Open Fracture Site Delays Pediatric Forearm Fracture Healing

Diaphyseal (long bone) arm forearm fractures are common among children – making up between three and six percent of fractures in children. Most often, the fracture can be set by a closed reduction, putting it back into place without surgery, and then casting. Up to 85 percent of arm fractures treated this way heal well. Because of this success rate, surgery is usually only recommended if there are any complications and the arm bone cannot be realigned without surgery. That being said, doing surgery for realigning the bone is controversial even though the surgery rates are rising. One particular procedure, inserting a nail to stabilize (IM nailing) has increased in use from 1.8 percent of cases to 22 percent, over a 10-year period.

Despite the increase in surgery, the IM nailing is considered the lesser invasive of surgeries, compared with inserting a plate, which is how this type of fracture is often treated in adults. The IM nailing has a good success rate, but the authors – as well as other researchers – have found that there are some problems associated with the procedure, such as delayed union of the bone, the need to expose the fracture site to do the procedure, compartment syndrome (pressure of the nerves, blood vessels and tissue), and wound problems. The authors reviewed their own long-term experience with the procedure for risks and complications.

Looking through the records, the researchers found that they had treated 2,297 such fractures. Of these, 155 underwent surgery and six were lost to follow-up, leaving 149 patients total. The patients were an average age of 11.2, ranging from 3 years to 17 years. Follow-up was an average of 5.1 months. IM was done alone in 69.1 percent of the children and about 29.5 percent were given plates. The IM group was on average 10.6 years, about two years younger than the average age of the plate group. A small group, 1.3 percent of the children were treated with both IM nail and plates.

The researchers found that there was a seven-fold increase in the procedure from the first year of the 11-years reviewed to the last year. The most common reason for the surgery was that the bones couldn’t align properly after closed reduction was tried (69.1 percent of cases). When IM nailing was done, 30 fractures needed an incision to insert the nail. Twenty three cases involved open fractures (where the skin was already torn) so this opening was used for the nail insertion.

On average, the time for bone healing – or union – was 8.6 weeks for fractures that had to be opened for nailing, compared to 6.9 weeks for fractures that did not need an incision to be made because of the already present opening. This compares similarly to fractures that were not open to begin with.

In looking at the 4 fractures treated with plate fixation, 26 had singlebone fixation and 16 needed plates on both bones, the radius and ulna. The average bone healing time was 9.2 weeks, with the time being a bit longer in the older patients.

There were complications for some patients. In the IM nail group, there were 15 complications:

– delayed union (six cases – in patients over 10 years old)
– compartment syndrome (two cases)
– infection (two cases)
– tendon laceration during nail insertion (two cases)

Compartment syndrome appeared to be connected to having the procedure done on the day of the injury.

The authors pointed out that they divided the IM nailing group into two: one group over 10 years old and the other 10 years old or younger. The younger children had better outcomes than their older counterparts.

Since surgeons have begun using IM nailing for aggressive management of such types of fractures, calling them less invasive than using plates, this does depend on how the fracture presents itself: closed (no open wound) or open. In this study, the authors found that open wounds, where another incision had to be made, had a slower bone healing time than closed wounds or open wounds where no extra incision needed to be made.