Subsequent Forearm Fractures Following Initial Surgical Fixation

Abstract

Introduction: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. Methods: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. Results: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort (P=0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site (P<0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P=0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. Conclusions: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. Level of Evidence: Level IV—retrospective case series.

A systematic review of tourniquet use in paediatric orthopaedic surgery: can we extrapolate from adult guidelines?

“…Tourniquet use was defined; however, this was not the primary outcome of these studies. These studies investigated complications following peripheral nerve blocks ( 69 ), surgical fixations for recurrent patellar dislocation ( 70 ), and forearm re-fractures after surgical fixation ( 71 ).…”

What’s New in Pediatric Orthopaedics

“…Recovery was less common if the injury was from a surgical procedure (6 of 10 cases) than from the trauma (32 of 34 cases) and permanent nerve injuries were also more commonly associated with open fractures. Another study evaluated 24 refractures following 349 forearm fractures treated with either elastic stable intramedullary nails or plate and screws, noting a 10.9% refracture rate with plates compared with 5.1% for nails 7 . Fractures occurred most commonly adjacent to the plate or at the site of the original injury if a nail was used, and 90% of plate refractures required a surgical procedure compared with 36% in the nail cohort.…”