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A prospective study of pediatric forearm bone fractures treated with closed intramedullary square nailing.

Rajeev Rao, Arakotaram.V.Yogishwar, R.Ramesh, Ashutosh Bhosale, Manish Chacko
Jubilee Mission Medical College, Thrissur

Address for Correspondence:
Rajeev Rao, Jubilee Mission Medical College, Thrissur, India.




Conservative treatment of forearm fractures is fraught with complications of cast, compartment syndrome, malunion and bayonet apposition. Prolonged hospitalization and high cost associated with plate fixation makes choice of treatment difficult. We prospectively evaluated outcome and cost effectiveness of closed nailing of forearm bone fractures in search of a better treatment.

Materials and Methods

26 children between age group of 5 to 15 yrs with forearm fractures were prospectively treated with closed intramedullary nailing with Talwalkar’s Square nails during June 2006 to June 2007. Diaphyseal fractures of both bones forearm were nailed with flexible square nails and were given splints for 4 weeks. Patients underwent implant removal once there was clinical and radiological union of fractures.


Of the 26 children with both bone fracture, 17 were operated within 24 hours from injury. Closed nailing was done in 18 children; mini open ulna was done in 1 child, mini open radius in 3 children and mini open of both radius and ulna in 4 children. The average operative time was 22.3 minutes. Average hospital stay was 4 days and average duration of immobilization being 4 to 6 weeks On analysis with Grace and Eversmann outcome scoring out of 26 patients 20 had excellent outcome (77%), 5 had good outcome (19.2%), 1 had acceptable outcome (3.8%) and there was no patient with unacceptable outcome. All fracture united by 6 to 8 weeks. There was no case with bayonet apposition, malunion, re fractures of bones. We had 7 complications in our study 2 olecranon bursitis, 2 superficial infection, 2 hypertrophied scars, and 1 ulna nail back out. We had no non-union, malunion or limb length discrepancies or compartment syndrome.


Intramedullary Square nail fixation is an easy and fast method for forearm fractures with minimal blood loss and minimal scar. It prevents malunion and bayonet opposition. Full range of movements was achieved without any significant complication

As cost of implant is very less and hospital stay is reduced to average of 4 days closed nailing for radius and ulna fracture is an effective way to reduce treatment cost and hospital occupancy burden.

J.Orthopaedics 2009;6(1)e12


Pediatric forearm bone fractures; intramedullary nailing; square nailing


Forearm bone fractures are common injuries in childhood. The children of this generation are more active and sport loving. The most common cause of forearm fractures is a fall in or around home and playground. Sports-related injuries are the second most common cause[i].

The fracture both bone forearm (radius and ulna) constitute 3.4% of all of pediatric fractures[ii]. The fracture of radius and ulna constitute 30% of all upper extremity fractures in children[iii].

There has been variety of treatment options for the management of both bone forearm fracture. The basic principle is to accurately align the fracture fragment and to maintain this position until the fracture is united. Forearm fractures in children can be treated differently from adult fractures because of continuing growth in both bones (radius and ulna) after the fracture has healed. As long as the physis is open, remodeling can occur.

Though the majority of pediatric both-bone fractures can be treated conservatively with closed reduction and cast, an estimated 10% are irreducible or unstable and require alternative fixation methods. An additional 7% of patients treated closed will displace in the initial cast, requiring further treatment[iv].  For displaced fracture forearm in children to achieve and maintain reduction in cast has been challenging for the surgeon as well as for their parents to get good functional outcome. Alternatives include pins and plaster, closed or mini-open reduction and intramedullary (IM) nailing, and open reduction and internal fixation (ORIF) with plates and screws.

In the present situation of nuclear families, prolonged hospitalization or cast immobilization of child at home causes social, psychological, and financial impacts on the child and his/her family. Hence the role of alternative procedures came into practice in the past few decades. They include ORIF with plates and screws, or IM nailing with Kirschner wires, Rush rods, or flexible nails like square nails and titanium (Nancy) nails with percutaneous fixation. Because of the risk of injury to the growing physis or their blood supply by intramedullary nailing, fixation techniques have been limited to plates and screws fixation. The complications associated with ORIF techniques, such as infections, overgrowth, and refracture has encouraged surgeons to develop flexible nails inserted in a percutaneous fashion for stable intramedullary fixation.

It is hence the need of the hour to evaluate the results of flexible nailing in pediatric forearm fractures and help the affected children in returning to active life by early mobilization and decrease the social, psychological, and financial burden on their family.

Materials and Methods:

This prospective study conducted from January 2006 to June 2007 after obtaining approval from our institutional review board, included consecutive groups of children aged 5 to 15 years with diaphyseal fractures of Radius and Ulna. Children with or without associated injuries like head injury, abdominal injury or poly trauma, closed fractures and Gustilo Anderson type 1 and 2 open fractures were included in the study. Since the focus of this study was children treated with square nails, we did not initiate data collection for children treated with other methods.

Children < 4 years and > 15 years old were excluded. Children with an underlying neuromuscular disease (cerebral palsy or myelomeningocele), metabolic bone disorder, pathological fractures, Gustilo Anderson type 3 open fractures and associated epiphyseal / metaphyseal radius and ulna injuries were also excluded from the study.

The aim of the study was to evaluate the clinical, functional and radiological outcomes of selected diaphyseal fractures of Radius and Ulna treated with intramedullary square nailing.

The study was conducted at the department of orthopedics, Jubilee Mission Hospital, Thrissur, Kerala, India

In our study Talwalkar’s square nails available in the size of 1.5 to 3 mm diameter and length of 11 to 20 cm were used. The Radius square nail was bent at proximal end, which helps in negotiating the medullary canal of distal fragment. Preoperative planning included measurement of the narrowest diameter of the medullary canal and multiplying by 0.4 to determine nail diameter; e.g., if the minimum canal diameter is 10 mm, two 4.0-mm nails are used. The optimal nail length was assessed by preoperative clinical / radiological measurement and under image intensifier guidance per operatively.

Steps of Operation:
Children were taken for surgery in 24 to 72 hours after pre anaesthestic checkup and informed consent. Under general or regional anaesthesia the procedure was done.

Position: Patient was placed supine on the table with a side arm board. An optimal closed fracture reduction was achieved under biplanar fluoroscopic control, prior to preparation and draping.

Procedure:  A pneumatic tourniquet was applied to the upper arm. Standard aseptic precaution and draping was used. Since ulna is subcutaneous, easily manipulated, and relatively straight, it is usually reduced and fixed first. Small incision is made over the olecranon process, and dissection is carried down through the subcutaneous tissue and triceps insertion to the bone. A small owl is used to create an entry hole for insertion of intramedullary nail. After fracture reduction the nail was passed in an antegrade fashion through the medullary under C-arm guidance and across the fracture site, short of 1 to 2 cm from distal physis. After intramedullary fixation of the ulna [least comminuted fracture between radius and ulna is fixed first], the radial fracture is reduced. A dorsal incision is made, just proximal to radial physis and medial to Lister’s tubercle, dissection is carried out between the second and third extensor compartments to cortical bone. Under C-arm confirmation that the approach has been made from proximal to distal physis a small fine tip owl is used on the dorsal surface directing the drill bit slightly proximal and volar allows easier passage of the intramedullary nail through the radial. The extensor pollicis tendon must be protected during drilling and nail passage. In some cases closed nailing was not possible after repeated attempts of passing nail across the fracture site. In such situations, fracture site was opened through small incision and reduction was achieved. After the nail has been passed across the fracture site and reduction has been confirmed with C-arm in both planes, the distal tip is bent and cut above the skin. The extremity is then placed in well padded long arm slab.

Postoperative management: In the postoperative period, immobilization with long arm slab was given. Elbow and finger mobilization was done early according to general condition and co-operation of the patient. Suture removal was done at 7 to 10 days after surgery, following which slab was removed and immobilization was done with forearm brace for additional 3 to 4 weeks.  Nails were removed when the fracture line was no longer visible radiologically, which typically was 4 to 6 months post operatively.

               The children were followed up at regular intervals of 6 weeks, 12 weeks, 6 months and 1 year and were assessed as following.

A)    Clinical assessment.

  • Entry point wound status and migration of the nail.

  • Pain and tenderness at the fracture site.

  • Abnormal mobility at the fracture site.

  • Range of motion of elbow and wrist.               

  • Rotational deformity of the limb.

  • Limb length disparity.

B)     Radiological Assessment.

  • Three cortices union.

  • Callus formation with reference to time.

  • Implant status.

  • Varus / Valgus angulations

C)    Functional assessment.      

  • Stay in hospital.

  • Operative time.

  • Time absent from school.

  • Time until full activity was allowed.

The clinical end point was defined as a healed fracture with a return to full activity. Children with complications were followed until the complications had resolved.

Complications such as unacceptable alignment, nail back out, refracture, an unplanned reoperation, and skin or wound problems were recorded.

Final outcome was assessed by Grace and Eversmann[i] scoring & American Academy of Orthopedic Surgeons Pediatric Outcomes Data Collection Instrument. (Version 2.0).


Between June 2006 to June 2007, 26 both bone forearm fractures were managed by closed square nailing in our institution and were followed up from 8 to 12 months.

There were 18 male patients and 8 female patients, with their ages ranging from 6 to 15 years (average age in boys being 9.2 years and average age in girls being 10.2 years). The both bone forearm fracture involved right side in 17 patients and left side in 9 patients. Out of the 26 children 24 had right side dominance, 2 had left side dominance.

There was one child with associated supracondylar fracture humerus. There was only 1 open injury, rest all being closed injury.

The site of both bone forearm fractures being 19 in middle third, 6  in lower third, and 1 in proximal third with a percentage of 73 %, 23.1%, and 3.9% respectively.

Of the 26 children with both bone fracture, 17 were operated within 24 hours from injury, 4 within 24 to 48 hours, 1 within a week, and rest 4 after 1 week.

Closed nailing was done in 18 children; mini open ulna was done in 1 child, mini open radius in 3 children and mini open of both radius and ulna in 4 children.

The average duration of surgery being 22.3 minutes (range 15 to 45 minutes).

Average hospital stay was 4 days (range 3 to 7 days) and average duration of immobilization being 4 to 6 weeks.

In our study all the fractures except 6 cases united at an average of 6 weeks time as evaluated radiologically by tricortical union. Out of the 6 cases 5 united within 8 weeks and 1 taking 10 weeks. There were no nonunion.

There were no limb length discrepancies in any of the cases. Almost all cases had full range of supination, pronation, elbow flexion and extension, and wrist dorsi flexion and palmar flexion at the time of their implant removal. One case had restriction in supination at the time of implant removal.


Statisticas Analysis: 

Occurrence of male & female patients is in the ratio 2:1. Using Chi square test; Chi square=0.077235 with P value 0.781081 (>0.05).  The difference between number of boys and girls is not significant.

Also the occurrences of fracture in middle third and lower third forearm is in the ratio 3:1,Chi square value -0.013333, P value - 0.908073(>0.05)

19/26 patients (73%) is affected by Middle third region, 6/26 (23.1%) in lower third and 1/26 (3.9%) in upper third region

There is a relationship between dominant side and injury. 17 out of 26 had right side dominance (73%). Chi Square 7.820534; p value - 0.005166 (<0.05)

Dominant Side on Side of Injury

Among 21 Patients under gone surgery within 48 hrs, average time for surgery since injury is 24 hrs with a SD 7 hrs. For 4 patients it is prolonged beyond 1 month due to late presentation.

Take the hypothesis that time interval between injury and surgery is in the ratio 3:1:1 (<24 hrs, 24-48 hrs & >48 hrs) Chi-square=0.410256 P-value=0.814543>0.05 

Duration 15-20 minutes 20-30minutes  >30minutes
CN 7 10 1
Mini open Radius 0 3 0
Mini open R&U 1 0 3
Mini open Ulna 0 1 0
Total 8 14 4
CN- closed nailing

Duration of surgery & type of surgery

Closed nailing was possible in 18 of 26 cases. Open reduction with mini-incision was required in 1 ulna and 3 radial fractures while in 4 cases both radius and ulna were opened. Among M/3, Closed Nailing is commonly done (13/19). But there is no statistically significant relation between site of fracture and type of procedure like closed nailing or open reduction with nailing. 

Chi square value - 0.28045; P value 0.869358 (>0.05)

The average duration of surgery was 22.3 minutes. Only 4 cases required more than 30 min for surgery. Out of 18 cases where closed nailing was possible only one case took > 30 minutes. In 8 cases where open reduction was required, only 3 cases had operative time > 30 minutes.

Duration of surgery is in the ratio 3:5:2 for <20 min, 20-30 min and >30 min.

Using chi square test chi-square=1.448639 with P value .835699(>.05).

This shows that operative time was not dependent on type of surgery or open reduction did not cause extra operative time.

The average hospital stay was 4 days with a range of 3 to 7 days.

 Nearly 50% patients required only 3 days of Hospital stay. Children with closed nailing were sent home on first postoperative day.

Chi-square 0.929731; P value 0.999583

The average union time was 6.7 weeks. Out of 18 cases where closed Nailing was possible, 17 fractures united in 6 weeks. Only 1 case out of 8 where open reduction was required united by 10 weeks.

On analysis with Grace and Eversmann outcome scoring out of 26 patients 20 had excellent outcome (77%), 5 had good outcome (19.2%), 1 had acceptable outcome (3.8%) and there was no patient with unacceptable outcome.

The relation between fracture site and final outcome was not statistically significant. Chi Square=0.000001 P value =0.999990 (>.05)

  Excellent Good Acceptable Unacceptable
L/3 5 1 0 0
M/3 15 3 1 0
P/3 0 1 0 0
Total 20 5 1 0

Functional outcome

Closed Nailing produce excellent result with 15 out of 18, Mini open Radius + Ulna produce excellent results with 3 out of 4. But Mini open Radius has 1 excellent outcome among 3 cases.

The outcome is excellent if the time for Surgery is <24 hrs in 15 out of 20 (75%).There was no statistically significant relation between final outcome and time interval between injury and surgery.

Chi square value - 0.077235 P value –0.781081

We had 7 complications in our study 2 olecranon bursitis, 2 superficial infection, 2 hypertrophied scars, and 1 ulna nail back out. We had no non-union, malunion or limb length discrepancies.

Conclusion :

The management of both bones forearm in children is critical for its functional outcome at later age. There is an excellent remodeling capacity of the pediatric long bones of forearm with conservative treatment; however the rotational deformity still persists. There is a big role of operative treatment in fracture both bone of forearm in children.

The fracture both bone forearms have been treated in past and till date by closed reduction and above elbow pop cast immobilization. This needs serial radiological reviews and change of cast till the fracture consolidation. The good result of union from conservative treatment have well proven[i] but involves regular hospital visits, change of plaster cast, care of cast, radiological reviews and at times operative intervention if angulation is observed. Care of plaster cast in pediatric age by the parents is very cumbersome job, which is the mainstay of treatment for good functional outcome.

The indication for operative intervention by plate osteosynthesis for both bones forearm fracture is to give a better functional outcome in displaced fractures. Despite of good results of rigid plate fixation, long incision and extensive dissection is needed[ii] [iii] [iv]. This has a risk of infection, poor cosmetic, and need of implant removal as second surgery, which again is an extensive procedure. Furthermore stress shielding, plate breakage, refracture are well known complication with surface fixation.

The role of external fixation in fracture of both bone forearm is limited only to open fractures and does not provide stable fixation. There is also a concern of delayed union, pin tract infection, joint stiffness and involves special care for external fixator in children. On the other side, intramedullary nail though biomechanically stable construct is not advised in children with growing physis for the risk of damage to physis, premature epiphysiodesis, or infection which are debatable.

In 1967 A K Talwalker[v] designed square nail for forearm fractures of radius an ulna using separate nails for treating adult forearm fractures. These nails were used by various traumatologist in treating long bone fractures with good results. Based on this concept surgeon from France Nancy and Metz developed elastic titanium implant for fixation of pediatric long bone fractures.

The technique of intramedullary fixation of both bone forearm offers several advantages of better anatomical-axial reduction, dynamic stabilization, short hospital stay, less visits, with early functional recovery, and simplified implant removal. The technique of closed intramedullary nailing is minimally invasive, respects biology of bone and soft tissues for better and early bony union. Open surgery is not necessary except in old or irreducible fracture. The minimal operative trauma, undisturbed periosteal and endosteal vasculature, and axial alignment maintained by nail which permits slight movement at fracture site. All these factors favor rapid fracture union in pediatric age group,

The square nail of Talwalker has a variable thickness from 1.5 to 3 mm. preoperative evaluation was done and one nail of adequate thickness was chosen to give a close fit to the bone. Square cross section of nail helps to maintain rotational alignment of radius and ulna by giving a close fit in medullary canal. We had no displacement, no refracture as the implant (square nail) was strong enough to hold the fracture till union.

The closed reduction technique used for P/3, M/3, and L/3 fractures was by application of traction to forearm in supination, midprone and pronation of distal fragment. The reduction was done under the control of image intensifier, by percutaneous K wire joystick technique or by mini open surgery for radius (7 cases), ulna (5 cases). This mini-open surgery was required when there was soft tissue interposition between fragments, periosteal tube penetration and with uneducable fractures. Although 8 cases required open reduction that has not affected union time or functional outcome.

The radial square nail was bent at the tip 10–20 degree for easy entry at distal radial metaphysic for easy negotiation across fracture site. This prebending was not a problem while maintaining radial bowing. 

The point of insertion of radius is just proximal to the physis, a small opening at distal metapysis (2 – 3 mm in length) and enlarged by the curve of haemostat mosquito forceps. Ulnar nail is inserted through the proximal ulna apophysis. As ulna square nail is smooth at the tip it does not interfear with the growth in children. The nails were passed short of 1 to 2 cm from physis.

The average time taken for surgery was 22.3 minutes, compared to 33. 5 minutes using titanium elastic nails by Richter et al 1998.

The duration of hospital stay in our series was 3 days in 50 % of our cases. All our patients were immobilized with long arm pop slab for one week, followed by further immobilization in forearm brace for 3 weeks. Those patients for whom mini open procedure was done were immobilized for 6 weeks.

The average time for fracture union in our series was 6.53 weeks and average time for hardware removal was between 6 to 7 months. None of our patients had non union. There was no limb length discrepancy noted in our series. Infections were treated with antibiotics. Olecranon bursa was excised at the time of implant removal.

Cullen et al 1998[vii] had a series of 20 children treated with Rush rods / Kirschner wires with average time to fracture union was 10 weeks (range 6 – 22) without nonunion. Removal of hardware was at an average 16 weeks (range, 6-34). 17 patients had excellent results 2 had good results and 1 had poor result. Complication occurred in 10 of 20 patients including 4 patients who required re-operation. Eighteen complications occurred in 10 of the 20 children, including hardware migration, infection, loss of reduction, re-operation, nerve injury, significant decreased range of motion, compartment syndrome, synostosis, muscle entrapment, and delayed union.

Richter et al11 has reported 30 children (ages 4 to 14 years, 12 girls, 18 boys) treated by titanium elastic nailing. 16 children were operated immediately and 14 children late following failed conservative treatment and fracture displacement. Average operative time was 33.5 minutes, and average duration of immobilization was 2 to 3 weeks. Implant removal was performed at an average 11.7 weeks (range 8 – 26) after nailing. 24 children did not have any discomfort, 3 had minimal discomfort, 3 had loss of supination of 10 degree, and 2 had deficit in muscle strength.

      The delay in the hardware removal in our series was due to late attendance as some of them waited for their school vacation for the procedure.

We had complication of olecranon bursitis, and Ulnar nail backout as some part of our ulnar nail was left out of bone for easy implant removal. Olecranon bursa was removed at the time of implant removal. No limb length discrepancies were noted as we took measures not to use drill for making entry.

We had no nerve injury in our series as meticulous care was taken for ulna proximal physis entry point such that the ulnar nerve is kept medial by rolling the skin.

We had no cross union/synostosis as we opened minimally by two different incisions with a gap of 5 cm when mini open reduction was done.

Reference :

  1. Worlock P, Stower M: Fracture patterns in Nottingham children. JPediatr Orthop 6:656–660, 1986.

  2. Landin L A. Fracture patterns in children. Analysis of 8,682 fractureswith special reference to incidence, etiology and secular changes ina Swedish urban population 1950–1979. Acta Orthop Scand Suppl. 1983;202:1–109.

  3. Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fracturesin 2,650 long-bone fractures in children aged 0–16 years. J Pediatr Orthop. 1990;10:713–716.

  4. Voto SJ,Weiner DS, Leighley B. Redisplacement after closed reduction offorearm fractures in children. J Pediatr Orthop. 1990;10:79–84.

  5. Grace T G, Eversmann W W Jr Forearm fracture; treatment by rigid fixation with early motion. J Bone Joint Surg. Am, 1980;62:433-438

  6. Creasman C, Zaleske DJ, Ehrlich MG: Analyzing forearm fracturesin children: The more subtle signs of impending problems. Clin Orthop 188:40–53, 1984.

  7. Wright J, Rang M. Internal fixation for forearm fractures in children. Techniques Orthop 1989;4:44-47.

  8. VanderReis WL, Otsuka NY, Moroz P, Mah J. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop 1998;18:9-13.

  9. Roy DR, Crawford AH. Operative management of fractures of the shaft of the radius and ulna. Orthop Clin North Am 1990;21:245-250.

  10. Talwalkar AK & Talwalkar CA 1967. internal fixation of fractures of radius and ulna in adults with Talwalkar intraamedullary nails. Indian Journal of Orthopaedics Vol 1, No.1Jun 1967;26-30.

  11. Richter, Dirk M.D.; Ostermann, Peter A. W. M. D.; Ekkernkamp, Axel M.D.; Muhr, Gert M.D.;Hahn, Micheal P. M.D. J Paed Ortop, vol 18(4),july/aug 1998,457-461.

  12. Cullen,Mark C. M.D.;Roy, Dennis R. M.D,;Giza,Eric B. S.;Crawford, Alvin H, M.D., F.A.C.S. J Paed Ortop, vol 18(1), jan/feb 1998,14-21

This is a peer reviewed paper 

Please cite as: Rajeev Rao: A prospective study of pediatric forearm bone fractures treated with closed intramedullary square nailing.

J.Orthopaedics 2009;6(1)e12





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