Unstable Diametaphyseal Forearm Fractures: Transepiphyseal Intramedullary Kirschner-Wire Fixation as a Treatment Option in Children

Abstract

Background: In unstable metaphyseal and diaphyseal forearm fractures the treatment of choice is percutaneous Kirschner wire (K-wire) fixation or elastic stable intramedullary nailing (ESIN), respectively. The optimal treatment for the diametaphyseal transition zone is still a matter of debate.

Methods: The diametaphyseal transition zone was defined as the square over the “physis of distal radius and ulna” minus the square of “physis of distal radius alone”. Transepiphyseal intramedullary K-wire fixation was performed in unstable fractures affecting this transitional area. The operative, postoperative and functional outcomes were assessed and compared to previously treated patients who were treated using other techniques (plate, external fixator or ESIN).

Results: 10 patients received transepiphyseal intramedullary K-wire fixation. Additionally the ulna was stabilized by antegrade ESIN in 5 cases. Cast immobilization was performed for 39, sports restriction for 43 and metal removal was done after 50 days. No complications, bone malalignment, or functional deficits occurred (mean follow-up: 17 months). 13 patients were treated using alternative options. 3 patients had plates with cast immobilization for 26 days, sports restriction for 63 and metal removal after 287 days. 5 patients were treated by external fixation for 54 days. Their sports restriction was 73 days. The remaining 5 patients had ESIN. In 1 of these cases additional cast immobilization was necessary. Their sports restriction was 51 days and metal removal was done after 88 days. In 4 cases a malalignment >10° of the radius was documented, and 1 patient had a functional deficit of forearm pro-/supination.

Conclusion: Transepiphyseal intramedullary K-wire fixation in unstable diametaphyseal forearm fractures is a minimally invasive, quick and technically easy treatment option but requires additional immobilization. Our data suggest that this technique offers advantages compared to alternative treatment options.

Key words

pediatric trauma - forearm - diametaphysis - intramedullary nailing - Kirschner wire

References

• 1 Kraus R, Ploss C, Staub L. et al . Fractures of long bones in children and adolescents.  Osteo Trauma Care. 2006;  14 39-44
• 2 Voto SJ, Weiner DS, Leighley B. Use of pins and plaster in the treatment of unstable peditric forearm fractures.  J Pediatr Orthop. 1990;  10 85-89
• 3 Noonan KJ, Price CT. Forearm and distal radius fractures in children.  J Am Acad Orthop Surg. 1998;  6 146-156
• 4 Slongo TF. The choice of treatment according to the type and location of the fracture and the age of the child.  Injury. 2005;  36 (Suppl. 1) A12-A19
• 5 Wilkins KE. Fractures of the distal radius and ulna. In: Rockwood and Wilkins' Fractures in Children. 4th ed. Philadelphia: Lippincott, Williams and Wilkins 1996; 486;
• 6 Lascombes P, Prevot J, Ligier JN. et al . Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases.  J Pediatr Orthop. 1990;  10 (2) 167-171
• 7 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
• 8 Lieber J, Joeris A, Knorr P. et al . ESIN in forearm fractures: clear indications, often used, but some avoidable complications.  Eur J Trauma. 2005;  31 3-11
• 9 Van der Reis WL, Otsuka NY, Moroz P. et al . Intramedullary nailing versus plate fixation for unstable forearm fractures in children.  J Pediatr Orthop. 1998;  18 9-13
• 10 Vainionapp S, Bostman O, Rokkanen P. Internal fixation of forearm fractures in children.  Acta Orthop Scand. 1987;  58 121-123
• 11 Helber MU, Ulrich C. External fixation in forearm shaft fractures.  Injury. 2000;  31 (1) 45-47
• 12 Weinberg AM, Reilman H, Lampert C. et al . Experience with external fixation in treatment of shaft fractures in childhood.  Unfallchirurg. 1994;  97 107-113
• 13 Gasco J, De Pablos J. Bone remodeling in malunited fractures in children.  J Pediatr Orthop. 1997;  6 126-132
• 14 Matthews LS, Kaufer H, Garver DF. et al . The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm.  J Bone Joint Surg. 1982;  64 14-17
• 15 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. 1984;  66 65-70
• 16 Hoël G, Kapandji AI. Osteosynthesis using intrafocal pins of anteriorly dislocated fractures of the inferior radial epiphysis.  Ann Chir Main Memb Super. 1995;  14 142-157
• 17 Guichet JM, Moller CC, Dautel G. et al . A modified Kapandji procedure for Smith's fractures in children.  J Bone Joint Surg Br. 1997;  79 (5) 734-737
• 18 Hidaka S, Gustilo RB. Refracture of bones of the forearm after plate removal.  J Bone Joint Surg. 1984;  66 1241-1243
• 19 Langkamer VG, Ackroyd CE. Removal for forearm plates: a review of the complications.  J Bone Joint Surg. 1990;  72 601-604
• 20 Sanderson PL, Ryan W, Turner PG. Complications of metalwork removal.  Injury. 1992;  23 (1) 29-30
• 21 Vince K, Miller J. Cross-union complicating fracture of the forearm Part II Children.  J Bone Joint Surg. 1987;  69 (A(5) 654-661
• 22 Pawelek C. Die Ratio “Länge distales Radiusfragment/Radiusgesamtlänge” als Parameter zur präoperativen Indikationsprüfung vor ESIN bei Unterarmschaftfrakturen bei Kindern. 23rd Meeting of the Pediatric Section of the German Society of Trauma Surgeons (DGU), Frankfurt/Main, June 18–19; 2004
• 23 Aribit F, Laville JM. Postero-medial elastic stable intramedullary nailing for anteriorly displaced distal diaphyso-metaphyseal fractures of the radius in children.  Revue de chirurgie orthopédique. 1999;  85 858-860
• 24 Yung PS, Lam CY, Ng BK. et al . Percutaneous transphyseal intramedullary Kirscher wire pinning: A safe and effective procedure for treatment of displaced diaphyseal forearm fractures in children.  J Pediatr Orthop. 2004;  24 (1) 7-12
• 25 Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children.  J Bone Joint Surg Am. 2006;  88 (1) 9-17

Correspondence