|Year : 2016 | Volume
| Issue : 4 | Page : 347-351
Closed reduction and Nancy nail fixation for forearm fractures in children
Ahmed El Naggar, Molham M Mohammad
Department of Orthopedics, Cairo University, Giza, Egypt
|Date of Submission||01-Sep-2013|
|Date of Acceptance||30-Dec-2013|
|Date of Web Publication||27-Jun-2017|
Molham M Mohammad
84 Road No. 10; Maadi, Cairo
Source of Support: None, Conflict of Interest: None
Background Forearm fractures in children are common. Children forearm fractures are managed differently than are similar injuries in adults. Treatment alternatives of irreducible unstable pediatric forearm fractures are closed remanipulation under general anesthesia and casting, Kirschner wire and casting, closed or miniopen reduction and intramedullary fixation, and open reduction and internal fixation with plates. The intramedullary nail fixation is preferable in many circumstances to open reduction and plating of the forearm bones as it prevents stripping of the soft tissues; in addition, there is little in the way of surgical scar tissue and is therefore cosmetically acceptable.
Patients and methods Thirty-six [32 (88.8%) boys and four (11.2%) girls] patients with fractures of both bones of the forearm were treated with elastic stable intramedullary nails. The surgery was performed within 20 h (range: 12 h–2 days). The fractures were classified according to the Orthopedic Trauma Association classification. All operations were carried out under general anesthesia and under an image intensifier control. Closed manipulation of fractures was performed to correct the length, rotation, and angulation. Blunt-ended 1.5–2.5-mm diameter titanium nails were used. An above elbow splint was applied.
Results Functional results were evaluated according to the criteria of Price and colleagues. An excellent result was achieved in 30 (83.3%) patients and a good result in six (16.7%) patients. Three (8.3%) patients had olecranon bursitis due to irritation of the nail, which was resolved after nail removal. Two (5.6%) patients had superficial wound infection (redness and hotness) at the entry site of radial nail and were treated with repeated dressings and empirical antibiotics for 10 days.
Conclusion The advantages of an elastic intramedullary nail fixation for the radius and ulna fractures are that it is technically straightforward, allows a high rate of osseous consolidation, is minimally invasive, and allows early mobilization.
Keywords: children, fractures, Nancy nails, radius and ulna
|How to cite this article:|
El Naggar A, Mohammad MM. Closed reduction and Nancy nail fixation for forearm fractures in children. Egypt Orthop J 2016;51:347-51
|How to cite this URL:|
El Naggar A, Mohammad MM. Closed reduction and Nancy nail fixation for forearm fractures in children. Egypt Orthop J [serial online] 2016 [cited 2018 Sep 23];51:347-51. Available from: http://www.eoj.eg.net/text.asp?2016/51/4/347/209004
| Introduction|| |
Forearm fractures in children are common. Diaphyseal fractures of the forearm account for ∼13% of all pediatric fractures ,. In boys, there is a bimodal peak, the first at approximately age 9 years and the second at ∼13 or 14 years. Girls show a single peak at approximately age 5 or 6 years. Children forearm fractures are managed differently than are similar injuries in adults. Historically, the results of nonoperative treatment of adult forearm fractures have been poor, with reports of nonunion, malalignment, and stiffness due to the lengthy immobilization required for union. Currently, most adults with both-bone forearm fractures are treated by open reduction and internal fixation. In pediatric patients, treatment is primarily nonoperative because of rapid healing and the potential for remodeling of residual deformity. A small proportion (3–4%) is unstable and requires operative intervention .
Treatment alternatives of irreducible unstable pediatric forearm fractures are closed remanipulation under general anesthesia and casting, Kirschner wire and casting , closed or miniopen reduction and intramedullary fixation , and open reduction and internal fixation with plates .
The intramedullary nail fixation is preferable in many circumstances to open reduction and plating of the forearm bones as it prevents stripping of the soft tissues; in addition, there is little in the way of surgical scar tissue and is therefore cosmetically acceptable .
The aim of our study was to evaluate the Nancy nails (elastic stable intramedullary nail) fixation as a modality of treatment for fractures of shaft of both bones of forearm.
| Patients and methods|| |
From March 2008 to September 2011, 36 [32 (88.8%) boys and four (11.2%) girls] patients with fractures of both bones of the forearm were treated with elastic stable intramedullary nails. This study approved by the Ethical committee of Cairo University, Giza, Egypt. Patients with the following criteria were included in our study: irreducible fractures, with or without soft-tissue interposition; fractures shortly before skeletal maturity; patients for whom it was not possible to achieve a stable reduction and thus had to undergo fixation under the same anesthesia; patients with unaccepted reduction; and patients with unstable fractures in whom redisplacement occurred within 1 week of closed reduction and casting.
Patients with open fractures and patients with a stable accepted reduction of fractures were excluded from the study.
Their average age at presentation was 10.5 years (range: 6–15 years). The right forearm was affected in 15 (41.7%) patients and left forearm in 21 (58.3%) patients. The mechanisms of injury were motor vehicle accident in two (5.5%) patients, fall during sporting activities in 26 (72.3%) patients, and bicycle accident in eight (22.2%) patients. The surgery was performed within 20 h (range: 12 h–2 days).
All patients were evaluated with radiography − anteroposterior and lateral views for forearm. The fractures were classified according to the Orthopedic Trauma Association classification. All the patients had simple fractures of both ulna and radius (22-A3). All patients had complete fractures; the fractures were angulated more than 20° in 23 (63.9%) patients, angulation between 10 and 20° in five (13.9%) patients, and unaccepted displacement (>75%) in eight (22.2%) patients.
The parents were consented for the operation and they were informed at the time of surgery that their child would need to attend hospital for a day for the removal of the implant under general anesthesia after the fractures were united.
All operations were carried out under general anesthesia and under an image intensifier control. A pneumatic tourniquet was applied to minimize bleeding. Closed manipulation of fractures was performed to correct the length, rotation, and angulation. Open reduction was not needed in any fracture. We introduced the first nail in the bone with the most accepted reduction. We used a standard distal approach to the radius and a proximal approach to the ulna, as described by Lascombes et al. , who entered the ulna just distal and lateral to the olecranon apophysis. The radius was approached radially just proximal to the distal physis with protection of the superficial radial nerve. A 45° oblique hole was drilled in the lateral cortex of the metaphysis to allow nail insertion. Blunt-ended 1.5–2.5-mm diameter titanium nails were used. The nails were curved slightly to allow three-point fixation. The tip was bent 30–40° to allow manipulation in the medullary canal. The bent tip should not exceed 5 mm in length. The nail was manipulated across the fracture site and advanced to the cancellous bone of the metaphysis. Rotation of the curved nail allows correction of angulation and restoration of radial bow. The range of motion was examined to assess restoration of normal range and to assess the stability of the fixation. The nails were then bent at the insertion site and cut short enough to avoid skin irritation ([Figure 1]).
|Figure 1 Radiography of left forearm in a 12 years boy showing fractures of radius and ulna before and after the elastic nail fixation.|
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An above elbow splint was applied. All patients remained in hospital overnight for assessment of postoperative pain and swelling.
Patients reviewed initially at weekly intervals for wound inspections and to ensure satisfactory position of the nails and the fracture. Splint was removed at 4 weeks and below elbow cast was applied for 2 weeks. Cast was removed at 6 weeks when callus appeared in radiography. The normal activity was allowed but sports activity was prohibited for 3 months. The fractures were followed up for union with radiography. The nails were removed after 6 months. The average follow-up time was 18 months (range: 6–24 months) ([Figure 2]).
|Figure 2 Radiography at time of cast removal at 6 weeks (a) and at 6 months before nails removal (b).|
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| Results|| |
The average operative time was 55 min (range: 35–90 min). The results were evaluated according to the fracture union, functional results, and complications. Bony union was observed in all patients in an average 7.4 weeks (range: 6–9 weeks).
Functional results were evaluated according to the criteria of Price et al. . They assessed the presence of pain and/or the degree of loss in forearm rotation ([Table 1]).
According to the criteria of Price et al. , an excellent result was achieved in 30 (83.3%) patients and a good result in six (16.7%) patients. Three (8.3%) patients had olecranon bursitis due to irritation of the nail, which resolved after nail removal. Two (5.6%) patients had superficial wound infection (redness and hotness) at the entry site of radial nail and were treated with repeated dressings and empirical antibiotics for 10 days.
None of the patients had complications such as compartment syndrome, limb-length discrepancy, epiphyseal damage, angular or rotational deformity, synostosis, limited elbow or wrist range of motion, or refracture after nail removal.
| Discussion|| |
The initial treatment of pediatric forearm fractures should be closed reduction and casting ,. However, this treatment is associated with loss of reduction and poor functional results in 5–7% of the patients ,.
There is controversy on the degree of acceptable angulation after closed reduction and casting. Despite reports considering more than 20° of angulation an indication for surgery in pediatric diaphyseal forearm fractures , many studies recommend surgical intervention in the presence of more than 10° of angulation following closed reduction ,,,,,,.
However, there is an agreement that a rotational deformity cannot be accepted in any case .
In fractures with angular deformities, the amount of spontaneous remodeling is related to the age of the patient ,, degree of deformity , proximity of the fracture line to the physis , and the degree of radial and/or volar angulation .
After the age of 10 years, the remodeling potential of the bones decreases significantly ,,,. Thus, anatomic reduction is essential in children older than 10 years to avoid limitation in forearm supination or pronation .
The localization of the fracture is another factor affecting the clinical outcome. It has been reported that middle-third fractures cause more functional limitations compared with distal-third diaphyseal forearm fractures ,.
For these reasons, the age of the patient in relation to the degree of angulation was considered in deciding the favor of the surgical intervention. Thus, angulations greater than 20 and 10° were treated surgically in children younger and older than 10 years, respectively .
Good results have been reported with open reduction and internal fixation using plates in the management of both-bone forearm fractures ,,,. However, this method requires a wide surgical exposure and is preferred in more skeletally mature pediatric patients .
Various types of intramedullary implants have been used to stabilize adult forearm fractures ,,,,. However, supplemental immobilization is often required, and nonunion rates in adults have ranged from 6 to 20% ,,,,. In children, nonunions are rare, and minimal intramedullary fixation can maintain acceptable alignment until fracture healing occurs. The advent of image intensification has made it easier to stabilize a closed reduction with intramedullary devices inserted through percutaneous routes. The relative simplicity and low morbidity of intramedullary fixation have popularized this technique for pediatric forearm fractures.
The site for ulnar nail insertion is controversial. Amit et al.  recommended pinning the ulna first through a 1-cm incision over the olecranon apophysis, and Rabinovich et al.  reported that intramuscular nail fixation through the olecranon apophysis for surgically indicated ulnar fractures has minimal outcome limitations, with no evidence of prospective growth disruption. We preferred to approach the ulna distal to the apophysis as Lascombes et al.  recommended, avoiding injury to apophysis and irritation at the elbow.
In general, it is easier to begin from the proximal ulna due to the subcutaneous approach, the straight shape of the bone, and wide medullary canal ,. However, we preferred to start with less-comminuted and less-displaced fracture as it is easier in introduction and it might help in restoring the length and alignment of the forearm.
Fixation of only one bone (when both are fractured) is a less invasive modification of the technique that facilitates treatment by allowing the other fracture to be rotated into reduction. Although Flynn and Waters  and Myers et al.  have reported good results with this technique, others have cited a slightly higher risk for loss of reduction with single-bone fixation ,.
Lascombes et al.  reported 6% of their patients needed an open reduction because of soft-tissue interposition but, on the contrary, Verstreken et al.  reported they did not need open reduction in any of their patients. In our study no patient needed an open reduction.
The necessity and duration of immobilization in the postoperative period is unclear. Some authors have recommended early active range of motion without immobilization for better soft-tissue and fracture healing ,. Lascombes et al.  reported secondary displacement of the fracture in 5% of the patients when postoperative immobilization was not used. In our study, postoperative immobilization was used as an adjunct to the osteosynthesis till callus formation after 6 weeks and no redisplacement was recorded.
Bony union was achieved in all patients and it was similar to the results of other reports using elastic intramedullary nails ,,,,.
Our functional results were comparable with the results of other surgeons using elastic intramedullary nails. Amit et al. , Versrtreken et al. , and Luhman et al.  reported excellent results in all their patients. Lascombes et al.  reported excellent results in 92% of their patients. Richter et al.  reported excellent results in 80% and good results in 16% of cases. Cullen et al.  obtained excellent or good clinical results in 95% of their patients.
Minor complications reported as wound infection and ulnar bursitis were reported in the literatures and they did not affect the functional results ,,.
Limitations of our study were the small number of patients and that there was no control group for comparison.
| Conclusion|| |
The advantages of an elastic intramedullary nail fixation for the radius and ulna fractures are that it is technically straightforward, allows a high rate of osseous consolidation, is minimally invasive, and allows early mobilization.
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Conflicts of interest
There are no conflicts of interest.
| References|| |
Benson MKD, Fixsen JA, Macnicol MF, Parsch K. Children’s orthopaedics & fractures. 2nd ed. London: Churchill Livingstone; 2002. pp. 609–32.
Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma 1993; 7:15–22.
Landin LA. Fracture patterns in children: analysis of 8628 fractures with special reference to incidence, etiology, and secular changes in a Swedish urban population, 1950–1979. Acta Orthop Scand Suppl 1983; 202:1–109.
Voto SJ, Weiner DS, Leighley B. Use of pins and plaster in the treatment of unstable pediatric forearm fractures. J Pediatr Orthop 1990; 10:85–89.
Qidwai SA. Treatment of diaphyseal forearm fractures in children by intramedullary Kirschner wires. J Trauma 2001; 50:303–307.
Wyrsch B, Mencio GA, Green NE. Open reduction and internal fixation of pediatric forearm fractures. J Pediatr Orthop 1996; 16:644–650.
Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop 1990; 10:161–171.
Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop 1990; 10:705–712.
Verstreken L, Delronge G, Lamoureux J. Shaft forearm fractures in children: intramedullary nailing with immediate motion: a preliminary report. J Pediatr Orthop 1988; 8:450–453.
Pugh DM, Galpin RD, Carey TP. Intramedullary Steinmann pin fixation of forearm fractures in children. Long-term results. Clin Orthop Relat Res 2000; 376:39–48.
Richter D, Ostermann PA, Ekkernkamp A, Muhr G, Hahn MP. Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop 1998; 18:457–461.
Smith VA, Goodman HJ, Strongwater A, Smith B. Treatment of pediatric both-bone forearm fractures: a comparison of operative techniques. J Pediatr Orthop 2005; 25:309–313.
Fuller DJ, McCullough CJ. Malunited fractures of the fore- arm in children. J Bone Joint Surg [Br] 1982; 64:364–367.
Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg [Am] 1982; 64:14–17.
Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994; 14:200–206.
Van der Reis WL, Otsuka NY, Moroz P, Mah J. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop 1998; 18:9–13.
Yung SH, Lam CY, Choi KY, Ng KW, Maffulli N, Cheng JC. Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children. J Bone Joint Surg [Br] 1998; 80:91–94.
Lee S, Nicol RO, Stott NS. Intramedullary fixation for pediatric unstable forearm fractures. Clin Orthop Relat Res 2002; 402:245–250.
Yung PS, Lam CY, Ng BK, Lam TP, Cheng JC. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children. J Pediatr Orthop 2004; 24:7–12.
Roberts JA. Angulation of the radius in children’s fractures. J Bone Joint Surg [Br] 1986; 68:751–754.
Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop 1998; 18:14–21.
Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg [Am] 1984; 66:65–70.
Spiegel PG, Mast JW. Internal and external fixation of fractures in children. Orthop Clin North Am 1980; 11:405–421.
Ortega R, Loder RT, Louis DS. Open reduction and internal fixation of forearm fractures in children. J Pediatr Orthop 1996; 16:651–654.
Knight RA, Purvis GD. Fractures of both bones of the forearm in adults. J Bone Joint Surg [Am] 1949; 31:755–764.
Sage FP. Medullary fixation of fractures of the forearm. J Bone Joint Surg Am 1959; 41:1489–1516.
Marek FM. Axial fixation of forearm fractures. J Bone Joint Surg Am 1961; 43:1099–1114.
Street DM. Intramedullary forearm nailing. Clin Orthop 1986; 212:219–230.
Smith H, Sage FP. Medullary fixation of forearm fractures. J Bone Joint Surg Am 1957; 39:91–188.
Amit Y, Salai M, Checkik A, Blankstein A, Horoszowski H. Closed intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: a preliminary report. J Pediatr Orthop 1985; 5:143.
Rabinovich A, Adili A, Mah J. Outcomes of intramedullary nail fixation through the olecranon apophysis in skeletally immature forearm fractures. J Pediatr Orthop. 2005; 25:565–569.
Ali AM, Abdelaziz M, El-Lakanney MR. Intramedullary nailing for diaphyseal forearm fractures in children after failed conservative treatment. J Orthop Surg 2010; 18:328–331.
Yalçinkaya M, DoğAn A, Özkaya U, Sökücü S, Üzümcügi̇L O, KabukçuoğLu Y. Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures. Acta Orthop Traumatol Turc 2010; 44:7–13.
Flynn JM, Waters PM. Single-bone fixation of both-bone forearm fractures. J Pediatr Orthop 1996; 16:655–659.
Myers GJC, Gibbons PJ, Glithero PR. Nancy nailing of diaphyseal forearm fractures, single bone fixation for fractures of both bones. J Bone Joint Surg [Br] 2004; 86B:581–584.
Herring JA. Fractures of the forearm. In: Tachdjian’s pediatric orthopedics. Vol 3. 3rd ed. Philadelphia: Saunders Elsevier; 2002. pp. 2230–2355.
Luhman SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both bone forearm fractures in children. J Pediatr Orthop 1998; 18:451–456.
[Figure 1], [Figure 2]