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 Table of Contents  
Year : 2023  |  Volume : 6  |  Issue : 1  |  Page : 20-26

Management of pediatric unstable diaphyseal both-bone forearm fractures (AO 22-D4 and AO 22-D5), A comparison between the results of intramedullary nailing using titanium elastic nail systems versus K-wires in the rural Indian children: A prospective study

1 Department of Orthopaedics, ESIC Hospital, Jajmau, Kanpur, Uttar Pradesh, India
2 Department of Orthopaedics, U.P.U.M.S., Saifai, Etawah, Uttar Pradesh, India
3 Department of Orthopaedics, RML IMS, Lucknow, Uttar Pradesh, India
4 Department of Orthopaedics, BRD Medical College, Gorakhpur, Uttar Pradesh, India
5 Department of Orthopaedics, AIIMS, Raebareli, Uttar Pradesh, India

Date of Submission24-Mar-2022
Date of Decision24-Sep-2022
Date of Acceptance03-Oct-2022
Date of Web Publication27-Dec-2022

Correspondence Address:
Santosh Kumar Singh
ESIC, Jajmau Kanpur, Uttar Pradesh
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jodp.jodp_33_22

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Background: Forearm fractures constitute the largest group of injuries in the pediatric age group. When treating these injuries, we seek to achieve a complete union while also restoring the appropriate axis and arm length, which determine the upper limb's normal function. Intramedullary fixation (IM fixation) is becoming an increasingly common choice for fracture fixation. Aim: The aim of this study was to compare the functional and radiological results of IM nailing by Titanium Elastic Nail Systems (TENS) versus K-wire in the pediatric displaced diaphyseal both-bone forearm fracture. Settings and Design: This prospective comparative study was conducted in the department of orthopedics at a rural tertiary care center in North India from April 2016 to November 2019. Materials and Methods: In total, 44 children between the age of 8 and 12 years with displaced diaphyseal fracture of both-bone forearm either closed or open were available for follow-up and included in the study. They were divided into two groups randomly. Reduction was done under general anesthesia and fluoroscopic images. First, a close reduction was tried, and if it failed, open reduction was tried. IM fixation was done subsequently either by TENS (Group-A, n = 23) or K-wire (Group-B, n = 21). Patients were followed up for 12 months. Functional and radiological outcomes and complications were compared between both groups. Conclusions: IM nailing is a safe, effective, and valid technique in treating displaced both-bone forearm fractures in the pediatric age group. Both TENS and K-wire are equivalent in terms of clinical results, fracture union time, surgical time, or complication rates.

Keywords: Both-bone forearm fractures, intramedullary nailing, pediatric

How to cite this article:
Singh SK, Singh PP, Arora J, Gill S P, Mishra L, Singh P. Management of pediatric unstable diaphyseal both-bone forearm fractures (AO 22-D4 and AO 22-D5), A comparison between the results of intramedullary nailing using titanium elastic nail systems versus K-wires in the rural Indian children: A prospective study. J Orthop Dis Traumatol 2023;6:20-6

How to cite this URL:
Singh SK, Singh PP, Arora J, Gill S P, Mishra L, Singh P. Management of pediatric unstable diaphyseal both-bone forearm fractures (AO 22-D4 and AO 22-D5), A comparison between the results of intramedullary nailing using titanium elastic nail systems versus K-wires in the rural Indian children: A prospective study. J Orthop Dis Traumatol [serial online] 2023 [cited 2023 Jan 30];6:20-6. Available from: https://jodt.org/text.asp?2023/6/1/20/365276

  Introduction Top

The diaphyseal both-bone forearm fractures are considered one of the most common injuries in children, with a yearly incidence ranging from 0.45 to 0.7 per 1000.[1],[2],[3] The average age of forearm fractures is 8.4 years.[2],[3] Boys are affected more than girls, approximately in the ratio of 2:1.[2],[3] Their incidence is on the rise.[3],[4] Closed reduction and casting can be used to treat metaphyseal fractures, and some deformities can be accepted and allowed to heal, which is beneficial at this site.[4],[5] However, diaphyseal fractures may not remodel completely, particularly in children older than 12 years of age, leaving behind a residual deformity with functional impairment.[6],[7],[8] In fractures in which acceptable closed reduction is not possible, especially in children over 12 years of age, surgical management is recommended.[9],[10] Currently, there is an increasing trend toward nailing in irreducible and unstable forearm fractures.[11] This may be due to reasons such as good results that are equivalent to plating, a minimally invasive approach resulting in decreased surgical dissection and maintaining the biologics around the fracture, a less time-consuming procedure, advancements in imaging, easier metal work removal, and increasing expectations of society.[12],[13]

Plate and screw fixation, plate-screw and intramedullary fixation (IM fixation), and single-bone fixation are also preferred surgical methods for the management of forearm fractures in children.[13],[14],[15] Most of the IM implants are made of either stainless steel or titanium. Among stainless steel implants, K-wire has the advantage of more flexibility compared to square nails. This makes it possible to avoid the epiphysis and introduce it from the metaphysis, which is at an angle to the medullary canal. This averts the risk of potential growth disturbance. K-wire is much cheaper than other implants. Titanium Elastic Nail Systems (TENS) have also gained popularity due to their elasticity and better rotational stability.[11],[16] Many studies confirm the good results of TENS. In this study, we have tried to compare the functional and radiological results and complications of IM nailing of displaced diaphyseal fracture of both bones of the forearm in children by TENS versus K-wire.

  Materials and Methods Top

This prospective comparative study was conducted in the department of orthopedics at a tertiary care center in North India from April 2016 to November 2019. The Institutional Ethical Committee approved the study. The written informed consent was taken from all the parents.

Inclusion criteria

Children in the age group between 8 and 12 years with displaced fractures of both-bone forearms (22-D4 and 22-D5 AO Pediatric Comprehensive Classification of Long Bone Fractures), either closed or open (Gustilo–Anderson type 1), are admitted to our institute. Failure to achieve or maintain acceptable reduction following manipulation and cast immobilization under anesthesia was an indication of internal fixation in our institute.

Exclusion criteria

Patients who refused surgery, had a significant neurological or vascular injury in the affected limb, associated dislocation of the proximal or distal radioulnar joints, pre-existing forearm deformity, a duration since injury of more than 15 days, any significant systemic illness, or a medical contraindication for surgery were all excluded from the study.

Initial assessment

At the time of admission, clinical and radiological assessments by X-ray were done. A radiograph of the forearm, including the wrist and elbow, was taken in the anteroposterior (AP) and lateral planes. The injured extremity was examined for a fracture, skin condition, neurovascular deficit, and other injuries in the body. After gross reduction and wound management when needed, the affected limb was immobilized in the above elbow plaster of paris slab. The indoor patient department registration number for the patient was recorded. Those with an odd number were placed in the K-wire group, and those with an even number were placed in the TENS group. After a preoperative workup, they were posted for surgery.

Operative procedure

Surgery was performed under general anesthesia and fluoroscopic guidance. The first close reduction was attempted. The operating surgeon used Titanium Elastic Nail in the TENS group and K-wire in the K-wire group. The surgeon bent the terminal 3 mm–5 mm of the K-wire at an angle of 20°–30° to facilitate entry and reduction. A single nail or K-wire of 2 or 2.5 mm in diameter was used for each forearm bone, depending on the medullary isthmus. It was ensured that the diameter of the nail was at least two-thirds the width of the isthmus of the medullary canal. The remaining portion of the nail or K-wire was bent at a moderate 30° angle to match the usual radius contour. Due to the nearly straight bone, just a 10° prebending was done for the ulna nail or K-wire.

The ulna was fixed by antegrade nailing. The entry was made just distal to the olecranon physis, along the posterolateral border, piercing the peripheral anconeus muscle.[12] If the olecranon epiphysis was found closed or near closure, an olecranon entry was used. The fixation of the radius was done by retrograde nailing; the entry point was located just proximal to the distal physis, just medial to Lister's tubercle. The IM implants were held with a T-handle and carefully and rotationally inserted into the holes. Under fluoroscopic control, a closed reduction by manipulative traction was accomplished. If closed reduction was unsuccessful, a curved artery forceps was introduced through a minimal stab incision, and manipulation was done. If still unreduced, a limited open reduction was made with a 2-cm incision. The Thompson approach was for the radius, while the dorsoulnar approach was used for the ulnar fractures.

The nail was embedded in the opposite metaphysis without crossing the physis. The extra length was then cut and bent. The tail end was buried subcutaneously, and the incision site was closed with skin sutures. An above-elbow pop slab was applied, and strict limb elevation was advised to all patients. After two postoperative dressings on the 3rd and 5th days, patients were discharged with proper instructions.


At 2 weeks, the stitches were removed, and the arm was kept in a long arm slab for 2–6 weeks, depending on the particular surgeon's preference, fracture comminution, and the intraoperative fracture stability. After the removal of the pop slab, active ranges of motion exercises were started.

Follow-up visits were scheduled every week for the first 3 months, monthly for the 4th, 5th, and 6th months, and finally after 12 months. The following data were also collected: (1) Radiograph callus in 2/4 of the cortices, (2) Pronation-supination range of motion of the fractured side, (3) Skin irritation around the hardware entry site, (4) Infection, including osteomyelitis, (5) Implant migration, implant bending, pin-site infection, (6) Elbow stiffness and any other significant complaints. Functional outcome results were assessed at the end of postoperative 12 months using criteria developed by Price et al.[Table 1].[17] Conventional goniometer was used for the measurement of the rotational range of movement of the fractured limb.
Table 1: Price et al. criteria[17] for clinical results

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Removal of implants

After the union of the fracture, as confirmed clinically by the return of forearm rotation and radiological, the IM implants were removed under general anesthesia.


Statistical analyses were done using IBM SPSS Statistics for Windows, Version 23.0. (Armonk, New York: IBM Corp. Released 2015). For comparing the variables, Pearson's Chi-squared test and Fisher's exact test were used. P < 0.05 was considered statistically significant.

  Results Top

A total of 110 children were diagnosed with diaphyseal both-bone forearm fractures from April 2016 to November 2019. Children aged <8 years and more than 12 years, with significant neurovascular insult in the affected extremity, diaphyseal fracture with proximal or distal radioulnar joint dislocation, injury duration of more than 15 days, and patients managed conservatively and refusing surgery (n = 61), were excluded from the study. Forty-nine patients met the inclusion as well as the exclusion criteria and were found suitable for the study. The patients with even indoor registration number were allocated in Group A (the TENS group), and those patients with odd indoor registration number were placed in Group B (the K-wire group). Three patients from the TENS group and two patients from the K-wire group were lost to follow-up, and the remaining 23 were in the TENS group and 21 were in the K-wire group [Figure 1].
Figure 1: Methodology of the study

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The cohort consists of 29 males and 15 females. The right upper limb was involved in 30 (68.18%) and the left side was involved in 14 (31.81%) children. There were 11 children with open fractures in total. Thirty-one patients were classified as AO type 22D4 and 13 patients were of AO type 22D5. Sixteen (36.36%) patients had both-bone forearm fractures in the proximal 1/3rd area, 19 (3.18%) patients involved in the middle 1/3rd, and 9 (20.4%) had the distal 1/3rd diaphyseal fracture. All demographic data in both the groups were comparable [Table 2].
Table 2: Preoperative data

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The average duration from injury to surgery was 5 days (range 1–15 days) in the TENS group and 6.5 days (range 1–20 days) in the K-wire group. The average duration of surgery was 43.4 min in the TENS group and 45 min in the K-wire group. Closed reduction was achieved in the majority of patients, whereas open reduction was required in 12 patients. Five patients needed open reduction for the ulna alone, four patients needed open reduction for the radius alone, and three patients needed open reduction for both bones. The limb was immobilized for an average of 4.1 weeks in the TENS group and 4.2 weeks in the K-wire group postoperatively. We did not find any significant delay in fracture union following open reduction and fixation. All the perioperative data and both radiographic and functional results were comparable in both the groups [Table 3], [Figure 2] and [Figure 3]. The mean time for the radiological bony union was 7.70 ± 1.55 weeks in the TENS group and 7.90 ± 1.338 weeks in the K-wire group, but the difference was not significant (P = 0.650). According to Price et al. criteria[17], the excellent, good, fair, and poor results were obtained in 12 (52.2%), seven (30.4%), three (13.0%), and 1 (4.3%) patients in TENS group, and 10 (47.6%), nine (42.9%), two (9.5%), and zero patients in K-wire group with no statistically significant difference as per Chi-square test. Two children in both the groups developed pin-tract infections and three children (one from the TENS group and two from the K-wire group) developed skin irritation [Table 4]. These were treated well with oral antibiotics and wound dressing. Implant migration was observed in three cases (one from TENS group and two cases from the K-wire group). There was proximal ulnar migration in all three cases. At a reasonably early time following surgery, we removed all the implants (mean 16.3 weeks in the TENS group and 16.1 weeks in the K-wire group).
Table 3: Perioperative data and clinical results at 1-year follow-up

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Table 4: Postoperative complications

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Figure 2: (a) Preoperative x ray, (b) Postoperative x ray, (c-e) Postoperative range of motion

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Figure 3: (a) Preoperative x ray, (b) Postoperative x ray, (c-d) Postoperative range of motion

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  Discussion Top

The forearm functions like a joint and only minor deformity are tolerated. Remodeling becomes inefficient in correcting malunion, especially after 8 years of age.[5] The main outcome of our study was that IM fixation of forearm fractures in children with TENS or K-wire does not affect the radiological and clinical results. There was no significant difference in the union time of fractures, postoperative complications, range of motion of the elbow and wrist, or postoperative complications. IM fixation of forearm fractures in children has effective results and a lower complication rate than those documented in other research when all the patients are analyzed together.[8],[18],[19]

Remodeling is responsible for the correction of residual deformity after union. In younger children, especially up to 8 years of age, remodeling potential is quite good, whereas in children older than 11 years of age, there is not much remodeling. Between 8 and 11 years, there is some remodeling. Due to the early closure of the epiphysis in girls, there is much less remodeling at any given age.[5] The mean age of the patients was 9.5 years (range: 8–12 years). The mean age of the TENS group was 10.04 ± 1.35 weeks, whereas it was 9.86 ± 1.35 weeks in the K-wire group, but there was no significant difference as P = 0.661. Of these 44 children, 29 were male and 15 were female. Almost all studies show that this fracture is more common in boys (around 70%).[3],[5],[20] This is possibly due to more outdoor sports activities among boys. Thirty patients had right-sided fractures, while 14 had left-sided fractures. This may be due to the higher prevalence of right-handed dominance. Similar results were found by Antabak et al. and Acharya et al.[17],[18] The average time gap between trauma and surgery was 7 days (2–15 days). Most of the studies quote a shorter time gap of 3–4 days.[3],[20],[21] Our findings may be due to a lack of resources among the people of this rural area. Close reduction was successful in 32 patients, while 12 needed open reduction in one or both bones. For statistical purposes, minimal stab incision was considered an open reduction. Similar results were observed by Acharya et al. and Makki et al.[21],[22] Open reduction must follow some failed attempts at closed reduction. Persistent attempts at closed reduction and IM nailing have a higher chance of compartment syndrome; whereas open reduction with IM nailing has a lower chance of compartment syndrome.[19],[23] Compartment syndrome, on the other hand, is less common when closed reduction and casting are used.[19] In our study, we did not have any case of compartment syndrome due to IM nailing.

The patients were followed up for a mean duration of 12 months (range, 11–18 months). Radiological fracture union was defined as the presence of a bridging callus in three out of four cortices in plain AP and lateral radiographs. It was 7.70 ± 1.55 weeks in the TENS group and 7.90 ± 1.338 weeks in the K-wire group, with an overall range of 6–12 weeks in all children. Statistically, this difference is not significant (P > 0.05). All fractures are united. There is much variability in the average time for radiological union using elastic IM implants among different studies, where the mean range falls between 6 and 13 weeks.[8],[16],[17],[21],[22] This may be due to differences in the criteria of union, usage of splintage, intraobserver variability, and complication rates.

Due to the ability of children's bones to remodel, the anatomical reduction is not crucial.[17] However, diaphyseal remodeling is age dependent and has an unpredictable nature.[24],[25] Different in vitro studies have revealed that persistent mid-shaft forearm angulation of 20 degrees or more results in forearm rotation loss. When adequate fracture reduction cannot be maintained or attained, surgical intervention is recommended to avoid functional morbidity.[25],[26]

A prospective comparative study conducted by Sahin et al.,[27] including 43 patients managed either by elastic nails or K-wires, showed no difference in clinical and radiological results. Heare et al.[28] compared outcome results and costs between titanium elastic nails, stainless steel elastic nails, and K-wires in the management of pediatric diaphyseal forearm fractures with IM fixation. They also reported no significant difference in time to radiographic union and complication rate between all three types of fixation methods. In the present study, at 12 months follow-up showed no statistically significant results between TENS group and K-wire group.

A total of 21 patients had complications. Six patients had elbow stiffness (three in each group); skin irritation due to prominent ulnar hardware in one patient in the TENS group and two patients in the K-wire group; implant bending in both bones in one patient in the TENS group and two patients in the K-wire group; infection at the entry site in two patients in each of the groups, treated with dressing and oral antibiotics. There were two patients with delayed union, and they had open fractures (each in both the groups). The complication rates of our study are comparable with those of Antabak et al., Yuan et al., and Calder et al.[18],[23],[29] Sahin et al.[27] also reported one case who developed pin-tract infection due to the skin irritation in the TENS group.

Implant removal is still a matter of contention. Plate removal is usually more difficult than nail removal. The possibility of refracture must be considered when removing metals. In some studies, all the patients nails were routinely removed, while in others, none or only a few were removed.[8],[11],[22],[30] Refractures were also reported in both the elastic stable intramedullary nailing and plating groups.[30],[31] The time it took to remove the implants was similarly varied. Early implant removal may result in refractures, yet delayed implant removal may disclose surgical complications. We removed all implants postoperatively at a relatively early stage (mean 16.3 weeks in the TENS group and 16.1 weeks in the K-wire group), and only one patient experienced refracture after implant removal due to a slip on the ground while playing, which was managed by open reduction and internal fixation with plating and ultimately achieved a good range of movements.


Even though all the patients were blinded for the type of implant, the orthopedic surgeon was not blinded for the clinical follow-up, which could have impacted clinical assessments. We used IM fixation on patients aged 8–12 years in this study. However, there may be an age barrier at which plate and screw fixation become more effective, particularly in older teenagers. A future study may be able to determine this. Furthermore, our study sample size was small.

  Conclusions Top

Our study showed that both the TENS group and the K-wire group achieved an early union with equivalent functional and radiological results, with minimal complications and no clinically significant difference in either method. Although TENS has theoretical benefits, they did not appear to improve outcomes significantly in our study. Stainless steel K-wire is a low-cost IM fixing implant that offers excellent stability. IM nailing for the stabilization of pediatric diaphyseal forearm fractures: Both TENS and K-wire fixation methods are effective, maintaining the limb length and allowing rapid mobilization of the limb.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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  [Figure 1], [Figure 2], [Figure 3]

  [Table 1], [Table 2], [Table 3], [Table 4]


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