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Percutaneous intramedullary elastic wiring of displaced diaphyseal forearm fractures in children. A modified technique
PERGAMON
Injury, Int. J. Care Injured 30 (1999) 21±24
Percutaneous intramedullary elastic wiring of displaced diaphyseal forearm fractures in children. A modi®ed technique M. Waseem a, *, R.W. Paton a, b a
Blackburn Royal In®rmary, Blackburn BB2 3LR, U.K. b University of Manchester, Manchester, U.K. Accepted 3 September 1998
Abstract Under the age of 11 years there are speci®c anatomic considerations which favour intramedullary wiring of displaced forearm fractures. The isthmus of radius and ulna is narrow (range=3±6 mm). The medulla is at its widest proximally in the (ulna) and distally in the radius. These are the optimum entry points for intramedullary progression of the wire. At these points there is a low stress raising eect minimising the risk of iatrogenic fracture. A 1.6 mm Kirschner wire is elastic enough to be prebent into a large radius. It is strong enough to resist deformity on entry, though elastic enough to achieve stability by intramedullary three-point contact. The tip of the wire is prebent to 30 degrees aiding closed reduction of displaced fractures. An oblique 4.5 mm drill hole is made through a <2 cm skin incision avoiding the epiphysis. This allows the wire to be introduced into the intramedullary canal at an optimum angle of 308. A smaller hole would not allow intramedullary progression e.g; in a 2.5 mm hole the angle of insertion would be 558. Wire is now held with a cannulated T-handle, which is tapped with a hammer thus bouncing the wire of the side wall into the medulla. Rotating the handle aids reducing of displaced fractures. There are advantages to this method over other methods of intramedullary ®xation e.g; Steinman pins, Rush pins, or Nancy nails. Also holds advantage over plating. Over the last 12 months 11 cases were treated by the above methods without signi®cant complications. # 1999 Elsevier Science Ltd. All rights reserved.
1. Introduction Displaced diaphyseal fractures of the forearm in children under eleven years of age have conventionally been treated non-operatively [1±6]. Redisplacement, malunion and residual loss of motion may occur [2±6]. There has recently been a resurgence of interest in intramedullary ®xation of these fractures [7±9]. Elastic intramedullary 1.6 mm stainless steel K-wires are the current minimal access method of choice [6, 11, 12]. There is a dearth of information on the operative method and this paper describes such a technique. 2. Patients and methods Between January 1997 and February 1998, 65 children with displaced forearm fractures were admitted for treatment in this hospital. Eleven were treated by percutaneous intramedullary wiring. The other 54 cases were manipulated under general anaesthesia and immobilised in a long arm plaster cast. The mean age of those wired was 8.2 years (range: 6±11). * Corresponding author. Tel.: +44-161-331-6000, fax +44-161331-6300; e-mail:[email protected]. 0020-1383/99/$19.00 # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 8 ) 0 0 1 8 9 - 2
The percutaneous technique was used in cases where it was impossible to achieve or maintain a satisfactory reduction in skeletally immature children by closed manipulation alone. 108 of angulation was deemed acceptable but rotational deformity was not accepted [2±5].
3. Results This series consisted of eleven cases with a mean age of 8.2 (range: 6±11 years) years. The mean angulation was 228 in the lateral plane and 128 in the anteroposterior plane for the radius and 168 and 78, respectively, for the ulna. In eight cases closed reduction was achieved using a combination of manipulation of the fracture with a K-wire as a guide wire was successful, in three patients an open reduction through a small localised incision of <2 cm over the fracture site was necessary. Both bones were involved in eight cases and three involved the radius only. The mean follow-up was 18.8 weeks (range: 4±22 weeks). On the radiographs the angle of entry of the wires with a 4.5 mm drill hole was mean 308 (26±328). This con®rmed the importance of the size of the hole in
22
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 1. Diagrammatic representation of advantages of a 4.5 mm entry drill hole.
achieving percutaneous entry into the intramedullary canal. All fractures progressed to bony union, with no deep or super®cial infection. In two cases there was loss of pronation of 158 and 308, with no cases of residual angulation. Early in the series there was one green-stick fracture of the ulna due to the unadvisable use of a distal introduction site for wiring of this bone. This problem was later overcome by using a proximal entry site for the ulnar wire [10, 11]. 4. Technique General anaesthesia was necessary in all cases. Patient position was supine with the operated arm extended over a radiolucent hand table, in order to use image intensi®cation. A 1.6 mm K-wire was prebent 308 at the tip (blunt end) and the whole wire was given a gentle curve [10, 11]. This shape achieves a three-point ®xation of the fracture. It also helps to negotiate the tip past the fracture site similar to an intramedullary guide wire as used in reamed nailing techniques. The wire is introduced into the intramedullary canal through a small <2 cm skin incision. The entry site was determined with the help of an image intensi®er, avoiding the growth plate. A distal entry point is used over the lateral radial surface and ulnar wires were introduced from a proximal posterior entry point. This entry point is preferred, as in this region the intramedullary canal is at its widest reducing the stress raising eect which could cause a fracture. In addition the wide intramedullary canal allows entry and progression of wire down the canal. A 4.5 mm drill is used to drill an oblique entry hole guided by a protective sleeve at an angle of 308 to the bone. The average diameter of the isthmus of the intramedullary canal is only 3±6 mm. The 4.5 mm hole drilled obliquely allows the wire to be introduced at a more acute angle easing its passage down the intramedullary canal (mean angle of insertion with a 4.5 mm drill hole is 308, while with a 2.5 mm drill hole it
would be 558) (Fig. 1). The 1.6 mm K-wire is elastic, whereas a 2 mm wire would be too rigid. The wire is held in a cannulated T-handle which when tapped with a hammer allows the wire to bounce o the opposite cortex and into the intramedullary canal without deformation of the wire. The wire can then progress down the canal to the fracture site. Rotating the wire using the T-handle allows reduction of the displaced fracture by the pre-bent tip in the majority of cases. If the fracture cannot be reduced by this method, a small <2 cm incision is used over the fracture site to remove interposed soft tissue and reduce the fracture. The wire which is lying within the intramedullary canal, proximal or distal to the fracture site can then be pushed through the reduced fracture. The wire ends were bent and left proud of the skin. The arm was placed in an above elbow cast for 4 weeks when the wires were removed. A below elbow cast was used for a further 2 weeks. Pre- and post-operative radiographs of a 9 year old boy are shown in Figs. 2±4.
5. Discussion The majority of displaced forearm fractures in children can be treated by non-invasive means [1±6]. Due to remodelling, perfect reduction is not usually necessary in children. Diaphyseal fractures show less potential for remodelling than their metaphyseal counterparts. Closed manipulation may not be able to correct all deformities fully [2, 3]. Percutaneous ®xation of a forearm bone using titanium nails (Nancy nails) has the problems of measurement of the nail length, breakage of the nail end, backing out of the nail and high cost [9, 12±15]. Steinman or Rush nails have disadvantages including insertion through the physeal plate as they are straight non-elastic implants being used in a curved bone [16, 17]. In adolescents, the desired rotational stability may not be achieved with this percutaneous technique, as the medullary canal is larger and the forces on the fracture site are greater. Achieving a three point ®xation with 1.6 mm pre-bent wire and correcting or maintaining signi®cant deformity in this age group may not be possible [18]. Intramedullary percutaneous elastic K-wiring in children under eleven years of age is an accurate, cost eective, easily reproducible technique with few complications. This intramedullary wiring technique can correct angulatory and rotational deformities, closed or with minimal access open reduction. Leaving the wire ends proud of the skin facilitates their removal. The cost of the treatment is acceptable, as these wires cost £3.20 per wire. The operative exposure is minimal with this percutaneous method in comparison with other methods of open reduction and internal ®xation such as plates [19].
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 2. Both forearm bone displaced diaphyseal fracture in a 9 year-old, anteroposterior view.
Fig. 3. Both forearm bone displaced diaphyseal fracture in a 9 year-old, lateral view.
23
24
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 4. Same fracture after ®xation, showing two wires and adequate reduction in both planes.
References [1] Wilkins KE. Operative management of children's fractures: Is it a sign of impetuousness or do the children really bene®t?. Journal of Pediatric Orthopaedics 1998;18:1±3. [2] Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. Journal of Pediatric Orthopaedics 1986;6:306±10. [3] Duruwalla JS. A study of radio-ulnar movements following fractures of the forearm in children. Clinical Orthopaedics and Related Research 1979;139:114±20. [4] Mathews LS, Kaufer H, Garver DF, Sonstegard DA, Arbor A. The eect on supination±pronation of angular malalignment of fractures of both bones of the forearm. Journal of Bone and Joint Surgery 1982;64A:14±17. [5] Nilsson BE, Obrant K. The range of motion following fracture of the shaft of the forearm in children. Acta Orthop. Scand. 1977;48:600±2. [6] Younger ASE, Tredwell SJ, Mackenzie WG. Factors aecting position at cast removal after pediatric forearm fracture. Journal of Pediatric Orthopaedics 1997;17:332±6. [7] Yung SH, Lam CY, Ng KW, Mauli N, Chang JCY. Percutaneous intramedullary Kirschner wiring for displaced forearm fractures in children. Journal of Bone and Joint Surgery 1998;80B:91±4. [8] Verstreken L, Delronge G, Lamoureux J. Shaft forearm fractures in children: Intramedullary nailing with immediate motion: A preliminary report. Journal of Pediatric Orthopaedics 1998;8:450±3. [9] Van der Reis WL, Otsuka NY, Maroz P, Mah J. Intramedullary nailing vs plate ®xation for unstable forearm
[10]
[11] [12] [13]
[14] [15] [16] [17] [18]
[19]
fractures in children. Journal of Pediatric Orthopaedics 1998;18:9±13. Perez Sicilia JE, Marote Jurado JL, Carbacho Girones JM, Hernandez Cabrera JA, Gonzalez Brendia R. Osteointesis percutanea en fracturas dia®sarias de ante braza en ninos y adolscentes. Rev. Esp. Cir. Ost. 1977;12:321±34. Parsch K. The Marote wiring in proximal and midshaft fractutes of the child. Opera Orthop. Trauma 1990;2:245±455. Mataizeau JP. L'osteosynthese chez l'enfant, Techniques et indications. Rev. Chir. Orthop. 1983;69:495±511. Lascombes P, Prevot J, Ligier JN, Mataizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. Journal of Pediatric Orthopaedics 1990;10:161±71. Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary ®xation of pediatric forearm fractures. Journal of Pediatric Orthopaedics 1998;18:14±21. Huber RI, Keller HW, Huber PM, Rehm KE. Flexible intramedullary nailing as fracture treatment in children. Journal of Pediatric Orthopaedics 1996;16:602±5. Wyrsch B, Mencio GA, Green NE. Open reduction and internal ®xation of pediatric forearm fractures. Journal of Pediatric Orthopaedics 1996;16:644±50. Flynn JM, Waters PM. Single bone ®xation of both bone forearm fractures. Journal of Pediatric Orthopaedics 1996;16:655±9. Amit Y, Salai M, Chechik A, Blankstien A, Horoszowski H. Closing intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: A preliminary report. Journal of Pediatric Orthopaedics 1985;5:143±6. Ortega R, Loder RT, Louis DS. Open reduction and internal ®xation of forearm fractures in children. Journal of Pediatric Orthopaedics 1996;16:651±4.
Injury, Int. J. Care Injured 30 (1999) 21±24
Percutaneous intramedullary elastic wiring of displaced diaphyseal forearm fractures in children. A modi®ed technique M. Waseem a, *, R.W. Paton a, b a
Blackburn Royal In®rmary, Blackburn BB2 3LR, U.K. b University of Manchester, Manchester, U.K. Accepted 3 September 1998
Abstract Under the age of 11 years there are speci®c anatomic considerations which favour intramedullary wiring of displaced forearm fractures. The isthmus of radius and ulna is narrow (range=3±6 mm). The medulla is at its widest proximally in the (ulna) and distally in the radius. These are the optimum entry points for intramedullary progression of the wire. At these points there is a low stress raising eect minimising the risk of iatrogenic fracture. A 1.6 mm Kirschner wire is elastic enough to be prebent into a large radius. It is strong enough to resist deformity on entry, though elastic enough to achieve stability by intramedullary three-point contact. The tip of the wire is prebent to 30 degrees aiding closed reduction of displaced fractures. An oblique 4.5 mm drill hole is made through a <2 cm skin incision avoiding the epiphysis. This allows the wire to be introduced into the intramedullary canal at an optimum angle of 308. A smaller hole would not allow intramedullary progression e.g; in a 2.5 mm hole the angle of insertion would be 558. Wire is now held with a cannulated T-handle, which is tapped with a hammer thus bouncing the wire of the side wall into the medulla. Rotating the handle aids reducing of displaced fractures. There are advantages to this method over other methods of intramedullary ®xation e.g; Steinman pins, Rush pins, or Nancy nails. Also holds advantage over plating. Over the last 12 months 11 cases were treated by the above methods without signi®cant complications. # 1999 Elsevier Science Ltd. All rights reserved.
1. Introduction Displaced diaphyseal fractures of the forearm in children under eleven years of age have conventionally been treated non-operatively [1±6]. Redisplacement, malunion and residual loss of motion may occur [2±6]. There has recently been a resurgence of interest in intramedullary ®xation of these fractures [7±9]. Elastic intramedullary 1.6 mm stainless steel K-wires are the current minimal access method of choice [6, 11, 12]. There is a dearth of information on the operative method and this paper describes such a technique. 2. Patients and methods Between January 1997 and February 1998, 65 children with displaced forearm fractures were admitted for treatment in this hospital. Eleven were treated by percutaneous intramedullary wiring. The other 54 cases were manipulated under general anaesthesia and immobilised in a long arm plaster cast. The mean age of those wired was 8.2 years (range: 6±11). * Corresponding author. Tel.: +44-161-331-6000, fax +44-161331-6300; e-mail:[email protected]. 0020-1383/99/$19.00 # 1999 Elsevier Science Ltd. All rights reserved. PII: S 0 0 2 0 - 1 3 8 3 ( 9 8 ) 0 0 1 8 9 - 2
The percutaneous technique was used in cases where it was impossible to achieve or maintain a satisfactory reduction in skeletally immature children by closed manipulation alone. 108 of angulation was deemed acceptable but rotational deformity was not accepted [2±5].
3. Results This series consisted of eleven cases with a mean age of 8.2 (range: 6±11 years) years. The mean angulation was 228 in the lateral plane and 128 in the anteroposterior plane for the radius and 168 and 78, respectively, for the ulna. In eight cases closed reduction was achieved using a combination of manipulation of the fracture with a K-wire as a guide wire was successful, in three patients an open reduction through a small localised incision of <2 cm over the fracture site was necessary. Both bones were involved in eight cases and three involved the radius only. The mean follow-up was 18.8 weeks (range: 4±22 weeks). On the radiographs the angle of entry of the wires with a 4.5 mm drill hole was mean 308 (26±328). This con®rmed the importance of the size of the hole in
22
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 1. Diagrammatic representation of advantages of a 4.5 mm entry drill hole.
achieving percutaneous entry into the intramedullary canal. All fractures progressed to bony union, with no deep or super®cial infection. In two cases there was loss of pronation of 158 and 308, with no cases of residual angulation. Early in the series there was one green-stick fracture of the ulna due to the unadvisable use of a distal introduction site for wiring of this bone. This problem was later overcome by using a proximal entry site for the ulnar wire [10, 11]. 4. Technique General anaesthesia was necessary in all cases. Patient position was supine with the operated arm extended over a radiolucent hand table, in order to use image intensi®cation. A 1.6 mm K-wire was prebent 308 at the tip (blunt end) and the whole wire was given a gentle curve [10, 11]. This shape achieves a three-point ®xation of the fracture. It also helps to negotiate the tip past the fracture site similar to an intramedullary guide wire as used in reamed nailing techniques. The wire is introduced into the intramedullary canal through a small <2 cm skin incision. The entry site was determined with the help of an image intensi®er, avoiding the growth plate. A distal entry point is used over the lateral radial surface and ulnar wires were introduced from a proximal posterior entry point. This entry point is preferred, as in this region the intramedullary canal is at its widest reducing the stress raising eect which could cause a fracture. In addition the wide intramedullary canal allows entry and progression of wire down the canal. A 4.5 mm drill is used to drill an oblique entry hole guided by a protective sleeve at an angle of 308 to the bone. The average diameter of the isthmus of the intramedullary canal is only 3±6 mm. The 4.5 mm hole drilled obliquely allows the wire to be introduced at a more acute angle easing its passage down the intramedullary canal (mean angle of insertion with a 4.5 mm drill hole is 308, while with a 2.5 mm drill hole it
would be 558) (Fig. 1). The 1.6 mm K-wire is elastic, whereas a 2 mm wire would be too rigid. The wire is held in a cannulated T-handle which when tapped with a hammer allows the wire to bounce o the opposite cortex and into the intramedullary canal without deformation of the wire. The wire can then progress down the canal to the fracture site. Rotating the wire using the T-handle allows reduction of the displaced fracture by the pre-bent tip in the majority of cases. If the fracture cannot be reduced by this method, a small <2 cm incision is used over the fracture site to remove interposed soft tissue and reduce the fracture. The wire which is lying within the intramedullary canal, proximal or distal to the fracture site can then be pushed through the reduced fracture. The wire ends were bent and left proud of the skin. The arm was placed in an above elbow cast for 4 weeks when the wires were removed. A below elbow cast was used for a further 2 weeks. Pre- and post-operative radiographs of a 9 year old boy are shown in Figs. 2±4.
5. Discussion The majority of displaced forearm fractures in children can be treated by non-invasive means [1±6]. Due to remodelling, perfect reduction is not usually necessary in children. Diaphyseal fractures show less potential for remodelling than their metaphyseal counterparts. Closed manipulation may not be able to correct all deformities fully [2, 3]. Percutaneous ®xation of a forearm bone using titanium nails (Nancy nails) has the problems of measurement of the nail length, breakage of the nail end, backing out of the nail and high cost [9, 12±15]. Steinman or Rush nails have disadvantages including insertion through the physeal plate as they are straight non-elastic implants being used in a curved bone [16, 17]. In adolescents, the desired rotational stability may not be achieved with this percutaneous technique, as the medullary canal is larger and the forces on the fracture site are greater. Achieving a three point ®xation with 1.6 mm pre-bent wire and correcting or maintaining signi®cant deformity in this age group may not be possible [18]. Intramedullary percutaneous elastic K-wiring in children under eleven years of age is an accurate, cost eective, easily reproducible technique with few complications. This intramedullary wiring technique can correct angulatory and rotational deformities, closed or with minimal access open reduction. Leaving the wire ends proud of the skin facilitates their removal. The cost of the treatment is acceptable, as these wires cost £3.20 per wire. The operative exposure is minimal with this percutaneous method in comparison with other methods of open reduction and internal ®xation such as plates [19].
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 2. Both forearm bone displaced diaphyseal fracture in a 9 year-old, anteroposterior view.
Fig. 3. Both forearm bone displaced diaphyseal fracture in a 9 year-old, lateral view.
23
24
M. Waseem, R.W. Paton / Injury, Int. J. Care Injured 30 (1999) 21±24
Fig. 4. Same fracture after ®xation, showing two wires and adequate reduction in both planes.
References [1] Wilkins KE. Operative management of children's fractures: Is it a sign of impetuousness or do the children really bene®t?. Journal of Pediatric Orthopaedics 1998;18:1±3. [2] Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. Journal of Pediatric Orthopaedics 1986;6:306±10. [3] Duruwalla JS. A study of radio-ulnar movements following fractures of the forearm in children. Clinical Orthopaedics and Related Research 1979;139:114±20. [4] Mathews LS, Kaufer H, Garver DF, Sonstegard DA, Arbor A. The eect on supination±pronation of angular malalignment of fractures of both bones of the forearm. Journal of Bone and Joint Surgery 1982;64A:14±17. [5] Nilsson BE, Obrant K. The range of motion following fracture of the shaft of the forearm in children. Acta Orthop. Scand. 1977;48:600±2. [6] Younger ASE, Tredwell SJ, Mackenzie WG. Factors aecting position at cast removal after pediatric forearm fracture. Journal of Pediatric Orthopaedics 1997;17:332±6. [7] Yung SH, Lam CY, Ng KW, Mauli N, Chang JCY. Percutaneous intramedullary Kirschner wiring for displaced forearm fractures in children. Journal of Bone and Joint Surgery 1998;80B:91±4. [8] Verstreken L, Delronge G, Lamoureux J. Shaft forearm fractures in children: Intramedullary nailing with immediate motion: A preliminary report. Journal of Pediatric Orthopaedics 1998;8:450±3. [9] Van der Reis WL, Otsuka NY, Maroz P, Mah J. Intramedullary nailing vs plate ®xation for unstable forearm
[10]
[11] [12] [13]
[14] [15] [16] [17] [18]
[19]
fractures in children. Journal of Pediatric Orthopaedics 1998;18:9±13. Perez Sicilia JE, Marote Jurado JL, Carbacho Girones JM, Hernandez Cabrera JA, Gonzalez Brendia R. Osteointesis percutanea en fracturas dia®sarias de ante braza en ninos y adolscentes. Rev. Esp. Cir. Ost. 1977;12:321±34. Parsch K. The Marote wiring in proximal and midshaft fractutes of the child. Opera Orthop. Trauma 1990;2:245±455. Mataizeau JP. L'osteosynthese chez l'enfant, Techniques et indications. Rev. Chir. Orthop. 1983;69:495±511. Lascombes P, Prevot J, Ligier JN, Mataizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. Journal of Pediatric Orthopaedics 1990;10:161±71. Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary ®xation of pediatric forearm fractures. Journal of Pediatric Orthopaedics 1998;18:14±21. Huber RI, Keller HW, Huber PM, Rehm KE. Flexible intramedullary nailing as fracture treatment in children. Journal of Pediatric Orthopaedics 1996;16:602±5. Wyrsch B, Mencio GA, Green NE. Open reduction and internal ®xation of pediatric forearm fractures. Journal of Pediatric Orthopaedics 1996;16:644±50. Flynn JM, Waters PM. Single bone ®xation of both bone forearm fractures. Journal of Pediatric Orthopaedics 1996;16:655±9. Amit Y, Salai M, Chechik A, Blankstien A, Horoszowski H. Closing intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: A preliminary report. Journal of Pediatric Orthopaedics 1985;5:143±6. Ortega R, Loder RT, Louis DS. Open reduction and internal ®xation of forearm fractures in children. Journal of Pediatric Orthopaedics 1996;16:651±4.