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- DOI 10.18231/j.ijos.2023.007
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Entry point decision in intramedullary fixation of radial shaft fractures in paediatric population- Should we care?
Introduction
Conservative management with closed reduction and immobilisation in slab or cast often complicates in malunion, compartment syndrome and stiffness in cases of paediatric both bone forearm fractures or isolated radial or ulna shaft fractures with significant angulation or malrotation.[1] Such cases typically require elastic stable intramedullary nailing (ESIN). Unlike indubitable ulna entry points there is no consensus for radial approaches. Standard approaches include Lister’s tubercle entry or lateral entry.[2] Biomechanically acting as internal splints, ESIN gives axial, translational, flexural and rotational stability.[3] The aim of this study was to determine whether lister’s tubercle entry for radial shaft fractures is associated with more significant complications than lateral entry.
Methods
Skeletally immature patients with radius shaft fracture or both bone forearm fractures with significant malrotation/angulation treated with ESIN were included in this prospective comparative study of 1 year at the same institution. The choice of approach rested with surgeon. The CHOP parameters were used to assess functional results and document complications.
Results
Study included seventeen patients (Mean age: 8.3 years, range:< 12 years) with closed injuries and intact neurovascular status treated with ESIN. Lister’s tubercle entry was taken in 8 patients and 9 patients were subjected to lateral entry. Fracture union was seen in mean time:44.5 days. Of the lister’s tubercle entry cases, one developed loss of index finger extension ([Figure 1]) which gradually worsened 6 weeks postoperatively and the other depicted thumb extension weakness 8 weeks post surgery.Both were diagnosed with extensor indicis (EI) ([Figure 2]) and extensor pollicis longus (EPL) tear respectively and were treated with tendon repair subsequently. They could get back to normalcy only after 12-16 weeks of the second surgery. One in 9 cases of lateral entry group suggested numbness over dorsal of hand post-operatively which resolved eventually. Study by Brooker et al. and Murphy et al. also concluded that EPL (Extensor pollicis longus) injury being most common tendon injury after Lister’s tubercle entry.[4], [5] No non-union, superficial infections or reduced wrist movements were documented unlike that seen in study conducted by Ali et al. and Parajuli et al.[6], [7] ([Table 1])
|
|
Group I (n) |
Group II (n) |
|
EI/EDC rupture |
1 |
0 |
|
EPL rupture |
1 |
0 |
|
Numbness of dorsum of hand |
0 |
1 |
|
Decreased wrist motion |
0 |
0 |
|
Superficial infection |
0 |
0 |
|
Delayed union/nonunion |
0 |
0 |
|
Growth disturbance |
0 |
0 |
Conclusions
Attritional tendon tear post lister’s tubercle entry is alarming if cautious and accurate placement of cut nail-end outside the tendon compartment is not ensured. The subsequent management for complications renders patient incapable in reverting back to normal activities for a prolonged duration. Furthermore, lateral entry complication was devoid of functional or structural deformity.
Source of Funding
None.
Conflict of Interest
None.
References
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