Both-bone forearm fractures are common injuries of children. Many of these fractures can be treated with closed reduction, although certain fractures cannot be reduced and require operative intervention. Intramedullary fixation has become a common method for treating these fractures. This article attempts to evaluate the potential risks of intramedullary fixation compared with nonsurgical management. The article specifically addresses the incidence of compartment syndrome.
The methodology consisted of a retrospective review of all patients treated at a single institution for diaphyseal both-bone forearm fractures over a two-year period. Mean follow-up was relatively short at five months. A large cohort of 285 patients was identified, with 235 closed fractures and 50 open fractures. The patients with closed fractures were treated by closed reduction and casting under conscious sedation. All casts were then univalved for one week. The casts were overwrapped at the one week follow-up appointment and casting was continued until union was evident. Thirty patients had unstable fractures that were irreducible or lost reduction during the follow-up period. These were taken to the operating room for closed reduction and intramedullary fixation with Kirschner wires. All 50 open fractures underwent irrigation and debridement and immediate intramedullary fixation. All patients undergoing intramedullary fixation were also treated in a long arm cast until radiographic healing was evident. The patients with closed reduction and casting were discharged to home and instructed to carefully monitor for evidence of compartment syndrome. Patients with operative fixation were examined after fracture fixation and carefully monitored in the hospital for a minimum of 24 hours. If there was any concern for compartment syndrome, compartment pressures were measured. Any pressure over 30 mm/Hg was considered positive for compartment syndrome. A volar fasciotomy was performed immediately and the skin was left open and reapproximated with crossed elastic bandages and staples. Delayed closure was then performed on these patients over the ensuing few days.
There was no statistical difference between those patients who developed compartment syndrome in terms of gender, age, or mechanism of injury. Comminution was also founded to be a non-significant contributing factor. Of the 285 patients, 205 were treated with closed reduction and no patient developed compartment syndrome. The remaining 80 patients required surgical intervention secondary to open fracture configuration, unstable injuries, or loss of reduction. Six of these patients, or 7.5%, developed compartment syndrome, all within the early postoperative period. Increased operative time and increased intraoperative fluoroscopy time was associated with the development of a compartment syndrome. This may imply more attempts at reduction and/or passes with the intramedullary fixation. No patient had neurologic deficit at the time of follow up, as volar fasciotomy was efficacious treatment for the compartment syndrome.
This study indicates a higher incident of compartment syndrome in those children that underwent intramedullary fixation of a both-bone forearm fracture. Increased operative time and increased fluoroscopic time were predictive values for compartment syndrome. This increased time may be an indicative of multiple attempts at reduction and additional soft tissue injury. Converting to an open reduction may have diminished the operative time and subsequently the risk of developing compartment syndrome. However, the fractures that were selected for operative treatment were more unstable and associated with greater soft-tissue trauma. In addition, the authors did not evaluate or assess the anatomic reduction in either group, which may lead to additional problems, such as loss of forearm rotation. While the possibility of compartment syndrome should be discussed with parents prior to surgery, the conclusions from this study should be taken in context.
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J Pediatr Orthop 2004;24:370-375.