Unterarmpseudarthrosen im Kindes- und Jugendalter

 

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Zusammenfassung

Ziel: Durch die Änderung der Therapie der Unterarmschaftfrakturen von einer eher konservativen zur einer zunehmenden operativen Stabilisierung, insbesondere durch die elastische stabile intramedulläre Nagelung (ESIN), treten nun Komplikationen auf, die bisher als solche im Kindesalter kaum beschrieben sind. Über Pseudarthrosen nach operativ versorgten Unterarmschaftfrakturen des Kindes und der Jugendlichen wird nur vereinzelt, im deutschsprachigen Raum noch gar nicht berichtet. Das Ziel dieser Studie ist es, prädisponierende Faktoren herauszuarbeiten, die nach Operation von Unterarmschaftfrakturen Pseudarthrosen begünstigen. Methode: Im Zeitraum von 1990 bis 2011 wurden alle Kinder mit einer Pseudarthrose nach Unterarmschaftfraktur, die in unserer Klinik behandelt wurden, eingeschlossen. Berücksichtigt wurden alle Kinder, bei denen 6 Monate nach einer Unterarmfraktur noch keine knöcherne Konsolidierung ihrer Unterarmschaftfraktur erfolgt war. Ausgeschlossen wurden alle Pseudarthrosen, die eine Grunderkrankung als Ursache hatten. Ergebnisse: Während eines Zeitraums von 21 Jahren wurden 14 Kinder behandelt, welche die Kriterien einer Pseudarthrose erfüllten. Von den 14 Kindern waren 9 Kinder auswärtig primär behandelt worden und 5 Kinder primär in unserer Klinik. Der Altersdurchschnitt lag bei 10,8 Jahren (7–15 Jahre). Es handelte sich um 13 Ulnaschaft- und um 1 Radiusschaft-Pseudarthrose. Bei 11 Kindern trat die Pseudarthrose im mittleren Drittel auf und bei je 1 Kind im proximalen bzw. distalen Ulnadrittel. 13-mal handelte es sich um Unterarmschaftfrakturen und in 1 Fall um eine Monteggia-Läsion. In 12 Fällen waren die Frakturen geschlossen und in 2 Fällen erstgradig offen. In 9 Fällen war eine offene Ulnareposition durchgeführt worden, der Radius war in 4 Fällen offen reponiert worden. Bei 5 Kindern trugen technische Fehler bei der osteosynthetischen Versorgung wesentlich zur Pseudarthrosebildung bei. Fünf der 14 Kinder hatten eine Refraktur. Bei 9 Kindern musste ein Revisionseingriff erfolgen. Diese Kinder wurden mit einer Plattenosteosynthese oder ESIN versorgt. Bei 5 Patienten kam es zu einer spontanen Pseudarthroseheilung. In 13 Fällen handelte es sich um hypertrophe und in 1 Fall um eine hypotrophe Pseudarthrose. Schlussfolgerung: Pseudarthrosen am Unterarm nach operativer Versorgung von Unterarmschaftfrakturen treten sowohl bei Kindern als auch bei Jugendlichen im Wesentlichem im mittleren Drittel der Ulna auf. Wird eine offene Reposition notwendig oder handelt es sich um offene Frakturen, so steigt das Risiko einer Pseudarthrose. Auch bei Kindern kann es bei nicht adäquater osteosynthetischer Versorgung zu Problemen bei der Knochenbruchheilung kommen. Trotz des Auftretens von Pseudarthrosen ist die Indikation zur ESIN unzweifelhaft. Das operative Trauma muss bei der offenen Reposition minimal gehalten werden und die Durchblutung des Knochens auch beim Kind respektiert werden.

Abstract

Aim: Due to the changing attitude of treating paediatric forearm fractures increasingly towards the surgical stabilisation rather than conservatively by the method of elastic stable intramedullary nailing (ESIN), we are confronted with complications which have not been described in childhood previously. Pseudarthrosis following surgically treated forearm fractures in children is only found in single reports with none in the German-speaking area. The goal of this study is to define predisposing factors which may lead to pseudarthrosis after surgery for forearm fractures. Method: From 1990 to 2011 all children having sustained a pseudarthrosis following forearm fractures treated in our institution were included. All children who did not demonstrate a complete consolidation of the forearm fractures after 6 months from injury were considered for the study. Those pseudarthroses which were caused through systemic diseases were excluded. Results: During the time period of 21 years, fourteen children were treated who fulfilled the criteria of having a pseudarthrosis. Nine of the fourteen children had primarily been treated in an outside hospital, five in our institution. The average age was 10.8 years (7–15 years). There were thirteen ulnar shaft and one radius shaft pseudarthroses. In 11 children the pseudarthrosis was located in the middle third and there was one child each with a pseudarthrosis in the proximal and distal third of the ulna. There were 13 ulnar shaft fractures and one monteggia lesion. Twelve of the fractures were primarily closed and there were two open cases. In nine cases an open reduction of the ulna was necessary, the radius was openly reduced in four patients. In five children technical mistakes of the osteosynthesis were identified to contribute to the formation of the pseudarthrosis. Five of the 14 children had experienced a re-fracture. Nine children had revision surgery. These children were treated by plate osteosynthesis or ESIN. In five patients the pseudarthrosis healed spontaneously without interference. There were 13 hypertrophic and one hypotrophic pseudarthroses. Conclusion: Pseudarthrosis of the forearm following surgical treatment of forearm fractures in children and adolescents mainly occurred in the middle third of the ulna. In primarily open fractures or in cases which needed to be openly reduced the risk of pseudarthrosis formation was higher. Inadequate osteosynthetic stabilisation is another factor to contribute to difficulties in fracture healing. Despite of the possibility of pseudarthrosis, the indication to ESIN treatment in paediatric forearm fractures is not doubted. It is important to keep the surgical trauma as small as possible if open reduction is required in order to not disturb the perfusion of the bone.

• Literatur

• 1 Schmittenbecher PP. State-of-the-art treatment of forearm shaft fractures. Injury 2005; 36 (Suppl. 01) A25-A34
  CrossrefPubMedGoogle Scholar
• 2 Adamczyk MJ, Riley PM. Delayed union and nonunion following closed treatment of diaphyseal pediatric forearm fractures. J Pediatr Orthop 2005; 25: 51-55
  PubMedGoogle Scholar
• 3 Ballal MS, Garg NK, Bruce C et al. Nonunion of the ulna after elastic stable intramedullary nailing for unstable forearm fractures: a case series. J Pediatr Orthop B 2009; 18: 261-264
  CrossrefPubMedGoogle Scholar
• 4 Ogonda L, Wong-Chung J, Wray R et al. Delayed union and non-union of the ulna following intramedullary nailing in children. J Pediatr Orthop B 2004; 13: 330-330
  CrossrefPubMedGoogle Scholar
• 5 Schmittenbecher PP, Fitze G, Gödecke J et al. Delayed healing of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop 2008; 28: 303-306
  CrossrefPubMedGoogle Scholar
• 6 Cullen MC, Dennis RR, Giza E et al. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop 1998; 18: 14-21
  CrossrefPubMedGoogle Scholar
• 7 Abd Rashid AH, Ibrahim S. Hypertrophic nonunion of the ulna in a child: treatment with an elastic stable intramedullary nail without bone graft. Strategies Trauma Limb Reconstr 2010; 5: 145-147
  CrossrefPubMedGoogle Scholar
• 8 Weber BG, Čech O. Pseudarthrosis: Pathophysiology, Biomechanics, Therapy, Results. Bern: Hans Huber; 1976
  Google Scholar
• 9 Helenius I, Lamberg TS, Kääriäinen S et al. Operative treatment of fractures in children is increasing. A population-based study from Finland. J Bone Joint Surg Am 2009; 91: 2612-2616
  CrossrefPubMedGoogle Scholar
• 10 Parsch KD. Die Morote-Drahtung bei proximalen und mittleren Unterarmschaftfrakturen des Kindes. Operat Orthop Traumatol 1990; 2: 245-255
  CrossrefPubMedGoogle Scholar
• 11 Perez Sicilia JE, Morote JL, Corbacho G et al. Osteosinthesis pecutanea en fracturas diafisarias de antebrazo en ninos y adolescentes. Rev Esp Cir Osteoartic 1977; 12: 321-334
  PubMedGoogle Scholar
• 12 Metaizeau JP. Lʼosteosynthèse de lʼenfant: techniques et indications. Rev Chir Orthop 1983; 69: 495-511
  PubMedGoogle Scholar
• 13 Lascombes P, Prevot J, Ligier N et al. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop 1990; 10: 167-171
  CrossrefPubMedGoogle Scholar
• 14 Dietz JF, Bae DS, Reiff E. Single bone intramedullary fixation of the ulna in pediatric both bone forearm fractures: analysis of short-term clinical and radiographic results. J Pediatr Orthop 2010; 30: 420-424
  CrossrefPubMedGoogle Scholar
• 15 Houshian S, Bajaj SK. Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases. Injury 2005; 12: 1421-1426
  PubMedGoogle Scholar
• 16 Reinhardt KR, Feldmann DS, Green DW et al. Camparison of intramedullary nailing to plating for both-bone forerarm fractures in older children. J Pediatr Orthop 2008; 28: 403-409
  CrossrefPubMedGoogle Scholar
• 17 Mehlmann CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kasser JR, eds. Rockwood and Wilkinsʼ Fractures in Children. 6th ed. Philadelphia: Lippincott, Williams & Wilkins; 2006: 399-441
  Google Scholar
• 18 Fernandez FF, Egenolf M, Carsten C et al. Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing. Injury 2005; 36: 1210-1216
  CrossrefPubMedGoogle Scholar
• 19 Wyrsch B, Menacio GA, Green NE. Open reduction and internal fixation of pediatric forearm fractures. J Pediatr Orthop 1996; 16: 644-650
  CrossrefPubMedGoogle Scholar
• 20 Jubel A, Andermahr J, Isenberg J et al. Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children. J Pediatr Orthop 2005; 14: 375-380
  CrossrefPubMedGoogle Scholar
• 21 Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop 1998; 18: 451-456
  CrossrefPubMedGoogle Scholar
• 22 Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop 2006; 26: 827-834
  CrossrefPubMedGoogle Scholar
• 23 Berger P, De Graaf JS, Leemans R. The use of elastic intramedullary nailing in the stabilisation of paediatric fractures. Injury 2005; 36: 1217-1220
  CrossrefPubMedGoogle Scholar
• 24 Celebi L, Muratli HH, Doğan O et al. [The results of intramedullary nailing in children who developed redisplacement during cast treatment of both-bone forearm fractures]. Acta Orthop Traumatol Turc 2007; 41: 175-182
  PubMedGoogle Scholar
• 25 Garg NK, Ballal MS, Malek IA et al. Use of elastic stable intramedullary nailing for treating unstable forearm fractures in children. J Trauma 2008; 65: 109-115
  CrossrefPubMedGoogle Scholar
• 26 Lobo-Escolar A, Roche A, Bregante J et al. A delayed union in pediatric forearm fractures. J Pediatr Orthop 2012; 32: 54-57
  CrossrefPubMedGoogle Scholar
• 27 Lieber J, Joeris A, Knorr P et al. ESIN in forearm fractures. Eur J Trauma 2005; 31: 3-11
  CrossrefPubMedGoogle Scholar
• 28 Mann D, Schnabel M, Baacke M et al. Ergebnisse der elastischen stabilen intramedullären Nagelung (ESIN) bei Unterarmschaftfrakturen im Kindesalter. Unfallchirurg 2003; 106: 102-109
  CrossrefPubMedGoogle Scholar
• 29 Van der Reis WL, Otsuka NY, Moroz P et al. Intramedullary nailing versus plate fixation for unstable forearm fractures in children versus. J Pediatr Orthop 1998; 18: 9-13
  CrossrefPubMedGoogle Scholar
• 30 Song KS, Kim HK. Nonunion as a complication of an open reduction of a distal radial fracture in a healthy child: a case report. J Orthop Trauma 2003; 17: 231-233
  CrossrefPubMedGoogle Scholar
• 31 Wright TW, Glowczewskie F. Vascular anatomy of the ulna. J Hand Surg (Am) 1998; 23: 800-804
  PubMedGoogle Scholar
• 32 Greenbaum B, Zionts LE, Ebramzadeh E. Open fractures of the forearm in children. J Orthop Trauma 2001; 15: 111-118
  CrossrefPubMedGoogle Scholar