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. 2020 Jan 14;20:125–130. doi: 10.1016/j.jor.2020.01.002

Flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents, a systematic review

Frideriki Poutoglidou 1,∗, Dimitrios Metaxiotis 1, Christos Kazas 1, Dimitrios Alvanos 1, Anastasios Mpeletsiotis 1
PMCID: PMC6997658  PMID: 32025135

Abstract

Background

Forearm fractures are common injuries among children and adolescents. Traditionally, they were managed conservatively with closed reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment. The treatment modalities available include plate and screws, flexible intramedullary nailing and external fixation devices – rarely used nowadays. The aim of this systematic review is to investigate the indications of flexible intramedullary nailing in the childhood population, to compare its results with plating and to provide detailed information considering technical pitfalls and complications that may be encountered.

Materials and methods

An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation. 56 articles were considered suitable for inclusion.

Results

The indications for surgery are unstable and irreducible fractures, open and fractures with neurovascular compromise. As far as the fracture site is concerned, radius and ulna shaft fractures, radial head and Monteggia fractures are suitable for nailing.

Although plates and nailing have comparable clinical outcomes and complication rates, flexible intramedullary nailing has the advantage of smaller incisions, less tissue disruption, shorter operative and hospital times and an ease in hardware removal.

Controversy exists over the need of single or double nailing in both-bone fractures of the forearm. In addition, there is no consensus as to which is the preferred nail diameter. Yet, all the authors agree that open reduction must be considered after certain failed closed reductions in order compartment syndrome to be avoided.

Flexible intramedullary nailing is not complication-free. Skin irritation, Extensor Pollicis Longus rupture, superficial radial nerve injury, delayed union or even nonunion, malunion and refractures are some of the complications that may be encountered.

Discussion

Flexible nails are excellent implants combining stability and elasticity. The procedure of passing the nails across radius and ulna is relatively simple, requiring a small learning curve. Flexible intramedullary nailing is an excellent treatment modality for the treatment of forearm fractures in children and adolescents.

Keywords: Forearm, Fracture, Flexible, Nailing

1. Introduction

Forearm fractures are common injuries in children, accounting for approximately 3–5% of all fractures and 30% of the fractures in the upper extremity.1,2 They include fractures of the proximal, medial or distal third of the shaft of the ulna or the radius, Monteggia and Galeazzi fractures.

Traditionally, forearm fractures in children were treated non-operatively, with reduction and cast immobilization. Non-operative treatment is successful in the vast majority of the patients, due to the high remodeling potential.3, 4, 5, 6, 7 Proper molding technique and three-point fixation is emphasized.

In the mid-19th century, ivory pins were used for fixation of forearm fractures. Those were gradually replaced by metal ones, such us the Küntscher nail. Because of its rigidity, it was hard physes to be avoided. In 1930's, the Rush nail was introduced. It was a more flexible choice, based on the principle of a three-point fixation in the inner cortex.8 In 1980's, surgeons in Nancy France developed an elastic intramedullary nail, whose concepts apply up to nowadays in the treatment of long-bone fractures in children.9

The aim of this systematic review is to elucidate the indications of flexible nailing in the forearm fractures of the child, to compare nailing to plating, to provide an overview of the techniques currently used, their clinical outcomes and their potential complications and subsequently aid the physicians in the decision making and management of those fractures.

2. Methods

This review was conducted according to the guidelines presented in the PRISMA Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).10 An extensive search was performed in the electronic databases (PubMed, EMBASE) from their inception up to June 2019 in order articles relevant to this review to be retrieved. The search terms used were the following: forearm fracture, both-bone fracture, pediatric, nailing, fixation with “AND” and “OR” as boolean terms. No filters were applied to the search strategies. In vitro studies, cadaveric and biomechanical studies were also included.

Two independent reviewers screened the titles and abstracts of the articles and assessed them for eligibility. Any disagreement was resolved by discussion between the two reviews after the full article was retrieved and if necessary a third investigator was consulted.

The electronic search yielded 251 articles. Hand searching found an additional 31 articles. After exclusion of duplicates and articles not relevant to this review, 56 articles were considered suitable for inclusion. Statistical analysis was not feasible due to the heterogeneity between studies and multiple elements being assessed [Fig. 1].

Fig. 1.

Fig. 1

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Flow diagram describing research strategy.

3. Results

3.1. Indications

Traditionally, forearm fractures were treated conservatively with close reduction and cast immobilization. The last decade there is an increasing trend towards operative treatment of forearm fractures in children. The indications for surgery are unstable and irreducible fractures,9 open and fractures with neurovascular compromise.11

There are many studies concluding that flexible intramedullary nailing for the treatment of forearm fractures in the adolescents is a suitable option.12, 13, 14, 15 Although adolescents have a lower remodeling potential, it seems that nailing remains a viable alternative.

Accept for radius and ulna shaft fractures, nailing can be used for the treatment of Monteggia7,16 and radial head17 fractures. In a Monteggia fracture, closed reduction of the ulna fracture should lead to complete and stable reduction of the radial head. If this is not possible, operative treatment with one nail in the ulna can be performed. As far as radial head fractures are concerned, one nail passed through the radius and then rotated provides the ability of reduction and stabilization of the radial head, known as Metaizeau technique.[Fig. 2].

Fig. 2.

Fig. 2

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Metazeau technique for the treatment of radial head fracture [Papageorgiou General Hospital of Thessaloniki].

3.2. Intramedullary nailing VS plating

There are many treatment modalities available, including plates and screws, intramedullary nails and external fixation devices – rarely used currently. Flexible intramedullary nailing is an excellent option, with many advantages over plating, including smaller incisions, improved cosmesis, less tissue disruption, shorter operative and tourniquet time and increased ease in hardware removal.7,17 However, plating is associated with a more anatomical restoration of the radial bow and a more rigid fixation which requires minimal postoperative immobilization.12,18 Flexible intramedullary nailing and plating have similar functional outcomes and a comparable complication rate.19,20

Flexible intramedullary nailing has the advantage of providing both stability and elasticity. Its mechanical properties are based on a three – point fixation of the inner cortex. Maximum curve of each nail must be obtained at the fracture site. As the nails are turned towards each other, they spread the interosseous membrane, providing stability. At the same time, due to their lack of rigidity, they allow micromotion, enhancing callus formation.17,21

3.3. Implant selection

As far as implant choice is concerned, k-wires,22,23 stainless steel pins24 and titanium nails have been used. In the literature, there seems to be an apparent superiority of the titanium implants including their biocompatibility, their modulus of elasticity, the osseointegration rate, the corrosion resistance,25 and the magnetic resonance imaging compatibility.26 Regardless the implant, no significant difference was found in radiographic union, complication rate and surgical time. Yet, titanium implants are the less cost effective.27

3.4. Surgical technique

Intramedullary nailing of the forearm is typically performed antegrade for the radius and retrograde for the ulna. The elbow is flexed 90° and the shoulder is externally rotated, so as the forearm is directly parallel to the floor. Usually, ulna is nailed first, as it is relatively easier, due to its straight medullary canal. The entry point for the ulna is at the olecranon apophysis, while the entry point for the radius is 2 cm proximal to the physis, either laterally or dorsally, through Lister's tubercle. A starting hole is made with an awl or a drill, 1 mm greater than the nail. Then the fracture is reduced, and the nail is passed through the medullary canal with the aid of a T-handle. The tip of the nail is bent and buried subcutaneously.17,28

Technical considerations include the diameter of the nail used and the bending of the tip of the nail. Fernadez et al.29 suggest that the diameter of the nail should be approximately 2/3 of the medullary canal, measured in the isthmus, while other authors support the theory that nail should be 50%,30 or 40%31 of the canal diameter. Skin irritation problems and tendon ruptures are often a result of sharp nail ends friction. As so, it is advised the nail ends to be placed well outside the tendon compartment when a dorsal approach is used for the radius.7 In addition, end caps must be used or a bending of the nail end must be performed. Gibon et al.32 advocate of bending the end of the nail 180° instead of 90° in order to avoid friction.

Great controversy exists over the use of single versus double nailing technique. Single bone fixation advocates suggest that it is less demanding, less invasive and safe. Flynn and Jones33,34 suggest radius to be fixed first, while Myers and al propose beginning with the bone with the greater deformity.35 The need for postoperative cast immobilization when a single nail is used is underlined. Other authors support ulna to be stabilized first, followed by clinical and fluoroscopic evaluation of radius reduction. If radius remains stable, they suggest not to be fixed.36 The advantage of this technique is the prevention of ulnar bowing, a common cosmetic problem. Also, it is very useful in fractures that a loss of reduction occurred, raising the need for secondary intervention. In many cases, early callus formation, prevents smooth nail passage through the canal and single nail fixation is an attractive alternative. On the other hand, many authors find the results of single bone fixation unacceptable and suggest both bones to be fixed always.23,37, 38, 39

Another issue raising concerns is the effect of open reduction when an intramedullary fixation is performed. The rate of open reduction from different studies is 9–33%.9,17,29,40 It has been suggested the “10- minute rule”; if the surgeon is unable to navigate the nails across the fractures site in 10 min, open reduction must be considered.41 In the same direction, it has been proposed that after 3 failed attempts of closed reduction, the fracture site must be opened.42 Multiple failed closed reductions and longer operative times are associated with compartment syndrome.12,43 Despite this, open reduction of the fracture involves periosteal stripping and blood circulation disruption around the fracture, leading to higher possibility of delayed union or even nonunion.9

3.5. Postoperative management

There are many postoperative rehabilitation protocols. Schmittenbecher7 encourages immediate movement after flexible intramedullary nailing. Others suggest a simple sling for 2–3 weeks,17 or even an above the elbow cast for 2–4 weeks.44

There are is an agreement that implant removal must not be attempted before at least 6 months, in order bony consolidation to be achieved. Earlier removal is associated with higher refracture rate.17,29,30

3.6. Complications

Although flexible intramedullary nailing is an excellent choice for the treatment of forearm fractures, many complications have been reported.7,8,12,17,21,28, 29, 30,38,40,45, 46, 47, 48, 49 The complication rate differs between studies from 8.9% to 69%.9,28,29,49, 50, 51

Skin irritation from the tips of the nails is a usual complication. Most of the times it can be resolved with oral antibiotics and rarely hardware removal is required. The need for caps for the nail ends or for proper bending of the tips is emphasized.

Tendon injury is another complication of flexible intramedullary nailing of the forearm. Extensor Pollicis Longus rupture has been reported as a result of friction with sharp nail ends, when a dorsal radial approach is used.14,30 In those situations an Extensor Indicis Proprius to Extensor Pollicis Longus tendon transfer is a reliable solution.

Superficial radial nerve is commonly injured when a lateral approach to the radius is performed. Care must be taken to recognize and protect the nerve. Hopefully, most of the times spontaneous healing occurs.30

Delayed union or even nonunion is an existing complication. Nonunion is defined as the absence of radiological and clinical bony union after a period of at least 6 months. Nonunion is almost always seen in the mid-shaft of the ulna. It seems that the middle-third of the ulna has a “watershed-zone” for the interosseous circulation.52 It has been suggested that the use of a too thick a nail can distract the ulna fracture resulting in delayed union or nonunion.21 The retrograde nailing of the ulna may also cause a distraction at the fracture site causing a disturbance in the healing process.53 Opening the fracture site to aid reduction is another factor that may lead to delayed callus formation.46,54 For the treatment, bone marrow injection as a first option or revision with plating and autologous iliac crest bone grafting has been suggested.21 Spontaneous healing is often seen, as so, in the absence of functional deficits, it is a well-established option to await the natural course of a hypertrophic pseudarthrosis.16

Displacement of the fracture may occur. Malalignment can block supination or pronation. The more proximal the injury is, the greater the effect on the range of motion.7,55, 56, 57, 58, 59 Spontaneous correction of the deformity can only be seen in the distal forearm.7,60 Despite this, it is very interesting the fact that most of the patients with a supination or pronation deficit do not complaint of facing difficulties in fulfilling their daily activities. It seems that malunion is rather a cosmetic than a functional problem. The acceptable reduction is usually based on the classic Price's guidelines of 10° angulation, 45° malrotation, complete displacement and some loss of radial bowing.61 However, the criteria should always be individualized, being more lenient for young patients and distal fractures.7,30

Refracture is another complication after intramedullary nailing of the forearm in children. The refracture rate reported in the literature is approximately 5%.16,51 Early hardware removal,17,29,30 open fractures or open reduction are associated with a higher rate of refracture.9 Refracture with the nail in situ has an incidence of 0.8–8.6% in the literature.62 Treatment modalities include nail straightening or exchanging, or revision with plate and screws. There is, though, an in vitro mechanical study that concludes that the stability of the nails is significantly reduced after one cycle of reversed bending.63

Compartment syndrome after flexible intramedullary nailing is a rare complication seen in 1,9–7,5% of the patients. It is associated with longer operative times, longer tourniquet times and open fractures.12,43 Immediate fasciotomies should be performed, in order permanent damage to be avoided.

Osteomyelitis is an ever more rare complication. [Fig. 3]. Fernadez et al.29 reported a case with osteomyelitis treated with revision surgery twice with a vacuum sealing and nails left in place. Subsequently, a bone sequestration in the ulna developed, but it was absorbed after a course of 14 months.

Fig. 3.

Fig. 3

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Rare complication of osteomyelitis of the ulna after flexible intramedullary nailing for both-bone forearm fracture.

The patient was treated with excision of the sequestrum, iliac crest autograft and stabilization with kw pins [Papageorgiou General Hospital of Thessaloniki].

4. Discussion

This review emphasizes that flexible intramedullary nailing in the treatment of forearm fractures in children and adolescents is a safe and reliable option. It is worth mentioning that pediatric and non-pediatric orthopaedic surgeons have similar clinical outcomes and complication rates.42

Although radius and ulna shaft fractures account for the vast majority of flexible intramedullary nailing in the forearm, radial head and Monteggia fractures can also be treated with nailing.

Although nailing and plating have similar functional outcomes in most studies, it seems that intramedullary nailing outweighs plating due to advantages including less soft tissue disruption and shorter operative time. Yet, plating is associated with a more anatomic restoration of the radial bow.

Titanium implants are superior regarding their biocompatibility, their modulus of elasticity, the osseointegration rate, the corrosion resistance and the magnetic resonance imaging compatibility. They are, however, the less cost effective.

Controversy still exists over the use of single versus double nailing in both-bone forearm fractures and a clear advantage of one technique over the other could not been proved. Also, there is no consensus regarding the most preferable nail diameter. It is clear, though, that open reduction should be attempted after certain failed closed reductions as they can lead to compartment syndrome.

Many complications have been reported. Complication rate varies among the studies from 8,9%–69%. Skin irritation from the tips of the nails, tendon or nerve injury, delayed union or nonunion, secondary displacement with a subsequent loss of supination and pronation, refracture, compartment syndrome and osteomyelitis in rare cases have been reported. However, with a proper surgical technique most of them can be avoided.

5. Conclusion

The authors suggest that intramedullary nailing must be considered in every orthopaedic center, when a forearm fracture in a child occurs, considering the good outcomes of the technique and the low complication rate.

Authors contributions

Metaxiotis Dimitrios encouraged Poutoglidou Frideriki to investigate the specific subject and supervised the project.

Poutoglidou Frideriki wrote the article with input from all authors.

Kazas Christos contributed to the design of the article.

All authors discussed the results and helped shape the final manuscript.

Declaration of competing interest

This study was not funded by any third party. There are no relationships that present a potential conflict of interest. This study does not contain any studies with human participants performed by any of the authors.

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