Delayed Union and Nonunion Following Closed Treatment of Diaphyseal Pediatric Forearm Fractures

Abstract

Delayed unions and nonunions of diaphyseal pediatric forearm fractures are exceedingly uncommon. In the past they generally have been reported in conjunction with open fracture or initial operative management of these fractures. The authors report six cases that occurred in low-energy, closed fractures initially managed with casting. The cases all occurred in teenage patients from age 13 to 16, and all cases involved the ulna. The mid-diaphysis was the most common location, and this may represent a watershed zone of perfusion with a relatively poor intraosseous blood supply. All of these patients were managed with compression plating with or without bone grafting. Three of these patients had rapid healing in an average of 2 months, while one had an inadequate radiographic record and another was lost to follow-up. The other patient had a more prolonged course to healing after surgery.

Ulnar Nonunion After Osteoclasis for Rotational Deformities of the Forearm

“…9,10 Therefore nonunion of forearm fractures in children is rare, with reported nonunion rates as low as 0.03%. 11 Nonunion or delayed union of the ulna is a rare complication after osteotomy as well. Ulnar-shortening osteotomy is performed most commonly in adults, with union rates afterward of 74% to 100%.…”

“…17 Therefore there is a relative watershed zone at the junction of the proximal and middle thirds of the ulna just distal to the nutrient artery. 11,17 Fractures in this watershed zone of the ulna have been associated with poor healing. Szabo and Skinner 18 reported nonunions in 7 of 28 closed, isolated ulna fractures.…”

A Concert between Biology and Biomechanics: The Influence of the Mechanical Environment on Bone Healing

“…In 1931 Pitkin and Blackfield were the first surgeons to advocate bi-cortical pins attached to two external fixation clamps, as a bilateral frame to improve fracture healing. Anderson et al presented a series of papers from 1933–1945 (Anderson, 1935, 1938; Anderson and Burgess, 1943), outlining the use of both half-pins and transfixation pins for the treatment of various long bone fractures, arthrodesis, and limb lengthening procedures (Christian, 1998). These gradual incremental improvements have resulted in the designs currently available today, providing external fixators that come in three major configurations (Figure 7): circular (A–D), monorail (unilateral) (E–F) and hybrid (G–H).…”

Hypertrophic nonunion of the ulna in a child: treatment with an elastic stable intramedullary nail without bone graft

“…The mid-diaphyseal region has been identified as a “watershed area” in the intraosseous blood supply of the ulna [2, 4]. The periosteal blood supply from the anterior and posterior interoseous arteries is the main vascular supply to this region [4].…”

“…Compression plating to treat nonunion has been advocated by several authors [2]. Two cases of nonunion reported by Moez et al were both treated with plating following removal of ESIN [9].…”