Introduction. Diaphyseal forearm fractures constitute the second most numerous group of injuries to
the locomotor system in children, right after the injuries of the distal part of forearm bones. Most often,
diaphyseal forearm fractures in children occur through an indirect mechanism. In the treatment of
diaphyseal forearm fractures in children, the aim is to achieve union, correct length and axis of both forearm
bones. Diaphyseal forearm fractures can be treated non-surgically, using a cast, and surgically. In children,
the most frequently used surgical method is closed reposition and intramedullary stabilization with the use
of TEN nailing. During treatment, possible complications must be taken into account.
Objective. The objective of the study is to analyse the most common late complications of diaphyseal
forearm fractures in children in relation to the treatment method.
Materials and methods. The study included 126 children aged 5-17 (mean age 11.4) hospitalized due
to diaphyseal forearm fractures at the Department of Children’s Orthopaedics and Rehabilitation of the
Medical University of Lublin between 2015-2021. All patients were qualified for closed osteosynthesis
and stabilization using elastic intramedullary nailing according to the Metaizeau technique. The analysis
covered the type and incidence of complications up to six months after removing the fixation, in relation to
the method of surgical treatment.
Results. The analysed group of patients at developmental age consisted of 126 patients, 26 girls and 100
boys. All children were qualified for surgical treatment using elastic intramedullary stabilization according
to Metaizeau. Of all the patients, 120 patients experienced no complications, 5 patients experienced
refractures, and 1 patient had delayed union. Non-union was not observed when using this method, and
refracture turned out to be the most common complication. Complications of surgical treatment in one
patient were treated non-surgically, and five patients were qualified for intramedullary restabilization. Every
twentieth child developed a form of complication.
Conclusions. Surgical treatment of diaphyseal forearm fractures using the Metaizeau technique in children
carries a very low rate of complications.
Wstęp. Złamania trzonów kości przedramienia stanowią drugą pod względem liczebności grupę obrażeń
narządu ruchu u dzieci, zaraz po urazach ich części dalszej. Najczęściej do złamań trzonów kości przedramienia
u dzieci dochodzi w mechanizmie pośrednim. W leczeniu złamań trzonów kości przedramienia u dzieci
dąży się do uzyskania zrostu, prawidłowej długości i osi obu kości przedramienia. Złamania trzonów kości
przedramienia leczyć można bezoperacyjnie w opatrunku gipsowym, jak i operacyjnie. U dzieci najczęściej
stosowaną metodą operacyjną jest zamknięta repozycja oraz stabilizacja śródszpikowa przy pomocy
prętów TEN. W trakcie leczenia nie należy zapominać o możliwych powikłaniach.
Cel. Celem pracy jest analiza najczęściej występujących późnych powikłań złamań trzonów obu kości
przedramienia u dzieci w odniesieniu do metody leczenia.
Materiał i metody. Badaniem objęto 126 dzieci w wieku 5-17 lat (średnia wieku 11,4 lat), hospitalizowanych
z powodu złamania trzonów obu kości przedramienia w Klinice Ortopedii i Rehabilitacji Dziecięcej
Uniwersytetu Medycznego w Lublinie w latach 2015-2021. Wszystkich pacjentów zakwalifikowano do
zabiegu zamkniętej osteosyntezy oraz stabilizacji odłamów elastycznymi prętami śródszpikowymi wg
metody Metaizeau. Analiza objęła rodzaj oraz częstość występowania powikłań do 6 miesięcy od usunięcia
zespolenia, w odniesieniu do metody leczenia operacyjnego.
Wyniki. Analizowaną grupę pacjentów w wieku rozwojowym utworzyło 126 pacjentów, 26 dziewczynek
oraz 100 chłopców. Wszystkie dzieci zakwalifikowano do leczenia operacyjnego poprzez elastyczną
stabilizację śródszpikową wg Metaizeau. Spośród wszystkich pacjentów u 120 nie odnotowano żadnych
powikłań, ponownego złamania doznało 5 pacjentów, u 1 osoby odnotowano opóźniony zrost. Braku
zrostu w przypadku tej metody nie stwierdzono.Najczęstszym powikłaniem leczenia okazała się refraktura.
Powikłania leczenia operacyjnego u 1 pacjenta zaopatrzono w sposób bezoperacyjny, natomiast 5
zakwalifikowano do ponownej stabilizacji śródszpikowej. Jakakolwiek forma powikłania leczenia wystąpiła
u co dwudziestego dziecka.
Wnioski. Operacyjne leczenie złamania trzonów kości przedramienia wg Metaizeau u dzieci niesie za sobą
bardzo niski odsetek powikłań.
Diaphyseal forearm fractures are by far the most numerous group of fractures at developmental age. When dividing the forearm into individual areas, diaphyseal forearm damage occurs most often, right after injuries of the distal part of the forearm bone. [9,11,25]. Diaphyseal forearm fractures most often occur through an indirect mechanism, i.e. by falling onto the open palms. Fractures through a direct mechanism are slightly less frequent . The main aim of treating diaphyseal forearm fractures is to achieve their full union, regaining the correct axis and length. The aim of treatment is to allow the upper limb to function properly. Fractures can be treated both non-surgically, using a brachio-palmar cast [2.24], and surgically. The method most often used in children today is osteosynthesis using elastic intramedullary nailing [1,3,4,6,20,23,24]. Despite its common use and very good therapeutic effects of the above surgical method, it is not without complications. The most common ones include: delayed union, non-union and refracture [15,17,18,24].
The objective of the study is to evaluate and compare the most common late complications of diaphyseal forearm fractures in children in relation to the method of osteosynthesis using elastic intramedullary nailing.
Materials and methods
Between 2015-2021, 126 patients were qualified for surgical treatment of diaphyseal forearm fractures at the Department of Children’s Orthopaedics and Rehabilitation of the Medical University of Lublin. In all children, the method of choice was osteosynthesis using elastic intramedullary nailing according to the Metaizeau technique. Patients were diagnosed and treated by the Clinic’s team of doctors. Data obtained from medical history, imaging tests, operating protocols and outpatient treatment summaries were analysed. The patients’ age ranged between 5 and 17. The mean age of the patients was 11.4. In the preparation of the material, the frequency of possible complications after surgical treatment was evaluated, together with their clinical and radiological symptoms. The c² compliance test was used for statistical purposes. The results were elaborated using Statistica™, based on the available mathematical models. The significance of differences and correlations was found at the significance level of p ≤ 0.05. The results presented in the form of figures, tables and diagrams are discussed in the discussion, and summarized with conclusions.
All patients included in the study experienced closed diaphyseal fractures in both forearms. The method of choice was osteosynthesis using elastic intramedullary nailing according to the Metaizeau technique.
Among all the patients at developmental age, there were 26 girls (20.63%), and 100 boys (79.37%) (Tab. 1).
Out of the entire study group, 120 patients had no complications (89.83%). The most common complication was refracture, which occurred 6 months after removing the fixation in five patients (3.97%). In 1 patient, delayed union was observed (0.79%), non-union was not observed after treatment using this method (Tab. 2).
In 1 patient, surgical treatment resulted in the maintenance of non-surgical treatment (0.79%), while the remaining 5 were qualified for intramedullary restabilization (3.97%) (Tab. 3).
Every twentieth person treated using the Metaizeau technique, experienced a form of treatment complication (4.76%) (Tab. 4).
A statistically significant correlation was observed between the surgical treatment and the incidence of complications (χ2 (1, N = 120) = 5.17; p < 0.05) and it was determined that the correlation is weak (contingency coefficient = 0.20).
The choice of treatment for diaphyseal forearm fractures in children is a topic frequently raised in the clinical community. A factor that prompts a discussion about this type of injury is the high incidence of this type of injury in the paediatric population [7,14,21,22]. It is necessary to treat fractures as best as possible, analyse treatment effects and evaluate possible late complications . A significant proportion of young patients who have suffered diaphyseal forearm fractures are successfully treated non-surgically by a closed fracture adjustment and an immobilizing brachio-palmar cast . Fractures, in the treatment of which immobilization in a cast is insufficient, qualify for surgical treatment.
The method of choice for patients at developmental age with diaphyseal forearm fractures is closed osteosynthesis with intramedullary stabilization using elastic titanium nailing according to Metaizeau, which is emphasized, among others, by Schmittenbecher or Flynn [5,22]. As with any treatment method, surgical treatment of this type of fracture with elastic titanium nailing also carries a risk of possible complications .
Analysing the above material, a significantly low rate of late complications is noticeable in the case of the described method of surgical treatment. Moreover, based on literature, stabilization with elastic intramedullary nailing is characterized by a much lower complication rate compared to the non-surgical method. A similar conclusion was drawn based on the observations made by Han et al. . In a fairly significant material, including 267 patients at developmental age, treated for diaphyseal forearm fractures using elastic intramedullary fixation, only 11 patients experienced late complications in the form of refractures. On this basis, they formulated a thesis that the complication in the form of refractures is rare in patients treated using elastic intramedullary fixation. Kruppa et al. reached a similar conclusion in their studies, as they observed 10 cases of refractures and 6 other forms of late complications. The study included 202 children hospitalized due to diaphyseal forearm fractures, treated using the Metaizeau surgical method. The conclusion of this study is that elastic intramedullary fixation currently constitutes the basis of treating diaphyseal forearm fractures in children .
An attempt to solve the problem of late complications was also undertaken by Kailis et al. Their study included 75 children who suffered diaphyseal forearm fractures in both forearms, both first-time and refractures. After treatment, each of the patients was provided with preventive orthosis stabilizing the forearm to be worn for six months. In addition, the patient could not undertake any physical activity during this time. The rate of late complications in the form of refractures reached the level of 0% . While the complete elimination of the possibility of complications from our treatment is an obvious incentive to use a similar prevention system, the question that automatically arises is whether the exclusion of a child from physical development for more than six months is an appropriate solution. Assuming that there will be no other injury requiring different treatment and possible rehabilitation. Moreover, cessation of physical activity still does not eliminate the possibility of another type of injury.
In the case of a diaphyseal forearm fracture in a patient at developmental age, involving significant displacement or shortening, which makes non-surgical treatment using a cast insufficient, the method of elastic intramedullary fixation can and should be used to obtain reliable and stable osteosynthesis, very good final results and a negligible rate of late complications.
Surgical treatment of diaphyseal forearm fractures in children using elastic intramedullary nailing entails a very low rate of complications (4.76%).
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