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Unstable Pediatric Forearm Fractures: Use of “Pins and Plaster”

Joseph Duncan, MD; Dennis Weiner, MD

The use of “pins and plaster” for unstable pediatric forearm fracture treatment provides satisfactory reduction and outcome and is preferred to other invasive techniques, which bear a higher overall incidence of minor and significant complications in this patient population.

multitude of articles malrotation exist, patients Adeal with pediatric fore- often have good results. They arm fracture treatment.1-6 The questioned treating pediatric vast majority of fractures forearm fractures with any- treated with closed reduction thing other than closed and casting achieve accept- reduction and casting. Kay et able results, but controversy al1 refuted this rationale in exists with the management 1986 when they found that of those in which failure to children aged Ͼ10 years with Materials and Methods distal third), closed or open, obtain or maintain an accept- malalignment achieve poor Patient Population and angulation, displacement, able alignment occurs. results with closed reduction Between 1978 and 1995, 32 and shortening. Suffice it to say, a diversity of alone. pediatric forearm fractures opinion exists concerning Although clear resolution (open growth plates) were Surgical Technique what constitutes an accept- of these issues remains, treated with “pins and plaster” The fingers are placed in able reduction. manipulative reduction and at Children’s Hospital Medical vertical traction and weight is Price et al7 stated that immobilization is uniformly Center of Akron by the senior suspended from the upper arm even in cases in which signif- applied and accepted in the author (D.W.). These cases with the elbow flexed via a icant residual angulation and treatment of displaced fore- were retrospectively reviewed padded sling (Figure 1). With arm fractures in children. for ultimate outcome with the arm in traction, a closed From the Department of Ortho- This article discusses the respect to alignment, cosmesis, reduction is performed and ver- pedic Surgery, Children’s Hospital technique used by the function, and minor or signifi- ified by image intensification. Medical Center of Akron, Ohio. authors to routinely avoid cant complications. Fractures Under sterile technique, two Reprint requests: Dennis Weiner, MD, 300 Locust St, Ste 160, Akron, placing metal across the frac- were classified with respect to smooth pins are percutaneous- OH 44302. ture site. location (proximal, middle, or ly inserted, one transversely

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years. No malrotation was Functionally and cosmetically, of the impetuous surgeon. accepted if recognized. all patients in this series had an Internal fixation may be indi- Of 32 patients (24 boys and excellent result determined by cated in open fractures, “float- 8 girls) treated by “pins and clinical and radiographic evalu- ing” elbows, grossly unstable plaster,” 17 had an anatomical ation. The relatively short fol- forearms, and when compart- result. Of the remaining 15 low-up was adequate because ment syndrome is present, patients, some residual angula- all patients were followed to although these are uncommon. tion remained; however, it was complete radiographic union Once the decision is made to less than that stated acceptable before release to activities. open the fracture site, the nat- for closed reduction. “Pins and Importantly, in addition to the ural order of healing is dis- plaster” were used as a primary excellent results obtained, no rupted. Plating achieves near perfect anatomical alignment but can cause retardation in healing.7,9-13 Closed intramedullary nail- ing is advocated by many for unstable forearm fracture treat- ment14-19; however, the intro- 1A duction of rods is not without across the prox- consequence. The ability of the imal ulna and the intramedullary rod to control other through the rotation has been questioned. first metacarpal neck (Figures 2 1B Stability at the fracture site is and 3). Betadine ointment is Figure 1: Pin insertion in the first metacarpal neck and across the proximal not as guaranteed as with plate 6 used during insertion to seal pin ulna in traction (A). Pins are incorporated in a long-arm cast and traction is fixation. Van der Reis et al sites after preparation with a removed (B). reported 2 nonunions, 1 standard 5-minute betadine preparation. A long-arm cast is applied with the pins incorpo- rated in the cast, and anteropos- terior (AP) and lateral radio- graphs are obtained (Figures 4- 6). The pins are removed between 4 and 5 weeks postop- eratively.

Results 2 Thirty-two forearm frac- Figure 2: Pin placement in the ulna. tures were selected for “pins Figure 3: Pin placement in the first metacarpal. 3 and plaster” for reduction of approximately 2200 cases of technique (failure to obtain nonunions, osteomyelitis, nerve osteomyelitis, 1 neuropathy, 1 closed reductions. The decision reduction) in 20 patients and injuries, hardware failures, or hardware failure, and 1 reflex to proceed with “pins and plas- secondary (failure to maintain pin tract infections occurred. sympathetic dystrophy in their ter” was based on the inability reduction) in 12 patients. Ulnar nerve injury or injury to series of open reduction and to obtain or maintain an accept- Average patient age was 9.6 the neurovascular structures of internal fixation. They reviewed able reduction. Acceptable years (range: 3-18 years). the thumb were not reported. 23 patients with plates and reduction was deemed Ͻ15° Thirty fractures were closed screws and 18 patients with angulation in children aged and two were grade I open Discussion intramedullary pins. Those Ͻ10 years and Ͻ10° angula- injuries. Average follow-up was Blount8 stated that the use treated with intramedullary tion in children aged у10 3.5 months (range: 2-5 months). of internal fixation was the way pins had 1 delayed union, 2 rotary

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Figure 4: Application of a long-arm children. Clin Orthop. 1967; cast incorporating pins. The cast is 51:93-107. extended above the elbow and 9. Stanley E, Wilkins K. Treat- trimmed to allow full thumb and ment of midshaft fractures of finger motion. the radius and ulna utilizing percutaneous intramedullary pinning. Orthopaedic Trans- actions. 1995; 20:305. 10. Voto SJ, Weiner DS, Leighley B. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop. 1990; 10:79-84. 4 11. Voto S, Weiner D, Leighley B. Use of pins and plaster in the treatment of unstable pediatric forearm fractures. J Pediatr Orthop. 1990; 10:85-89. 12. Anderson LD, Sisk D, Tooms RE, Park WI III. Compression plate fixation in acute diaphyseal fractures of the radius and ulna. J Bone Joint Surg Am. 1975; 57:287-297. 13. Bednar D, Grandwilewski W. Complications of forearm plate removal. Can J Surg. 1992; 5B 35:428-431. Figure 5: AP (A) and lateral (B) radiographs with pins and plaster in place. 14. Creasman C, Zaleske DJ, Ehrlich MG. Analyzing forearm fractures in children. Clin Orthop. 1976; 120:172-184. management. Advantages Philadelphia, Pa: Lippincott 15. Cullen MC, Roy DR, Giza E, Williams & Wilkins; 1993. 5A include avoiding fracture site Crawford AH. Complications of 3. Mih AD, Cooney WP, Idler RS, intramedullary fixation of pedi- invasion and complications Lewallen DG. Long-term follow- atric forearm fractures. J Pediatr malunions, and 1 compartment associated with the insertion of up of forearm bone diaphyseal Orthop. 1998; 18:14-21. syndrome. metallic fixation. plating. Clin Orthop. 1994; 16. Hughston JC. Fractures of the 299:256-258. Cullen et al15 reported 14 The limited literature on forearm in children. J Bone Joint 4. Nielsen A, Simonsen O. Dis- Surg Am. 1962; 44:1678-1693. complications in 10 of 20 patients this technique is based on the placed forearm fractures in chil- 17. Jones K, Weiner DS. The man- treated with intramedullary fixa- fact that few orthopedic sur- dren treated with AO plates. agement of forearm fractures in tion. Complications included 1 geons are taught the technique Injury. 1984; 15:393-396. children: a plea for conservatism. synostosis, 5 hardware compli- in training. It is a relatively 5. Roy DR, Crawford AH. Opera- J Pediatr Orthop. 1999; 19:811- tive management of fractures of 815. cations, 4 infections, significant simple technique that adds the shaft of the radius and ulna. 18. Lascombes P, Prevot J, Ligier JN, loss of range of motion in 2 only 10-15 minutes to the Orthop Clin North Am. 1990; Metaizeau JP, Poncelet T. Elastic 21:245-250. patients, and neuropraxias in 2 standard closed reduction. stable intramedullary nailing in 6. Van der Reis WL, Otsuka NY, forearm shaft fractures in chil- patients. Moroz P, Mah J. Intramedullary dren: 85 cases. J Pediatr Orthop. Currently, an aggressive References nailing versus plate fixation for 1990; 10:161-171. “surgical mentality” exists with 1. Kay S, Smith C, Oppenheim WL. unstable forearm fractures in chil- 19. Amit Y, Salai M, Chechik A, dren. J Pediatr Orthop. 1998; many orthopedic surgeons that Both-bone midshaft forearm frac- Blankstein A, Horoszowski H. tures in children. J Pediatr 18:9-13. Closed intramedullary nailing for demands revisiting a more con- Orthop. 1986; 6:306-310. 7. Price CT, Scott DS, Kurzner ME, the treatment of diaphyseal fore- arm fractures in adolescence: a servative approach. The use of 2. In: MacEwen G, Kasser J, Flynn JC. Malunited forearm preliminary report. J Pediatr “pins and plaster” should be an Heinrich S, eds. Pediatric fractures in children. J Pediatr Orthop. 1990; 10:705-712. Orthop. 1985; 5:143-146. additional technique in the Fractures: A Practical Approach to Assessment and Treatment. 8. Blount WP. Forearm fractures in armamentarium of fracture

Section Editor: Steven F. Harwin, MD

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