Conservative treatment for refracture of the forearm with elastic stable intramedullary nails in situ in an adolescent: A case report

Abstract

Elastic stable intramedullary nailing (ESIN) for forearm shaft fractures in children and adolescents is generally associated with favorable outcomes. However, refracture with ESINs in situ is a rare complication. We report a rare case of refracture with implants in situ in a 14-year-old male patient. Six months after the initial surgery, the patient sustained a reinjury while playing soccer. Radiographs confirmed forearm shaft refracture of both the radius and ulna, and both intramedullary nails were bent at the fracture sites but remained unbroken. We performed emergent closed manual reduction after an ultrasound-guided axillary nerve block and successfully realigned the fractures and straightened the intramedullary nails without breakage. Although exchanging the ESINs was proposed, the patient and his family declined surgery, leading to conservative therapy. Bone union was achieved 2 months after refracture, resulting in a favorable outcome. This minimally invasive treatment is a useful first-line option because it requires no new implants and can be performed in emergency departments or outpatient settings. To our knowledge, this is the first report of this specific treatment in East Asian populations.

Highlights

• •Forearm refracture occurred with ESINs in situ.
• •Implant-preserving conservative therapy was successful.
• •Closed reduction that preserves the implants may be an option in similar cases.

Introduction

Surgery using elastic stable intramedullary nailing (ESIN) for forearm shaft fractures in children and adolescents is associated with favorable outcomes [1], [2], [3]. Refracture with ESINs in situ is a rare complication, reported in 1.2% of cases [4]. We report a rare case of refracture with implants in situ in an adolescent male patient treated conservatively, with implant preservation.

Case

A 14-year-old male patient (161 cm tall, 44 kg body weight) collided with another player and fell while playing soccer. His right forearm was injured when the other player fell on it. The patient had no pre-existing comorbidities. Radiographs revealed right forearm radial and ulnar shaft fractures (Association for the Study of Internal Fixation/Orthopaedic Trauma Association (AO/OTA) classification: 22-D/4.1) (Fig. 1A, B) [5]. Surgery using ESIN was performed the next day (Fig. 1C, D). We used a 2-mm-diameter titanium elastic nail (DePuy Synthes, West Chester, PA, USA) for both the radius and ulna. Three months postoperatively, the fracture had united (Fig. 1E, F), and because of the patient's strong desire, we permitted a return to sports without removal of the intramedullary nails. Six months after the initial fracture, the patient fell while playing soccer and reinjured his right forearm. At presentation to our hospital, he reported pain in his right forearm, and marked deformity was obvious (Fig. 2A). We diagnosed forearm shaft refracture of both the radius and ulna on X-ray examination (Fig. 2B, C). Both intramedullary nails were bent at the fracture sites but were unbroken. In an emergency procedure the same day, we performed manual closed reduction after an ultrasound-guided axillary nerve block. Both fractures were successfully realigned, and the intramedullary nails were straightened without breakage (Fig. 3A, B). We proposed surgery to exchange the intramedullary nails to prevent future nail breakage. However, the patient and his family did not prefer this treatment, and we performed post-procedure conservative therapy with a splint for 2 weeks. Bone union was achieved 2 months after refracture (Fig. 3C, D). Eight months after refracture, we removed both intramedullary nails (Fig. 3E). One year after refracture, range of motion (unaffected side) was as follows: wrist: flexion 90° (90°), extension: 90° (90°); forearm: pronation: 75° (90°), supination: 90° (90°); elbow flexion: 140° (140°), extension: 0 (0); Mayo Wrist Score: 100, and Mayo Elbow Performance Score: 100. Compared with the unaffected side, there was mild limitation in forearm pronation, but the patient was able to return to activities of daily living and sports without notable issues.

Fig. 1.

Images at the time of the initial operation.

Initial posttraumatic X-rays: (A) anteroposterior (AP) view, (B) lateral view.

X-rays after the initial operation: (C) AP view, (D) lateral view.

X-rays 3 months after the initial surgery showing fracture union: (E) AP view, (F) lateral view.

Fig. 2.

Images at the time of refracture.

Photograph of the patient's forearm at the time of refracture (A).

X-rays at the time of refracture: (B) AP view, (C) lateral view.

Fig. 3.

Imaging after refracture treatment.

X-rays after manual reduction for refracture: (A) AP view, (B) lateral view.

X-rays 2 months after refracture showing fracture union: (C) AP view, (D) lateral view.

X-rays 1 year after re-fracture showing fracture healing: (E) AP view.

Discussion

We experienced a case of forearm refracture in an adolescent patient with existing intramedullary nails. We performed closed reduction while preserving the intramedullary nails, achieved acceptable reduction, and proceeded with conservative management. This resulted in bone union and a favorable outcome. There are few comprehensive reports on refracture with ESIN, and there is no consensus on treatment methods [4], [6], [7]. Similar to our case, closed reduction and conservative therapy for refracture with ESINs in situ have been associated with good outcomes when treated while preserving the intramedullary nails [8], [9], [10], [11]. To our knowledge, this treatment has not been reported previously in East Asian populations. This treatment method is minimally invasive, can be performed in emergency departments or outpatient settings, requires no new implants, and is a useful first-line treatment option. However, there has been a report of implant breakage in a patient who underwent manual reduction; therefore, caution regarding this complication is necessary [3]. While ESIN removal should be considered, straightening the nail to restore its shape is unavoidable because removing a bent ESIN is difficult. Because of this requirement, manual reduction should be considered early to improve the patient's symptoms. In cases of implant breakage after manual reduction, surgical removal is necessary [3]. Importantly, surgeons must consider implant strength after straightening a bent ESIN because nail strength is reduced after straightening. Therefore, exchanging the ESIN is an option for refractures after manual reduction [10].

Conclusions

We experienced a case of refracture with ESIN implants in situ. For similar fractures with ESINs in situ, closed reduction and implant preservation may be an option. Closed reduction with implant preservation can be considered a minimally invasive and effective alternative in selected cases of ESIN refracture, provided that nail integrity is maintained.

CRediT authorship contribution statement

Hiroo Nakajima: Conceptualization, Formal analysis, Writing – original draft, Writing – review & editing. Jiro Ando: Conceptualization, Data curation, Writing – original draft, Writing – review & editing. Masaki Iguchi: Data curation, Investigation, Writing – original draft. Shuhei Hiyama: Data curation, Investigation, Writing – original draft. Tsuneari Takahashi: Writing – original draft, Writing – review & editing. Kazuki Abe: Writing – original draft, Writing – review & editing. Yoshiya Nibe: Writing – original draft, Writing – review & editing. Tomohiro Matsumura: Conceptualization, Supervision, Writing – original draft, Writing – review & editing. Katsushi Takeshita: Supervision, Writing – original draft, Writing – review & editing.

Informed consent statement

Written consent was obtained from the patient for the publication of this case report, as well as the associated images. This case report was approved by the Institutional Review Board of Jichi Medical University.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.