Elastic stable intramedullary nailing in pediatric diaphyseal forearm bone fracture

Poojan Kumar Rokaya, Mangal Rawal, Javed Ahmad Khan, Praveen Kumar Giri


Background: Pediatric forearm bone fracture present significant challenges where most of them are managed with closed reduction and casting. Irreducible, unstable and open fracture usually requires operative stabilization. Intramedullary nailing is considered minimal invasive however it is not free of complication. The aim of this study is to analyze the outcome and complications after elastic stable intramedullary nailing in pediatric diaphyseal forearm fracture.

Methods: A descriptive observational study was carried out for four years (2013-2016) in diaphyseal pediatric forearm fracture stabilized with titanium elastic stable intramedullary nailing. Final range of motion, complications and outcome were assessed using Clavien-Dindo classification modification appropriate for orthopedic surgery.

Results: We report the outcome of 36 patients with complete medical records. Closed reduction and nailing was successful in 25 patients (69.4%) whereas eleven patients (30.6%) required open reduction (both radius and ulna in 6 patients 16.7%, ulna in 3 patients 8.3% and radius in 2 patients 5.6%). Radiological union was achieved at an average of 7.75±1.5 weeks (range 6 to 16 weeks). Forearm rotation was limited in 7 patients with average loss of 16° pronation and 18° supination. The overall rate of complication was 22.2%. According to Clavien-Dindo classification excellent results were noted in 29 patients (80.6%), good in 3 patients (8.3%) and fair in 4 patients (11.1%).

Conclusions: Elastic intramedullary nailing in pediatric diaphyseal forearm bones fracture is minimally invasive with low rate of complication and the outcomes are fair to excellent.


Elastic intramedullary nailing, Forearm, Fracture, Complication

Full Text:



Vopat ML, Kane PM, Christino MA, Truntzer J, McClure P, Katarincic J, et al. Orthop Rev (Pavia). 2014;6(2):5325.

Yalcinkaya M, Dogan A, Ozkaya V, Sokucu S, Uzumcugil O, Kabukcuoglu Y. Clinical results of intramedullary nailing following closed or mini open reduction in pediatric unstable diaphyseal forearm fractures. Acta Orthop Traumatol Turc. 2010;44(1):7-13.

Bochang C, Katz K, Weigl D, Jie Y, Zhigang W, Bar-On E. Are frequent radiographs necessary in the management of closed forearm fractures in children? J Child Orthopaed. 2008;2:217-20.

Patel A, Li L, Anand A. Systematic review: functional outcomes and complications of intramedullary nailing versus plate fixation for both-bone diaphyseal forearm fractures in children. Injury. 2014;45:1135–43.

Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop. 2006;26:827-34.

Lyman A, Wenger D, Landin L Pediatric diaphyseal forearm fractures: epidemiology and treatment in an urban population during a 10-year period,with special attention to titanium elastic nailing and its complications. J Pediatr Orthop B. 2016;25:439-46.

Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6:146–56.

Schmittenbecher P, Fitze G, Go¨ deke J, Kraus R, Schneidmuller D. Delayed healing of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop. 2008;28:303–6.

Clavien P, Barkun J, de Oliveira ML, Vauthey JN, Dindo D, Schulick RD, et al. The Clavien-Dindo Classification of surgical complications. Ann Surg. 2009;250:187–96.

Boone D, Azen S. Normal range of motion of joints in male subjects. J Bone Joint Surg Am. 1979;61:756–9.

Youm Y, Dryer RF, Thambyrajah K, Flatt AE, Sprague BL. Biomechanical analyses of forearm pronation-supination and elbow flexion-extension. J Biomech. 1979;12:245–55.

Sinikumpu JJ, Lautamo A, Pokka T, Serlo W. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Injury. 2013;44:431–6.

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.

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.

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.

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.

Jubel A, Andermahr J, Isenberg J, Issavand A, Prokop A, Rehm KE. Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children. J Pediatr Orthop B. 2005;14:375–80.

Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven year’s experience in the operative management of pediatric forearm fractures. J Pediatr Orthop. 2010;30:313–9.

Furlan D, Pogorelić Z, Biočić M, Jurić I, Budimir D, Todorić J, et al. Elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures. Scand J Surg. 2011;100:208-15.

Blackman AJ, Wall LB, Keeler KA, Schoenecker PL, Luhmann SJ, O’Donnell JC, et al. Acute compartment syndrome after intramedullary nailing of isolated radius and ulna fractures in children. J Pediatr Orthop. 2014;34:50–4.

Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop. 1998;18:451-6.

Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop. 1998;18:14-21.

Martus JE, Preston RK, Schoenecker JG, Lovejoy SA, Green NE, Mencio GA. Complications and outcomes of diaphyseal forearm fracture intramedullary nailing: a comparison of pediatric and adolescent age groups. J Pediatr Orthop. 2013;33:598–607.

Shah AS, Lesniak BP, Wolter TD, Caird MS, Farley FA, Vander Have KL. Stabilization of adolescent both-bone forearm fractures: a comparison of intramedullary nailing versus open reduction and internal fixation. J Orthop Trauma. 2010;24:440-7.

Antabak A, Luetic T, Ivo S, Karlo R, Cavar S, Bogovic M, Medacic SS. Treatment outcomes of both-bone diaphyseal paediatric forearm fractures. Injury. 2013;44 (3):11–5.

Lieber J, Joeris A, Knorr P, Schalamon J, Schmittenbecher P. ESIN in forearm fractures. Eur J Trauma. 2005;31:3–11.

Ogonda L, Wong-Chung J, Wray R, Canavan B. Delayed union and non-union of the ulna following intramedullary nailing in children. J Pediatr Orthop B. 2004;13:330–3.

Wright TW, Glowczewskie F. Vasclar anatomy of ulna. J Hand Surg Am Vol. 1998;23:800-4.

Kelly BA, Miller P, Shore BJ, Waters PM, Bae DS. Exposed versus buried intramedullary implants for pediatric forearm fractures: a comparison of complications. J Pediatr Orthop. 2014;34:749-55.

Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop. 1990;10:705-12.