[Greenstick fractures of the forearm shaft-Is it obligatory or facultative to break the cortex?] / Grünholzfraktur des Unterarmschafts ­ Überbrechen obligatorisch oder fakultativ?

BACKGROUND: To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft. OBJECTIVE: The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate. METHODS: Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population. RESULTS: Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate. CONCLUSION: As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

Bilateral femoral shaft fractures in osteomalacia: A case report and literature review.

INTRODUCTION AND IMPORTANCE: When two non-traumatic femoral shaft fractures happen at the same time, they are usually not caused by high-energy trauma or medical conditions like osteomalacia caused by poor nutrition, long-term bisphosphonate medication use, or steroid use. Because this phenomenon is connected to inadequate bone mineralization and bone metabolism, it occurs when a bone is consistently under high stress. CASE PRESENTATION: A 40-year-old lady with a medical history of osteomalacia, including continuous vitamin D replacement therapy, showed up at the emergency room complaining of discomfort and swelling in her right thigh caused by a fall. During the emergency examination, X-rays showed a subtrochanteric fracture with a short oblique fracture line and a displaced oblique fracture in the right femoral shaft, but no fragmentation in the left femoral shaft. Osteomalacia caused the bilateral femoral shaft fracture in which the patient was identified as being displaced. We planned a surgical correction that included a closed reduction with intramedullary nailing and distal static screws on the right side, as well as intramedullary nailing followed by locking screw insertion on the left. Following the operation, the avoidance of bisphosphonate medications gained precedence. CLINICAL DISCUSSION: Patients of any age who come with bone pain, non-traumatic fractures, and muscle weakness should have their blood vitamin D, ALP levels, and BMD evaluated for osteomalacia. If a conventional X-ray shows normal, an MRI or bone scan of both hips is recommended to rule out any underlying fatigue fractures. Finding and treating the underlying cause of osteomalacia can help improve the prediction. CONCLUSION: Intramedullary nailing with screws is the most effective treatment for femoral shaft fractures. Improving patient outcomes relies on identifying and treating the underlying cause of osteomalacia. Given the patient's history and condition, avoiding bisphosphonate medicines following surgery was a primary priority in this case.

Trends in Epidemiology and Treatment of Humerus Fractures in the United States, 2017-2022.

Background Fractures of the humerus are one of the more common fractures in the United States and a cause of fragility fractures in the elderly population. This study aims to understand recent trends in the demographic factors correlated with humeral shaft fractures (HSF) and humeral shaft fracture nonunion (HSFN) following open reduction internal fixation (ORIF) and intramedullary nailing (IMN). Methods The TriNetX database was used to query using International Classification of Diseases-10 (ICD10) diagnosis codes for patients who sustained HSF between 2017 and 2022. Patients were then organized into cohorts based on Current Procedural Terminology (CPT) codes 24515 and 24516 for ORIF and IMN of HSFs, respectively. Subsequent nonunion after operative management was queried. Descriptive and comparative analysis was performed to examine the differences observed between patients based on age, sex, ethnicity, race, and smoking status as well as surgical management across the six-year study period. Results The incidence of HSF increased from 7,108 in 2017 to 8,450 in 2022. The rate of HSF ORIF increased from 12% to 17% while the nonunion rate following ORIF decreased from 4% to 3%. The rate of HSF IMN increased from 4% to 6% and the rate of nonunion following IMN increased from 2% to 4%. The overall rate of HSFN surgery was 1.7% with slight decreasing trend over the past year. Conclusion It is speculated that improved care and surgical indications resulted in a lower rate of nonunion despite an increase in the overall rate of HSF and its operative managements.

Steroid-responsive anemia with bony dysplasias: What lurks behind!

Ghosal hematodiaphyseal dysplasia (GHDD) is an autosomal recessive disorder characterized by diaphyseal dysplasia of long bones, bone marrow fibrosis, and steroid-responsive anemia. Patients with this disease have a mutation in the thromboxane-AS1 (TBXAS1) gene located on chromosome 7q33.34. They present with short stature, varying grades of myelofibrosis, and, hence cytopenias. Patients with the above presentation were evaluated through clinical presentation, X-ray of long bones, bone marrow examinations, and confirmed by genetic testing. In this article, we present two cases: The first case is a 3-year-old boy who presented with progressive pallor and ecchymotic patches for a year. On investigation, he had bicytopenia and bone marrow fibrosis. His anemia was steroid responsive and was finally diagnosed as GHDD. The second case is a 20-month-old girl who presented with blood in stools, developmental delay, anemia, and increased intensity of long bones on X-ray. Since other investigations were normal, suspicion of GHDD was raised, and a genetic workup was conducted which suggested mutation in TBXAS1 gene, confirming the diagnosis of GHDD. Children with refractory anemia and cortical thickening on skeletogram should always be evaluated for dysplasias. Timely treatment with steroids reduces transfusion requirements and halts bone damage, thus leading to better growth and improved quality of life.

Management of pediatric distal humerus metaphyseal-diaphyseal junction fracture: A systematic review and meta-analysis.

Purpose: Fractures occurring at the metaphyseal-diaphyseal junction of the distal humerus in children are not commonly documented in the literature. Until this moment, there is no gold standard technique regarding its management and most surgeons treat it as a regular supracondylar humerus fracture by conventional pinning. This systematic review explores the relevant literature to assess the efficacy of different techniques. Methods: This review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Our literature search encompassed several online databases, including PUBMED/MEDLINE, Scopus, Web of Science Core Collection, and Google Scholar. Data from articles that met our general inclusion criteria were extracted and categorized into treatment method groupings. Functional and cosmetic outcomes, demographic characteristics, and complications were the main parameters used to analyze the data. Results: Ten retrospective studies met our inclusion criteria with a total of 178 participants of unilateral pediatric distal humerus metaphyseal-diaphyseal junction fractures. Most literature chose closed reduction and percutaneous pinning in seven articles, followed by elastic stable intramedullary nail technique used in three articles, then conservative treatment was chosen in two articles, while only one article used lateral miniplate and assisted K-wire and another article used combined closed reduction and percutaneous pinning and intramedullary K-wire. As regards the operation time; elastic stable intramedullary nails had the shortest time with a mean of 39.7 min (range: 37.5-41.9 min), while closed reduction and percutaneous pinning had the longest time with a mean of 75.47 min (range: 55.9-92.1 min). The shortest healing time was observed in miniplate with a mean of 7.2 weeks, while the most prolonged was in conservative management with a mean of 12 weeks and closed reduction and percutaneous pinning was a mean of 10 weeks. Regarding Flynn's criteria, all participants received excellent and good except in closed reduction and percutaneous pinning; 13 cases were fair and 2 cases were poor. Regarding complications, the most commonly observed complication after metaphyseal-diaphyseal junction fracture was cubitus varus, the highest incidence was in conservative management (33% of cases), followed by closed reduction and percutaneous pinning (10.9% of cases), the least incidence was observed in elastic stable intramedullary nails (3.77% of cases), and none of the cases treated with mini plate developed this complication. Other complications were observed only with closed reduction and percutaneous pinning; 8.5% of cases developed fixation loss, 6.2% of cases had a significantly reduced range of motion, and one case refractured. Conclusion: Pediatric distal humerus metaphyseal-diaphyseal junction fractures should be distinguished from the more prevalent supracondylar humerus fractures, as conventional pinning techniques are associated with a higher incidence of complications and increased both operative and healing times.Level of evidence: III.

[Application of external fixator combined with Kirschner wire fixation for oblique and comminuted distal humeral metaphyseal-diaphyseal junction fractures in children].

Objective: To analyze the effectiveness of external fixator combined with Kirschner wire (EF-KW) fixation in the treatment of oblique and comminuted distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children. Methods: A clinical data of 22 children with DHMDJ fractures who met the selection criteria between April 2021 and December 2023 was retrospectively analyzed. All patients were treated with EF-KW fixation. There were 14 boys and 8 girls with an average age of 6.8 years (range, 1.5-12.0 years). The time from injury to operation was 14-38 hours (mean, 24.2 hours). There were 18 cases of comminuted fractures and 4 cases of oblique fractures; and 1 case of median nerve injury and 1 case of radial nerve injury before operation. The occurrence of postoperative complications was recorded. At last follow-up, the function of the affected elbow joint was evaluated according to the Mayo elbow joint function score, and the Baumann's angle (BA) and humero-capitellar angle (HCA) of the affected and healthy sides were recorded and compared. Results: All fractures were successfully treated with closed reduction and no complications such as nerve injury occurred. Superficial infection occurred in 4 cases after operation and healed after symptomatic treatment. The incisions of other patients healed by first intention. All patients were followed up 9-24 months (mean, 13.8 months). At last follow-up, according to the Mayo elbow joint function score, the elbow joint function was rated as excellent in 15 cases, good in 6 cases, and fair in 1 case, with an excellent and good rate of 95.5%. The neurologic injury before operation recovered gradually. X-ray films reexamination showed that all fractures healed, and the healing time of fractures ranged from 29 to 61 days, with an average of 35.6 days. At last follow-up, there was no significant difference in BA and HCA between the healthy side and the affected side ( P>0.05). During follow-up, 1 case developed mild cubitus varus, while the other patients had no serious complications. Conclusion: EF-KW fixation for oblique and comminuted DHMDJ fractures in children has the advantages of less trauma, simple operation, easy reduction, good stability after reduction, low incidence of serious complications, and good elbow functional recovery.

Biomechanical study of using patient-specific diaphyseal femoral cone in revision total knee arthroplasty (rTKA).

Background: The primary objective of revision total knee surgery is to achieve solid bone fixation. Generally, this could be accomplished using sleeves and long stems, which require substantial remaining bone stock and may increase the risk of stem tip pain. An alternative approach involves the use of customized diaphyseal cones, which can preserve the integrity of the bone canal. This study evaluates the impact of employing femoral diaphyseal cones with various stem lengths on stress distribution and relative motion. Methods: CT scan data from five patients were used to generate the 3D model of the femur, cement, customized stems, and cones, along with assigning patient-specific material for each candidate's femur. Three different stem lengths, both with and without the customized cone, were assessed under three gait loading conditions to compare the resulting Von Mises stress distribution and relative motion. Results: Analysis indicated that the use of customized femoral cones moderately increases stress distribution values up to 30 % while significantly reducing relative motion at the femoral canal-cone interface by nearly 60 %. The presence of the cone did not significantly alter relative motion with varying stem lengths, although stem length variation without a cone substantially affected these values. Conclusion: Incorporating cones alongside stems enhances metaphyseal fixation, reduces stress shielding, potentially allowing for the use of shorter stems. Furthermore, cones promote osseointegration by minimizing relative motion, ultimately improving prosthetic stability.

Factors Associated with Development of Thigh Compartment Syndrome Following Subtrochanteric and Diaphyseal Femoral Fractures.

Objectives: Acute compartment syndrome of the thigh (CST) is an ongoing challenge for orthopaedic surgeons as the diagnosis is often difficult to establish. Currently, there is a shortage of studies investigating risk factors for the development of thigh compartment syndrome following subtrochanteric and diaphyseal femoral fractures. This study aimed to identify risk factors associated with the development of CST following femoral fractures. Methods: Retrospective review performed in a level one trauma center from January 2011 to December 2020 for all patients with non-pathological acute subtrochanteric or diaphyseal femoral fractures. Variables collected included demographics, injury severity score (ISS) scores, mechanism of injury, classification of femoral fracture, open versus closed injuries, development of compartment syndrome, time to compartment syndrome diagnosis, number of subsequent surgeries, and primary wound closure versus split-thickness skin graft. The statistical analysis of this study included descriptive analysis, simple logistic regression, paired T-test, and Wilcoxon Signed Rank. Results: Thirty-one (7.7%) patients developed thigh compartment syndrome following 403 subtrochanteric or diaphyseal femoral fractures. The mean (SD) age for those who developed CST was 27.35 (8.42). For every unit increase in age, the probability of developing CST decreased. Furthermore, male gender had 18.52 times greater probability of developing CST (P <0.001). AO/OTA 32-C3 and subtrochanteric femoral fracture patterns demonstrated 15.42 (P = 0.011) and 3.15 (P <0.001) greater probability of developing CST, respectively. Patients who presented to the hospital following a motor vehicle accident (MVA) or gunshot wound (GSW) had 5.90 (P= 0.006) and 14.87 (P < 0.001) greater probability of developing CST, respectively. Conclusion: Patients who were male, younger in age, and had a 32-C3 and subtrochanteric femoral fractures were at increased probability of developing CST. High energy trauma also increased the risk of developing CST. A high index of suspicion should be expressed in patients with these risk factors.

Pediatric Diaphyseal Forearm Fracture Management with Biodegradable Poly-L-Lactide-Co-Glycolide (PLGA) Intramedullary Implants: A Longitudinal Study.

Background: Pediatric forearm fractures represent a substantial proportion of childhood injuries, requiring effective and minimally invasive treatments. Our study investigated the mid-term outcomes of biodegradable poly-L-lactide-co-glycolide (PLGA) intramedullary implants in managing diaphyseal forearm fractures in children. Methods: A follow-up cohort study was conducted with 38 patients treated with PLGA implants. Control examinations were performed one year post-operation, assessing bone healing through radiographic evaluations and functional outcomes using injured and uninjured limb range of motion (ROM) comparisons. Scarring was evaluated employing the Vancouver Scar Scale (VSS), and satisfaction via a questionnaire. Results: Children were predominantly female (76.4%), with a mean age of 9.71 (SD: 2.69) years. Effective fracture stabilization and bone healing were found in all patients, with a minor reduction (mean difference of -1.5°, p = 0.282) in elbow flexion on the operated side (139.3°) compared to the intact (140.8°). Elbow extension presented negligible average changes (0.2°, p = 0.098). Forearm movements were slightly reduced on the operated side (mean pronation: 80.8° vs. 83.7°, p = 0.166; average supination: 83.5° vs. 85.7°, p = 0.141). Wrist palmar flexion and dorsiflexion showed no significant differences. VSS ratings indicated minimal scarring (mean guardian and doctor scores were 1.13 and 0.55, respectively, p = 0.020), and all patients reported satisfaction with the treatment outcomes. Conclusions: Biodegradable implants are effective for pediatric forearm fractures, providing stable bone healing while preserving functional ROM with minimal scarring and high patient satisfaction. PLGA proved to be a viable alternative to traditional metal implants, eliminating secondary removal surgeries.

Reamed intramedullary nailing of diaphyseal multifragmentary femur fractures (AO/OTA 32-C) without fluoroscopy guidance: prospective analysis of methods and short-term outcomes in a low-resource setting.

PURPOSE: To describe the methods and outcomes of reamed intramedullary nailing (IMN) of diaphyseal multifragmentary femur (AO/OTA C2 and C3) fractures (DMFFs) in a low-resource setting without fluoroscopy and fracture table. METHODS: The prospective study involved 35 DMFFs among 318 femur fractures treated ≤ 3 weeks post-injury with SIGN nails. The fractures were fixed without fluoroscopy, fracture table and power reaming. Closed, mini-open or open reduction was done. Anatomical length and alignment were ensured using a surgical support triangle during retrograde nailing, and by an assistant during antegrade nailing. Follow-ups were done at 6 weeks, 12 weeks and 6 months. RESULTS: DMFFs constituted 11.0% of the 318 fractures. Twenty-four (68.6%) were males. The mean age was 39.0 years (range 17-75 years). About 94.3% were injured in road traffic accidents. Fracture reduction was closed in 18, mini-open in 8 and full-open in 9. The operative times were significantly shorter for closed than open reduction (p = 0.001). Five fractures received a supplemental fixation with plate or lag screws. By the 12th post-operative week, 97.1% demonstrated continuing radiographic healing, 94.1% tolerated painless weight-bearing and 91.2% could squat & smile. There was no infection or noticeable rotational malunion. Five fractures healed with a limb-length discrepancy of < 2 cm. CONCLUSION: The study demonstrates the feasibility of reamed IMN of DMFFs without fluoroscopy. The outcomes were satisfactory. Although the small sample size and short follow-up period are limitations, the study could serve as a basis for future larger studies in low-resource settings.

Modified elastic intramedullary nail internal fixation for distal tibial metaphyseal junction fracture.

Objective: To investigate the application of modified elastic intramedullary nail and the outcomes between modified elastic stable intramedullary nailing and traditional elastic stable intramedullary nailing in children with distal tibial metaphyseal junction fracture. Methods: A retrospective study was conducted. From January 2018 to January 2021, a total of 36 children with distal tibial metaphyseal junction fracture were treated in our hospital. All of them were treated with closed reduction and elastic stable intramedullary nailing internal fixation. A total of 18 children were treated by modified elastic stable intramedullary nailing and 18 children were treated by traditional elastic stable intramedullary nailing. Postoperative imaging, clinical efficacy, and complications were analyzed. Results: The mean follow-up time was 20 (15-36) months in modified group and 22 (16-33) months in traditional group. There were no complications such as infection, loss of reduction, and unequal length of lower limbs in modified group while loss of reduction occurred in two cases in traditional group. In these two cases of loss of reduction, we preformed manual reduction and replacement of long leg casts, and there was no loss of reduction, and the patient achieved a good prognosis. In the last follow-up, American Orthopaedic Foot & Ankle Society score was used. In modified group, excellent outcome achieved in 17 cases, good outcome achieved in 1 case, and satisfactory therapeutic effect was achieved. In traditional elastic stable intramedullary nailing group, excellent outcome achieved in 14 cases, and good outcome achieved in 4 cases. There was no statistical difference in the scores between the two groups. Conclusion: It was concluded that modified elastic stable intramedullary nailing fixation is a safe and effective treatment.

Case Report: Halting terminal osseous overgrowth post tibia amputation in children: a report of three cases.

Terminal osseous overgrowth is a common complication after trans-diaphyseal amputation in children, leading to pain, soft tissue problems, and recurrent surgical procedures. We report three different cases with post-amputation issues of osseous overgrowth, ulceration, and deformity over the amputation site. The first case involves a 9-year-old boy with a right leg congenital amputation secondary to amniotic band syndrome. The right below-knee stump later experienced recurrent episodes of osseous overgrowth, leading to ulceration. After the prominent tibia was resected and capped with the ipsilateral proximal fibula, a positive outcome was achieved with no more recurrent overgrowth over the right leg stump. The second case involves a 9-year-old girl born with an amniotic constriction band over both legs. Her left leg remained functional after a circumferential Z-plasty, but the right leg was a congenital below-knee amputation. Multiple refashioning surgeries were performed on the right leg due to osseous overgrowth but the patient continued to experience recurrent overgrowth causing pain and difficulty fitting into a prosthesis. We performed osteocartilaginous transfer of the proximal part of the ipsilateral fibula to the right tibial end, successfully preventing the overgrowth of the tibia without any complications. The third case involves an 11-year-old boy with a history of meningococcal septicemia who underwent a right below-knee amputation and left ankle disarticulation due to complications of septic emboli. He experienced a prominent right distal tibia stump, which later developed into valgus deformity as a result of the previous insult to the proximal tibial growth plate. We performed a corrective osteotomy over the proximal right tibia and capped the entire tibia with the ipsilateral fibula as an intramedullary splint for the osteotomy site. Post-operatively, we achieved satisfactory deformity correction and successfully halted the recurrent overgrowth over the right tibia stump. The method of ipsilateral fibula capping is safe and effective in managing the osseous overgrowth complications in trans-diaphyseal amputations among children. Therefore, it is a reasonable option during primary below-knee amputations in children compared to multiple refashioning surgeries.

An Outcome Analysis of Pediatric Diaphyseal Fractures Treated Surgically With the Titanium Elastic Nailing System.

Introduction Pediatric fractures account for one-fourth of all pediatric injuries. Stabilizing the fracture, regulating the length and alignment, encouraging bone healing, and minimizing morbidity and problems for the child and family are the objectives of treatment for diaphyseal fractures of long bones in children. Our goal is to investigate how pediatric diaphyseal long bone fractures are treated with a titanium elastic nailing system (TENS). Methods A prospective interventional study was conducted on 24 children who had displaced diaphyseal fractures of major long bones, involving 31 diaphyseal fractures of long bones. Utilizing Flynn's grading standards, the result was examined. Results The mean age was 12.20 years. The youngest child was seven years old and the eldest child was 16 years old. There were 20 boys (83.33%) and four girls (16.67%). The male-to-female ratio was noted to be 5:1. The commonest mode of injury was road traffic accidents (12 cases, 50%), followed by falls while playing (10 cases, 41.67%). Other causes included falls from height (one case, 4.17%) and blunt trauma (one case, 4.17%). The commonest bone to get fractured was the femur (37.50%), followed by both bones of the forearm (29.17%), tibia (20.83%), humerus (8.33%), and ulna alone (4.17%). The middle third (21 fractures, 67.74%) was the most prevalent location for fractures. Five fractures each (16.13%) accounted for in the proximal and distal thirds. Twelve fractures (38.71%) were detected on the left side, while the majority of fractures (19 fractures, 61.29%) were seen on the right side. Most of the fractures in this group were transverse fractures (18 fractures, 58.06%) followed by oblique fractures (eight fractures, 25.81%). Comminuted fractures accounted for five fractures (16.13%). Of the 31 fractures, open reduction had to be done in two fractures, after unsuccessful attempts at closed reduction. Closed reduction was done in 29 fractures. There were 15.12 weeks in the average union term. The range is six weeks to 39 weeks. The most frequent side effect was discovered to be skin irritation at the entry site. The extraosseous portion of nails caused irritation at two entry sites (6.45%). A case had delayed union (3.23%) and restricted knee range of movements. Conclusion For the treatment of juvenile diaphyseal fractures of the long bones, the TENS is the best option. It is a quick, straightforward, safe, dependable, and efficient way to treat pediatric long-bone fractures in patients aged five to 16 years. The healing process takes a fair amount of time, while the surgery takes less time. It does away with the necessity for extended bed rest and significantly shortens hospital stays. It provides stability and elastic mobility, which is perfect for early mobilization and quick union at the fracture site. It has a low rate of complications and produces excellent functional results.

Treatment of unstable forearm fractures at the metaphyseal-diaphyseal junction in children: antegrade ESIN vs. transepiphyseal intramedullary K-wire fixation.

BACKGROUND: Treatment of unstable forearm fractures in the metaphyseal-diaphyseal junction (MDJ) zone is still a matter of debate. Major drawbacks of all types of fixations include either invasiveness, technical impracticality, or lack of acceptance by patients. This study reports results after antegrade ESIN (a-ESIN) compared to transepiphyseal intramedullary K-wire (TIK) for unstable MDJ forearm fractures. METHODS: The MDJ of the forearm was defined as the square over the joints of both forearm bones subtracted with the square over the metaphysis of the radius alone. The data of 40 consecutive patients < 16 years of age who were treated either by a-ESIN (later treatment period) or TIK (early treatment period) for an unstable MDJ forearm fracture at a single high-volume pediatric trauma center were retrospectively analyzed. RESULTS: The average age was slightly lower in the first group (TIK = 7.42 years; a-ESIN = 10.5 years). An additional ulna fracture was found in 50% of cases and was treated with a classic antegrade ESIN in 10/20 (TIK) and 6/20 cases (a-ESIN). Additional plaster cast immobilization was performed in all cases with TIK and in three cases with a-ESIN. After TIK, no complication, malalignment, or functional limitation occurred. After a-ESIN, 19/20 patients had an event-free course with stable retention and healing without axial malalignment. In one case, a temporary sensor dysfunction occurred. The same patient suffered a refracture two months after the original trauma, which required a closed reduction. Metal removal was performed after 84 days (TIK) and 150 days (a-ESIN). The outcome in all patients was good. CONCLUSION: Both a-ESIN and TIK are minimally invasive procedures that are technically easy to perform. Both methods are safe and lead to a complete restoration of the forearm's range of motion. The decisive advantage of a-ESIN is the possibility of postoperative immobilization-free rehabilitation.

Elastic Stable Intramedullary Nailing Versus Plate Internal Fixation for Pediatric Diaphyseal Femur Fractures: A Systematic Review and Meta-analysis.

Background: Elastic stable intramedullary nailing (ESIN) and plates are currently the main internal fixation for treating Pediatric Diaphyseal Femur Fractures (PDFF), and the optimal choice of internal fixation is controversial. The purpose of this meta-analysis is to compare the surgical outcomes and complications of the two fixation methods. Materials and Methods: MEDLINE, Embase, and the Cochrane Library were systematically searched for studies published up to March, 2023, that compared ESIN and plate fixation techniques for treating PDFF. Pooled analysis identified differences in surgical outcomes between ESIN and plate, mainly regarding surgical outcomes and postoperative complications, such as time at surgery, fracture healing time, blood loss and related complications. Results: We included 10 studies with 775 patients with PDFF in our review. Of these, 428 and 347 were treated with ESIN and Plate, respectively. In terms of postoperative complications, ESIN led to a shorter surgery time [MD = - 28.93, 95% CI (- 52.88 to - 4.98), P < 0.05], less blood loss [MD = - 66.94, 95% CI (- 87.79 to - 46.10), P < 0.001] and more fracture healing time [MD = 2.65, 95% CI (1.22-4.07), P < 0.001]. In terms of postoperative complications, ESIN led to fewer fections (RR = 0.77, 95% CI 0.37, 1.60, P = 0.48), fewer angulation deformities (RR = 0.80, 95% CI 0.35, 1.83, P = 0.60) and more prominent implants (RR = 3.36, 95% CI 1.88, 6.01, P < 0.001), more delayed unions (RR = 4.06, 95% CI 0.71, 23.06, P = 0.11). Conclusions: ESIN and Plate have similar rates of complications besides a prominent implant rate, while ESIN has a shorter period of operation and less intraoperative bleeding. Although both options are suitable, the results of this study support the use of ESIN rather than plates in the treatment of PDFF in terms of complication rates. In clinical applications, surgeons should choose the appropriate treatment method according to the actual situation.

[Research progress in the treatment of distal humeral metaphyseal-diaphyseal junction fracture in children].

Objective: To summarize the research progress in the treatment of distal humeral metaphyseal-diaphyseal junction (DHMDJ) fractures in children and to provide reference for clinical practice. Methods: The characteristics and treatment methods of transverse and comminuted DHMDJ fractures in children were summarized and analyzed by referring to relevant literature at home and abroad. Results: DHMDJ fractures in children are not uncommon clinically, with high fracture line position, multi-directional instability, difficult closed reduction in treatment, and easy to cause complications such as coronal and sagittal deformity of the elbow. The Kirschner wire technique was effective for DHMDJ fractures with the fracture line at the middle and low levels, but was prone to iatrogenic ulnar nerve injury. Elastic stable intramedullary nail is suitable for higher-position transverse DHMDJ fractures. However, this technique requires a second operation to remove the internal fixator, and may cause iatrogenic epiphysis plate injury in children. External fixator is a new way to treat DHMDJ fractures, and it can show satisfactory results for transverse and comminuted DHMDJ fractures. However, at present, there are few relevant studies, and most of them focus on biomechanical studies, and the efficacy lacks high-quality clinical research support. Conclusion: The ultimate goal of DHMDJ fracture treatment in children is to restore the anatomical alignment of the fracture and prevent the loss of reduction. The choice of internal fixator depends on the location of the fracture line and the shape of the fracture to provide personalized treatment.

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends.

BACKGROUND: Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020. METHODS: This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period. RESULTS: The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033). CONCLUSION: The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

A Comparison of Anteromedial Plating Versus Anterolateral Plating for Humerus Shaft Fractures Using the Anterolateral Approach.

Background Plate osteosynthesis is the gold standard treatment for the management of humeral shaft fractures. In the present study, we performed plate osteosynthesis on the anteromedial and anterolateral surfaces using the anterolateral approach to compare the functional outcomes. Aims and objectives To study and compare the functional outcome, time to achieve union and associated complications of anteromedial and anterolateral plating in humerus shaft fracture by anterolateral approach. Methods This prospective, randomised control study was performed at Dr Baba Saheb Ambedkar Medical College and Hospital, New Delhi, India. This study had 46 patients in total, who were divided into two equal groups at random. All of the fractures in group A were treated using a limited contact dynamic compression plate (LCDCP) on the anterolateral surface using an anterolateral approach, while all of the fractures in group B were corrected using an anteromedial surface using an anterolateral approach using LCDCP. All the patients were followed for six months at regular intervals. At each follow-up, patients were assessed radiologically with X-rays and clinically by Rodriguez-Merchan criteria (RM criteria). Results and conclusions The union was achieved in the majority of the cases of the anteromedial plating group within 12 weeks (78.3%) with a mean union time of 11.7±1.5 weeks than the anterolateral group (56.5%) with a mean union time of 12.3±1.8 weeks. Based on functional assessment according to RM criteria, the excellent outcome was achieved in 69.6% and 65.2% of the anterolateral and anteromedial plating groups, respectively. There was no case of non-union and radial nerve palsy in anteromedial plating cases whereas in anterolateral cases one patient did not achieve union and two (8.7%) had radial nerve injury, which recovered completely by the end of the study. An anterolateral approach with anteromedial surface plating on the flat medial aspect of the humerus is a good technique for fixing humeral fractures.

A secondary atypical diaphyseal femoral fracture after intramedullary nailing for an atypical subtrochanteric femoral fracture: A case report.

Intramedullary nailing is the gold standard of treatment for atypical femoral fractures, with a few reports of secondary atypical subtrochanteric femoral fractures following intramedullary nailing for atypical diaphyseal femoral fractures. However, there are no reports of secondary atypical diaphyseal femoral fractures following intramedullary nailing for atypical subtrochanteric femoral fractures. A 71-year-old woman with adult-onset Still's disease sustained a right atypical subtrochanteric femoral fracture and was treated with a mid-length intramedullary nail. One year after the surgery, the patient sustained a contralateral atypical diaphyseal femoral fracture and was treated with a long-length intramedullary nail. Moreover, 6 months after the second surgery, the patient complained of right-thigh pain, and a radiograph of the lateral view of the femur revealed a diaphyseal femoral fracture at the distal screw-insertion site. Revision surgery was performed using a long-length nail and screws directed toward the femoral head. Bony union of the bilateral diaphyseal femoral lesion was obtained, but the subtrochanteric lesion remained unhealed 1.5 years postoperatively. Mid-length intramedullary nailing for atypical subtrochanteric femoral fractures can cause secondary atypical diaphyseal fractures because of stress concentration at the distal screw-insertion site. For atypical subtrochanteric femoral fractures, the use of long-length nails and proximal screws directed toward the femoral head may be important to prevent secondary atypical diaphyseal femoral fractures.

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique.

BACKGROUND: Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation. PATIENTS AND METHODS: A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up. RESULT: There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients. CONCLUSION: In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.