Pediatric Forearm Refracture with Intramedullary Nail Bending In Situ: Options for Treatment

Zhamilov, Vadym; Reisoğlu, Ali; Basa, Can Doruk; Kaçmaz, İsmail Eralp; Ağuş, Haluk

doi:10.7759/cureus.6744

Cited by 3 publications

(5 citation statements)

References 16 publications

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Section: Discussionsupporting

confidence: 66%

“…Similar to the present study, there are many descriptions of forearm fractures with retained ESINs being treated with closed reduction and immobilization in the literature, sometimes under general anesthesia. 7,13,15,17,22,24 Han et al 10 recommends fractures with retained ESIN with <20 degrees angulation undergo closed reduction and casting, while those with over 20 degrees angulation undergo ESIN removal and reinsertion of new ESINs after reduction. The biomechanical rationale for this approach is that there is no macroscopic evidence of metal fracture or fatigue after 1 cycle of an ESIN being reverse bent to 21 degrees, however, the average force required for permanent deformation of a previously bent nail was reduced by 37% for both titanium and stainless steel nails (21 to 13.2 N and 25 to 15.7 N, respectively).…”

Section: Discussionmentioning

confidence: 99%

“…10,[15][16][17][18] The treatment of these subsequent fractures has been anecdotally described in the literature. For example, refracture with retained ESIN has been treated with in situ ESIN closed reduction and casting, 15,[21][22][23] exchange nailing, 16,24 as well as ESIN removal and plating. 16 Alternatively, refracture with retained plate has been treated with closed reduction and casting, plate removal and ESIN, or revision plating.…”

mentioning

confidence: 99%

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Subsequent Forearm Fractures Following Initial Surgical Fixation

Lindgren

Sendek

Manhard

et al. 2023

Journal of Pediatric Orthopaedics

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Introduction: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. Methods: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. Results: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort (P=0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site (P<0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P=0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. Conclusions: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. Level of Evidence: Level IV—retrospective case series.

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Section: Discussionsupporting

confidence: 66%

Section: Discussionmentioning

confidence: 99%

mentioning

confidence: 99%

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Subsequent Forearm Fractures Following Initial Surgical Fixation

Lindgren

Sendek

Manhard

et al. 2023

Journal of Pediatric Orthopaedics

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“…The most common mechanisms of refracture were falls, wheeled vehicle use and playground activities. The median average time to refracture was 5 months (range 1 month ‐ 8 years) 5,11,12,18–23,25–31,35,36,38–40,43–45,47,48,51,53,54 . Only one study documented an average time to refracture greater than 9 months, recording an average of 20 months 51 .…”

Section: Resultsmentioning

confidence: 99%

“…The median average time to refracture was 5 months (range 1 month -8 years). 5,11,12,[18][19][20][21][22][23][25][26][27][28][29][30][31]35,36,[38][39][40][43][44][45]47,48,51,53,54 Only one study documented an average time to refracture greater than 9 months, recording an average of 20 months. 51 This may be because this was a study of unstable fractures.…”

Section: Patient Detailsmentioning

confidence: 99%

Re‐fractures of the paediatric radius and/or ulna: A systematic review

Bhanushali

Axelby

Patel³

et al. 2021

ANZ Journal of Surgery

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Background: Fractures of the radius and/or ulna are one of the most common injuries in children. Evidence identifying risk factors for refracture, however, has not been summarised in a systematic review. Guidance for counselling patients and parents to minimise the risk of refracture is limited. The aims of this study are to 1) to determine if casting time 6 weeks or less is a risk factor for refracture after paediatric radius and/or ulna fractures, 2) to identify other risk factors for refracture after paediatric radius and/or ulna fractures and 3) to develop more accurate guidelines for counselling parents after a radius and/or ulna fracture in their child. Methods: A thorough search was performed in accordance with the Joanna Briggs Institute (JBI) guidelines for systematic review. JBI Critical Appraisal checklists were used for risk of bias assessment. Results: Diaphyseal both-bone fractures treated non-surgically should be casted for longer than 6 weeks. Surgically treated patients can be casted for less than 6 weeks. Diaphyseal and greenstick fractures have a higher risk of refracture. Residual angulation and incomplete healing in greenstick fractures may lead to a higher risk of refracture. Gender does not affect refracture risk. Falls, use of wheeled vehicles, playground activities and trampolining confer high-risk of refracture. Refracture risk is greatest up to 9 months from initial fracture. Conclusion: Further case-controlled studies with sub-group analysis are required to further investigate risk factors for refracture after radius and/or ulna fractures in children.

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Case Report of Both Bone Forearm Refracture in an 8-year-old Girl

Daccache¹,

Bassil²,

Badra³

et al. 2022

JOCR

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Introduction: Pediatric both bone forearm fracture is a common injury in children. A multitude of current treatments are available, with Titanium Elastic Intramedullary Nail system becoming very popular. The advantages of this treatment are many; however, refracture of these nails in situ is a reported uncommon complication, and there is a paucity in the literature on the appropriate management in these cases. Case Report: An 8-year-old girl suffered from a left both bone forearm fracture after a fall from height, for which she was treated with the use of Titanium Elastic Intramedullary Nail system. Despite callus formation and fracture healing on X-rays, the nails were not removed at the intended time of 6 months due to the economic status of the country and the viral outbreak of COVID-19. Therefore, after 11 months of fixation, the patient presented again after a fall from height with the left both bone forearm refracture with the Titanium Elastic Intramedullary Nail system in situ. Intraoperative closed reduction was achieved with removal of the previous bent nails and refixation with new elastic nails. Follow-up of the patient 3 weeks later revealed satisfactory reduction with callus formation. Conclusion: Pediatric both bone forearm refracture with Titanium Elastic Intramedullary Nail system in situ can be treated by gentle closed reduction and exchange nailing. This is not the first case to be managed with exchange nailing; however, it is one of the very few to have been treated as such and therefore these cases must be reported for further comparison with the different methods described in the literature to attain the optimal modality of treatment. Keywords: Both bone forearm refracture, titanium elastic intramedullary nail system in situ, exchange nailing.

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Pediatric Forearm Refracture with Intramedullary Nail Bending In Situ: Options for Treatment

Cited by 3 publications

References 16 publications

Subsequent Forearm Fractures Following Initial Surgical Fixation

Subsequent Forearm Fractures Following Initial Surgical Fixation

Re‐fractures of the paediatric radius and/or ulna: A systematic review

Case Report of Both Bone Forearm Refracture in an 8-year-old Girl

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