Abstract
Purpose
Nonunions are a very rare complication after surgical treatment of displaced forearm fractures in children, but can occur in both the radius or ulna. The aim of this study is to evaluate predisposing factors for non-unions and to discuss treatment options.
Methods
We conducted a retrospective analysis of all patients who were treated primarily or secondary at our institution for nonunion after forearm fractures and operative treatment. Therefore, we retrospectively reviewed the medical charts and radiographs of affected patients from 1990 to 2020. We analysed demographic and fracture-related data as well as treatment options.
Results
Twenty-seven cases were identified. Median age was 12 years (7–16 years). The ulna was affected in 20 cases and the radius in 7. The most common location for ulna nonunion was the middle third of the shaft, and for the radius the mid and distal shaft. In 21 cases an open reduction was required. In 9 cases technical problems were identified. In most cases (26/27) a hypertrophic nonunion occurred. 10 of 27 (37%) nonunions healed without any surgical management after 9 (7–15) months. The median age of the conservatively managed group was 10 (6–13) years, younger than in the group with managed with reoperation [median 13 (7–16) years]. Indications for surgical intervention were increasing deformity, pain and limitation of movement.
Conclusion
Open reduction and technical problems seem to be influencing factors. A conservative approach can be adopted in asymptomatic patients, otherwise an operative management, constituting plate osteosynthesis with or without bone grafting, should be performed.
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Availability of data and material
Data were obtained from the hospital servers with personal accounts.
References
Lyman A, Wenger D, Landin L. Pediatric diaphyseal forearm fractures: epidemiology and treatment in an urban population during a 10-year period, with special attention to titanium elastic nailing and its complications. J Pediatr Orthop B. 2016;25(5):439–46. https://doi.org/10.1097/BPB.0000000000000278.
Korner D, Gonser CE, Bahrs C, Hemmann P. Change in paediatric upper extremity fracture incidences in German hospitals from 2002 to 2017: an epidemiological study. Arch Orthop Trauma Surg. 2020;140(7):887–94. https://doi.org/10.1007/s00402-019-03321-5.
Fernandez FF, Langendörfer M, Wirth T, Eberhardt O. Failures and complications in intramedullary nailing of children’s forearm fractures. J Child Orthop. 2010;4(2):159–67. https://doi.org/10.1007/s11832-010-0245-y.
Schmittenbecher PP. State-of-the-art treatment of forearm shaft fractures. Injury. 2005;36(Suppl 1):A25-34. https://doi.org/10.1016/j.injury.2004.12.010.
Franklin CC, Wren T, Ferkel E, Arkader A. Predictors of conversion from conservative to operative treatment of pediatric forearm fractures. J Pediatr Orthop B. 2014;23(2):150–4. https://doi.org/10.1097/BPB.0000000000000018.
Fernandez FF, Egenolf M, Carsten C, Holz F, Schneider S, Wentzensen A. Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing. Injury. 2005;36(10):1210–6. https://doi.org/10.1016/j.injury.2005.03.004.
Barry M, Paterson JM. A flexible intramedullary nails for fractures in children. J Bone Jt Surg Br. 2004;86(7):947–53. https://doi.org/10.1302/0301-620x.86b7.15273.
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):330–3. https://doi.org/10.1097/01202412-200409000-00009.
Schmittenbecher PP, Fitze G, Godeke J, Kraus R, Schneidmuller D. Delayed healing of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop. 2008;28(3):303–6. https://doi.org/10.1097/BPO.0b013e3181684cd6.
Kruppa C, Bunge P, Schildhauer TA, Dudda M. Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: a retrospective study of 202 cases. Medicine (Baltimore). 2017;96(16):e6669. https://doi.org/10.1097/MD.0000000000006669.
Lieber J, Schmittenbecher P. Developments in the treatment of pediatric long bone shaft fractures. Eur J Pediatr Surg. 2013;23(6):427–33. https://doi.org/10.1055/s-0033-1360460.
Fernandez FF, Eberhardt O, Langendörfer M, Wirth T. Nonunion of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop B. 2009;18(6):289–95. https://doi.org/10.1097/BPB.0b013e32832f5b20.
Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop. 2006;26(6):827–34. https://doi.org/10.1097/01.bpo.0000235397.64783.d6.
Salonen A, Salonen H, Pajulo O. A critical analysis of postoperative complications of antebrachium TEN-nailing in 35 children. Scand J Surg. 2012;101(3):216–21. https://doi.org/10.1177/145749691210100313.
Fernandez Fernandez F, Langendorfer M, Wirth T, Eberhardt O. Pseudarthrosis following surgically treated forearm fractures in children and adolescents. Z Orthop Unfall. 2013;151(4):364–70. https://doi.org/10.1055/s-0032-1328667.
Lewallen RP, Peterson HA. Nonunion of long bone fractures in children: a review of 30 cases. J Pediatr Orthop. 1985;5(2):135–42.
Kwa S, Tonkin MA. Nonunion of a distal radial fracture in a healthy child. J Hand Surg Br. 1997;22(2):175–7. https://doi.org/10.1016/s0266-7681(97)80056-3.
Arslan H, Subasy M, Kesemenli C, Ersuz H. Occurrence and treatment of nonunion in long bone fractures in children. Arch Orthop Trauma Surg. 2002;122(9–10):494–8. https://doi.org/10.1007/s00402-002-0439-y.
Song KS, Kim HK. Nonunion as a complication of an open reduction of a distal radial fracture in a healthy child: a case report. J Orthop Trauma. 2003;17(3):231–3. https://doi.org/10.1097/00005131-200303000-00015.
Adamczyk MJ, Riley PM. Delayed union and nonunion following closed treatment of diaphyseal pediatric forearm fractures. J Pediatr Orthop. 2005;25(1):51–5. https://doi.org/10.1097/00004694-200501000-00012.
Orzechowski W, Morasiewicz L, Dragan S, Krawczyk A, Kulej M, Mazur T. Treatment of non-union of the forearm using distraction-compression osteogenesis. Ortop Traumatol Rehabil. 2007;9(4):357–65.
Ballal MS, Garg NK, Bruce CE, Bass A. Nonunion of the ulna after elastic stable intramedullary nailing for unstable forearm fractures: a case series. J Pediatr Orthop B. 2009;18(5):261–4. https://doi.org/10.1097/BPB.0b013e32832f0648.
Shrader MW, Stans AA, Shaughnessy WJ, Haidukewych GJ. Nonunion of fractures in pediatric patients: 15-year experience at a level I trauma center. Orthopedics. 2009;32(6):410. https://doi.org/10.3928/01477447-20090511-11.
Abd Rashid AH, Ibrahim S. Hypertrophic nonunion of the ulna in a child: treatment with an elastic stable intramedullary nail without bone graft. Strateg Trauma Limb Reconstr. 2010;5(3):145–7. https://doi.org/10.1007/s11751-010-0089-5.
Ritting AW, Weber EW, Lee MC. Exaggerated inflammatory response and bony resorption from BMP-2 use in a pediatric forearm nonunion. J Hand Surg Am. 2012;37(2):316–21. https://doi.org/10.1016/j.jhsa.2011.10.007.
Saini P, Meena S, Shekhawat V, Kishanpuria TS. Nonunion of forearm fracture: a rare instance in a toddler. Chin J Traumatol. 2012;15(6):379–81.
Memeo A, Verdoni F, De Bartolomeo O, Albisetti W, Pedretti L. A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma. Injury. 2014;45(2):418–23. https://doi.org/10.1016/j.injury.2013.09.021.
Di Gennaro GL, Stilli S, Trisolino G. Post-traumatic forearm nonunion in healthy skeletally immature children: a report on 15 cases. Injury. 2017;48(3):724–30. https://doi.org/10.1016/j.injury.2017.01.023.
Sinikumpu JJ, Lautamo A, Pokka T, Serlo W. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Injury. 2013;44(4):431–6. https://doi.org/10.1016/j.injury.2012.08.032.
Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kessar JR, editors. Rockwood and Wilkins’ fractures in children. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006. p. 399–441.
Weber BG, Čech O. Pseudarthrosis: pathophysiology, biomechanics, therapy, results. Berne: Hans Huber; 1976.
Giebel GD, Meyer C, Koebke J, Giebel G. Arterial supply of forearm bones and its importance for the operative treatment of fractures. Surg Radiol Anat. 1997;19(3):149–53. https://doi.org/10.1007/bf01627964.
Wright TW, Glowczewskie F. Vascular anatomy of the ulna. J Hand Surg Am. 1998;23(5):800–4. https://doi.org/10.1016/S0363-5023(98)80153-6.
Greenbaum B, Zionts LE, Ebramzadeh E. Open fractures of the forearm in children. J Orthop Trauma. 2001;15(2):111–8. https://doi.org/10.1097/00005131-200102000-00007.
Lobo-Escolar A, Roche A, Bregante J, Gil-Alvaroba J, Sola A, Herrera A. Delayed union in pediatric forearm fractures. J Pediatr Orthop. 2012;32(1):54–7. https://doi.org/10.1097/BPO.0b013e31823832ea.
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Loose, O., Fernandez, F., Morrison, S. et al. Treatment of nonunion after forearm fractures in children: a conservative approach. Eur J Trauma Emerg Surg 47, 293–301 (2021). https://doi.org/10.1007/s00068-020-01583-y
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DOI: https://doi.org/10.1007/s00068-020-01583-y