Jim Kling

October 09, 2010

October 9, 2010 (San Francisco, California) — Flexible intramedullary nailing works well in 12- to 18-year-old patients with diaphyseal fractures of the radius and ulna, a group generally that is typically treated with anatomic reduction using plate stabilization. Nails are less invasive, and plates carry the risk for nerve or blood vessel damage. The research was presented here at the American Academy of Pediatrics 2010 National Conference and Exhibition.

In adults with diaphyseal fractures of the radius and ulna, anatomic reduction with plate stabilization is standard care. Various techniques have been used with skeletally immature patients with these fractures, with intramedullary fixation becoming increasingly accepted, but there is much variability in how adolescents with forearm fractures are treated.

"The question is, At what age are they too old and you have to think about using plates and screws?" Lindley Wall, MD, an orthopaedic resident at Washington University School of Medicine in St. Louis, Missouri, who presented the research, told Medscape Medical News.

The researchers studied clinical and radiographic outcomes in adolescents after intramedullary fixation of both forearm bone fractures. The study was a retrospective review of 32 patients (aged 12 - 18 years) who had undergone intramedullary fixation of both forearm bone fractures in the previous 20 years at the Washington University School of Medicine. They excluded patients with Galeazzi, Monteggia, radial head, and distal metaphyseal fractures.

The researchers used radiographic evaluation to determine union, postoperative radial bow, and clinical follow-up to determine postoperative complications and range of motion of the wrist, forearm, and elbow.

Mean age at time of fracture was 14.1 years. There were 19 closed fractures, 9 grade 1 fractures, 3 grade 2 fractures, and 1 grade 3b fracture. Of the patients, 15.6% experienced limited range of motion after the operation. All patients aged 15 to 18 years had full range of motion. Decrease of radial bow was not associated with limited range of motion. Union occurred in 98% of cases, and all were completed by 7.5 months. Three major complications occurred: 2 refractures and 1 case of ulnar hardware migration and subsequent radius nonunion in the patient with a grade 3b injury.

"The older pediatric population getting close to skeletal maturity actually does very well with the same type of treatments that we're using in younger kids. We're not needing to use plate and screw fixation for these kids. We're seeing that maybe the adolescent population, [similar to] the pediatric population, has an ability to remodel so that the angle of their radius doesn't have to be perfect. Maybe they're not fully mature in their soft tissue or bones, so that they're still able to compensate," said Dr. Wall.

"It's a challenging group of patients to deal with. Adolescents are between children and adults, and I think [Dr. Wall's team] has shown pretty nicely that in their hands, a technique that's been used for children can be extended up to almost the adult range. There are some definite advantages to it. The big one is that plating is a much more invasive procedure, takes much longer, and there's more pain," said William Phillips, MD, chief of orthopaedics at Texas Children's Hospital in Houston, who attended the session,

"I'm kind of excited about it. I've been doing this procedure and (in light of these results) I'll probably push the envelope a little more," Dr. Phillips told Medscape Medical News.

One of the authors of the study (Eric Gordon) is a consultant for OrthoPediatrics, which manufactures surgical nails. Dr. Phillips and Dr. Wall have disclosed no relevant financial relationships.

American Academy of Pediatrics 2010 National Conference and Exhibition: Abstract 9936. Presented October 3, 2010.

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