1. Forearm Fractures in Children
Intramedullary Pin Fixation

2. Norman Ramirez MD

4. 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

5. Always Have A Direct Line Of Sight !!

6. Pins Placed Proximal to Distal

8. Pins Placed Distal to Proximal

9. Ulnar Fixation

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

11. Ulnar Fixation
Exposing Distal Ulna

12. Drilling Ulnar Metaphysis

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

14. Two Curves in the Distal portion
30 Degree Short
Gentle Metaphyseal

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

16. 2. Hand Tap With Mallet

17. 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

18. 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

19. Final Pin Placement Next To Metaphysis

20. Radius Fixation

21. Beware!!
Superficial Radial
Nerve
Radial Incision

22. 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

23. Drilling Metaphysis
2.5 mm drill

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

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

26. Then Passing
Proximally
Entering Proximal
Fragment

27. Terminal Insertion

28. Final Position

29. X- Rays
Plain Films to Check
Final Position

30. 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

31. 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