Forearm Fractures in Children Intramedullary Pin Fixation

Norman Ramirez MD

Indications for Surgical Intervenion Grade I Open Fractures Associated Soft Tissue Injuries Inability To Maintain A Closed Reduction Floating elbow Refractures (relative) Pediatric forearm fractures :decision making ,surgical techniques and complications. J Flynn Instr Course 2002 Eleven years experience in the operative management of pediatrics forearm fractures J Flynn et al JPO 2010

Always Have A Direct Line Of Sight !!

Pins Placed Proximal to Distal

Pins Placed Distal to Proximal

Ulnar Fixation

Dorsal Branch Ulnar Nerve Ulnar Incision Beware 2nd Route Dorsal Branch Ulnar Nerve Usual Route

Ulnar Fixation Exposing Distal Ulna

Drilling Ulnar Metaphysis

Preparing the Pin End (Two Curves) 2.Proximal Gentle Curve 1.Terminal 30 degree

Two Curves in the Distal portion 30 Degree Short Gentle Metaphyseal

Passing the Pin Proximally Two Methods : 1. Hand Drilling Pin by Rotation

2. Hand Tap With Mallet

Exposed Nails There were no significant differences seen in number of infections, refractures, or overall complications Exposed versus buried intramedullary implants for pediatric forearm fractures: a comparison of complications. Kelly BA JPO 2014

180 degree Bend To Produce Low-Profile Influence of the bending of the tip of elastic stable intramedullary nails on removal and associated complications in pediatric both bone forearm fractures: a pilot study. Gibon E Int J Surg 2015

Final Pin Placement Next To Metaphysis

Radius Fixation

Beware!! Superficial Radial Nerve Radial Incision

Deep Structures Extensor Pollicus Brevis Brachioradialis Extensor pollicis longus rupture after fixation of radius and ulna fracture with titanium elastic Nail (TEN) in a child : a case report Kravel et al J Trauma 2007 Incidence and Risk Factors for Extensor Pollicis Longus Rupture in Elastic Stable Intramedullary Nailing of Pediatric Forearm Shaft Fractures. Lee AK JPO 2016

Drilling Metaphysis 2.5 mm drill

Approaching the Fracture Site Insertion Radial Pin Gentle Curve Allows Bouncing Off Cortex

Then Rotating Pin In Proximal Fragment To Reduce Fracture Rotating 30 degree bend in prox . fragment to engage the canal in the proximal fragment

Then Passing Proximally Entering Proximal Fragment

Terminal Insertion

Final Position

X- Rays Plain Films to Check Final Position

Two Months Follow Up Good Strong Callous Pins Stimulate Endosteal Callous Clinical results of IM following closed or mini open reduction in pediatrics unstable diaphyseal forearm fractures Yalcinkaya et al Acta Orthop Traumatologica Turc 2010

Complications…. 14 % 1. Compartment Syndrome ( > three attempts) 2. Hardware migration 3. No union 4. Infection 5. Neurologic problems 6. Tendon Ruptures 7. Delayed union ( > 10 years) Compartment syndrome following intrarmedullary fixation of pediatric forearm fractures Yuan et al JPO 2004 Complications and outcomes of diaphyseal forearm fracture intramedullary nailing: a comparison of pediatric and adolescent age groups. Martus J. JPO 2013 Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children.Blackman AJ J Pediatr Orthop. 2014