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 Table of Contents  
Year : 2020  |  Volume : 12  |  Issue : 2  |  Page : 134-137

Evaluation of Clinical Outcomes of Management of Pediatric Both Bone Forearm Fractures Using the Titanium Elastic Nailing System: A Prospective Study of 50 Cases

Department of Orthopaedics, Government Medical College, Amritsar, Punjab, India

Date of Submission08-Oct-2015
Date of Acceptance26-Mar-2020
Date of Web Publication28-Dec-2020

Correspondence Address:
Dr. Rajesh Kapila
2-B, Circular Road, Amritsar - 143 001, Punjab
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jotr.jotr_40_15

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Context: Forearm fractures are common injuries in children. In older children, their management is difficult due to increased chances of redisplacement after closed reduction. Aims: The aim of this prospective study was to evaluate the clinical outcome of managing pediatric forearm fractures using the titanium elastic nailing system (TENS). Subjects and Methods: Fifty patients in the age group of 6–14 years with fractures both bones forearm were managed by internal fixation using the TENS, and prospective follow-up was done for 6 months. Results: On final evaluation, we had excellent outcomes in 92% patients and good in 8%. There were no significant complications except for superficial pin-tract infections at entry site of nail in only 6% of patients. Conclusions: We conclude that TENS is an effective and minimally invasive method of fixation of forearm fractures with excellent results in terms of bony union and functional outcomes with minimal complications and without jeopardizing the integrity of the physis.

Keywords: Forearm fractures, intramedullary fixation, pediatric, titanium elastic nailing system

How to cite this article:
Kapila R, Sharma R, Chugh A, Goyal M. Evaluation of Clinical Outcomes of Management of Pediatric Both Bone Forearm Fractures Using the Titanium Elastic Nailing System: A Prospective Study of 50 Cases. J Orthop Traumatol Rehabil 2020;12:134-7

How to cite this URL:
Kapila R, Sharma R, Chugh A, Goyal M. Evaluation of Clinical Outcomes of Management of Pediatric Both Bone Forearm Fractures Using the Titanium Elastic Nailing System: A Prospective Study of 50 Cases. J Orthop Traumatol Rehabil [serial online] 2020 [cited 2021 Jul 25];12:134-7. Available from: https://www.jotr.in/text.asp?2020/12/2/134/305084

  Introduction Top

Forearm fractures are common injuries in children. These account for 45% of all fractures in childhood and 62% of upper-limb fractures.[1],[2] The incidence of fractures shaft forearm bones is more common in 6–16 years' old children, with a higher incidence in children between 12 and 16 years of age.[3] As the fractures tends to occur in older children, their management becomes all the more difficult because of more proximal location of the fracture, and hence, more chances of redisplacement even after a successful closed reduction.[4]

Hence, it becomes essential to manage these with some kind of internal fixation to maintain a good fracture reduction and hence achieve satisfactory functional outcome. There are various methods of management of fractures of both bones forearm in children. Historically, closed reduction and plaster cast application have been the gold standard in the management of these fractures; however, there are increased chances of redisplacement, particularly in older children.[5] As a result, there is a rising trend to fix most of these fractures. Fracture fixation may be done by extramedullary devices such as plates which have various disadvantages such as large incisions, more soft-tissue dissection, more chances of infection, and a resurgery of almost similar magnitude for the removal of implant. Therefore, taking into suggestion made by Shoemaker et al., that the ideal mode of fixation of pediatric forearm fractures should maintain alignment, be minimally invasive and inexpensive, and carry an acceptable risk profile, the trend of fixing these fractures has shifted to use of intramedullary devices such as kirschner wires, rush pins, and recently, titanium elastic nailing system (TENS).[6],[7],[8],[9],[10]

Kirschner wires/rush pins have the disadvantages that they have to be passed across the physis and do not provide 3-point fixation and have to be supplemented by some external immobilization such as plaster of Paris (POP) splint/cast; hence, early mobilization and excellent functional outcomes cannot be achieved many a times. TENS, on the other hand, is a minimally invasive procedure that spares physis, provides 3-point fixation, and hence, mostly does not requires POP splint/cast, thereby allowing the early mobilization to achieve excellent functional outcomes.

The aim of the present study was to assess the clinical outcome of managing pediatric forearm fractures using TENS.

  Subjects and Methods Top

The present study was conducted on fifty patients of both bone forearm fractures in the age group of 6–14 years who admitted to the orthopedics department of a tertiary care center during a period of 3 years. Besides age, other inclusion criteria were displaced fractures and fractures where closed reduction failed. A minimum follow-up of 6 months was done to assess the final functional outcome.

Operative technique: under general anesthesia, closed reduction was done under image intensifier. After achieving satisfactory reduction, the ulna was fixed by antegrade nailing through the lateral surface of olecranon about 1.5–2 cm distal to physis. Radius was fixed by retrograde nailing through the dorsal aspect of distal radius proximal to radial physis and just medial to lister's tubercle. Special care was taken not to injure extensor tendons and superficial radial cutaneous nerve. The nail was prebent 30° at the tip with additional gentle bend given, so as the apex of bend overlaps with fracture site. The length and diameter of nails were varied as observed under the image-intensifier control. Wherever required, limited open reduction was carried out to achieve the accurate reduction. The ends were bent and cut flush to the bone leaving enough length for subsequent removal and buried under the skin in all cases.

Postoperatively, majority of patients required no external immobilization. However, depending on fracture stability, in some patients, POP splint was given maximum up to 3 weeks in more comminuted fractures.

Early range of motion exercises was started, and the results were evaluated at 2, 4, 8, 12, and 24 weeks. Clinical results were evaluated as per the scale developed by Price et al. for pain and range of motion of supination and pronation [Table 1].[11]
Table 1: Price et al. criteria[11] for results

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  Results Top

[Table 2] shows preoperative observations.
Table 2: Observations and results

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No significant complications were observed except for superficial pin-tract infections at the site of entry of nail in three (6%) patients. However, no deep infection, malunion, nonunion, nerve palsy, refracture, and nail migration were observed.

On final evaluation at 6 months, there was no pain in all the patients. However, some loss of forearm supination and pronation movements (between 15° and 30° loss of motion) was seen in four (8%) patients. The mean time for radiological bony union was 9.2 weeks (range = 6–13 weeks).

According to Price et al. criteria, 46 patients (92%) had excellent results and four patients (8%) had good results. None of the patients had fair or poor results.

  Discussion Top

Historically, closed reduction and POP cast immobilization has been the mainstay of treatment for fractures both bones forearm in children. However, fractures tend to redisplace, especially in older children and more proximal location. How much malreduction is acceptable has always been a matter of great debate. Several authors have suggested that a reduction is unacceptable if the patient has an angular deformity >10° or complete displacement.[6],[12] Furthermore, younger children tend to tolerate greater deformity much better than older ones due to better remodeling potential.[1],[13],[14],[15]

In the present study, majority of children were in the age group of 11–16 years, with a mean age of 11.2 years. Similar observations were also made by Qidwai (11 years) and Garg et al. (11.8 years).[16],[17]

We had 46 simple (closed) fractures, constituting 92% of total patients and 4 compound (open) fractures (Gustilo and Anderson Grade I) constituting 8% of total patients. This is in accordance to a study conducted by Kang et al. in which 9% patients had open fracture and remaining (91%) were closed. This can be due to the fact that the injuries in children are low-energy injuries.[18]

We had a fracture of shaft of forearm bones at proximal 1/3rd in 20 patients (40%), of which 16 patients were among the age group of 11–16 years. There was fracture forearm at middle 1/3rd in 23 (46%) and 15 among these were of the age group of 11–16 years. Fracture forearm at distal 1/3rd in 7 (14%) who were in the age group of 6–10 years. The incidence of proximal third fractures was similar in a study conducted by Celebi et al. in which the mean age of the patient was 10.6, which is similar to the mean age group of our study (11.2 years). These findings are indicative of the fact that proximal fractures are more likely to occur in older children (>10 years) and distal fractures are more common in younger children (<10 years).[19]

We achieved closed reduction and intramedullary fixation in 47 patients (94%) under image-intensifier guidance. However, three patients required open reduction and intramedullary fixation (6%). This is in accordance to a study conducted by Mohammed et al. on 21 children with forearm fractures, in which four patients (19%) had required open reduction and internal fixation with elastic stable intramedullary nailing and 19 were managed with closed reduction internal fixation.[20]

On final follow-up at 24 weeks, 46 (92%) patients had loss of movement at forearm by <15°, four (8%) patients had loss of movement at forearm by 15°–30°, and no patient had loss of movement at forearm more than 30°. The final results of movement at forearm at 24 weeks in this study are in accordance to a similar study conducted by Kapoor et al., in which 16% of patients had some loss of motion at forearm.[21]

Mean time for radiological bony union was 9.2 weeks (range = 6–13 weeks), which is comparable to a study done by Ali et al.[22] in which mean time for union was 10 weeks.

All fifty patients had excellent results in terms of fracture union. We had 46 patients (92%) with excellent results and four patients (8%) with good results according to the Price criteria. The final results are in accordance with a study conducted by Parajuli et al., in which 94% patients had excellent results and 6% had good results.[2]

Preoperative [Figure 1]a and postoperative radiographs [Figure 1]b show bony union at 9 weeks. Postoperative clinical pictures showing excellent functional outcomes [Figure 2]a,[Figure 2]b,[Figure 2]c,[Figure 2]d,[Figure 2]e,[Figure 2]f.
Figure 1: (a) Preoperative radiograph antero-posterior and lateral view of fracture both bones forearm. (b) Postoperative radiograph antero-posterior and lateral at 6 months showing bony union

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Figure 2: (a) Clinical photograph showing full flexion at the elbow. (b) Clinical photograph showing full extension at the elbow. (c) Clinical photograph showing full supination. (d) Clinical photograph showing full pronation. (e) Clinical photograph showing full palmar flexion at the wrist. (f) Clinical photograph showing full dorsiflexion at the wrist

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  Conclusions Top

Pediatric forearm fractures are quite common. However, the management tends to become difficult in more proximal fractures in older children (11–14 years) due to a high incidence of redisplacement. Herein lies the importance of internal fixation. TENS is a modality, which aids in the maintenance of radial bow and interosseous space between forearm bones while sparing the physis, thus achieving good functional results in terms of forearm movements. From the present study, we conclude that TENS is an effective and minimally invasive method of fixation of forearm fractures with excellent results in terms of bony union and functional outcomes with minimal complications. Therefore, we strongly recommend its use in the management of pediatric forearm fractures.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Amstrong PF, Jouglin VE, Clarke HM, Greene NE, Swiontkowski MF. Pediatric fracture of forearm, wrist and hand. In: Skeletal Trauma in Children. Philadelphia: Saunders; 1998. p. 161-257.  Back to cited text no. 1
Parajuli NP, Shrestha D, Dhoju D, Dhakal GR, Shrestha R, Sharma V. Intramedullary nailing for paediatric diaphyseal forearm bone fracture. Kathmandu Univ Med J (KUMJ) 2011;9:198-202.  Back to cited text no. 2
Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6493 fractures. J Pediatr Orthop 1999;19:344-50.  Back to cited text no. 3
Creasman C, Zaleske DJ, Ehrlich MG. Analyzing forearm fractures in children. The more subtle signs of impending problems. Clin Orthop Relat Res 1984;188:40-53.  Back to cited text no. 4
Jones K, Weiner DS. The management of forearm fractures in children: A plea for conservatism. J Pediatr Orthop 1999;19:811-5.  Back to cited text no. 5
Shoemaker SD, Comstock CP, Mubarak SJ, Wenger DR, Chambers HG. Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children. J Pediatr Orthop 1999;19:329-37.  Back to cited text no. 6
Calder PR, Achan P, Barry M. Diaphyseal forearm fractures in children treated with intramedullary fixation: Outcome of K-wire versus elastic stable intramedullary nail. Injury 2003;34:278-82.  Back to cited text no. 7
Kucukkaya M, Kabukcuoglu Y, Tezer M, Eren T, Kuzgun U. The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures. J Orthop Trauma 2002;16:340-4.  Back to cited text no. 8
Lee S, Nicol RO, Stott NS. Intramedullary fixation for pediatric unstable forearm fractures. Clin Orthop Relat Res 2002;402:245-50.  Back to cited text no. 9
Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998;18:451-6.  Back to cited text no. 10
Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-12.  Back to cited text no. 11
Fynn JM, Jones KJ, Garner MR, Goebel J. Eleven years' experience in operative management of pediatric forearm fracture. J J Pediatr orthop 2010;30:313-19.  Back to cited text no. 12
Schmittenbecher PP. State-of-the-art treatment of forearm shaft fractures. Injury 2005;36 Suppl 1:A25-34.  Back to cited text no. 13
Merchan PE. Pediatric fractures of forearm. Clin Orthop RelatRes 2005;432:65-72.  Back to cited text no. 14
Teoh KH, Chee YH, Shortt N, Wilkinson G, Porter DE. An age-and sex-matched comparative study on both-bone diaphyseal paediatric forearm fracture. J Child Orthop 2009;3:367-73.  Back to cited text no. 15
Qidwai SA. Treatment of diaphyseal forearm fractures in children by intramedullary Kirschner wires. J Trauma 2001;50:303-7.  Back to cited text no. 16
Garg NK, Ballal MS, Malek IA, Webster RA, Bruce CE. Use of elastic stable intramedullary nailing for treating unstable forearm fractures in children. J Trauma 2008;65:109-15.  Back to cited text no. 17
Kang SN, Mangwani J, Ramachandran M, Paterson JM, Barry M. Elastic intramedullary nailing of paediatric fractures of the forearm: A decade of experience in a teaching hospital in the United Kingdom. J Bone Joint Surg Br 2011;93:262-5.  Back to cited text no. 18
Celebi L, Muratli HH, Doğan O, Yağmurlu MF, Akşahin E, Biçimoğlu A. The results of intramedullary nailing in children who developed redisplacement during cast treatment of both-bone forearm fractures. Acta Orthop Traumatol Turc 2007;41:175-82.  Back to cited text no. 19
Mohammed H, Salloom F, Albagali M, Aljahromy I. Flexible intramedullary fixation of pediatric forearm fractures – Report on 21 patients. Bahrain Med Bull 2009;31.  Back to cited text no. 20
Kapoor V, Theruvil B, Edwards SE, Taylor GR, Clarke NM, Uglow MG. Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children. Injury 2005;36:1221-5.  Back to cited text no. 21
Ali AM, Abdelaziz M, El-Lakanney MR. Intramedullary nailing for diaphyseal forearm fractures in children after failed conservative treatment. J Orthop Surg (Hong Kong) 2010;18:328-31.  Back to cited text no. 22


  [Figure 1], [Figure 2]

  [Table 1], [Table 2]


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