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Year : 2017  |  Volume : 3  |  Issue : 1  |  Page : 29-33

Safety, efficacy, and functional outcome of elastic stable intramedullary nailing in unstable fractures of both bones of forearm in children

Paediatric Orthopaedics Unit, Christian Medical College, Vellore, Tamil Nadu, India

Date of Web Publication17-Feb-2017

Correspondence Address:
Vrisha Madhuri
Professor and Head, Paediatric Orthopaedics Unit, Christian Medical College, Vellore - 632 004, Tamil Nadu
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/2249-9008.200293

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Aims: To determine the clinical profile and clinical, functional, and radiological outcomes and complications in children who underwent elastic stable intramedullary nailing (ESIN) for unstable fractures of both bones of forearm. Materials and Methods: A retrospective observational study was conducted in the Paediatric Orthopaedic Unit of the institution. Children with forearm fractures, who underwent ESIN of both the bones with titanium nails from January 2004 to June 2010, were included in the study. Clinical evaluation for deformity, range of motion at wrist and elbow, Daruwalla’s grading for forearm fractures, and radiological evaluation for bony union, malalignment, and radial bow were done. Paediatric Outcomes Data Collection Instrument (PODCI) questionnaire was used to assess functional outcome. Results: Twenty-six patients were followed up for a mean of 2.14 years. These included one primary internal fixation for unstable injury in a 15-year old, 10 open fractures, and 15 with malalignment after closed reduction. Age ranged from 5 to 15 years (mean of 11.39). Average time to bony union was 6 weeks. Twelve children had excellent, 12 good, and two fair outcomes according to Daruwalla’s grade. Average PODCI score was 50.78 (standardized range is minimum of −140 to maximum of 53). There were no major complications related to ESIN. Three patients had paraesthesia over superficial radial nerve distribution, three patients had hypertrophied scars, and one patient had superficial wound infection. One child had distal radial physeal arrest following inadvertent physeal injury during implant removal. Conclusion: ESIN is safe and effective for internal fixation of unstable forearm fractures.

Keywords: ESIN, paediatric both bones forearm fractures, PODCI questionnaire

How to cite this article:
James D, Madhuri V. Safety, efficacy, and functional outcome of elastic stable intramedullary nailing in unstable fractures of both bones of forearm in children. Paediatr Orthop Relat Sci 2017;3:29-33

How to cite this URL:
James D, Madhuri V. Safety, efficacy, and functional outcome of elastic stable intramedullary nailing in unstable fractures of both bones of forearm in children. Paediatr Orthop Relat Sci [serial online] 2017 [cited 2020 Aug 14];3:29-33. Available from: http://www.pors.co.in/text.asp?2017/3/1/29/200293

  Introduction Top

Forearm diaphyseal fracture is one of the three common upper limb fractures in the paediatric population.[1],[2] Although management of adult forearm diaphyseal fractures has evolved, paediatric forearm fracture management has been stagnant with limited role of operative interventions despite reports of poor outcome of conservative management of paediatric forearm fractures.[3],[4],[5],[6] Complications in paediatric forearm diaphyseal fractures are relatively rare, but certainly not negligible.[6],[7] Indications for operative management are very specific and selective, and conservative management continues to be the mainstay for a vast majority of these cases.[4],[5],[6] Options for internal stabilization include Kirschner wires, Steinmann’s pins, rush rods, rigid plate osteosynthesis, and even stainless steel (SS) wires.[8] Lascombes et al.,[9] from Nancy, France, has popularized the concept of using two prebent, physeal-sparing intramedullary flexible titanium nails to recreate the interosseous space and provide three-point fixations, while simultaneously providing for biological fracture healing and more convenient hardware removal.[9]

The remodeling capacity of children is determined by age, level of fracture, and magnitude of angulations.[8] Children younger than 10 years with a greater growth potential tend to achieve angular correction better than their older counterparts.[8] As growth plate activity diminishes beyond 10 years of age, the ability to remodel decreases after 10 years. Rotational malalignment does not correct with time.[7],[10] Very definite indications have been cited for internal fixation of these fractures including unstable fractures, which are defined as complete diaphyseal fracture of both bones of the forearm, at or near the same level with convergent displacement.[11],[12],[13] The complication rates cited in the case series reporting operative management of paediatric forearm fractures is not only less than in the adult group, but far outweighs the complications and risk associated with any forearm osteotomy that may be necessitated for malunion.[11],[14]

  Materials and Methods Top

A retrospective observational study was carried out in our unit between May 2009 and October 2010. The study was approved by the Institutional Review Board. Twenty-six patients who underwent flexible nailing for diaphyseal fracture of both bones of the forearm were included in this study. Baseline and perioperative data of these patients were collected from inpatient records, outpatient records, and Picture Archiving and Communication System (PACS) system. The unstable fractures were defined as fractures of both bones at the same or near same level or oblique converging fracture of both bones compromising interosseous space.[9],[10] All patients were immobilized postoperatively for 4–6 weeks in an above elbow posterior slab with elbow in 90° flexion and forearm in midprone. These patients were followed up through office consultation and in the outpatient department (OPD). Preoperative and postoperative follow-up radiographs were analyzed. Modified Schemitsch and Richards method was used to assess maximal radial bowing and locate its site with respect to the total radial length in immature skeleton in all patients.[15]

The elbow, forearm, and wrist movement of the operated limb was clinically assessed and compared with the nonoperated limb. Forearm rotation in each patient was clinically graded according to the Daruwalla’s system.[16] Paediatric Outcomes Data Collection Instrument (PODCI) upper limb questionnaire was administered to 21 children.[17] All children were over 10 years of age at the time of follow-up and were administered the self-reported adolescent PODCI questionnaire. Group 1 consisted of nine patients with more than 2 years of follow-up. Group 2 consisted of 17 patients who had less than 2 years of follow-up.

  Results Top

In 11 out of 26 patients, flexible nailing was done as the primary treatment. Unacceptable malalignment after closed reduction and inherent instability required internal fixation in the rest [[Figure 1] and [Figure 2]]. Among the 11 patients who underwent primary internal fixation, 10 patients presented with open fracture of the forearm, and one was an older child with an unstable fracture pattern (15 years).
Figure 1: A 14-year-old boy with unstable fracture of both bones of the right forearm with unacceptable alignment after closed reduction

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Figure 2: One-year and 6-month follow-up radiograph shows reestablishment of the radial bow with physeal-sparing flexible titanium nails in situ, flush with the distal radial and proximal ulna bony contours

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The average age at presentation was 11.23 years, ranging from 5 to 15 years. Nineteen injuries were to left forearm and seven injuries to the right forearm; 15 out of 18 children sustained fracture of the both middle third bones of the forearm. Two patients had fracture of the proximal third of both bones and one child had a displaced fracture of the distal third diaphysis of both forearm bones. In 18 children, the diaphyseal fractures of both radius and ulna were at the same level and the interosseous space was decreased. The radial fracture was located more proximal in eight cases.

The fracture pattern of the radial diaphysis was transverse in 19 children, short oblique in four children, and oblique in three children. The fracture pattern of the ulna diaphysis was transverse in five children, short oblique in eight children, oblique in 11, and comminuted in two cases.

The procedures were carried out by paediatric orthopedic consultants, fellows, and postgraduates of the department.

The diameter of the nails used were 2.0 mm in six cases, 2.5 mm in 17 cases, and 3.0 m in three cases.

The average hospital stay was 3.66 days for closed forearm fractures and 6.5 days for open fractures. Only two patients had mild restriction of terminal wrist movement. Three patients complained of persistent paraesthesia over the superficial radial nerve distribution. Three patients developed hypertrophied scars over the nail entry points. Implants were removed in 12 patients at an average internal fixation − implant exit interval of 63.16 weeks. Two patients required early implant exit at 20 weeks after the internal fixation, because of nail prominence [Figure 3]. In both the cases, nails were removed after bony union.
Figure 3: Prominent radial flexible titanium nail causing soft tissue irritation. Early implant exit was done 20 weeks after surgery

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Twenty-four patients had excellent or good results according to the Daruwalla’s clinical grading. Group 1 consisted of nine patients with more than 2 years of follow-up; six of them reported excellent and three had good results. There were no poor results in Group 1. Group 2 consisted of 17 patients who had less than 2 years of follow-up; six patients reported excellent results and nine had good results. Two patients had fair results in this group. Smaller nail size and poor maneuverability of a very proximal level fracture were associated with fair results.

Twenty-one children completed the PODCI upper extremity functional assessment questionnaire. Higher score implies better outcome; seven belonged to Group 1 and 14 belonged to Group 2. The mean PODCI scores were comparable between both the groups. The mean PODCI upper extremity functional assessment score for Group 1 was 51.285; six scored a maximum 53 points and one patient scored 41. The mean PODCI upper extremity functional assessment score for Group 2 was 50.285; 11 patients scored 53, two patients scored 41, and one patient scored 39. All four children who scored less than 53 on the PODCI upper extremity functional assessment questionnaire had good or fair results as per Daruwalla’s clinical grading. But not all who scored 53 on PODCI questionnaire had excellent grading on clinical examination.

The postoperative radial and ulnar angulations in orthogonal planes were within the prescribed normal limits in all but two patients. Noonan and Price[1] published limits of angulation and malrotation in displaced fractures to be 15 and 45° in children under 9 years and 10 and 30° in children over 9 years, with complete displacement. Use of inadequate nail size (too small) and a very proximal level fracture in one case were responsible for malalignment in the two patients.

We used the Firl’s modification of Schemitsch and Richard’s method to calculate the location of radial bow in the children who underwent flexible nailing. The mean distance of the site of the radial bow was located at 64.73% (standard deviation, SD, ±6.5%) of the radial length. The mean value of maximum radial bow was 5.71% (SD ±0.79%). These values fall within the range of values for normal children. Firl and Wunsch[15] and Shah et al.[18] specified that the mean distance of the radial bow should be around 60% and the maximum radial bow should be less than 10% of the radial length.

  Discussion Top

The management of forearm fractures in children is undergoing a change, with the realization that closed reduction with some deformity in children is acceptable and will remodel. But a policy of closed reduction irrespective of instability and higher degree of deformity and malalignment can cause unacceptable cosmetic and functional results.[6],[7] The present criteria for acceptable angulation, displacement, and rotation are much stricter.[2]

In our group, 60% undergoing surgery had a failed reduction or loss of reduction. Twenty (77%) children were 10 years or older. Instability, malreduction, and loss of reduction account for 50–90% of internal fixation described in the literature.[10],[19] An unusual predominant indication in our series was open fractures because of fall from height leading to high-velocity unstable injury. Approximately, 10% of all paediatric fractures of both bones of the forearm are unstable and warrant internal fixation.[11]

There are many implant-related issues in elastic stable intramedullary nailing (ESIN) such as biomechanical properties of various intramedullary devices and both bone versus single bone fixation.[10] Owing to the elastic nature of the titanium nails, there can be a relative movement of up to 2° at the fracture site during forearm rotation.[10] Immature skeleton with thick periosteum not only augments the stability but also promotes healing by external callus formation. The flexibility of the nails allows microscopic oscillating movements at the fracture site and applies varying amount of compression at the fractures site.[10],[14]

Choosing the appropriate nail size is important. ESIN is based on the principles of converting traction and shearing forces acting at the fracture fragments into compression force. It produces a dynamic three-point cortical apposition.[11],[20] A prebent elastic nail introduced in a long bone produces compression at its convex side and distraction at its concave side. A second prebent elastic nail of the same diameter introduced in a reversed C shape produces exactly the opposite effect. Thus, two nails provide maximum cortical apposition, maintain length, and give rotational stability.[19] To do this, the elastic nails must together occupy at least 80% of the medullary canal diameter.[20] In one of our cases, the nail size was suboptimal and the cause for malalignment.

Favorable clinical outcome following elastic stable intramedullary fixation with titanium nails in this study correlates with other studies such as Jubel et al.,[21] Richter et al.,[19] Bhasker,[22] and Lascombes et al.[9] Flexible nailing of paediatric fractures of both bones of the forearm has several advantages over plate osteosynthesis. Fast healing, less periosteal and soft tissue dissection, more cosmetic procedure, and fewer incidences of complications are seen with flexible nailing.[18],[23] Intramedullary nailing is a more favored operative procedure because it does not disturb the fracture biology.[19],[20]

Postoperative immobilization of the operated upper limb is not universally accepted.[20],[24] We do not consider postoperative immobilization in a child to be as deleterious as in adults because the immobilization period is shorter and recovery is faster. We prefer to immobilize the operated forearm in an above elbow posterior slab with elbow in 90° flexion and forearm in midprone for a period of 4 weeks. Stability provided by the flexible nails is relative and not rigid. There is a risk of loss of rotational and angular alignment in the postoperative period. It also helps in decreasing the postoperative edema and pain, and promotes a sense of caution on behalf of the patient.[8]

The novelty of this study was objective functional outcome analysis using the PODCI questionnaire and score. It has not been commonly done for paediatric forearm trauma.[17] High PODCI outcome score corroborate the excellent/good results in this group. The PODCI outcome score was comparative between those who had less than 2 years follow-up and those with more than 2 years follow-up. Maximum functional score was achieved in 1 year. Routine follow-up for more than 1 year therefore seems unwarranted and should be for those children who have any growth-related issues. Flexible titanium nails are biocompatible with bone. The risk of long-term implant-related malignancy is extremely miniscule with no definite causal relationship.[25] In view of the long life of our patients, one expects the implant to be in situ for 50–80 years. We cannot scientifically justify removal of intramedullary elastic titanium nails, but prefer removing them after adequate surgery − implant exit interval of at least 1 year as a safer option.

Universal acceptance of flexible nailing as the state of the art technique for unstable paediatric forearm fractures has raised concerns over its overuse and abuse. Rare incidents of delayed union and pseudoarthrosis have been reported.[26],[27] In most cases, excessive soft tissue handling, open reduction, and technical error are the culprits. We did not encounter delayed fracture healing in our children.

Malunions, refractures, compartment syndromes, neurological and vascular injuries, and tendon ruptures because of chronic attrition and rare nonunions basically sums up the possible complications in paediatric forearm fractures.[10],[28],[29] Delayed union and nonunion have been described less frequently with conservative management of paediatric diaphyseal forearm fractures.[30] Most of these were not encountered in this case series. There was no nonunion or refractures in our case series.

Our series had three patients who developed paraesthesia over the superficial radial nerve distribution. Three patients had hypertrophied scars and one patient had superficial wound infection over the entry point of the ulna. There was one case wherein the distal radial physis was inadvertently damaged while removing the radial nail. She developed a medial and dorsal physeal arrest and had restriction of terminal 10° of wrist dorsiflexion. This incident occurred in a child in whom hardware exit was attempted through the previous scar but the distal-end radial nail had proximally migrated. This case highlights the need for careful planning and adequate supervision for even a relatively simple procedure of removing a forearm implant in children.

Considering the good results obtained in the grossly unstable and open diaphyseal fractures of paediatric forearm bones, we propose flexible intramedullary nailing as a useful method in our scenario, for internal stabilization of unstable paediatric forearm diaphyseal fractures.

  Conclusions Top

This series is too small to draw high-end conclusions for paediatric forearm fracture management. Having said that, based on the trends that we witnessed during the course of this study, we posit that ESIN is a safe and reliable method for internal fixation of unstable forearm fractures. Careful selection of nail size retains the correction obtained. We found that the lateral entry point for radial nail puts the superficial radial nerve at risk and a proximal transphyseal ulna insertion to bursitis. Deviation from the basic standard techniques is associated with complications.

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Conflicts of interest

There are no conflicts of interest.

  References Top

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Madhuri V, Dutt V, Gahukamble AD, Tharyan P. Conservative interventions for diaphyseal fractures of the forearm bones in children. Cochrane Database Syst Rev 2013;2013:CD008775.  Back to cited text no. 2
Anderson D, Sisk TD, Tooms RE, Park WI III. Compression plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am 1975;57:287-96.  Back to cited text no. 3
Hughston JC. Fractures of the forearm in children. An Instructional Course Lecture, the American Academy of Orthopaedic Surgeons. J Bone Joint Surg Am 1962;44-A: 1678-87.  Back to cited text no. 4
Fuller DJ, McMullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg 1982;64:364-7.  Back to cited text no. 5
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Gandhi RK, Wilson P, Mason-Brown JJ, Macleod W. Spontaneous correction of deformity following fractures of the forearm in children. Br J Surg 1962;50:5-10.  Back to cited text no. 7
Flynn JM, Sarwark JF, Waters PM, Bae DS, Lenke LP. The operative management of pediatric fractures of the upper extremity. J Bone Joint Surg Am 2002;84:2078-98.  Back to cited text no. 8
Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop 1990;10:167-71.  Back to cited text no. 9
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Pankovitch AM. Flexible intramedullary nailing of long bone fractures. A review. J Orthop Trauma 1987;1:78-95.  Back to cited text no. 13
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Daruwalla JS. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res 1979;139:114-20.  Back to cited text no. 16
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Shah AS, Lesniak BP, Wolter TP, Caird MS, Farley FA, Vander Have KL. Stabilization of adolescent both bone forearm fractures: a comparison of intramedullary nailing versus open reduction and internal fixation. J Orthop Trauma 2010;24:440-7.  Back to cited text no. 18
Richter D, Ostermann PA, Ekkernkamp A, Muhr G, Hahn MP. Elastic intramedullary nailing: A minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop 1998;18:457-61.  Back to cited text no. 19
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Bhasker A. Treatment of long bone fractures in children by flexible titanium elastic nails. Indian J Orthop 2005;39:166-8.  Back to cited text no. 22
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Ballal MS, Garg NK, Bruce CE, Bass A. Nonunion of the ulna after elastic stable intramedullary nailing for unstable forearm fractures; a case series. J Pediatr Orthop B 2009;18:261-4.  Back to cited text no. 26
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Lieber J, Joeris A, Knorr A, Schalamon J, Schmittenbecher PP. ESIN in forearm fractures, clear indications, often used, but some avoidable complications. Eur J Trauma 2005;31:3-11.  Back to cited text no. 28
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