Intramedullary Fixation of Radial and Ulnar Shaft Fractures in Skeletally Immature Patients
Maya E. Pring, MD
Hilton P. Gottschalk, MD
Henry G. Chambers, MD
Dr. Pring or an immediate family member serves as a board member, owner, officer, or committee member of the American Academy for Cerebral Palsy and Developmental Medicine and the Pediatric Orthopaedic Society of North America. Dr. Chambers or an immediate family member serves as a paid consultant to or is an employee of Allergen and OrthoPediatrics and serves as a board member, owner, officer, or committee member of the American Academy of Orthopaedic Surgeons, the American Academy for Cerebral Palsy and Developmental Medicine, and the Pediatric Orthopaedic Society of North America. Neither Dr. Gottschalk nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter.
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The vast majority of pediatric forearm fractures can be treated nonoperatively. Pediatric fractures heal much more quickly and have remodeling potential so when the physes are open, anatomic alignment of the fracture is not always necessary (see Table 1
furthermore, because children rarely have difficulty with stiffness, early mobilization is not as important as it is with adults.2
The small percentage (˜10%) of pediatric forearm fractures that require surgical fixation are treated differently than similar fractures in adults. Adult forearm fractures are commonly fixed with plates and screws to maintain alignment and allow early mobilization to prevent stiffness. Although it is an option, plates and screws are not as commonly used in the skeletally immature patient for the following reasons: they disrupt the periosteal blood supply and fracture hematoma, which may alter the healing potential, and they create a stress riser both while the plate is in place and once it is removed, which leads to increased risk of repeat fracture as children return to regular activities. Intramedullary (IM) fixation is a minimally invasive and relatively safe method of fixing pediatric forearm fractures that are not amenable to routine casting. This technique minimizes soft-tissue disruption and scarring and allows for easy implant removal. However, the reported rate of complication with this procedure is between 14 and 21%.3,4
The complication rate increases with increasing age of the patient.5
No significant difference has been found in complication rates of intramedullary nails (IMN) when compared with plates and screws.6
TABLE 1 General Guidelines for Acceptable Values in Both-Bone Forearm Fractures
Younger than 9 yr
9 yr or older with >2 yr of growth remaining
≤10° for proximal fractures, ≤15° for distal fractures
Data from Noonan KJ, Price CT: Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998;6(3):146-156.
Diagnostic imaging includes AP and lateral radiographs of the forearm and dedicated views of the wrist and the elbow to ensure that the proximal radioulnar joint (PRUJ) and the distal radioulnar joint (DRUJ) are intact. A Monteggia fracture (ulnar fracture with dislocation of the radiocapitellar joint) (Figure 2
) or a Galeazzi fracture (radial fracture with dislocation of the DRUJ) is easily missed if the joints above and below the fracture are not
carefully examined radiographically. The dislocation may occur far from the fracture and be missed by a radiograph centered on the deformity.
FIGURE 2 Radiographs demonstrate the importance of imaging adjacent joints. A, Lateral radiograph of forearm shows an ulnar shaft fracture and a distal radial buckle fracture. B, Dedicated lateral radiograph of the same patient’s elbow shows a Monteggia variant and a dislocation of the proximal radiocapitellar joint.
FIGURE 3 Illustration shows the operating room setup for intramedullary fixation of a forearm fracture.
Distal Forearm Fractures: Both-Bone Forearm Fracture Intramedullary Nailing: Step 1. Kelly D. Carmichael, MD; Chris English, MD (25 min)
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