Pediatric forearm fractures: evaluating implant removal timing and complications with exposed titanium-elastic nail tips

Year 2023, , 1366 - 1372, 29.10.2023

Fatih Gölgelioğlu , Mustafa Yalın

https://doi.org/10.32322/jhsm.1354354

Abstract

Aims: The current study investigates complication rates, timing of implant removal, and correlations between removal timing and complications/refractures in pediatric forearm fracture patients who had exposed titanium-elastic nail (TEN) tips.
Methods: This retrospective single-center study analyzed pediatric forearm fractures in patients who underwent TEN with exposed tips. Inclusion criteria covered cases between August 2018 and January 2022, focusing on children with both-bone forearm fractures and unsuccessful conservative treatment. Data included demographics, fracture details, reduction type, implant removal timing, complications, and refracture rates.
Results: Between August 2018 and August 2022, the study involved 65 children (54 boys, 11 girls), aged 4 to 15 years. Implant removal occurred at 4 to 11 weeks, on average at 7.17±1.52 weeks. Fracture location was distal 1/3 (9.2%), middle 1/3 (78.5%), proximal 1/3 (12.3%). The predominant causes of fractures were falls (89.2%). Fracture types consisted of open fractures (6.2%) and closed fractures (93.8%). Reduction methods included mini-open reduction (9.2%) and closed reduction (90.8%). Implant removal occurred at or before 6 weeks for 43.1% of cases, while it exceeded 6 weeks for 56.9% of cases. Complications were noted in 21.5% of cases, encompassing delayed union (14.3%), hypertrophic granuloma (7.1%), infection (21.4%), skin irritation (42.9%), and refracture (14.3%). Clinical outcomes were classified as excellent in 83.1% of cases and good in 16.9% of cases. No statistically significant differences were observed in complications (p=0.351) or clinical outcomes (p=0.441) based on implant removal timing.
Conclusion: Contrary to belief, exposing nail tips, not burying them, is safe, cost-effective, and leads to minimal complications with positive clinical outcomes. Implant removal timing did not significantly impact clinical outcomes or complications. TENs used in forearm fractures can be removed before 6 weeks when adequate union is observed.

Keywords

pediatric forearm fractures, titanium elastic nail, exposed tips, implant removal

Ethical Statement

The study was initiated with the approval of the Fırat University Medical Faculty Clinical Researches Ethics Committee (Date: 2023, Decision No: 11-16).

References

• Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0-16 years. J Pediatr Orthop. 1990;10(6):713-716.
• Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908-915.
• Mehlman CT, Wall EJ. Injury to the shafts of the radius and ulna. In: Rockwood CA, Wilkins KE, Beaty JH, et al, eds. Rockwood and Wilkins’ Fractures in Children. Philadelphia, PA: Lippincott Williams & Wilkins. 2006:347-404.
• Franklin CC, Robinson J, Noonan K, Flynn JM. Evidence-based medicine: management of pediatric forearm fractures. J Pediatr Orthop. 2012;32 Suppl 2:S131-S134.
• 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(4):507-512.
• Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop. 2010;30(4):313-319.
• 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(1):9-13.
• Myers GJ, Gibbons PJ, Glithero PR. Nancy nailing of diaphyseal forearm fractures. single bone fixation for fractures of both bones. J Bone Joint Surg Br. 2004;86(4):581-584.
• Jubel A, Andermahr J, Isenberg J, Issavand A, Prokop A, Rehm KE. Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children. J Pediatr Orthop B. 2005;14(5):375-380.
• 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. J Bone Joint Surg Br. 2011;93(2):262-265.
• Loder RT, Feinberg JR. Orthopaedic implants in children: survey results regarding routine removal by the pediatric and nonpediatric specialists. J Pediatr Orthop. 2006;26(4):510-519.
• Raney EM, Freccero DM, Dolan LA, Lighter DE, Fillman RR, Chambers HG. Evidence-based analysis of removal of orthopaedic implants in the pediatric population. J Pediatr Orthop. 2008;28(7):701-704.
• Simanovsky N, Tair MA, Simanovsky N, Porat S. Removal of flexible titanium nails in children. J Pediatr Orthop. 2006;26(2):188-192.
• Peterson HA. Metallic implant removal in children. J Pediatr Orthop. 2005;25(1):107-115.
• Kahle WK. The case against routine metal removal. J Pediatr Orthop. 1994;14(2):229-237.
• 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(2):167-171.
• Kelly BA, Miller P, Shore BJ, Waters PM, Bae DS. Exposed versus buried intramedullary implants for pediatric forearm fractures: a comparison of complications. J Pediatr Orthop. 2014;34(8):749-755.
• Das De S, Bae DS, Waters PM. Displaced humeral lateral condyle fractures in children: should we bury the pins?. J Pediatr Orthop. 2012;32(6):573-578.
• Dinçer R, Köse A, Topal M, Öztürk İA, Engin MÇ. Surgical treatment of pediatric forearm fractures with intramedullary nails: is it a disadvantage to leave the tip exposed?. J Pediatr Orthop B. 2020;29(2):158-163.
• Price CT. Acceptable alignment of forearm fractures in children: open reduction indications. J Pediatr Orthop. 2010; 30:S82–S84.
• Segev E, Hemo Y, Wientroub S, et al. Intra- and interobserver reliability analysis of digital radiographic measurements for pediatric orthopedic parameters using a novel PACS integrated computer software program. J Child Orthop. 2010;4(4):331-341.
• Köse A, Aydın A, Ezirmik N, Can CE, Topal M, Tipi T. Alternative treatment of forearm double fractures: new design intramedullary nail. Arch Orthop Trauma Surg. 2014;134(10):1387-1396.
• Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop. 1990;10(6):705-712.
• Daruwalla JS. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res. 1979;(139):114-20.
• Demirtaş İ, Asfuroğlu ZM, Çolak M. Technical aspects that may affect the outcomes of pediatric patients with both-bone forearm diaphyseal fractures treated using elastic stable intramedullary nails [published online ahead of print, 2023 May 29]. J Pediatr Orthop B. 2023;10.1097/BPB.0000000000001093.
• Chan LW, Siow HM. Exposed versus buried wires for fixation of lateral humeral condyle fractures in children: a comparison of safety and efficacy. J Child Orthop. 2011;5(5):329-333.
• Adamczyk MJ, Riley PM. Delayed union and nonunion following closed treatment of diaphyseal pediatric forearm fractures. J Pediatr Orthop. 2005;25(1):51-55.
• Ogonda L, Wong-Chung J, Wray R, Canavan B. Delayed union and non-union of the ulna following intramedullary nailing in children. J Pediatr Orthop B. 2004;13(5):330-333.
• Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below-the-elbow plaster casts for distal forearm fractures in children. a randomized controlled trial. J Bone Joint Surg Am. 2006;88(1):1-8.
• Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop. 1998;18(1):14-21.
• Sommerfeldt DW, Schmittenbecher PP. Elastic stable intramedullary nailing (ESIN) in the adolescent patient-perils, pearls, and pitfalls. Eur J Trauma Emerg Surg. 2014;40(1):3-13.
• Kutsikovich JI, Hopkins CM, Gannon EW 3rd, et al. Factors that predict instability in pediatric diaphyseal both-bone forearm fractures. J Pediatr Orthop B. 2018;27(4):304-308.
• Qairul IH, Kareem BA, Tan AB, Harwant S. Early remodeling in children's forearm fractures. Med J Malaysia. 2001;56 Suppl D:34-37.
• Kong JS, Huang Y, Chen T, et al. Comparison of open reduction and internal fixation with plate and titanium elastic intramedullary nail in treating pediatric humeral fracture. Orthop Surg. 2021;13(2):434-441.