Levent ÇELEBİ, HASAN HİLMİ MURATLI, Özgür DOĞAN, Mehmet Fırat YAĞMURLU, Ertuğrul AKŞAHİN, ALİ BİÇİMOĞLU

Alçı tedavisi sırasında tekrar deplase olmuş çocuk önkol kırıklarında intramedüller çivileme sonuçları

Amaç: Bu çalışmada önkol çift kırığı sonrası uygulanan alçı tedavisi sırasında redüksiyon kaybı görülen çocuk hastalarda intramedüller çivileme sonuçları değerlendirildi. Çalışma planı: Önkol çift kırığı nedeniyle redüksiyonun başarısız olması üzerine 28 çocuk hastaya (19 erkek, 9 kız; ort. yaş 10.6; dağılım 8-15) konservatif tedavinin ortalama dördüncü haftasında (dağılım 3-6 hafta) açık (n=8) veya kapalı (n=20) redüksiyon sonrasında intramedüller çivileme uygulandı. Tespitte ilk 10 hastada K-teli, 18 hastada titanyum elastik çivi kullanıldı. Tek kemik tespiti dört hastada (%14.3) yapılabildi. Kötü kaynama maksimum radial eğimin miktarı ve yerleşimine bakılarak değerlendirildi ve sağlam tarafla ve benzer yaştaki çocuklardan oluşan kontrol grubuyla karşılaştırıldı. İşlevsel sonuçlar Grace ve Eversmann’ın ölçütlerine göre değerlendirildi. Hastalar ortalama 14 ay (dağılım 12-18 ay) izlendi. Sonuçlar: Tek kemik tespiti yapılan bir hastadaki kaynamayan ulna kırığı dışında bütün olgularda normal dizilim sağlanabildi ve ortalama yedi haftada (dağılım 6-8 hafta) kaynama elde edildi. Kırık taraftaki ortalama maksimum radius eğimi ve maksimum radial eğim yerleşimi sağlam taraf ve kontrol ekstremitelere göre anlamlı farklılık göstermedi (p>0.05). İşlevsel sonuçlar 25 hastada (%89.3) mükemmel, iki hastada (%7.1) iyi, bir hastada (%3.6) kabul edilemez bulundu. Hiçbir hastada enfeksiyon ya da nörapraksi, çivi çıkarılması sonrasında yeniden açılanma, kırık ve ekstremite eşitsizliği görülmedi. Çıkarımlar: Alçı tedavisi sırasında redüksiyon kaybına uğrayan önkol çift kırıklarında intramedüller tespit, mükemmel anatomik ve işlevsel sonuçları yanı sıra güvenli, ucuz ve erken harakete izin veren bir yöntemdir.

Anahtar Kelimeler:

Radius kırıkları, Kemik çivileri, Yaralanma şiddeti skoru, Hareket açıklığı, eklem, Kemik telleri, Kırık tespiti, intramedüller, Ulna kırıkları, Tedavi sonucu

The results of intramedullary nailing in children who developed redisplacement during cast treatment of both-bone forearm fractures

Objectives: We assessed the results of intramedullary nailing in children who developed redisplacement during cast treatment of both-bone forearm fractures. Methods: Twenty-eight children (19 boys, 9 girls; mean age 10.6 years; range 8 to 15 years) were treated with intramedullary fixation upon failure of initial reduction of both-bone forearm fractures after a mean of four weeks (range 3 to 6 weeks) of cast treatment. Intramedullary fixation was performed following closed (n=20) or open (n=8) reduction using K-wires in the first 10 cases, and titanium elastic nails in 18 cases. Single bone fixation was possible in four (14.3%) cases. For malunion assessment, the amount and location of the maximum radial bow were measured and compared with the normal side and with corresponding extremities of age-matched controls. Functional results were assessed using the Grace-Eversmann criteria. The mean follow-up was 14 months (range 12 to 18 months). Results: Except for a nonunion of the ulna in one patient who underwent single bone fixation, all correction losses could be restored to normal alignment and united within a mean of seven weeks (range 6 to 8 weeks). The amount and location of the maximum radial bow did not differ significantly from those of the normal side and control extremities (p>0.05). Functional results were excellent in 25 patients (89.3%), good in two patients (7.1%), and unacceptable in one patient (3.6%). None of the patients developed infection, neurapraxia, or after removal of the nail, angulation, refracture, or extremity length discrepancy. Conclusion: Intramedullary fixation for correction losses during cast treatment of both-bone forearm fractures is a safe and inexpensive treatment, allowing early mobilization and providing excellent anatomic and functional results. Key words: Child; forearm; fracture fixation, intramedullary; radius fractures/surgery; recurrence; ulna fractures/surgery.

Keywords:

Radius Fractures, Bone Nails, Injury Severity Score, Range of Motion, Articular, Bone Wires, Fracture Fixation, Intramedullary, Ulna Fractures, Treatment Outcome,

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1. Voto SJ, Weiner DS, Leighley B. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 1990;10:79-84.
2. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop Relat Res 1976;(120): 172-83.
3. Evans EM. Fractures of the radius and ulna. J Bone Joint Surg [Br] 1951;33:548-61.
4. 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.
5. Nilsson BE, Obrant K. The range of motion following fracture of the shaft of the forearm in children. Acta Orthop Scand 1977;48:600-2.
6. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop 1986;6:306-10.
7. Amit Y, Salai M, Chechik A, Blankstein A, Horoszowski H. Closing intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: a preliminary report. J Pediatr Orthop 1985;5:143-6.
8. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg [Am] 1992; 74:1068-78.
9. Grace TG, Eversmann WW Jr. Forearm fractures: treatment by rigid fixation with early motion. J Bone Joint Surg [Am] 1980;62:433-8.
10. Price CT, Mencio GA. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins’ fractures in children. 5th ed. Philadelphia: Lippincott Williams & Wilkins; 2001. p. 443-82.
11. Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and the ulna on supination and pronation. J Bone Joint Surg [Br] 2002;84:1070-4.
12. Tynan MC, Fornalski S, McMahon PJ, Utkan A, Green SA, Lee TQ. The effects of ulnar axial malalignment on supination and pronation. J Bone Joint Surg [Am] 2000; 82:1726-31.
13. Fuller DJ, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg [Br] 1982;64:364-7.
14. Roberts JA. Angulation of the radius in children’s fractures. J Bone Joint Surg [Br] 1986;68:751-4.
15. Proctor MT, Moore DJ, Paterson JM. Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg [Br] 1993;75:453-4.
16. Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair AM. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop 1994;14:211-3.
17. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury 1995;26:691-2.
18. Bhatia M, Housden PH. Re-displacement of paediatric forearm fractures: role of plaster moulding and padding. Injury 2006;37:259-68.
19.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.
20. Tabak AY, Tasbas BA, Yagmurlu MF, Muratli HH. Closed intramedullary nail application in pediatric forearm shaft fractures of both bones. [Article in Turkish] Acta Orthop Traumatol Turc 2000;34:374-8.
21. Kucukkaya M, Kabukcuoglu Y, Tezer M, Eren T, Kuzgun U. The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures. J Orthop Trauma 2002;16:340-4.
22.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.
23. Kirkos JM, Beslikas T, Kapras EA, Papavasiliou VA. Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius. Injury 2000;31:591-6.
24. Flynn JM, Waters PM. Single-bone fixation of both-bone forearm fractures. J Pediatr Orthop 1996;16:655-9.
25. Myers GJ, Gibbons PJ, Glithero PR. Nancy nailing of dia physeal forearm fractures. Single bone fixation for fractures of both bones. J Bone Joint Surg [Br] 2004;86:581-4.
26. Herring JA. Fractures of the forearm. In: Tachdjian’s pediatric orthopaedics. Vol. 3, 3rd ed. Philadelphia: W. B. Saunders; 2002. p. 2230-1.
27. 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.
28. Cullen MC, Roy DR, Giza E, Crawford AH. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop 1998;18:14-21.
29. Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop 1990;10:167-71.
30. Ogden JA. Radius and ulna. In: Skeletal injury in the child. 3rd ed. New York: Springer-Verlag; 2000. p. 567-649.