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ORIGINAL ARTICLE
Year : 2018  |  Volume : 11  |  Issue : 6  |  Page : 499-505  

Comparative study in the outcome of intramedullary nailing to plating for both-bone forearm fracture in early and mid-adolescent age group


Department of Orthopaedics, Manipal Teaching Hospital, Pokhara, Nepal

Date of Submission04-Jul-2018
Date of Acceptance03-Aug-2018
Date of Web Publication15-Nov-2018

Correspondence Address:
Upendra Jung Thapa
Department of Orthopaedics, Manipal Teaching Hospital, Phulbari, Pokhara 33411, Kaski
Nepal
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_84_18

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  Abstract 


Objective: The objective of this study was to compare the outcome of intramedullary nailing to plating for both-bone forearm fractures in early and mid-adolescent age group. Design: This was a retrospective, comparative study. Methods: A total of 76 skeletally immature adolescents with a mean age of 12.5 years; range 10–17 years treated operatively for both-bone forearm fractures from 2012 to 2017. Patient with fixation of only one bone, hybrid fixation, bilateral forearm injuries, previous forearm injuries, Galeazzi, Monteggia and radial head fracture, underlying bone pathology, and fracture associated with neurovascular injury were excluded from the study. Intervention: Forty-six patients (mean age, 12.33 years) underwent intramedullary nailing and 30 patients (mean age, 12.77 years) underwent plating. Main Outcome Measure: Time to fracture union, magnitude and location of maximum radial bow (both as a percentage of radial length), forearm rotation, and complications. Results: The mean union time for nail was 7.86 weeks and for the plate was 7.33 weeks which showed no statistically significant differences between the groups for the union of fracture at 3 months (P = 0.780). There were no significant differences between the two groups for the value of maximum radial bow magnitude and its location (P = 0.60). The maximum radial bow magnitude was significantly different from normative values in both groups (P = 0.003 nail and P = 0.001 plate); however, no statistically significant differences for the location of maximum radial bow (P = 0.370 nail and P = 0.632 plate). There were no residual angulation, displacement, or malrotation. Nearly 88% of patients in both groups regained full forearm rotation. There were one major complication and seven minor complications in the intramedullary nailing group and one major complication in plating group. Conclusion: Based on similar functional and radiographic outcomes, intramedullary nail and plate fixation in early and mid-adolescent age group patients for both-bone forearm diaphyseal fractures are equally effective treatment.

Keywords: Adolescent, both bone, forearm fracture, intramedullary nail, open reduction and internal fixation


How to cite this article:
Thapa UJ, Wahegaonkar K, Ranjeet N, Sapkota K, Onta PR, Thapa P. Comparative study in the outcome of intramedullary nailing to plating for both-bone forearm fracture in early and mid-adolescent age group. Med J DY Patil Vidyapeeth 2018;11:499-505

How to cite this URL:
Thapa UJ, Wahegaonkar K, Ranjeet N, Sapkota K, Onta PR, Thapa P. Comparative study in the outcome of intramedullary nailing to plating for both-bone forearm fracture in early and mid-adolescent age group. Med J DY Patil Vidyapeeth [serial online] 2018 [cited 2018 Dec 19];11:499-505. Available from: http://www.mjdrdypv.org/text.asp?2018/11/6/499/245440




  Introduction Top


Both-bone fractures of the forearm are a common injury in children and adolescents. Most of the fractures of the forearm in children younger than 10 years are treated nonoperatively with closed reduction and casting with excellent results.[1],[2],[3] Although closed reduction and casting remain the viable treatment for children more than 10 years and older,[4] debate exists to what constitutes an acceptable reduction and at what age remodeling capacity inherent to children becomes less effective. Forearm fractures in older children treated with closed reduction and cast application have a failure rate of 11%, and these fractures require revision surgery.[5],[6]

In general, the most common indications for surgical fixation are open fractures and inability to maintain an acceptable reduction in a cast. Unacceptable reductions are determined by measuring the angulation, displacement, magnitude, and location of radial bow.

As children reach near to skeletal maturity, tolerance for displacement resembles adult-like parameters. There is an increasing trend in operative management for both-bone fractures in older children,[6] and whenever, there is a decision to operate, controversy exists regarding the optimal method of fixation.

Fractures in the age group of 10–17 years which cannot be maintained in acceptable alignment with closed reduction can be treated with either open reduction internal fixation (ORIF) with plates and screws or intramedullary flexible nail. Intramedullary nailing has advantages of smaller incision, shorter duration of anesthesia, limited soft-tissue dissection, rapid union and excellent recovery of range of motion,[7],[8] over plates, and screws; however, open reduction and plating allow a more anatomic reduction of fracture resulting in more accurate restoration of the radial bow which is important for complete restore of forearm rotation. The purpose of this study is to compare the radiographic and functional results of intramedullary (IM) nailing with plate and screw fixation in treating both-bone forearm fractures in skeletally immature early and mid-adolescent age group from 10 to 17 years.


  Methods Top


Among 180 patients who attended for forearm both-bone diaphyseal fractures between March 2012 and March 2017 in Manipal Teaching Hospital, Pokhara, 76 children were selected and treated with either IM flexible nail or ORIF with plate and screws. Inclusion criteria were aged between 10 and 17 years, unstable fracture with grossly displaced and grossly rotated fractures after closed reduction, and closed fractures and open fractures Type 1 and Type 2 and patients who followed to union time. Exclusion criteria were as follows: fixation of only one bone, hybrid fixation, bilateral forearm injuries, previous forearm injuries, concomitant wrist or humerus fracture (e.g., Galeazzi, Monteggia, and radial head fracture), underlying bone pathology (e.g., pathological fracture and metabolic bone disease), fracture with neurovascular injury, and patient with lost follow-up.

Demographic data of the patient, mechanism of injury, type of fracture (closed or open fracture with open fracture graded using Gustillo and Anderson classification), site and location of injury, fixation method, date of removal of hardware when applicable, and complications were recorded [Table 1].
Table 1: Demographic data

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Preoperative and latest follow-up standard anteroposterior (AP) and lateral radiographs of the forearm were reviewed. All fractures were classified according to the Arbeitsgemeinschaft für osteosynthesefragen/orthopedic trauma association (AO/OTA) classification of diaphyseal fractures.[9]

Restoration of radial bow was evaluated on the latest follow-up AP radiographs using the technique described by Firl and Wünsch where the magnitude and location of the maximum radial bow, both expressed as a percentage of radial length is calculated, and these values were compared with the normal values of 7.21% ±1.03% for bow magnitude and 60.39% ±3.74% for bow location in children.[10]

Complication rates, time for fracture union, and final range of motion were evaluated in subsequent follow-up. Patients were regularly followed up at 2 weeks, 6 weeks, 12 weeks, 6 months, and every 6 months thereafter. Fracture union was defined as bridging callus on AP and lateral radiographs across three cortices of bone and nontender fracture sites. Delayed union defined as union beyond 3 months and beyond 6 months as nonunion. Complications during the follow-up were classified as either major (long-term sequelae or return to the operating room) or minor (resolved with minimal treatment). Clinical results were evaluated according to scale developed by price criteria,[5] and the patients were assessed for injured arm range of motion, as compared with the contralateral uninjured arm including forearm pronation and supination as well as elbow and wrist flexion and extension at latest follow-up. [Figure 1]a shows the preoperative X-ray of 11-year-old male patient with AO 22 A3.2 type fracture planned for intramedullary nailing; [Figure 1]b shows immediate postoperative X-ray after nailing; [Figure 1]c shows union of fracture at 6 weeks; [Figure 1]d shows postoperative X-ray after implant removal done at 6 months; and [Figure 1]e, [Figure 1]f, [Figure 1]g, [Figure 1]h shows flexion, extension, pronation, and supination movement of elbow joint, respectively. [Figure 2]a shows the preoperative X-ray of 16-year-old male patient with AO 22 A3.2 type fracture planned for open reduction and internal fixation with plate and screw; [Figure 2]b shows immediate postoperative X-ray after plating; [Figure 2]c and d shows follow-up X-ray at 6 weeks and 3 months with radiological union; and [Figure 2]e, [Figure 2]f, [Figure 2]g, [Figure 2]h shows flexion, extension, pronation, and supination movement of elbow joint, respectively.
Figure 1: (a) Preoperative X-ray for nailing, (b) immediate postoperative X-ray for nailing, (c) union of fracture after nailing, (d) removal of nail, (e) flexion of elbow joint in patient with nail, (f) extension of elbow joint in patient with nail, (g) pronation of elbow joint in patient with nail, (h) supination of elbow joint in patient with nail

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Figure 2: (a) Preoperative for plating, (b) immediate postoperative for plating, (c) follow-up at 6 weeks, (d) union of fracture after plating, (e) flexion of elbow joint in patient after fixation with plate and screw, (f) extension of elbow joint in patient after fixation with plate and screw, (g) pronation of elbow joint in patient after fixation with plate and screw, (h) supination of elbow joint in patient after fixation with plate and screw

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Patient treated with open reduction and internal fixation with plates and screw was followed for 2 years. The removal of plate and screw was done in 18 months. Postoperatively, the patient was kept in above elbow posterior slab for 4 weeks to prevent refracture from the weakening of bone due to stress yielding.

Patient treated with intramedullary flexible nail was followed for 9 months–1 year. The removal of nail was usually done in 6–9 months.

Statistical analysis

A t-test was used to compare the two groups for age at the time of injury, maximum radial bow magnitude, and location (both as a percentage of radial length).

Fisher's exact test calculated to compare the groups for the presence of normal magnitude of radial bow, fracture union at 3 months, and loss of rotation.

The one-sample t-test used to compare the location of the maximum radial bow of each group to a previously reported normal value.

For all analysis, a P < 0.05 was considered statistically significant.

Statistical analyses were performed using SPSS 16.0 (SPSS Inc., Chicago, IL, USA).


  Results Top


A total of 46 patients, 34 boys and 12 girls were treated with intramedullary nail. A total of 30 patients, 24 boys and 6 girls were treated with plate. The mean age at the time of injury of IM group (12.33 ± 1.96 years) and of plate group (12.77 ± 2.06 years) was not statistically significant (P = 0.06) [Table 2].
Table 2: Age, radiological outcome, and functional outcome

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In the nailing group, 41 patients underwent closed IM nailing, and five patients underwent mini-open with direct visualization of the fracture site. For AO/OTA fracture geometry, the IM nailing group had two complex geometry, 22 C2.2 (19 patients with 22 A3.2, 17 patients with 22 A3.3, 6 patients with 22 A3.1, and 2 patients with 22 B3.1) whereas plating has one complex geometry, 22 C2.2 (12 patients with 22 A3.2, 12 patients with 22 A3.3, and 5 patients with 22 A3.1). The most common mechanism of injury was fall on an outstretched hand for both groups, and the right side was commonly involved in both sides.

Radiological outcome

The mean union time for nail was 7.86 weeks and for the plate was 7.33 weeks. No statistically significant differences were found between the groups for the union of fracture at 3 months (P = 0.780) [Table 2]. The average maximum radial bow magnitude was 6.09% (range 4.5%–7.6%), and the location was 65.14% (range 51%–78%). Normal values by Firl for children are 7.21% ±1.03% and 60.39% ±3.74%, respectively. There were no significant differences between both groups for the value of maximum radial bow magnitude and its location (P = 0.60 and P > 0.05) [Table 3]. However, the maximum radial bow magnitude was significantly different from normative values in both groups (P = 0.003 nail and P = 0.001 plate); however, there were no statistically significant differences for the location of maximum radial bow (P = 0.370 nail and P = 0.632) [Table 4].
Table 3: Comparison of maximum radial bow magnitude and location between two groups

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Table 4: Comparison of mean maximum radial bow magnitude and location with normative patient

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There were no residual angulation, displacement, or malrotation.

Functional outcome

Loss of forearm rotation was defined as a loss of >10° of supination or pronation as compared to contralateral uninjured arm. In both groups, there was a similar number of patients who have loss of forearm rotation. Four patients had some loss of pronation and supination in plating group whereas five patients had some loss of pronation and supination in IM nailing group. However, Fisher's exact test indicated that the loss of forearm rotation was not significantly different between the groups (P = 0.734) [Table 2]. All patients in both groups had full flexion and extension of elbow and wrist at the latest follow-up for 6 months.

Complications

The IM nailing group had seven minor complications (five superficial wound infections and two bursitis over olecranon) and one major complication (tendons adhesion). Tendon adhesion with patient inability to fully extend the ring finger at metacarpophalangeal joint level was seen in type 2 open fracture both bone fixed with IM nail. Later on, adhesiolysis between flexor digitorum profundus tendons to the ulna fracture site was done in 6-week postoperative period, and then the patient regained full extension. Five patients developed superficial wound infection due to prominence of hardware leading to irritation of superficial skin at ulnar nail insertion site. In oral antibiotics, dressing with early removal of hardware was done in five patients. Excision of ulnar bursa was done at the time of nail removal. Delayed union was seen in three patients treated with nailing for closed bending wedge type of fracture and type 1 open transverse fracture. The mini-open reduction was done in five patients where closed nailing was not successful due to soft-tissue interposition at the fracture site. None of the patient treated with ORIF with plate and screw had difficulty in removing the implant.

Postoperatively after plate removal at 18 months, the plating group had one major complication of hematoma formation for which the patient underwent hematoma evacuation.


  Discussion Top


Both intramedullary nailing and plating are successful treatment modalities for both-bone forearm fractures. Majority of both-bone forearm fractures in younger children can be treated nonoperatively with the restoration of forearm function due to the presence of tough periosteum, an open physis, and rapid remodeling capacity. Unlike younger children, operative treatment of choice for adults is ORIF with plate and screws. However, controversy exists for older children and adolescent age group patients due to unpredictable remodeling capacity.

Nailing and plating both have their advantages and disadvantages. Surgical treatment with ORIF with plate and screw provides accurate and stable fixation but causes opening of fracture site, wide periosteal stripping, and loss of fracture hematoma. In addition, there are other associated complications such as intraoperative neurovascular complication and postoperative problems such as delayed union, scarring, infection, and nonunion due to loss of biological environment of factors.[11] Moreover, the removal of plates may be associated with significant complications such as refracture and soft-tissue injury. Similarly, intramedullary fixation is minimally invasive procedure, easy to perform, maintains proper bony alignment and promotes rapid fracture healing,[6],[7] may be associated with less surgical morbidity and easy hardware removal but may be associated with potential complications such as compartment syndrome, nonunion due to persistent gap created by distraction at fracture ends, and refracture after nail removal.

The decision to proceed with operative intervention may depend on several variables such as age of the patient, fracture angulation and rotation, fracture location and displacement, and type of fracture. There is no clear consensus as to the exact amount of angulation and malrotation. Studies have shown that patients with age beyond 10 years, more than 10° of angulation is unlikely to remodel spontaneously.[12] General consensus suggests up to 10° of angulation and up to 30° of malrotation is acceptable.[13]

Our study shows that excellent results were obtained for both operative interventions, with near-normal restoration of forearm function. We reviewed similar studies comparing IM nailing with plating in literature, and the results are shown in [Table 5]. These studies did not find any significant differences in functional outcome, radiological outcome, and complications between either operative methods. We had excellent to good results in both nailing and plate groups as accordingly to price criteria.
Table 5: Comparative study

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One of the shortcomings of our study is age and sex discrepancy between two groups of patients. Although the mean age for boys and girls was not statistically significant between two groups in our study, the other indicators of physiological maturity which corresponds to the bone age of children could have been included in the study. Physiological rates of skeletal maturity are different for boys and girls with girls reaching skeletal maturity 2 years earlier than boys. Therefore, age- and sex-matched study would eliminate two interconnected and potential compounding factors.

Studies have shown the remodeling of the bone is less for proximal diaphysis both-bone fractures and mid-diaphysis both-bone fractures as compared to distal both-bone fractures with higher incidence of malunion.[17] Hence, the location of fracture may be another compounding factor.[18] Other factors which influence the decision-making process is hardware removal and patient acceptability. The removal of hardware is difficult with plates as compared to nails with risk of refracture and prolonged restriction of activities. Patient acceptability, especially regarding cosmesis, is higher for nail than plates with smaller scars.[19] Limitation of our study includes the retrospective study and presence of the compounding factors.


  Conclusion Top


Intramedullary nail and plate fixation in early and mid-adolescent age group patient for both-bone forearm diaphyseal fractures is equally effective treatment but certain aspects such as hardware removal, cosmesis, total operative time, and period of restriction of activities after implant removal, all should be taken into consideration.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Carey PJ, Alburger PD, Betz RR, Clancy M, Steel HH. Both-bone forearm fractures in children. Orthopedics 1992;15:1015-9.  Back to cited text no. 1
    
2.
Jones K, Weiner DS. The management of forearm fractures in children: A plea for conservatism. J Pediatr Orthop 1999;19:811-5.  Back to cited text no. 2
    
3.
Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-12.  Back to cited text no. 3
    
4.
Zionts LE, Zalavras CG, Gerhardt MB. Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop 2005;25:507-12.  Back to cited text no. 4
    
5.
Shoemaker SD, Comstock CP, Mubarak SJ, Wenger DR, Chambers HG. Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children. J Pediatr Orthop 1999;19:329-37.  Back to cited text no. 5
    
6.
Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop 2010;30:313-9.  Back to cited text no. 6
    
7.
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;10:167-71.  Back to cited text no. 7
    
8.
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.  Back to cited text no. 8
    
9.
Fracture and dislocation compendium. Orthopaedic trauma association committee for coding and classification. J Orthop Trauma 1996;10 Suppl 1:v-ix, 1-154.  Back to cited text no. 9
    
10.
Firl M, Wünsch L. Measurement of bowing of the radius. J Bone Joint Surg Br 2004;86:1047-9.  Back to cited text no. 10
    
11.
Armstrong PF, Joughin VE, Clarke HM. Pediatric fractures of the forearm, wrist, and hand. In: Green NE, Swiontkowski MF, editors. Skeletal Trauma in Children. 2nd ed. Philadelphia: W.B. Saunders; 1998. p. 161-70.  Back to cited text no. 11
    
12.
Bae DS. Pediatric distal radius and forearm fractures. J Hand Surg 2008;33:1911-23.  Back to cited text no. 12
    
13.
Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998;6:146-56.  Back to cited text no. 13
    
14.
Reinhardt KR, Feldman DS, Green DW, Sala DA, Widmann RF, Scher DM, et al. Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children. J Pediatr Orthop 2008;28:403-9.  Back to cited text no. 14
    
15.
Shah AS, Lesniak BP, Wolter TD, Caird MS, Farley FA, Vander Have KL, et al. Stabilization of adolescent both-bone forearm fractures: A comparison of intramedullary nailing versus open reduction and internal fixation. J Orthop Trauma 2010;24:440-7.  Back to cited text no. 15
    
16.
Kose O, Deniz G, Yanik S, Gungor M, Islam NC. Open intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children. J Orthop Surg (Hong Kong) 2008;16:165-9.  Back to cited text no. 16
    
17.
Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986;6:306-10.  Back to cited text no. 17
    
18.
Ogden JA, Beall JK, Conlogue GJ, Light TR. Radiology of postnatal skeletal development. IV. Distal radius and ulna. Skeletal radiol 1981;6:255-66.  Back to cited text no. 18
    
19.
Fernandez FF, Egenolf M, Carsten C, Holz F, Schneider S, Wentzensen A, et al. Unstable diaphyseal fractures of both bones of the forearm in children: Plate fixation versus intramedullary nailing. Injury 2005;36:1210-6.  Back to cited text no. 19
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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