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A 12 year old boy sustains a dislocated fracture of the right ulna and radius. No pathological neurological findings, palpable pulses.
As conservative treatment (reduction and casting in anaesthesia) fails, the decision is made to operate on the limb. 2 days after the initial reduction two elastic nails are inserted over two small incision in the distal radius / proximal ulna.
The boy is kept as an outpatient after an overnight stay. The arm is given free for movement but not for putting weight on. Within few weeks the fracture is completely resolved and the nails may be removed.
Final examination shows consolidated bones and free mobility of shoulder, elbow, and wrist.
Forearm fractures in childhood may often be treated conservatively. The aim is to achieve a good reduction of the fracture, which is stable to traction and rotation. In many cases casting of the whole arm should be appropriate (Alpar).
Deviation of the longitudinal axis greater than 15°, secondary dislocation especially in midshaft forearm fractures of the radius and / or ulna, and unstable reduction are indications for indicate operative treatment.
Options for fixation are open reduction and osteosynthesis with plates as well as closed reduction and intramedullary fixation using elastic nails. The aim is to achieve stable osteosynthesis, reduction of the fractured bone, and good functional outcome with minimal effort. The principle of the elastic nail is to wedge the nail inside the bone and to bring tension the membrana interossea. In simple fractures of the radius or ulna alone the intact second bone stabilises the fixation. After inserting the nail it is guided by the bone cavity and finally supports the cortex from inside at three points. This has been previously described many times, for paediatric forearm fractures as well as in femur and humerus fractures (Prevot).
Open reduction and stabilisation with plates leads to prolonged hospital stay, increased scarring and the possibility of radial nerve injury. All of these complications are minimized using the Prevot-method.
Some operative techniques & tips:
- Limb should be prepped & draped fully mobile and accessible from both proximally and distally using an armtable.
- Ensure that the sensory branch of the radial nerve and the cephalic vein are spared during the insertion into the distal radius.
- Cartilaginous conjunctions must be preserved!
- A difficult reduction may be made more easy by temporarily screwing a Schanz pin into one end of the bone in order to use it as lever.
- Open the bone using an awl and insert the implant under fluoroscopic surveillance.
Post-op treatment should include physiotherapy. Do not forget to remove implant early after consolidation of the bone (3-6 Month [Rueger])
Alpar, E. K., K. Thames, R. Wen, J.F. Taylor: Midshaft fractures of forearms in children. Injury 13 (1982) 153 – 158
Prevot J, Lascombes P, Ligier JN. The ECMES [Centro-Medullary Elastic Stabilising Wiring) osteosynthesis method in limb fractures in children. Principle, application on the femur. Apropos of 250 fractures followed-up since 1979 Chirurgie 1993-94;119(9):473-6
Rueger, J.M., A. Kratzer, N.M. Meenen Frakturen im Wachstumsalter: Unterarmfrakturen OP-Journal 15 (1999) 136 - 141
trauma.org (7:2) February 2002