Esin- a gold standard for the management of forearm fractures in children

Transcription

1 Original Article Esin- a gold standard for the management of forearm fractures in children Mahesh Goyal*, Radhe Shyam Garg**, Rajesh Kapila*** * Junior resident,** Associate professor, ***Associate professor Department of Orthopaedics Government Medical College, Amritsar, Punjab ABSTRACT Forearm fractures are common in children and the fractures if remain inadequately reduced after closed reduction require internal fixation to achieve optimal functional outcome. Aim of the study is to evaluate the role of flexible intramedullary nails in forearm fractures in children.the forearm fractures in 30 children were fixed with flexible intramedullary nails under general anaesthesia. There were 27 males and 3 females. The POP above elbow POP splint was given from 10 days to 3 weeks after operation depending upon fracture type.the mean operating time was minutes. There was no restriction of movement except for 3 (10%) patients who had loss of forearm movements (pronation/supination) of less than 200. There was no major complication other than superficial nail tract infection in 3 (10%) patients. The mean time of fracture union was 9 weeks. All patients had excellent functional outcome.the fixation of forearm fracture with flexible intramedullary nails in children is a promising method of fixation as it has minimal complications, high union rates and excellent functional outcome. Keywords: CRIF (Closed reduction internal fixation), ORIF (Open reduction internal fixation), K-wires, Flexible intramedullary nails/ ESIN (Elastic Stable Intramedullary Nails). INTRODUCTION Fractures of forearm bones are common in children; the incidence is about 1 in These fractures are more common in 6-16 years old children, with higher incidence in older children between years of age 2. The forearm fractures in older children are difficult to manage because of the following reasons: 1. These fractures tend to be more proximal in older children 3 and many experienced clinicians have pointed out increasing difficulty in treatment of such fractures 3,4. 2. Forearm fractures treated by closed reduction and POP cast immobilisation tend to redisplace more commonly in older children probably due to more proximal location of fracture. Corresponding Author : Dr Mahesh Goyal, 52- Rose Avenue, Malerkotla Disst. Sangrur, Punjab. maheshgoyal@yahoo.com Therefore there lies the need of managing forearm fractures in children with closed reduction and internal fixation with devices such as Elastic Stable Intramedullary Nails (ESIN). The primary mechanism of injury in radial and ulnar shaft fractures is a fall on an outstretched hand that transmits indirect force to the bones of the forearm leading to fracture of radius and ulna at same or different levels 5 and fractures at different levels occur due to rotational component of injury. Deformity and pain are the classic findings. In the past, the gold standard of management of forearm shaft fractures in children had been closed reduction 6 and POP cast immobilization. Because of higher chances of redisplacement in cast especially in older children particularly years old and in fractures which tend to be proximal, there has been shift of trend of managing these fractures from closed reduction and POP cast immobilization to reduction and fixation with Intramedullary or extramedullary devices. Currently, intramedullary fixation is the preferred method of internal fixation of forearm fractures in children As compared to intramedullary fixation, ORIF with plates and screws has got several disadvantages such as large incisions 36

2 Garg et al with poor cosmesis, more soft tissue dissection, higher incidence of infections and difficult removal. As far as Intramedullary fixation is concerned there are several impants such as k-wires, Steinmann pin and rush nails but they have their own disadvantages such as these implants pass through physis, provide no three point fixation and no early mobilization is possible. Because these disadvantages, ESIN has now become very popular method for managing forearm fractures in children. Advantages of ESIN over k-wires include: Three point fixation Spares physes Maintains radial bow MATERIAL AND METHODS 30 Children with both bones or single bone displaced (angulated >200 and displaced >50%) forearm fractures, in age between 6-16 years who had failure of closed reduction, were included in studi conducted in our department. Majority of them were between years (60%) with mean age of 11.6 years. Out of 30 children, 27 were males (90%) and 3 were females (10%). 28 children out of 30 were brought to the hospital within 24 hours of injury. 24 children sustained injury by a fall on outstretched hand while playing (80%) and 6 children suffered injury in a road traffic accident (20%). 21 children had fracture both bones of forearm (70%) and 9 had fracture single bone of forearm (30%) out of which 7 had fracture of radius (24%) and two had fracture of ulna (6%). The thickness of the nail was decided on diameter of narrowest potion of medullary canal of forearm bones which is middle third in radius and distal third in ulna. The thickness of the nail used in study varied between 2.0mm to 3.5 mm. SURGICAL TECHNIQUE The nailing procedure was performed under general anaesthesia with patient in a supine position and affected arm on a side table. A tourniquet was applied to the upper arm and was inflated only if an open reduction of the fracture was required. For the ulna, the stab incision was made on the proximal end of forearm over lateral surface of the olecranon 2 cm distal to physis under fluoroscopy. An awl was introduced to make an oblique entry hole in the ulna 2 cm distal to olecranon physis. The nail was which was prebent at 300 at the tip was introduced in the oblique entry hole and gently negotiated and pushed distally. Fluoroscopy was used during reduction. If required, fracture site was exposed by a small incision and reduction accomplished. The bent tip of pin aided in the reduction and the pin was pushed into the distal ulna, stopping short of the physis under the guidance of fluoroscopy. The pin was cut close to the bone, leaving enough end for easy removal later but without any tenting the skin. The skin was closed over the cut end. Skin over the incision made for exposing the fracture, if given, was closed too. For the radius, a 2 cm long incision was made on the dorsal aspect of distal end of forearm over the radius medial to lister s tubercle proximal to the radial physis under fluoroscopy. A blunt dissection was made to avoid superficial branch of radial nerve and extensor tendons. An oblique entry hole was similarly made over dorsal aspect of radius as in case of ulna. The prebent nail was advanced through fracture site as in case of ulna and was stopped short of the physis, at the level of bicipital tuberosity. The POP splint after operation was given to all patients. Stitches were removed on 10th day and splint was continued depending on stability of fracture for more more comminuted fractures. It was continued upto 3 weeks otherwise it was discarded after 10 days and active movements were encouraged. EVALUATION Patients were followed up at 3, 6, 9, 12, 18 and 24 weeks after the operation. The patients were evaluated for range of movement at wrist, elbow and forearm, time taken by fracture to unite and pain. Each criterion was given score between1-4 as tabulated below. Radiological union was defined as bony trabeculae traversing the fracture 11. The maximum possible score was 20 and minimum possible score was 5. The functional outcome was scaled excellent, good, fair or poor according to the following table: RESULTS Right forearm was fractured in 18 children (60%) and left forearm was fractured in 12 children (40%). Out of 30 forearm fractures, 27 were closed fractures (90%) and 3 were open Gustillo and Anderson type I fractures (10%). Functional Outcome Score Excellent Good Fair 9-12 Poor?8 37

3 Esin- a gold standard for the management of forearm fractures in children Score Criterion Loss of range Loss of Flexion or < ?310 of motion Extension at Wrist Loss of Flexion or < ?310 Extension at Elbow Loss of Supination or < ?910 pronation at Forearm Union (in weeks)?9 >9-?12 >12-?18 >18 Pain No pain Mild pain with Mild pain with Pain strenuous daily routine even physical activity at rest activity Fig 1. Preoperative Fig 2. Postoperative Fig 3. Showing union There was fracture of shaft of forearm bones at proximal 1/3rd in 10 (30%) patients (Fig. 1). Among these 10 patients two were among age group of 6-10 years and eight were among age group of years. There was fracture of shaft of forearm bones at middle 1/3rd in 15 (50%) patients. Among these 15 patients 4 were among age group of 6-10 years and 11 were among age group of years. There was fracture of shaft of forearm bones at distal 1/3rd in 5 (16.66%) patients. All these patients were among age group of 6-10 years. Closed reduction and internal fixation (CRIF) of forearm fractures was accomplished in 24 (80%) patients. However, six (20%) patients required limited open reduction and internal fixation (ORIF). All cases which required ORIF were single bone fractures involving radius only. The duration of surgery (from incision to closure of 38

4 Garg et al wound) was less than or equal to 30 minutes in 24 patients and all these patients had closed reduction and internal fixation. The operating time was more than 30 minutes in 6 (20%) patients and all these patients had open reduction and internal fixation. The operating time ranged between minutes with mean operating time being minutes. In early postoperative period, no patient had compartment syndrome or nerve palsy. Three (10%) patients had superficial infection and none had compartment syndrome, nerve palsy, deep infection, malunion, nonunion or rupture of tendon. At final follow up, no patient had any pain at fracture site even with strenuous activities like participation in sporting activities. At final follow up none had any loss of movement at wrist and elbow. At final follow up, 27 (90%) patients had loss of movement at forearm by less than 100, 3 (10%) patients had loss of movement at forearm by and no patient had loss of movement at forearm by more than 300 (supination/pronation). There was evidence of radiological union of fracture at 6 weeks in 3(10%) patients (Fig 2). There was evidence of radiological union of fracture at 9 weeks in 24(80%) patients. There was evidence of radiological union at 12 weeks in remaining 3 (10%) patients. The average time for union of fracture was 9 weeks (Fig 3). All 30 patients had excellent results comprising 100% of total patients (Fig 4-9). DISCUSSION The majority of children with forearm fractures were in age group of years constituting 63.33% of total patients with mean age of 11.6 years. The remaining patients (40%) were in age group of 6-10 years. This is in accordance to studies conducted by Garg NK et al (2008) 12 (11.8 years) and Qidwai Fig 4. Full dorsiflexion at left wrist. Fig 5. Full palmarflexion at left wrist Fig 6. Full extension at left elbowphotograph Fig 7. Full flexion at left elbow 39

5 Esin- a gold standard for the management of forearm fractures in children Fig 8. Full pronation at left forearm Fig 9. Full supination at forearm SA (2001) 13 (11 years). Relative increased occurrence in older children (11-16) can be due to their more participation in outdoor sporting and playful activities. There were 27 male children with forearm fracture constituting 90% of total patients and three female children with forearm fracture constituting 10% of total patients. This is in accordance to study conducted by Mohammed H et al (2009) 14 in which males comprised 90.5% and females comprised 9-5% of total patients. In most of the other studies, males outnumbered females, but this was not to such an extent. This can be due to the reason that study conducted by Mohammed H et al was in an Islamic country wherein social preference is given to male child and male children are much more involved in outdoor activities and here in India too, such conditions prevail. There were 28 (93.33%) patients who were brought to hospital within 24 hours following injury. There were two (6.67%) patients who were brought to hospital within 1 week following injury (on 6th day). Early reporting of patients to hospital can be due to the fact that parents are more worried and concerned in case of child who is in lots of pain because of fracture. Because of illiteracy and ignorance prevalent in region, many a times children are taken to quacks and such patients report to hospitals so late that malunion has already occurred and such cases were not included in study. The mode of injury was fall on outstretched hand, mostly while playing, in 24 (80%) patients. The mode of injury was road side accident (RSA) in 6 (20%). This is in accordance to study conducted by Aktas S et al (1999) 15 in which mode of injury was fall while playing in 80% of patients and road side accident in 20% of patients. This can be due to the fact that children are more involved in playful activities with their peers in and around their houses and get injured during such activities and also children are not usually allowed by parents to go alone on roads on bicycles or otherwise, at distant places. There were 18 fractures of forearm on right side constituting 60% of total patients and there were 12 fractures of forearm on left side constituting 40% of total patients. This observation indicates slight predominance on right side, which is in accordance to study conducted by El-Khadrawe TA (2006) 16 on 14 children with forearm fractures wherein 8 (57.1%) patients had injury on right side and 6 (42.9%) patients had injury on left side. There were 27 simple (closed) fractures constituting 90% of total patients. There were three compound (open) fractures (Gustilo and Anderson grade I) constituting 10% of total patients. This is in accordance to study conducted by Kang SN et al (2011) 17 in which 9% patients had open fracture and remaining (91%) were closed. This can be due to the fact that the injuries in children are low energy injuries. The majority of fractures of forearm bones were both bone fractures in 21 patients (70%).There were 9 (30%) single bone fractures of forearm out of which 7(23.33%) were of radius and two (6-67%) were of ulna. This is because forearm bones are more commonly fractured as a result of transmission of indirect forces while falling on outstretched hand to forearm which has additional rotational component resulting in both bone fracture. Direct injury results in single bone fracture, which is relatively rare in children. There was fracture of shaft of forearm bones at proximal 1/3rd in 10 patients (33.33%). Among these 8 patients, two were among age group of 6-10 years and 8 were among age group of years. There was fracture forearm at middle 1/3rd in 15 (50%). Among these 15 patients, 4 were among age 40

6 Garg et al group of 6-10 years and 11 among age group of years. There was fracture forearm at distal 1/3rd in 5 (16.67%) who were in age group of 6-10 years. The incidence of proximal third fractures was similar in study conducted by Celebi L et al (2007) 18 in which mean age of patient was 10.6 which is similar to mean age group of our study (11.6). These findings are indicative of the fact that proximal fractures are more likely to occur in older children (>10 years) and distal fractures are more common in younger children (<10 years). Closed reduction and internal fixation with flexible intramedullary nails was accomplished under fluoroscopy in 24 patients (80%) comprising of total patients. However, 6 patients (20%) mostly with single bone fractures involving radius, required open reduction and internal fixation. This is in accordance to study conducted by Mohammed H et al (2009) 14 on 21 children with forearm fractures in which 4 patients (19%) had open reduction and internal fixation with ESIN and 19 patients had closed reduction and internal fixation with ESIN. This is due to the fact that radius is difficult to manipulate while doing CRIF in case only radius is fractured and often ORIF is required. The operating time ranged between minutes with mean operating time being minutes. This is more or less in accordance to study conducted by Ali AM et al (2010) 19 on children with forearm fractures managed by ESIN in which mean operating time was 36 minutes. The least 15 minutes was taken in single ulna bone fracture. Three (10%) patients had infection which was superficial at entry point of nail. In late postoperative period and none had deep infection, malunion, nonunion, refracture or nail migration, compartment syndrome, nerve palsy or rupture of tendon. This is in accordance to the study by Berger P et al (2005) 20 in which there was superficial infection in 6% (2 out of 30) patients with no report of deep infection, compartment syndrome, nerve palsy, nonunion, malunion, refracture or nail migration. The average time for union of fracture was 9 weeks whereas the average time for union of fracture was 7 weeks in a study conducted by Kapoor V et al (2005) 11 on forearm fractures in children treated by ESIN. The difference could be due to our follow up interval which was at 3, 6, 9, 12, 18 and 24 weeks. At 24 weeks, no patient had any pain at fracture site even with strenuous activities like participation in sporting activities. These findings are in accordance with study by Ali AM et al (2010) 19. At 24 weeks none had loss of movement at wrist and elbow. This is in accordance to study conducted by Fernandez FF et al (2005) 21 which was done to compare outcome between plating and nailing (ESIN) in forearm fractures in children wherein there was no restriction of movement at wrist and elbow in group of patients managed by ESIN. At 24 weeks, 27 (90%) patients had loss of movement at forearm by less than 10 0, 3 (10%) patients had loss of movement at forearm by and no patient had loss of movement at forearm by more than 300. The final results of movement at forearm at 24 weeks in study are in accordance to similar study conducted by Kapoor V et al(2005) 11, in which 16% of patients had loss of motion at forearm. All 30 patients had excellent results in terms of fracture union and functional recovery. The final result is in accordance with study conducted by Kanellopoulos AD et al (2005) 22 in which all patients had excellent results. CONCLUSION From the above study we conclude that fixation of pediatric forearm fractures with flexible intramedullary nails is easy, safe, reproducible and highly promising method of fixation with negligible complications in trained hand. We strongly believe that this method of CRIF with ESIN will probably become a gold standard in times to come in view of highly satisfying and excellent results especially in older children. We also strongly recommend removal of ESIN at the earliest compatible with radiological evidence of strong union in forearm bones, anytime after 4 months to avoid possible complications of ESIN incorporation in the bone and angulatory deformity of forearm bone if left unremoved. REFRENCES 1. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg 2001; 26A: Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6493 fractures. J Pediatr Orthop 1999; 19 (3): Creasman C, Zaleske DJ, Ehrlich MG. Analyzing forearm fractures in children: the more subtle signs of impending problems. Clin Orthop Relat Res 1984; 188: Ostermann PA, Richter D, Mecklenburg K, Ekkernkamp A, Muhr G, Hahn MP. Pediatric forearm fractures: indications, technique, and limits of conservative management. J Orthop Trauma 2000; 14 (1): McGinley JC, Hopgood BC, Gaughan JP, Sadeghipour K, Kozin SH. Forearm and elbow injury: the influence of rotational position. J Bone Joint Surg Am2003; 85-A (12): Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 1999; 19(6):

7 Esin- a gold standard for the management of forearm fractures in children 7. Calder PR, Achan P, Barry M. Diaphyseal forearm fractures in children treated with intramedullary fixation: outcome of K-wires versus elastic stable intramedullary nail. Injury 2003; 34 (1): Kucukkaya M, Kabukcuoglu Y, Tezer M, Eren T, Kuzgun U. The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures. J Orthop Trauma 2002; 16 (5): Lee S, Nicol RO, Stott NS. Intramedullary fixation for pediatric unstable forearm fractures. Clin Orthop Relat Res 2002; 402: Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998; 18 (4): Kapoor V, Theruvil B, Edwards SE, Taylor GR, Clarke NMP, Uglow MG. Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children. Injury, Int. J. Care Injured 2005; 36 (10): Garg NK, Ballal MS, Malek IA, Webster RA, Bruce CE. Use of elastic stable intramedullary nailing for treating unstable forearm fractures in children. J Trauma 2008; 65 (1): Qidwai SA. Treatment of diaphyseal forearm fractures in children by intramedullary Kirschner wires. J Trauma 2001; 50 (2): Mohammed H, Salloom F, Albagali M, Aljahromy I. Flexible Intramedullary Fixation of Pediatric Forearm Fractures - Report on Twenty-One Patients. Bahrain Med Bull 2009; 31 (1). 15. Aktas S, Saridogan K, Moralar U, Ture M. Patterns of single segment nonphyseal extremity fractures in children. Int Orthop 1999; 23 (6): El-Khadrawe TA. Elastic intramedullary titanium rod fixation of pediatric forearm fractures. Bull Alex Fac Med 42 no. 4, Kang SN, Mangwani J, Ramachandran M, Paterson JM, Barry M. Elastic intramedullary nailing of paediatric fractures of the forearm: a decade of experience in a teaching hospital in the United Kingdom.The Journal of Bone and Joint Surgery. British Volume 2011; 93 (2): Celebi L, Muratli HH, Doðan O, Yagmurlu MF, Aksahin E, Bicimoglu A. The results of intramedullary nailing in children who developed redisplacement during cast treatment of both-bone forearm fractures. Acta Orthop Traumatol Turc 2007; 41 (3): Ali AM, Abdelaziz M, El-Lakanney MR. Intramedullary nailing for diaphyseal forearm fractures in children after failed conservative treatment. Journal of Orthopaedic Surgery 2010; 18(3): Berger P, De Graaf JS, Leemans R. The use of elastic intramedullary nailing in the stabilisation of paediatric fractures. Injury, Int. J. Care Injured 2005; 36 (10): Fernandez FF, Egenolf M, Carsten C, Holz F, Schneider F, Wentzensen A. Unstable diaphyseal fractures of both bones of the forearm in children: Plate fixation versus intramedullary nailing. Injury, Int. J. Care Injured 2005; 36 (10): Kanellopoulos AD, Yiannakopoulos CK, Soucacos PN. Flexible intramedullary nailing of pediatric unstable forearm fractures. Am J Orthopaedic 2005; 34 (9):