Tips and Tricks Diaphyseal Forearm Fractures

4/19/2019

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Atlanta Trauma Symposium

Pediatrics: Tips and Tricks

Jorge A. Fabregas, MDEducation Director at Children’s Healthcare of Atlanta at SRChief Of Pediatric Orthopaedics at AMC

Children’s Healthcare of Atlanta

• Forearm fracture fixation• Supracondylar pinning• Lateral condyle fractures• Elastic nails for femur

fractures


Diaphyseal Forearm

Fractures

WHAT TO ACCEPT

• Up to 10-20° angulation in kids < 10 y/o• No more than 10° angulation >10 y/o• Complete displacement• 30° malrotation• Stabilize floating elbow• Open Fractures • Monteggia ??

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IM Fixation

• Minimally invasive• Easy• Avoid multiple passes

– 2-3– Increase risk of Compartment syndrome

• Near anatomic alignment– Loss of radial bow ??


Radial Fixation

• Small flexible nail – Usually 2.0

• Proximal to Lister’s Tubercle– Beware of EPL rupture due to buried wire

• Radial insertion– Between 1st and 2nd Dorsal compartment

• APL, EPB and ECRL, ECRB

– Radial sensory nerve


Ulna fixation

• Proximal and lateral– Flexible nail– Smaller diameter

• Proximal– Flexible nail– K wire– Rush Rod– Locking nail

– Beware of FDP Entrapment

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Single Bone Fixation

• BBFA with distal 1/3 fx radius – Avoid proximal radius fx

• Acceptable reduction• Enough time to remodel

– 8 to 12 year olds– At least 2 years of growth

• Older patients treat as adults


Plate Fixation

• Advantage– Rigid Fixation– Complete correction of

malrotation– Useful within 1-2 years

of skeletal maturity

• Disadvantage• Larger incisions• Cost• Increase tourniquet time


Supracondylar Humerus

FracturesPitfalls of Pin

Placement

• Pins Too Close together• Fracture displacement

• Access stability• Get one pin in lateral and one in

medial column

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Adequate Reduction?

• No varus/valgus• anterior hum line• minimal rotation• translation OK

From M. Rang, Children’s Fractures


Best Pinning Technique

• Lateral vs Crossed• Lab results proven in clinical practice• Avoid Late Displacement• Minimize of Cubitus Varus• Decrease Risk Iatrogenic nerve injury

– Median and ulnar nerve reported on both techniques


Lee et al. –JPO 2002

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Newton et al. JPO 2014

13mm pin spread at fracture site.


Lateral Pin Entry

maximize separation of pins at fracture siteMaximize

Engage medial and lateral columns proximal to fractureEngage

Engage sufficient bone in distal and proximal fragmentsEngage

Low threshold for 3rd pinLow

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After You Fixed it.

• If pin fixation is used, the pins are usually bent and cut outside the skin.

• The skin is protected from the pins by placing felt pad around the pins.

• The arm is immobilized.• The pins are removed in the clinic 3 weeks later,

after radiographs show periosteal healing.• In most cases, full recovery of motion can be

expected.


Femur Fractures

• Most Common scenario

• Isolated– Midshaft

• Flexible IM nails (Nancy, TEN, Enders, etc.)

• Ex Fix

• Trochanteric nail?

• Submuscular plating

– Subtrochanteric

• Multiple trauma– Ex Fix– Flexible IM Nails– ORIF – plating– Trochanteric nail

• Not antegrade IM Nail through piriformis fossa AVN

Considerations

• Age >11yo• Weight >50 kg• Fracture Pattern

– long spiral (fracture length > 2x bone diameter at that level)

– comminuted

Rigid Nail ?

InstrumentationTitanium vs. Stainless SteelDiameter of nails up 4.5mmCanal fill 80%

How many nails ?

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Unstable Fracture Pattern: Can we flex nail it?

Standard Flexible Nail:Titanium Nails up to 4.5mm

•approach•all distal approach

•2cm incision medially and laterally at level of distal physis•spread with hemostat to starting point 2cm proximal to physis

•instrumentation•nail size determined by multiplying the width of the isthmus of femoral canal by 0.4•the goal is 80% canal fill•Slight bend on tip of nail

•complications•the most common complication is pain at insertion site near the knee

•in up to 40% of patients•recommended that < 25mm of nail protrusion and minimal bend of the nail outside the femur are present

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My Preference

• 2 or 4 rods• Insert up to level of lesser trochanter for stable• Can engage troch apophysis

• Cut then damp• Avoid cutting too long/short• Knee Immobilizer Post Op

Lateral Condyle Fracture: Staying Out of Trouble

• Intra articular – Need anatomic reduction

• Internal Oblique– Assess displacement

• Avoid Posterior dissection– AVN

• Casting 4-5 weeks

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Lateral Condyle :

Classification

CRPP

ORIF

Indications: CRPP


Arthrogram• Posterior• 1-2 cc• If prior to fixation may obscure landmarks

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How about treating displaced with CRPP

• Traction• Varus force• Kwires to joy stick fragment• Hypextend elbow• Supinate forearm• Valgus force• Assess reduction

– Less than 2mm – Arthrogram

Alternative:

Screw Fixation

• Bicortical• Use depth gauge for

compression• Check ROM

– Crepitus/clicking• Arthrogram

1. Metaphyseal Insertion

2. Avoid Olecarnon Fossa


4. Place second pin temporarilyremove to aid compression

• ? Engage lateral Cortex– fractures

• Partially vs fully threaded screws– 4.0 mm or 4.5 mm– Washer Optional

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My Preference

• CRPP minimally displaced(2 to 4 mm) increasing displacement over time intra-articular extension on an arthrogram

• Can attempt closed reduction on displaced

• Displaced fractures are best treated with open reduction and internal fixation

• Pin FixationScrew fixation for delayed unionsUnreliable family


Thank You !

Jorge A. Fabregas, MDCel (770)880-8029

[email protected]

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Tips and Tricks Diaphyseal Forearm Fractures

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