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Study: Avoid elastic IM nailing in pediatric radius fractures with small distal fragments

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BERLIN — A two-part clinical study yielded an algorithm that uses the length of the distal fragment in children’s radius fractures to determine whether it is safe to manage fractures with an elastic-stable intramedullary nail.

Dirk W. Sommerfeldt, MD, of Hamburg, presented the study at the 13th EFORT Congress 2012.

“The method is simple,” he said.  The team developed the algorithm from a retrospective analysis of 67 cases completed between 1998 and 2002, which included the learning curve with elastic-stable intramedullary (IM) nailing.

Review of radiographs

Sommerfeldt and colleagues reviewed radiographs to determine the patients’ total radial length (TRL) and then calculated the distal fragment length (DFL) compared to the TRL.

“The ratio of this cohort in terms of distal fragment length vs. total radial length was 0.54,” Sommerfeldt said.

However, for seven patients in the cohort (10.5%), surgeons had to change from the preplanned use of an IM nail and to another type of fixation, he noted. The researchers calculated the DFL in the patients with an altered surgical plan at 0.25 or one-fourth the TRL, “which means if the distal radial fragment is shorter than one-fourth of the total radial length, you should not consider IM nailing in the first place,” Sommerfeldt said.

Prospective study

The researchers tested their theory in a prospective study of 122 pediatric patients with distal radius fractures treated with IM nailing who were followed from 2003 to 2007.

“We did the same thing only with the difference that now we knew about the total length of the radius, and therefore we only had three patients where we had to change the implant intraoperatively in a much greater number of patients, and therefore the incidence of the complications were much less,” Sommerfeldt said.

Using the new algorithm, the DFL vs. TRL was 0.57. The investigators found 2.4% of the cohort developed complications.

Sommerfeldt encouraged orthopedists to continue to use their “gut” instincts, but to also apply the new algorithm.

“IM nails are the mainstay for all forearm fractures that you have to treat operatively because they are unstable, if they occur in the shaft, in the middle or proximal third. If you get to the lower third, therefore the most difficult third of the radius, you should consider other options. You can use this ratio if you are not sure what your “gut feeling” is and measure the DFL. If you get below 0.3, you should consider an alternate technique,” he said.

Reference:

• Sommerfeldt DW. Distal fragment length (DFL) to total radial length (TRL) ratio as a decision-making tool in the treatment radial of
• forearm fractures during childhood and adolescence. Paper #12-3518.  Presented at the 13th EFORT Congress 2012. May 23-25. Berlin.
• Disclosures: Sommerfeldt has no relevant financial disclosures.