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Year |
2002 |
|---|---|
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Question Number |
167. |
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Category |
Pediatric Orthopaedics |
Question
A 15 year old boy has a both-bone forearm fracture of the forearm. Radiographs after closed reduction are shown in figure 45. management should consist of:
1- A long arm cast
2- A short arm cast
3- A functional brace
4- Open reduction and internal fixation
5- Repeat closed reduction
Figures
Answer (click for answer)
Preferred response: (4) open reduction and internal fixation.
The AP and lateral xrays of a splinted forearm demonstrate a middle third, trasverse fracture of the radius, with minimal angulation and almost 100% displacement, and a minimally displaced and angulated middle third fracture of the ulna in a nearly skeletally mature patient.
Fractures of the middle third of the forearm rarely require open reduction, especially in younger children in whom significant fracture remodeling can be expected. Vittas, Larsen, and Torp-Pedersen emphasized the importance of the physis in fracture remodeling in children, noting that this importance decreases in late childhood and is less pronounced in the midshaft than in the distal forearm. Their study correlated with the experimental study by Karaharju, Ryoppy, and Makiner, who found that physeal growth plays an important role in the remodeling process of diaphyseal fractures in animals and that despite a lack of correction of fracture angulation, correction at the physis occurred as a secondary reaction to angulation. Price et al., in a study of 39 malunited diaphyseal both-bone forearm fractures, found that distal fractures had a better prognosis than more proximal fractures. In their patients, mild loss of forearm rotation was not disabling. They recommend closed reduction as the treatment of choice for skeletally immature patients with diaphyseal fractures of the radius and ulna, and note that rotational alignment should be accurately restored, using the position of the radial tuberosity as a guide. Although anatomical alignment is ideal, Price et al. believe that 40 degrees of malrotation, 10 degrees of angulation, complete displacement, and loss of radial angle can be accepted rather than resorting to open reduction.
According to Weber, Brunner, and Frueler, operative treatment is indicated for (1) an open fracture, (2) fracture in an older child (shortly before maturity), (3) malunion, (4) a fracture that is irreducible because of soft tissue interposition, or (5) multiple refractures occurring in a short period of time. We agree with Nielson and Simonsen that open reduction also is indicated in an older child when several attempts at closed reductions have failed. As King has noted, in an older child when remodeling is not expected, open reduction and internal fixation are preferable to malunion and loss of motion. Fuller and McCullough noted that, with gross malunion, correction of the deformity did not occur in girls after 8 years of age or in boys after 10 years of age. Although the complications of infection and scar formation may be more likely, open reduction with internal fixation is preferable to open reduction without internal fixation; the use of internal fixation avoids the complications of nonunion or recurrence of the malposition. Of the 177 fractures of the forearm in children in our series, only two had open reduction and internal fixation, and both were middle third fractures in older children with malreductions after several closed attempts; both had internal fixation with compression plates. The technique of open reduction and internal fixation for both-bone fractures is described in Campbell’s Operative Orthopedics. The compression plate should not cross an open physis, even in an older child. Vainionpaa et al. used small compression plates, one third tubular plates, and medullary Kirschner wires for fixation in 14 patients with severely displaced diaphyseal fractures of both bones of the forearm. They recommend open reduction and internal fixation for all severely displaced fractures of the forearm.
Lascombes et al. obtained excellent results and full ranges of motion in 92% of 85 children with forearm fractures treated with elastic intramedullary nails. They recommend this fixation for displaced forearm fractures in children older than 10 years of age and in younger children when conservative treatment fails. Verstreken, Delronge, and Lamoureux reported good results with medullary nailing of completely displaced shaft fractures in six children. They recommend closed nailing through a distal approach to avoid extensive dissection and to allow motion of the extremity immediately after surgery. Compression plate fixation techniques may be used in older children as in adults, but the physis must be avoided. It must be remembered that open reduction may result in nonunion, infection, nerve injury, ischemic contracture, or radioulnar synostosis. Voto, Weiner, and Leighley recommend the use of pins and plaster to avoid open reduction and internal fixation or medullary nailing of unstable forearm fractures in children. They used pins through the second metacarpal and the olecranon in the treatment of 20 fractures, and all healed in satisfactory alignment.
Reference: Verstreken L, Delronge G, Lamoureux J: Shaft forearm fractures in children: intramedullary nailing with immediate motion. A preliminary report. J Pediatr Orthop 1988;8:450-3.
Price C, Phillips J, Devito D: Management of fractures, in Morrissy RT, Weinstein Sl (ed): Lovell and Winter’s pediatric orthopeadics, ed 5. Phila, PA Lippincott Williams and Wilkins, 2001, 1319-1422.
Canale ST. Campbell’s operative orthopedics, 9th ed. 1998; 2380-1.