Displaced fractures of the forearm are common. Similar to adult fractures, there is a continual trend toward internal fixation. Different types of internal fixation devices have been utilized with increasing popularity of intramedullary devices. Eighty-four children under the age of 14-years are included in this study, all of whom sustained a displaced fracture of one or both bones of the forearm. Treatment was percutaneous transphyseal intramedullary Kirschner wire fixation. Irreducible fractures required a mini-open approach through a small incision over the fracture site. Kirschner wires with a diameter of 1.6 mm were used in the majority of patients, except in children less than 4 years of age (1.1 mm diameter). The Kirschner wires were advanced into the metaphysis without violation of the other physis located at the other end of the bone. The wire(s) were left in a percutaneous position and the limb casted. Cast and wires were removed between 4 and 6 weeks after surgery.
Mean age of children was 7.5 years. 64 fractured both bones, 10 fractured only the radius and 10 only the ulna. Twenty-four required a small open incision for reduction. Minimum follow-up was 2 years (average 70 months). Only 12 patients required physical therapy. Only one patient had any considerable loss of motion (20-degrees of pronation and 10-degrees of supination) compared to the contralateral side. No patient showed evidence of physeal arrest attributed to the wire. One patient had physeal closure of the ulna secondary to the fracture as the bone was not secured with a wire. No deep infections were reported. Two patients had re-fracture after trauma between 6 and 8 months after initial injury.
The treatment of the pediatric forearm fracture continues to evolve over time. Intramedullary devices offer substantial benefit with regards to fracture stabilization, restoration of alignment, and stress sharing. The physis remains a barrier to insertion of large intramedullary devices as physeal injury would negate any benefit from fracture stabilization. The transphyseal route is simpler that any technique to avoid the growth plate. The authors provide ample evidence that transphyseal placement of a wire with a diameter of 1.6-mm after the age of 4 years is safe and effective. The issue of indications with regards to angulation and displacement is still unresolved.
J Ped Orthop