Nancy nail versus intramedullary-wire fixation of paediatric forearm fractures

Management of Isolated Radial Diaphyseal Fractures in the Paediatric Population

Introduction Paediatric forearm fractures are common, but isolated radial diaphyseal fractures are rare, representing a small subset. Unlike fractures involving both the radius and ulna, these fractures lack well-established management guidelines. The potential for alignment loss during treatment underscores the need for specific protocols. This study highlights the importance of a tailored approach based on fracture classification. Stable fractures can be managed conservatively, but prompt surgical intervention is critical for unstable cases to prevent malalignment. Methods This retrospective study evaluated 597 paediatric forearm fractures surgically treated between 2011 and 2017. Of these, 49 cases of isolated radial diaphyseal fractures met the inclusion criteria. Patients with distal or proximal epiphyseal/metaphyseal fractures and those older than 18 years were excluded. To guide management, the study developed a simple classification system based on fracture pattern, angulation, and displacement. Results The fractures were classified into three groups based on a simple classification system developed for this study: stable fractures, moderately displaced fractures, and severely displaced or unstable fractures. Stable fractures, characterized by minimal angulation (<10°) and no significant displacement (<2 mm), were managed conservatively with immobilization. All 18 patients in this group achieved union without complications. Moderately displaced fractures, defined as angulation between 10° and 20° or displacement of 2-5 mm, typically required closed reduction, while five cases in this group underwent surgical fixation using elastic stable intramedullary nailing (ESIN). Outcomes for these patients were satisfactory, although some experienced mild complications such as transient stiffness. Severely displaced or unstable fractures, with angulation exceeding 20° or displacement greater than 5 mm, necessitated surgical intervention in all 15 cases. ESIN was the preferred method for stabilization, achieving good alignment and functional recovery, although one patient experienced transient nerve irritation. These results highlight the importance of a tailored approach to management based on the severity of fracture displacement and angulation. Conclusion The proposed classification and treatment protocol standardize management and improve outcomes for paediatric isolated radial diaphyseal fractures. Further research is required to validate these findings and refine treatment strategies for this rare injury.

Technical aspects that may affect the outcomes of pediatric patients with both-bone forearm diaphyseal fractures treated using elastic stable intramedullary nails

We assessed the radiological and functional results of pediatric both-bone forearm diaphyseal fractures treated using elastic stable intramedullary nails (ESINs), as well as factors affecting the results. In total, 36 patients (33 males and three females; mean age, 11.6 years) were included. The mean follow-up time was 41.5 (18-96) months. Patient demographic characteristics and the details of the surgical techniques were analyzed retrospectively. In addition to standard radiographic evaluations, the ratio between the nail diameter and medullary canal diameter (ND/MCD) was measured, as well as the maximal radial bowing. According to the criteria of Price and Flynn, 28 (77.8%) and eight (22.2%) patients had excellent and good results, respectively. There were no cases of nonunion or delayed union. There was no significant difference in functional or radiological results according to whether titanium nails (24 patients) or stainless steel nails (12 patients) were used (all P  > 0.05). Nail prebending (performed in 19 patients) did not affect the functional or radiological results ( P  > 0.05). Loss of reduction was observed in four patients with an ND/MCD ratio <40%. The maximal radial bowing improved in all patients. The mean change was significantly greater in patients with diastases and 22D/4.1 fractures. Regardless of nail type or prebending status, surgery using ESIN placement effectively treats both-bone forearm diaphyseal fractures; radial bow remodeling outcomes are excellent. We recommend that the ND/MCD ratio should be 40-70%.

Surgical approach for elastic stable intramedullary nail in pediatric radius shaft fracture: a systematic review

When using elastic stable intramedullary nailing in children's distal radius shaft fractures, the surgical approach can either be lateral or dorsal. The aim of this article was to carry out a systematic review of the literature comparing the two types of approaches in terms of complications. An electronic search of databases was performed. Titles of articles were screened, and abstracts and full text were read. Data were extracted in terms of demographics and complications. The dorsal approach had a 2.6% rate of extensor pollicis longus tendon rupture, whereas the lateral approach had a 2.9% rate of transient superficial radial nerve palsy and 0.3% rate of permanent damage. These complications should be considered when deciding between the two surgical approaches.

Intramedullary Implant Choice and Cost in the Treatment of Pediatric Diaphyseal Forearm Fractures

OBJECTIVES

To compare outcomes and costs between titanium elastic nails (TENs), stainless steel elastic nails (SENs), and Kirschner wires (K-wires) in the treatment of pediatric diaphyseal forearm fractures with intramedullary fixation.

DESIGN

Retrospective cohort study.

SETTING

Level 1 Pediatric Trauma Center.

PATIENTS/PARTICIPANTS

A total of 100 patients (65 male and 35 female) younger than 18 years with diaphyseal forearm fractures treated with intramedullary fixation were included in the study.

INTERVENTION

Patients received single or both bone intramedullary fixation with either TENs, SENs, or K-wires.

MAIN OUTCOME MEASUREMENTS

Time to radiographic union, complication rate, surgical time, and average cost per implant.

RESULTS

One hundred patients were included in the study. Thirty-one patients were treated with TENs, 30 with SENs, and 39 with K-wires. No significant difference in time to radiographic union, complication rate, or surgical time was found between the 3 types of fixation. Average time to union was 9.4 ± 5.4 weeks, and complication rate was 12.9% for TENs, 10.0% for SENs, and 12.8% for K-wires. There was a significant difference in cost per implant, with an average cost of $639, $172, and $24 for TENs, SENs, and K-wires, respectively (P < 0.001).

CONCLUSIONS

This study demonstrates no difference between TENs, SENs, and K-wires in the treatment of pediatric diaphyseal forearm fractures with regards to outcome, time to union, surgical time, or complication rates. Given the significant cost difference between these implants, we recommend that surgeons consider modifying their implant selection to help mitigate cost.

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Influence of the bending of the tip of elastic stable intramedullary nails on removal and associated complications in pediatric both bone forearm fractures: a pilot study

OBJECTIVES

Both bone forearm fractures are efficiently treated by elastic stable intramedullary nail (ESIN). According to the original technique, the tip of the nail must be bent at 90° and buried under the skin. However, skin irritation is commonly reported and may lead to early surgery to shorten the tip or remove the hardware. The purpose of this study was to investigate the influence of the bending of the tip of the nail in this procedure.

METHODS

We retrospectively reviewed 72 children operated on using this technique with the tip bent either at 90° or at 180°. In both groups we recorded complication rates after the procedure and at the removal.

RESULTS

Time until removal and duration of the removal were similar in both groups. Three complications (6.7%) that required additional surgery were recorded when the tip was bent at 90° whereas no complications were found with the tip bent at 180°.

CONCLUSION

We advocate bending the tip of the nail at 180° before burying it in order to avoid skin irritation and additional procedures.

LEVEL OF EVIDENCE

Level III—retrospective comparative study.

Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

INTRODUCTION

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture.

MATERIALS AND METHODS

In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs.

RESULTS

Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°-10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail.

CONCLUSIONS

These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.

Titanium elastic nailing radius and ulna fractures in adolescents

Over the last 40 years, anatomic reduction with plate stabilization has become the standard in adult patients with diaphyseal fractures of the radius and ulna. When operative fixation has been indicated in skeletally immature patients with these fractures, a variety of techniques have been reported, with intramedullary fixation becoming increasingly accepted. There is currently significant variability in the treatment of adolescents with forearm fractures. The purpose of this study was to investigate the clinical and radiographic outcomes in the adolescent population after intramedullary fixation of both bone forearm fractures. A retrospective review identified 32 patients 12-18 years of age who had undergone intramedullary fixation of both forearm bones in the past 20 years at our institution. Galeazzi, Monteggia, radial head, and distal metaphyseal fractures were excluded. Radiographic evaluation was performed to determine union and postoperative radial bow. Clinical follow-up was carried out for postoperative complications and range of motion of the wrist, forearm, and elbow. The mean age of the patients was 14.1 years. A total of 19 fractures were closed injuries, nine were grade 1, three were grade 2, and one fracture was a grade 3b. Of the patients, 15.6% had limited postoperative range of motion. All patients in the older age group, 15-18 years of age, had a normal range of motion. A decrease in radial bow was not associated with limitation in motion. There was a 98% union rate, and all unions occurred by 7.5 months. Only three major complications occurred, two refractures and one ulnar hardware migration, and subsequent radius nonunion occurred in the one grade 3b injury. Flexible intramedullary nailing of both bone forearm fractures provides reliable bony union and excellent postoperative clinical results in adolescents. Level of evidence, IV.

Surgical interventions for diaphyseal fractures of the radius and ulna in children

BACKGROUND

Diaphyseal forearm fractures in children are a common injury usually resulting from a fall. The treatment options include non-surgical intervention (manipulation and application of cast) and surgical options such as internal fixation with intramedullary nails or with plate and screws.

OBJECTIVES

To assess the effects (benefits and harms) of a) surgical versus non-surgical interventions, and b) different surgical interventions for the fixation of diaphyseal fractures of the forearm bones in children.

SEARCH METHODS

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2011 Issue 1), MEDLINE (1948 to February week 4 2011), EMBASE (1980 to 2011 week 09), trial registers and reference lists of articles.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials that compared surgical with non-surgical intervention, or different types of surgical intervention for the fixation of diaphyseal forearm fractures in children.

DATA COLLECTION AND ANALYSIS

All review authors independently examined the search results to identify trials for inclusion.

MAIN RESULTS

After screening of 163 citations, we identified 15 potentially eligible studies of which 14 were excluded and one is an ongoing trial. There were thus no studies suitable for inclusion in this review.

AUTHORS' CONCLUSIONS

There is a lack of evidence from randomised controlled trials to inform on when surgery is required and what type of surgery is best for treating children with fractures of the shafts of the radius, ulna or both bones.

Isolated diaphyseal fractures of the radius in skeletally immature patients

Diaphyseal radius fractures without associated ulna fracture or radioulnar dislocation (isolated fracture of the radius) are recognized in adults but are rarely described in skeletally immature patients. A search of our database (1974-2002) identified 17 pediatric patients that had an isolated fracture of the radius. Among the 13 patients with at least 1 year follow-up, ten were treated with manipulative reduction and immobilization in an above elbow cast and three had initial operative treatment with plate and screw fixation. These 13 patients were evaluated for an average of 18 months (range, 12 to 45 months) after injury using the system of Price and colleagues. The incidence of isolated diaphyseal radius fractures in skeletally immature patients was 0.56 per year in our database and represented 27% of the 63 patients with a diaphyseal forearm fracture. All 13 patients, with at least 1 year follow-up, regained full elbow flexion and extension and full forearm rotation. According to the classification system of Price, all 13 patients (100%) had an excellent result. As in adults, isolated radius fractures seem to occur in children more frequently than previously appreciated. Treatment of isolated radius fractures in skeletally immature patients has a low complication rate, and excellent functional outcomes are the rule.

Biomechanical study of flexible intramedullary nails

BACKGROUND

Flexible intramedullary (IM) nailing is considered a safe, minimally invasive fixation technique with relatively low complication rates for long-bone fractures in the pediatric population. At our institution, questions have arisen about stability of fixation based on the distance of the nail past the fracture site. Clinically, this question arises with proximal or distal fractures and when the nail is unable to be passed to the desired distance past the fracture site. The purpose of our study was to compare biomechanical resistance with bending forces for fixation constructs whose IM nails are at differing distances beyond the fracture site in different bones.

METHODS

This study tested matched pairs of canine radii, ulnas, and tibias in 4-point bending and compared the biomechanical properties of length of nail fixation past the fracture site in relation to bone diameter.

RESULTS

Fixations of 1 or 2 diameters past the osteotomy yielded gross instability. There was no difference found in bending failure force, displacement, stiffness, or energy when comparing 3 versus 5 diameters of fixation past the fracture site.

CONCLUSIONS

Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more beyond the fracture site, the length does not significantly affect the biomechanical properties of the construct.

CLINICAL RELEVANCE

Flexible IM nails act as internal splints to align the fracture ends. At 3 diameters or more past the fracture site, the length of the nail does not greatly affect the biomechanical properties of the construct. This knowledge may be helpful in clinical scenarios where there is uncertainty about the expected strength of a shorter fixation. Examples include when the nail cannot be passed completely to the distal metaphysis and in proximal or distal long-bone fractures. Further clinical studies are needed to determine implications in a patient setting.

Flexible nailing of fractures in children using stainless steel Kirschner wires

Elastic titanium nails are widely used for the established procedure of Elastic Stable Intramedullary Nailing (ESIN), but are costly. Thirty-five diaphyseal fractures in various long bones in children were treated by flexible nailing using stainless steel Kirschner (K) wires. The results were comparable with reports by other authors using titanium nails and stainless steel K wires. Cost-effective K wires and instrumentation are easily available. A stainless steel K wire is 92% cheaper than a Nancy nail and 84% cheaper than a Synthes titanium elastic nail. K wires can be used for flexible nailing of fractures in children with results comparable with those after using titanium nails.