Merter YALÇINKAYA, Ahmet DOĞAN, Ufuk ÖZKAYA, SAMİ SÖKÜCÜ, Onat ÜZÜMCÜGİL, Yavuz KABUKÇUOĞLU

Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures

Amaç: Çocuklarda dengesiz önkol cisim kırıklarının intramedüller çivi ile tedavisinde mini insizyonla açık ve kapalı yerleştirme uygulamalarının sonuçları karşılaştırıldı. Çalışma planı: Dengesiz önkol 1/3 orta cisim kırığı nedeniyle intramedüller çivileme yöntemi ile tedavi edilen 45 çocuk hasta geriye dönük olarak değerlendirildi. İntramedüller çivileme öncesinde, bu hastaların 24’üne (grup 1; 5 kız, 19 erkek; ort. yaş 10; dağılım 5-14) mini insizyonla açık yerleştirme; 21’ine (grup 2; 5 kız, 16 erkek; ort. yaş 11.5; dağılım 8-13) kapalı yerleştirme uygulandı. Grup 1’de 16 kırık kapalı, yedisi Gustilo-Anderson tip 1, biri tip 2 açık kırık iken, grup 2’de 15’i kapalı, altısı tip 1 açık kırıktı. Yaralanmadan cerrahi girişime kadar geçen süre grup 1’de 5 gün (dağılım 1-20 gün), grup 2’de 3.1 gün (dağılım 1-5 gün) idi. Bütün hastalarda Rush çivisi veya Kirschner teli kullanıldı. Grup 1’deki hastaların hepsinde hem radius hem ulna tespit edilirken, grup 2’de üç hastada sadece ulna, 18 hastada her iki kemik birden tespit edildi. İşlevsel sonuçlar Price ve ark.nın ölçütlerine göre değerlendirildi. Ortalama takip süresi grup 1’de 33 ay (dağılım 12-89 ay), grup 2’de 37 ay (dağılım 14-52 ay) idi. Sonuçlar: Grup 1’de ortalama 7.1±1.0 haftada (dağılım 6-9 hafta), grup 2’de ortalama 6.5±1.0 haftada (dağılım 6-10 hafta) kaynama sağlandı. Çivilerin çıkarılma süreleri grup 1’de ortalama 7.2±1.7 hafta (dağılım 6-10 hafta), grup 2’de ortalama 8.1±0.4 hafta (dağılım 8-10 hafta) idi. Ortalama kaynama süresi (p=0.036) ve çivilerin çıkarılma süresi (p=0.002) açısından iki grup arasında anlamlı fark görüldü. Price ve ark.nın ölçütlerine göre, grup 1’de 19 hastada mükemmel (%79.2), beş hastada (%20.8) iyi; grup 2’de 18 hastada (%85.7) mükemmel, üç hastada (%14.3) iyi sonuç alındı. Grupların işlevsel sonuçları arasında anlamlı fark saptanmadı (p>0.05). Komplikasyonlar iki grupta benzerlik gösterdi: Grup 1’de bir önemli (%4.2), yedi hafif (%29.2) komplikasyon görülürken, grup 2’de bir önemli (%4.8), sekiz hafif (%38.1) komplikasyon görüldü. Hiçbir olguda üst ekstremite uzunluk eşitsizliği, epifizyel hasar, açısal ya da rotasyonel deformite, sinositoz, dirsek ve önkol hareket açıklıklarında kısıtlılık gibi komplikasyonlar görülmedi. Çıkarımlar: Çocuklarda dengesiz önkol cisim kırıklarının intramedüller çivi ile tedavisinde, kapalı yerleştirme veya mini insizyonla açık yerleştirme tekniklerinde işlevsel sonuçların ve komplikasyonların benzer olduğu görülmektedir.

Anahtar Kelimeler:

Ulna kırıkları, Tedavi sonucu, Ön kol, Ateller, Kemik çivileri, Turnikeler

Çocuklardaki dengesiz önkol cisim kırıklarında kapalı veya mini açık yerleştirme ile intramedüller çivilemenin klinik sonuçları

Objectives: We compared the clinical results of open reduction with a mini incision and closed reduction in pediatric unstable diaphyseal forearm fractures treated with intramedullary nailing. Methods: We retrospectively evaluated 45 children who were treated with intramedullary nailing for unstable middle third diaphyseal forearm fractures. Before intramedullary nailing, 24 patients (group 1; 5 girls, 19 boys; mean age 10 years; range 5 to 14 years) underwent open reduction with a mini incision, and 21 patients (group 2; 5 girls, 16 boys; mean age 11.5 years; range 8 to 13 years) underwent closed reduction. There were 16 closed, seven Gustilo-Anderson type 1, and one type 2 open fractures in group 1, and 15 closed and six type 1 open fractures in group 2. The mean time to surgery was 5 days (range 1 to 20 days) in group 1, and 3.1 days (range 1 to 5 days) in group 2. Rush rods or Kirschner wires were used for fixation. In group 1, both radius and ulna were fixed in all the patients, whereas fixation involved both bones in 18 patients, and only ulna in three patients in group 2. Functional results were evaluated according to the criteria of Price et al. The mean follow-up period was 33 months (range 12 to 89 months) in group 1, and 37 months (range 14 to 52 months) in group 2. Results: Union was obtained in a mean of 7.1±1.0 weeks (range 6 to 9 weeks) in group 1, and 6.5±1.0 weeks (range 6 to 10 weeks) in group 2. The implants were removed after a mean of 7.2±1.7 weeks (range 6 to 10 weeks) in group 1, and 8.1±0.4 weeks (range 8 to 10 weeks) in group 2. The two groups differed significantly with respect to union and implant removal times (p=0.036 and p=0.002, respectively). According to the criteria of Price et al., the results were excellent in 19 patients (79.2%) and 18 patients (85.7%), and good in five patients (20.8%) and three patients (14.3%) in group 1 and 2, respectively. There was no significant difference between the functional results of the two groups (p>0.05). Complications showed a similar profile in the two groups, being one major (4.2%) and seven minor (29.2%) in group 1, one major (4.8%) and eight minor (38.1%) in group 2. None of the patients had complications such as limb-length discrepancy, epiphyseal damage, angular or rotational deformity, synostosis, or limited elbow or forearm range of motion. Conclusion: Closed reduction or open reduction with a mini incision before intramedullary nailing yield similar functional results, with a similar complication profile in the treatment of pediatric unstable diaphyseal forearm fractures.

Keywords:

Ulna Fractures, Treatment Outcome, Forearm, Splints, Bone Nails, Tourniquets,

___

1. Lee S, Nicol RO, Stott NS. Intramedullary fixation for pediatric unstable forearm fractures. Clin Orthop Relat Res 2002;(402):245-50.
2. Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop 1998;18:14-21.
3. Richter D, Ostermann PA, Ekkernkamp A, Muhr G, Hahn MP. Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop 1998;18:457-61.
4. Smith VA, Goodman HJ, Strongwater A, Smith B. Treatment of pediatric both-bone forearm fractures: a comparison of operative techniques. J Pediatr Orthop 2005;25:309-13.
5. Verstreken L, Delronge G, Lamoureux J. Shaft forearm fractures in children: intramedullary nailing with immediate motion: a preliminary report. J Pediatr Orthop 1988;8:450-3.
6. Özkaya U, Parmaksızoğlu AS, Kabukçuoğlu Y, Yeniocak S, Sökücü S. Surgical management of unstable both-bone fore arm fractures in children. [Article in Turkish] Acta Orthop Traumatol Turc 2008;42:188-92.
7. Yung SH, Lam CY, Choi KY, Ng KW, Maffulli N, Cheng JC. Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children. J Bone Joint Surg [Br] 1998;80:91-4.
8. Yung PS, Lam CY, Ng BK, Lam TP, Cheng JC. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children. J Pediatr Orthop 2004;24:7-12.
9. Van der Reis WL, Otsuka NY, Moroz P, Mah J. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop 1998;18:9-13.
10. 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.
11. Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998;18:451-6.
12. Wyrsch B, Mencio GA, Green NE. Open reduction and internal fixation of pediatric forearm fractures. J Pediatr Orthop 1996;16:644-50.
13. Ortega R, Loder RT, Louis DS. Open reduction and internal fixation of forearm fractures in children. J Pediatr Orthop 1996;16:651-4.
14. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg [Am] 1976;58:453-8.
15. Küçükkaya M, Kabukçuoğlu Y, Tezer M, Eren T, Kuzgun Ü. The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures. J Orthop Trauma 2002;16:340-4.
16. Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-12.
17. Pugh DM, Galpin RD, Carey TP. Intramedullary Steinmann pin fixation of forearm fractures in children. Longterm results. Clin Orthop Relat Res 2000;(376):39-48.
18. Tabak AY, Taşbaş BA, Yağmurlu MF, Muratlı HH. Closed intramedullary nail application in pediatric forearm shaft fractures of both bones. [Article in Turkish] Acta Orthop Traumatol Turc 2000;34:374-8.
19. Younger AS, Tredwell SJ, Mackenzie WG, Orr JD, King PM, Tennant W. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop 1994;14:200-6.
20. 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.
21. Fuller DJ, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg [Br] 1982;64:364-7.
22. Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg [Am] 1982;64:14-7.
23. Qidwai SA. Treatment of diaphyseal forearm fractures in children by intramedullary Kirschner wires. J Trauma 2001; 50:303-7.
24. Tarr RR, Garfinkel AI, Sarmiento A. The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg [Am] 1984;66:65-70.
25. Çelebi L, Muratlı 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. [Article in Turkish] Acta Orthop Traumatol Turc 2007;41:175-82.
26. 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.
27. Kalenderer Ö, Ağuş H, Zincircioğlu G, Şanlı C. Çocuk önkol çift kırıklarında sınırlı kesiden açık redüksiyon ve intramedüller çivileme. Artroplasti Artroskopik Cerrahi 2002;13:164-8.
28. Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children. Vol. 3, 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p. 399-441.
29. Choi KY, Chan WS, Lam TP, Cheng JC. Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children. A report of 157 cases. J Bone Joint Surg [Br] 1995;77:797-801.