University of Oulu

Pediatric forearm fractures with special reference to operatively treated shaft fractures and ulnar styloid process nonunion

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Author: Korhonen, Linda1,2,3
Organizations: 1University of Oulu Graduate School
2University of Oulu, Faculty of Medicine, Medicine, Medical Research Center (MRC)
3Oulu University Hospital
Format: ebook
Version: published version
Access: open
Online Access: PDF Full Text (PDF, 4.5 MB)
Persistent link: http://urn.fi/urn:isbn:9789526226019
Language: English
Published: Oulu : University of Oulu, 2020
Publish Date: 2020-05-07
Thesis type: Doctoral Dissertation
Defence Note: Academic dissertation to be presented with the assent of the Doctoral Training Committee of Health and Biosciences of the University of Oulu for public defence in Auditorium 12 on 20 May 2020, at 12 noon
Tutor: Docent Juha-Jaakko Sinikumpu
Professor Willy Serlo
Reviewer: Docent Kari Vanamo
Professor Timo Raatikainen
Opponent: Professor Ilkka Helenius
Description:

Abstract

During childhood, the forearm is the most typical area to succumb to fractures. Of these fractures, shaft fractures and ulnar styloid process (USP) fractures are overwhelmingly associated with impaired union. Elastic stable intramedullary nailing (ESIN) is the preferred surgical treatment method for shaft fractures; yet, the method has its limitations. ESIN is not always performed according to recommendations, resulting in inferior outcomes. Furthermore, there are limitations in traditional methods to measure the function during follow-up, clinically. The rate and risk factors of USP nonunion are mostly unknown.

This study aimed to compare the new surgical method, biodegradable intramedullary nailing (BIN), with ESIN. Another aim was to critically analyze the tension metal frame construct of two pre-bended, opposing nails in ESIN. The congruence between the new computer-assisted measuring method and handheld goniometer/dynamometer was aimed to be researched, as well as the rate and long-term morbidity of USP nonunion.

Biodegradable nails were produced of poly(L-lactide-co-glycolide) (PLGA) for the purposes of the study. A randomized trial was performed using either BIN or ESIN, and outcomes were evaluated at the two-year mark. The technical deviations of ESIN, as compared with the current recommendations, were studied in a retrospective cohort. E-link was analyzed through comparative study. The rate of USP nonunion in the patients with a previous distal forearm fracture was analyzed with a mean of 11 years of follow-up.

The two-year clinical outcomes of forearm shaft fractures were good regardless of the BIN or ESIN treatment option. Two unexpected refractures occurred in adolescents treated with BIN. The recommended tension metal frame in ESIN was not achieved in 79% of the cases. Thicker nails and open reduction were associated with impaired bone healing. The computer-assisted measuring method was feasible in practice but not congruent with the traditional measuring methods. The nonunion rate of USP fractures was high (16%), but long-term morbidity was low. Half of the nonunion cases had not been diagnosed for USP fractures at the time of injury.

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Tiivistelmä

Lapsilla luun murtumat ovat kaikkein yleisimpiä kyynärvarren alueella. Kyynärvarren murtumista putkiluun keskiosan kahden luun murtumat sekä kyynärluun distaalisen puikkolisäkkeen murtumat ovat alttiita komplikaatioille.

Tutkimuksen tavoitteena oli selvittää kyynärvarren keskiosan murtumien hoitoa uudella ydinnaulaustekniikalla käyttäen sulavia ydinnauloja (biodegradable intramedullary nailing, BIN). Lisäksi tavoitteena oli tutkia joustavan ydinnaulauksen (elastic stable intramedullary nailing, ESIN) teknistä onnistumista. Tavoitteena oli tutkia yläraajamurtuman kliinisten myöhäistuloksien mittaamista tietokoneavusteisella menetelmällä sekä selvittää kyynärluun puikkolisäkkeen (ulnar styloid process, USP) luutumattomuutta.

Sulavien ydinnaulojen kahden vuoden tuloksia verrattiin titaanisilla joustavilla ydinnauloilla hoidettuihin potilaisiin satunnaistetussa, etenevässä hoitokokeessa. ESIN:n muodostaman jännitteisen, metallisen kaksoiskaaren saavuttamista analysoitiin taannehtivasti sairaalan potilasaineistossa. Tietokoneavusteista mittausmenetelmää tutkittiin vertailevassa työssä ja USP:n luutumattomuudesta seuraavia pitkäaikaistuloksia arvioitiin pitkäaikaisessa (keskimäärin 11 v.) seurantatutkimuksessa.

Sulavilla ydinnauloilla hoidettujen potilaiden 2-vuoden liikeala ja puristusvoimat olivat yhtä hyvät kuin titaanisilla nauloilla hoidetuilla. Titaaniset esitaivutetut ydinnaulat oli useimmilla (79 %) potilailla aseteltu vastoin suositusta niin, että ydinnaulat eivät muodostaneet jännitteistä kaksoiskaarikehikkoa. Tietokoneavusteisen mittauksen etuna oli vaivattomuus, mutta mittaustulokset eivät olleet yhtenevät perinteisen kulma- ja puristusvoimamittauksen kanssa. Puikkolisäkkeen luutumattomuus oli yleistä (16 %) rannemurtuman jälkeen, mutta oireita oli harvalla. Puolet puikkolisäkkeen murtumista oli jäänyt alun perin havaitsematta.

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Osajulkaisut / Original papers

Osajulkaisut eivät sisälly väitöskirjan elektroniseen versioon / Original papers are not included in the electronic version of the dissertation.

  1. Korhonen, L., Perhomaa, M., Kyrö, A., Pokka, T., Serlo, W., Merikanto, J., & Sinikumpu, J.-J. (2018). Intramedullary nailing of forearm shaft fractures by biodegradable compared with titanium nails: Results of a prospective randomized trial in children with at least two years of follow-up. Biomaterials, 185, 383–392. https://doi.org/10.1016/j.biomaterials.2018.09.011

    Rinnakkaistallennettu versio / Self-archived version

  2. Linda, K., Nicolas, L., & Juha-Jaakko, S. (2020). The Association of Metal Frame Construct of ESIN and radiographic bone healing of pediatric forearm fractures. Injury, 51(4), 856–862. https://doi.org/10.1016/j.injury.2020.03.028

  3. Korhonen, L., Pokka, T., Holappa, A., Serlo, W., & Sinikumpu, J.-J. (2019). The Measurement Methods of Movement and Grip Strength in Children with a Previous Upper Extremity Fracture: A Comparative, Prospective Research. Scandinavian Journal of Surgery, 145749691985726. https://doi.org/10.1177/1457496919857261

  4. Korhonen, L., Victorzon, S., Serlo, W., & Sinikumpu, J.-J. (2019). Non-union of the ulnar styloid process in children is common but long-term morbidity is rare: a population-based study with mean 11 years (9–15) follow-up. Acta Orthopaedica, 90(4), 383–388. https://doi.org/10.1080/17453674.2019.1596561

    Rinnakkaistallennettu versio / Self-archived version

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Series: Acta Universitatis Ouluensis. D, Medica
ISSN: 0355-3221
ISSN-E: 1796-2234
ISSN-L: 0355-3221
ISBN: 978-952-62-2601-9
ISBN Print: 978-952-62-2600-2
Issue: 1570
Type of Publication: G5 Doctoral dissertation (articles)
Field of Science: 3126 Surgery, anesthesiology, intensive care, radiology
3123 Gynaecology and paediatrics
Subjects:
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