, rotation, and axis within the age-specific correction limits. Sufficient stability ensures early functional postoperative treatment without load.

INDICATIONS

Dislocated diametaphyseal forearm or radius fractures that cannot be closed, stably reduced, or remain outside the age-specific correction limits.

CONTRAINDICATIONS

Radius or forearm fractures located distal or proximal to the defined area. Soft tissue defects, contamination or infections located in the access path.

SURGICAL TECHNIQUE

In the course of the Thompson approach, the soft spot between the extensor digitorum and extensor carpi radialis brevis muscles is located and an approx. 3-4 cm skin incision is made. Then blunt preparation down to the bone, sparing the profundus and superficial radial nerve. Retraction of the musculature with two Langenbeck hooks. Opening of the cortex with an awl. If necessary, a 2.5 mm drill with tissue protection can be used beforehand if the cortex is very hard. A titanium elastic nail (TEN) diameter is selected so that it fills approximately 2/3 of the medullary canal. It is recommended to flatten the TEN runner with parallel flattening forceps. After closed reduction, the TEN is then brought up in front of the growth plate with slightly rotating movements. The TEN is bent over at the proximal end and pinched off above the muscle bellies. Alternative procedures include Kirschner wire osteosynthesis or retrograde TEN from radial or dorsal, with or without bending.

POSTOPERATIVE MANAGEMENT

The aim of osteosynthesis is early functional follow-up without load. Sports abstinence is recommended for 8 weeks. Metal removal can be performed after consolidation between 3 and 6 months.

RESULTS

Clearly dislocated or outside the correction limits infantile radius and forearm fractures show very good treatment results with a low risk profile after the described osteosynthesis technique. Pseudarthrosis and nerve damage were not observed. Secondary dislocation has not occurred.

Introducing the forearm fracture index to define the diametaphyseal junction zone through clinical evaluation in a cohort of 366 diametaphyseal radius fractures

BACKGROUND

Unstable diametaphyseal radius fractures (DMRFs) can be prone to complications, and treatment strategies are heterogeneous. Studies are difficult to interpret as definitions of the diametaphyseal junction zone (DMJZ) are impractical for clinical use, imprecise, or prone to error.

METHODS

We introduce the forearm fracture index (FFI) to define DMRFs in radiographs and ultrasound. The FFI is calculated by the ratio of the fracture's distance to the distal radius growth plate over the width of the radius growth plate. The higher the FFI, the more proximal the fracture is. We define DMRFs to have an FFI between 1 and 2. All DMRFs treated at our institution between 2010 and 2020 were identified, and demographic data, fracture characteristics, and therapeutic strategies were assessed retrospectively. Comparative sub-analysis was performed between DMRFs(-) as defined in previous publications (Lieber in Unfallchirurg 114:292-299, 2011) and DMRFs( +) that were more proximal but still met our criteria.

RESULTS

516 DMRFs were identified, representing 13.0% of all screened radius fractures. Excluding buckle fractures and patients lost to follow-up, 366 DMRFs were eligible for further analysis. Conservatively managed DMRFs were more distal than those managed operatively, represented by a lower FFI (1.28 vs. 1.34, p = 0.0051). 21 (5.7%) of all DMRFs were identified as DMRFs( +). These were significantly more dislocated and necessitated surgery more often than DMRFs(-) (52.4 vs. 24.6%, p = 0.009).

CONCLUSIONS

The FFI may be a good tool to identify and describe DMRFs. It can help guiding treatment decisions and make future studies on this entity more comparable.

LEVEL OF EVIDENCE

Study of Diagnostic Test, Level II.

Treatment of unstable forearm fractures at the metaphyseal-diaphyseal junction in children: antegrade ESIN vs. transepiphyseal intramedullary K-wire fixation

BACKGROUND

Treatment of unstable forearm fractures in the metaphyseal-diaphyseal junction (MDJ) zone is still a matter of debate. Major drawbacks of all types of fixations include either invasiveness, technical impracticality, or lack of acceptance by patients. This study reports results after antegrade ESIN (a-ESIN) compared to transepiphyseal intramedullary K-wire (TIK) for unstable MDJ forearm fractures.

METHODS

The MDJ of the forearm was defined as the square over the joints of both forearm bones subtracted with the square over the metaphysis of the radius alone. The data of 40 consecutive patients < 16 years of age who were treated either by a-ESIN (later treatment period) or TIK (early treatment period) for an unstable MDJ forearm fracture at a single high-volume pediatric trauma center were retrospectively analyzed.

RESULTS

The average age was slightly lower in the first group (TIK = 7.42 years; a-ESIN = 10.5 years). An additional ulna fracture was found in 50% of cases and was treated with a classic antegrade ESIN in 10/20 (TIK) and 6/20 cases (a-ESIN). Additional plaster cast immobilization was performed in all cases with TIK and in three cases with a-ESIN. After TIK, no complication, malalignment, or functional limitation occurred. After a-ESIN, 19/20 patients had an event-free course with stable retention and healing without axial malalignment. In one case, a temporary sensor dysfunction occurred. The same patient suffered a refracture two months after the original trauma, which required a closed reduction. Metal removal was performed after 84 days (TIK) and 150 days (a-ESIN). The outcome in all patients was good.

CONCLUSION

Both a-ESIN and TIK are minimally invasive procedures that are technically easy to perform. Both methods are safe and lead to a complete restoration of the forearm's range of motion. The decisive advantage of a-ESIN is the possibility of postoperative immobilization-free rehabilitation.

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique

BACKGROUND

Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation.

PATIENTS AND METHODS

A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up.

RESULT

There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients.

CONCLUSION

In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.

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.

Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children

OBJECTIVE

Although mini-plate fixation is an attractive treatment option for distal radius metaphyseal diaphysis junction (DRMDJ) fractures in children, the benefits of minimally invasive fixation (MIF) with pre-bent elastic stable intramedullary nails (MIF) remain underexplored. Therefore, this study aimed to evaluate the clinical efficacy of MIF administration in children with DRMDJ fractures.

METHODS

This retrospective study enrolled 40 patients with DRMDJ fractures who underwent MIF or mini-plate fixation from January 2016 to January 2021. Radiographic parameters, such as palmar inclination and ulnar deflection angle, were examined postoperatively to assess the anatomical reduction of the wrist joint. Clinical outcomes, including the range of wrist flexion and back extension, were examined to analyze the recovery of the wrist range of motion. Additionally, the Gartland-Werley scoring system was used to assess the recovery status of wrist function and healing condition. The student t-test and χ2 test were used to compare differences among groups.

RESULTS

All included patients successfully underwent the operation and were followed up for 12-24 months. Patients in the MIF group had a smaller surgical incision length (0.49 ± 0.06 cm) compared to those in the mini-plate fixation group (4.41 ± 0.73 cm) (t = 22.438, p = 0.000). Palmar inclination and ulnar deflection were within the normal range in patients of both groups, and the fractures were successfully anatomically reduced. Moreover, wrist flexion and back extension in the MIF group and mini-plate group were (72.50° ± 0.64° vs. 70.18° ± 0.56°) and (59.55° ± 1.75° vs. 60.04° ± 1.37°), and differences were statistically significant (t = 2.708, p = 0.010 and t = 0.885, p = 0.382, respectively). Furthermore, MIF treatment resulted in a higher proportion of excellent Gartland-Werley scores (94.44%) than mini-plate fixation (86.36%) (p = 0.390). In addition, one case in the mini-plate fixation group experienced re-fracture following the removal of the internal fixation, and the fracture healed after reduction and cast fixation. All patients achieved satisfactory bone healing without other complications.

CONCLUSION

Compared with mini-plate fixation, MIF has the advantages of small incision length, superior range of motion of thr wrist joint, and better maintenance of the physiological radian, providing a promising approach for clinical and surgical treatment of DRMDJ fractures.

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal radius.

METHODS

The data of patients who were treated at a children's hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.

RESULTS

The study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).

CONCLUSIONS

K-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.

LEVEL OF EVIDENCE

III, a case-control study.

Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?

Fractures involving the distal radius metaphyseal-diaphyseal junction (MDJ) present a unique challenge for pediatric orthopedic surgeons. These fractures are too proximal for percutaneous K -wire fixation and too distal for retrograde flexible nailing. The purpose of this study was to: (1) determine the safety of a described antegrade approach from the posterior interosseous nerve (PIN); (2) assess the efficacy of antegrade nailing in cases of distal MDJ fractures; and (3) describe a standardized lateral approach to the proximal radius. A cadaveric study was performed using 10 adult forearms. Anterograde flexinail was introduced at the proximal radius based on the described "safe zone". Distal MDJ fractures were created using osteotomes. We evaluated the distance between the entry point to the PIN in addition to the quality of the reduction for the fracture. The average distance between the entry point and piercing instrument to the PIN was 5.4 cm (range: 4.7 to 6.0 cm). When grouped based on sex, the average distance was significantly further for males (5.8 cm, range: 5.2 to 6.0 cm) versus females (4.9 cm, range: 4.7 to 5.2 cm), P =0.004. Fracture reduction was not maintained after the introduction of the antegrade flexible nail across the fracture site. For all specimens, >25% displacement was seen on the anterior-posterior imaging. Our modified lateral approach to the starting point in the proximal radius is safe as long as the entry point for antegrade flexible nailing stays proximal to the radial tuberosity during the lateral approach to the proximal radius while the elbow is flexed and the forearm pronated.

Comparison of three fixation methods in paediatric metaphyseal-diaphysis junction fracture of the distal radius: a retrospective study in two centres

Background

The distal radial metaphyseal-diaphysis junction fractures (DRMDJ) have various treatment methods and are easily lead to complications. This study aims to compare the anterograde elastic stable intramedullary nailing (ESIN-A), retrograde K-wire fixation (KW-R), and retrograde precision-shaping elastic intramedullary nailing (ESIN-RPS) for the treatment of pediatric DRMDJ fractures.

Materials and methods

A total of 113 patients with DRMDJ fractures (36 in the ESIN-A group, 52 in the KW-R group, and 25 in the ESIN-RPS group) from two centres were retrospectively analysed. Perioperative operation time, intraoperative bleeding, fluoroscopy times, alignment rate and angulation on radiography were compared among the three groups. Forearm rotation, healing, wrist function, and complications were compared at the last follow-up.

Results

The mean operation times of the three groups were as follows: KW-R (72 ± 13 min) > ESIN-A (65 ± 18 min) > ESIN-RPS (52 ± 11 min), with a significant difference (P < 0.01). The incision length and intraoperative blood loss of ESIN-A (1.8 ± 0.2 cm; 8.3 ± 3.7 ml) were significantly higher than ESIN-RPS (1.4 ± 0.8 cm; 5.5 ± 2.7 ml) (P < 0.05), respectively. The postoperative alignment rate on the anteroposterior (AP) and the lateral plane of ESIN-RPS (93.1 ± 4.4%; 95.01 ± 2.8%) was significantly greater than that of KW-R (82.1 ± 6.8%; 88.5 ± 4.5%) and ESIN-A (79.2 ± 5.2%; 83.2 ± 2.5%) (P < 0.01). The residual angulation of ESIN-RPS (3.3 ± 1.2°; 2.9 ± 0.8°) was significantly greater than that for ESIN-A (5.1 ± 1.7°; 4.9 ± 2.1°) and KW-R (6.6 ± 2.8°; 7.5 ± 1.6°) (P < 0.05). The excellent and good ratio of ESIN-RPS (95.8%) was significantly higher than that of ESIN-A (86.5%) and KW-R (86.1%) according to the Gartland-Werley standard. There was a significant difference in delayed union between the KW-R and ESIN-A (P < 0.05). Additionally, there were two cases of radial nerve injury in the ESIN-A group, one case of tendon rupture in the ESIN-RPS group, and one case of tendon rupture in the KW-R group. The ESIN-RPS group had significantly fewer complications than the KW-R group (P < 0.05). The ESIN-A group also had significantly fewer complications than the KW-R group (P < 0.05).

Conclusion

Compared with ESIN-A and KW-R, ESIN-RPS has the advantages of a shorter operation time, less intraoperative blood loss, less radiation, better alignment, and fewer complications. The ESIN-RPS was suggested as an optimal choice for paediatric DRMDJ fractures.

Precision shaping of elastic stable intramedullary nail for the treatment of metaphyseal diaphysis junction fracture of the distal radius in children: a preliminary report in two centers

BACKGROUND

This study introduces a novel retrograde precision shaping elastic stable intramedullary nailing (ESIN-RPS) technique and reports clinical outcomes in pediatric distal radius metaphyseal diaphysis junction (DRMDJ) fracture.

METHODS

Data about DRMDJs were collected from February 1, 2020, to April 31, 2022 at two hospitals, retrospectively. All patients were treated with closed reduction and ESIN-RPS fixation. The operation time, blood loss, fluoroscopy times, alignment, and residual angulation on X-ray were recorded. At the last follow-up, the function of wrist and forearm rotation were evaluated.

RESULTS

Totally, 23 patients were recruited. The mean time of follow-up was 11 months and the minimum was 6 months. The mean operation time was 52 min, and the mean fluoroscopies pulses were 6 times. The postoperative anterioposterior (AP) alignment was 93 ± 4% and the lateral alignment was 95 ± 3%. The postoperative AP angulation was (4 ± 1)°, and the lateral angulation was (3 ± 1)°. At the last follow-up, the evaluation of the Gartland and Werley demerit criteria of wrist revealed 22 excellent cases and 1 good case. The forearm rotation and thumb dorsiflexion functions were not limited.

CONCLUSION

The ESIN-RPS is a novel, safe, and effective method for the treatment of pediatric DRMDJ fracture.

Diametaphyseal Distal Forearm Fractures in Children: A STROBE Compliant Comparison of Outcomes of Different Stabilization Techniques Regarding Complications

Diametaphyseal forearm fractures are difficult to treat because standard methods for long-bone fracture stabilization in the metaphyseal or diaphyseal regions are less effective in this transition zone. We hypothesized that there is no difference in outcomes between conservative and surgical treatment of diametaphyseal forearm fractures. This retrospective analysis included 132 patients who had undergone treatment for diametaphyseal forearm fracture between 2013 and 2020 at our institution. The primary analysis compared complications occurring in patients treated conservatively with those occurring in patients managed surgically (ESIN, K-wire fixation, KESIN stabilization, or open reduction and plate osteosynthesis). In a subgroup analysis, we compared the two most frequently applied surgical stabilization techniques in distal forearm fractures (i.e., ESIN and K-wire) with conservative treatment. The mean age of the patients at the time of intervention was 9.43 ± 3.78 years (mean ± SD). Most patients were male (91; 68.9%), and 70 of 132 (53.1%) patients underwent surgical stabilization. The rate of re-intervention or complications was similar after conservative and surgical treatment, and ESIN or K-wire fixation achieved comparable complication rates. Recurrent displacement of fragments was the most frequent reason for re-interventions (13 of 15 patients; 86.6%). There was no permanent damage as a result of a complication. The median time of exposure to image intensifier radiation was comparable between ESIN (95.5 s) and K-wire fixation (85.0 s), but significantly lower during conservative treatment (15.0 s; p = 0.001).

Fractures of the proximal segments of the pediatric distal radial metaphysis exhibit less angular stability than fractures of the distal segments

The distal part of the forearm is divided into the physis, metaphysis, diaphyseal metaphyseal junction (DMJ) and diaphysis. The treatment of radial DMJ fractures is challenging because this region has diaphyseal characteristics. We speculated that the stability of metaphyseal fractures could vary depending on their proximity to the DMJ or physis. Our study aimed to investigate the stability of pediatric distal radius fractures in the physis, metaphysis and DMJ. Ninety-five patients were classified into three groups: group D, fracture line located within 1/2 of the width of the radius (WOR) from the physis; group M, fracture line located between 1/2 and 1 WOR from the physis; and group P, fracture line located between 1 and 2 WOR from the physis. We measured sagittal angulation and coronal angulation. A correction loss of less than 9° was defined as a 'stable reduction' outcome and one greater than 10° as a 'loss of reduction' outcome. The correction losses for sagittal angulation were significantly greater in groups M and P than in group D. The correction losses for coronal angulation were significantly greater in group P than in groups D and M. The incidence of 'loss of reduction' outcomes was significantly higher in groups M and P than in group D. The proximal segments of distal radial metaphyseal and DMJ fractures showed less angular stability than distal segments.

Radial vs. Dorsal Approach for Elastic Stable Internal Nailing in Pediatric Radius Fractures—A 10 Year Review

Background: Forearm fractures are one of the most common fractures in children. Over the last years, a tendency towards surgical treatment was seen, especially closed reduction and internal fixation with elastic stable internal nailing (ESIN). Despite an overall low complication rate being described, a risk of intraoperative complications remains. Material and Methods: A total of 237 patients (mean age 8.3 ± 3.4 (1–16) years) with forearm or radius fractures treated with ESIN between 2010 and 2020 were included in the study. The retrospective review of 245 focused on fracture pattern, pre- and postoperative fracture angulation, intra- and postoperative complications, and surgical approach for nail implant. The fracture pattern and pre- and postoperative angulation were measured radiographically. Complications such as ruptures of the extensor pollicis longus (EPL) tendon and sensibility disorders of the superficial radial nerve were further analyzed. Results: In 201 cases (82%), we performed a dorsal approach; 44 fractures (17.9%) were treated with a radial approach. In total, we found 25 (10%) surgery-related complications, of which 21 (8.6%) needed further surgical treatment. In total, we had 14 EPL ruptures (5.7%), 4 sensibility disorders of the superficial radial nerve (1.6%), 2 refractures after implant removal (0.8%), 2 superficial wound infections (0.8%), and 1 child with limited range of motion after surgery (0.4%). No statistical significance between pre- and postoperative angulation correlated to fracture patterns or diameter of the elastic nail was seen. As expected, there was a significant improvement of postoperative angulation. Using radial approach in distal radial fractures showed a lower rate of surgical related complications, 2.3% of which need further surgical treatment as well as better postoperative angulations compared to the dorsal approach (8.5%). Conclusion: Especially due to the low risk of damaging the EPL tendon, the radial approach showed a lower complication rate which needed further surgical treatment. The risk of lesions of the superficial radial nerve remains.

Bioresorbable implants vs. Kirschner-wires in the treatment of severely displaced distal paediatric radius and forearm fractures - a retrospective multicentre study

BACKGROUND

Distal radius fractures are very common in paediatric patients. Severely displaced fractures may require surgical intervention. The gold standard surgical method is percutaneous K-wire osteosynthesis followed by immobilisation. Metal implants can be removed with a second intervention; however, these extra procedures can cause further complications. Several studies confirm the benefits of bioabsorbable implants for paediatric patients. The aim of this retrospective study was to compare the complication rates of displaced distal metaphyseal radius (AO 23r-M/3.1) and forearm (AO 23-M/3.1) fractures in children operated on with K-wires versus a novel technique with bioresorbable implants.

METHODS

We retrospectively reviewed 94 patients in three paediatric trauma centres who underwent operations due to severely displaced distal forearm or metaphyseal radial fractures between January 2019 and January 2020. The mean age was 8.23 (ranging from 5-12). 30 patients (bioresorbable group, BR-group) were treated with biodegradable PLGA implants (Bioretec®, ActivaPin®), 40 patients with one or two stainless steel Kirschner-wires (K-wires, Sanatmetal®) which were buried under the skin (KW I-group) and 24 children with K-wires left outside the skin. (KWII. Group). We examined the number of minor and major complications as well as the need for repeated interventions. Follow-up was at least one and half year.

RESULTS

There was no significant difference between the complication rates at the two KW groups (p = 0.241; Cramer's V = 0.211), while the complication rate of the BR group was significantly lower. (p = 0.049; Cramer's V = 0.293 and p = 0.002; Cramer's V = 0.418 respectively). No later than half a year after the injury, no difference was observed between the functional outcomes of the patients in each group. One and a half years after the injury, no signs of growth disturbance were found in any of the children. No second surgical intervention was required in the BR group.

CONCLUSIONS

Surgeries with bioresorbable intramedullary implants may have fewer complications than K- wire osteosynthesis in the treatment of severely displaced distal forearm fractures. The benefits are most pronounced in the first six weeks after surgery, reducing the number of outpatient visits and increasing the child's sense of comfort. As no second intervention is required, this can lead to significant cost savings. After half a year, there is no difference in the outcomes between the different surgical treatment strategies.

Limited Open Reduction and Transepiphyseal Intramedullary Kirschner Wire Fixation for Treatment of Irreducible Distal Radius Diaphyseal Metaphyseal Junction Fracture in Older Children

OBJECTIVE

This study aimed to compare limited open reduction and transepiphyseal intramedullary fixation with Kirschner wire (LOR-TIKW) versus open reduction and internal fixation with plate and screw (ORIF-PS) for treatment of irreducible distal radius diaphyseal-metaphyseal junction (DMJ) fracture in older children.

METHODS

Data of children (aged 10-14 years) treated in our hospital for distal radius DMJ fractures with LOR-TIKW or ORIF-PS from January 2018 to December 2019 were retrospectively analyzed. Follow-up was until radiographic union. Demographic, clinical, and radiographic data; treatment cost; healing time; functional outcome (by Price criteria); complications; and postoperative angulation and displacement were compared between children treated by the two methods. Statistical analysis was performed with alpha set at P < 0.05.

RESULTS

A total of 26 children were included: 14 treated with LOR-TIKW and 12 with ORIF-PS. Operation time was less (22.1 min vs. 46.7 min, P < 0.0001), surgical incision smaller (2.43 cm vs. 5.00 cm, P < 0.0001), cost of internal fixation lower (US$, 40.6 vs. 2020, P < 0.0001), and healing time shorter (4.79 weeks vs. 5.64 weeks, P = 0.03) with LOR-TIKW; however, postoperative fracture angulation was slightly larger (1.07° vs. 0.83°, P = 0.85) and displacement slightly more (0.86 mm vs. 0.58 mm, P = 0.44) in the LOR-TIKW group. Rate of union, functional outcome, and complications were not significantly different between the groups.

CONCLUSION

For irreducible DMJ fracture of distal radius in older children, LOR-TIKW appears to be a promising method with several advantages over ORIF-PS.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

Background

Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as “difficult to manage” with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure.

Methods

This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures.

Results

Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%).

Conclusion

The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

Treatment of completely displaced distal radial fractures with a straight plaster or manipulation under anaesthesia

AIMS

The management of completely displaced fractures of the distal radius in children remains controversial. This study evaluates the outcomes of surgical and non-surgical management of 'off-ended' fractures in children with at least two years of potential growth remaining.

METHODS

A total of 34 boys and 22 girls aged 0 to ten years with a closed, completely displaced metaphyseal distal radial fracture presented between 1 November 2015 and 1 January 2020. After 2018, children aged ten or under were offered treatment in a straight plaster or manipulation under anaesthesia with Kirschner (K-)wire stabilization. Case notes and radiographs were reviewed to evaluate outcomes. In all, 16 underwent treatment in a straight cast and 40 had manipulation under anaesthesia, including 37 stabilized with K-wires.

RESULTS

Of the children treated in a straight cast, all were discharged with good range of mo (ROM). Five children were discharged at six to 12 weeks with no functional limitations at six-month follow-up. A total of 11 children were discharged between 12 and 50 weeks with a normal ROM and radiological evidence of remodelling. One child had a subsequent diaphyseal fracture proximal to the original injury four years after the initial fracture. Re-displacement with angulation greater than 10° occurred for 17 children who had manipulation under anaesthesia. Four had a visible cosmetic deformity at discharge and nine had restriction of movement, with four requiring physiotherapy. One child developed over- granulation at the pin site and one wire became buried, resulting in a difficult retrieval in clinic. No children had pin site infections.

CONCLUSION

Nonoperative management of completely displaced distal radial fractures in appropriately selected cases results in excellent outcomes without exposing the child to the risks of surgery. This study suggests that nonoperative management of these injuries is a viable and potentially underused strategy. Cite this article: Bone Joint J 2021;103-B(5):902-907.

Antegrade Elastic Intramedullary Nailing Insertion Technique Results in Higher Incidence of Symptomatic Implants in Pediatric Ulnar Fractures

Retrograde and antegrade nailing techniques are the two options available to a surgeon when using elastic stable intramedullary nailing; however, the literature comparing these two nailing techniques is scarce. Thus, we conducted a retrospective review of all pediatric and adolescent ulnar fractures treated with elastic stable intramedullary nailing at our facility. We hypothesize that the clinical outcomes (implant and wound complications) and the time between surgery and radiographic union will be similar for both techniques.

Methods

A retrospective chart review of pediatric ulnar fracture patients treated at our facility was performed. Demographic and health information associated with the injury were collected, and the clinical outcomes of the two techniques were compared.

Results

A total of 53 patients with 54 fractures were included in this study. Antegrade nail insertion was used to treat 59.2% fractures. Radiographic union was achieved in all patients. Nail insertion technique was not associated with postoperative wound complications, time to radiographic union or implant removal, or significant deficits in upper extremity rotation (P > 0.05). Antegrade nailing resulted in a symptomatic implantation 3.97 times more frequently than compared with retrograde nailing (P = 0.036).

Discussion

Antegrade nailing demonstrates a similar healing profile but higher implant complications compared with the retrograde nailing technique in pediatric ulnar fractures.

Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator

Background

Conservative treatment remains the preferred choice for distal radius fracture in children. However, loss of reduction is problematic, especially in an older child. Crossed Kirschner-wires is widely used to treat distal radius fracture in adolescents. This study aimed to compare the application of crossed Kirschner-wiring (KW) and non-bridging external fixator (EF) for the treatment of delayed distal radial fracture involving metaphyseal diaphyseal junction (MDJ) in adolescents.

Methods

Between January 2012 to January 2017, 146 (male = 101, female = 45) patients in EF group and 117 (male = 76, female = 41) in KW group, were reviewed retrospectively. Preoperative data were collected from the hospital database, and postoperative clinical outcomes data were collected during the follow-up visits. We used SPSS for data analysis.

Results

There existed no significant difference between EF and KW regarding sex, body weight, fracture side, duration from injury to surgery. The duration of surgery was significantly shorter in EF (30.5 ± 6.1 min) than the KW group (44.6 ± 9.4 min), P < 0.001. The number of intraoperative X-ray images was significantly lower in EF (6.5 ± 1.1) than KW (11.8 ± 2.3), P < 0.001. The incidence of tendon irritation is significantly higher in the KW (19.7%) than the EF group (0%), P < 0.001. The residual angulation on the AP view was higher in KW (3.8 ± 2.3, degrees) than the EF group (2.5 ± 1.6, degrees), P < 0.001. The volar tilting is better in EF (6.6 ± 1.1, degrees) than the KW group (1.0 ± 1.5, degrees), P < 0.001. However, the functional outcomes of the wrist showed no significant difference between EF and KW group, P = 0.086.

Conclusion

The EF was superior to KW in the treatment of radial MDJ fractures in adolescents. The EF displayed shorter duration of surgery, less tendon irritation, and better radiographic outcomes than the KW. However, the cost-effect analysis remains to be investigated, because the EF is more expensive than KW.