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Single-Bone Intramedullary Nailing of Pediatric Both-Bone Forearm Fractures: A Systematic Review.

Diaphyseal both-bone forearm fractures (BBFF) are one of the most common fractures among the pediatric population. (1,2) The majority are treated conservatively by casting with operative options being plating and intramedullary nailing (IMN). (2-4) Although open reduction and plate fixation ensures a more immediate fixation, it is associated with higher rates of complications, such as infection, synostosis, and re-fracture. (3,5,6) It also risks long scars and nerve injury during plate removal as the nerve is often difficult to identify due to adhesions and fibrosis. (5) In comparison, IMN has a shorter operating time, easier operative technique, simpler implant removal, and improved cosmesis while maintaining rates of union and forearm rotation comparable to plate fixation in pediatric patients. (5-9) For all of these reasons, IMN is preferred in pediatric populations, and indications are now being extended to adolescents.

The goals of IMN of both-bone forearm fractures reflect the anatomy of the forearm. The ulna and the radius act as a ring, and a fracture that shortens either bone results in disruption of the other forearm bone. (10) The ulna, which is relatively straight, serves as an axis around which the laterally bowed radius rotates in supination and pronation. A loss of supination and pronation may result from radial shaft fractures in which the lateral curvature ("radial bow") has not been restored. (10) Intramedullary nailing restores this anatomy and resists bending and axial loads. (11) However, stabilization is not rigid and allows for micromovement at the fracture site, which promotes secondary bone healing. (11)

In recent decades, the elastic stable intramedullary nail (ESIN) has become the most frequently used IMN technique, followed by Kirschner-wires. (12) Whereas K-wires are stiff, ESIN is flexible and inserted after being pre-bent. The tendency for the nails to bend back produces counteracting lateral forces and bending moments, stabilizing the fracture site. (11,12)

Regardless of the intramedullary technique chosen, the traditional operative treatment for BBFF was to nail both bones. (13,14) However, recent literature suggests that in some instances, a single nail may be used for BBFF in the pediatric population. Single-bone fixation offers the advantage of being technically less demanding, minimally invasive, and therefore safer. (1,14)

Despite this theoretical advantage, there are questions regarding single-bone IMN that need to be addressed. It is unclear if single-bone IMN achieves the parameters for an adequately reduced fracture as some have reported an unacceptable loss of reduction. (8,13) Furthermore, it has not been definitively established which forearm bone should be nailed. The purpose of this systematic review was to examine these issues in studies that included single-bone IMN of pediatric BBFF.

Materials and Methods

The review followed guidelines recommended by the PRISMA protocol. (15) The criteria for study inclusion and analysis were specified in advance in a protocol (Table 1). We then examined studies that analyzed intramedullary fixation of both-bone diaphyseal forearm fractures. For inclusion, articles needed to be in English, a primary study (not a review, case report or series, or editorial) of pediatric patients (less than 18 years old) and published in a peer-reviewed journal.

Studies were identified by searching Medline (1946 to present) and Embase (1974 to present) with the last search conducted on August 13, 2015. We used the following search terms: "intramedullary fracture fixation," "ulna fractures," "radius fractures," "both bone forearm fracture," "bone wire," and "bone nail." The search strategy is presented in Table 2. Eligibility assessment and data extraction were performed independently by two reviewers. Disagreements were discussed in detail and then resolved by consensus.

From each study, we gathered information on: 1. study design (type of study, IMN technique, bones fixed, mean age of participants, and length of follow-up period); and 2. type of outcome measure (date of cast or nail removal, radiographic assessment, and functional assessment). Study validity was assessed by evaluating selection bias, adequacy of comparison methods, and transparency regarding missing data. Publication bias and selective reporting were also analyzed.


Study Selection and Characteristics

A total of 11 studies were reviewed as identified in our search flow diagram (Fig. 1). The initial search on Medline and Embase yielded 294 articles. From that selection, we excluded 261 studies based on the inclusion criteria. We then examined the full text of the remaining 33 articles and excluded an additional 22 studies because they did not specifically discuss single-bone IMN of pediatric BBFF.

Out of the 11 studies selected for review, two were prospective cohort studies, (16,17) while the remaining 9 were retrospective reviews (Table 3). (1,4,8,13,14,18-21) One study, by Colaris and coworkers, (16) was a prospective randomized controlled trial. All were published in English language peer-reviewed journals. A total of 358 participants were involved in the studies with sample sizes ranging from 10 to 64 patients.

The main inclusion criterion was a both-bone diaphyseal forearm fracture that required IMN. Exclusion criteria were metaphyseal fractures and Monteggia or Galeazzi fracture-dislocations. In all studies except the one by Lee and associates, (8) the primary outcome was limitation of pronation and supination compared to the uninjured arm. Secondary outcomes were limitation of flexion and extension of the wrist and elbow, complications related to fixation method (loss of reduction, delayed union, and redisplacement), and radiographic assessment of angulation. For Lee and associates, (8) radiographic assessment of angulation was the primary outcome.

The majority of studies used K-wire (4,8,13,14,19-21) or ESIN (1,13,16-18) as the operative technique. Seven studies included two groups, a single-bone group and a both-bone group. (1,4,8,16,19-21) The time at which the cast was removed ranged from 3 to 16.6 weeks, and the time at which hardware was removed ranged from 3.5 to 44.7 weeks. Cullen and colleagues (21) did not report cast removal time, Lee and associates (8) and Myers and coworkers (1) did not report hardware removal time, and Flynn and Waters (14) did not indicate either cast or hardware removal time. The follow-up period ranged from 10 weeks to 2.75 years (Myers and coworkers through phone interview), (Table 3).

Analysis of Methodological Techniques

Nine of the 11 studies were retrospective reviews (1,4,8,13,14,18-21) and therefore were affected by some limitations inherent to retrospective design. Although all studies clearly defined the criteria for choosing single-bone fixation over double-bone fixation, not all studies specified or controlled for the surgeons performing the operation. Surgeries were performed by a large number of surgeons, including trainees with supervision, (8) surgeons from the same group, (19) and pediatric fellowship-trained surgeons. (13) The surgeons in two studies (20,21) were not identified. In the remaining four retrospective studies, (1,4,14,18) the investigators being the surgeons could be inferred.

In addition, the material used for IMN was not consistent within some retrospective reports. Dietz and colleagues (13) used a combination of nailing techniques, including K-wires, ESIN, and Rush rods. Luhmann and associates (20) and Cullen and coworkers (21) used K-wires and Rush rods, while Shoemaker and colleagues (19) used K-wires and Steinmann pins. The remaining studies all used a single type of nailing material: K-wires (4,8,14) or ESIN. (1,18)

In studies that included both a single-bone fixation cohort and a both-bone fixation cohort, the assignment of outcomes to each cohort was frequently unclear. For instance, Yung and colleagues (4) reported that one patient had a pronation and supination loss, and six patients had residual radial or ulna angulation. However, it was unclear whether these patients were in the single or both-bone fixation cohort. This complicated efforts at a direct comparison of outcomes. Similarly, although Colaris and associates (16) reported the exact number of patients who had pronation and supination loss and complications, such as redisplacement, they did not specify whether these patients had the ulnar or the radius fixed.

A related trend was that not every outcome was clearly reported. Colaris and coworkers, (16) Shoemaker and colleagues, (19) Luhmann and associates, (20) and Flynn and Waters (14) provided organized tables that listed the pronation and supination outcome for every patient and calculated the mean or median pronation and supination loss. However, Cullen and coworkers (21) and Alnaib and colleagues (18) provided qualitative descriptions, such as "decreased range of motion" and "reduced supination," but did not report exact numbers. As a result, it was difficult to infer the mean pronation and supination loss and measures of precision, such as standard deviations or interquartile ranges. The remaining studies did not provide explicit tables but provided quantitative descriptions within the text. (1,4,13,17) This pattern was consistent for reporting secondary outcomes, such as radiographic reangulation.

We did not detect significant evidence of publication or reporting bias, as studies reported all outcomes, although sometimes not clearly quantified, and mentioned when patients were lost to follow-up.

Synthesis of Results

Table 4 summarizes the outcomes of the studies.

Single-Bone and Both-Bone Fixation

Seven studies included cases of both single-bone and both-bone fixation (1,4,8,16,19-21) with 6 of the 7 including the primary outcome measure regarding pronation and supination. In the only randomized controlled trial, Colaris and coworkers (16) found the same median pronation and supination limitation of 5[degrees] to 10[degrees] for single-bone and both-bone fixation groups. However, the single-bone group had a greater number of complications, primarily redisplacement of the non-nailed bone, and was casted for a longer duration than the both-bone group. The investigators stated that the study was underpowered for statistical comparisons but suggested that more redisplacement problems were associated with the single-bone group.

Other investigators (1,4,21) also noted that the two groups had similar rates of loss of pronation and supination. In contrast, the percentage of pronation and supination loss was determined to be higher in the single-bone than the both-bone group by Shoemaker and colleagues (22% versus 12%) (19) and Luhmann and associates (42% versus 23%). (20) Using angulation as their primary outcome measure, Lee and associates (8) reported reangulation of 33% of non-nailed radii requiring additional intervention in the single-bone group (22 ulna, 3 radius) compared to none in the both-bone group (N = 24) needing any further treatment as initial alignment was maintained.

Secondary outcomes included one delayed union in single-bone fixation, (20) two loss of reduction in single-bone and two delayed unions in both-bone, (21) and three loss of reduction in single-bone. (19) One group reported no adverse secondary outcomes in either single-bone or both-bone. (1) Yung and coworkers (4) described six patients with residual angulation without indicating group assignment but suggested these would remodel.

Ulna Only Nailing

In Houshian and Bajaj's (17) prospective study of 20 single-bone IMN with 3 ulna-only cases, all patients had full pronation and supination. Flynn and Waters (14) retrospectively reviewed 10 single-bone fixations, including 9 ulna-only, and reported that all patients achieved full restoration of forearm rotation, except for a 5[degrees] loss of pronation in two. In the examination of single-bone fixation of 38 ulna, Dietz and colleagues (13) noted a pronation and supination loss in 8% (3 of 38). However, they found 13 (34%) had a radial angulation of 10[degrees] or greater with 2 (5%) requiring re-operation.

For the studies that had included patients with both-bone fixation, pronation or supination loss in the ulna-only cases was found in 1 of 7 (14%), (1) 0 of 1, (19) 2 of 5 (40%), (20) 1 of 8 (13%) (21) and was a median of 5[degrees] to 10[degrees] at 9 months of follow-up. (16) Additionally, Lee and associates (8) reported re-angulation of the radius in 7 of 21 (33%) at 2 to 3 weeks after surgery.

Radius Only Nailing

Using radius-only fixation, Alnaib and colleagues in 29 BBFFs, (18) Houshian and Bajaj in 17 cases, (17) and Flynn and Waters in 1 patient (14) demonstrated no loss of pronation and supination or radiological non-union.

For the studies that had included patients with both-bone fixation, pronation and supination loss in the radius-only cases was found in 4 of 18 (22%), (1) 2 of 8 (25%) (one patient lost to follow-up), (19) 3 of 7 (43%), (20) 0 of 2 (21) and was a median of 5[degrees] to 10[degrees] at 9 months of follow-up. (16) Additionally, Lee and associates (8) reported that final angulation was not significant in their three radius-only fixations.

Myers and coworkers (1) in their single-bone fixation of 25 children, directly examined the outcomes of radius-only versus ulna-only fixation. At final follow-up at an average of 9 months, 22% (4 of 18) of radius-only and 14% (1 of 7) of ulna-only fixations had loss of pronation and supination. After tabulating the rates of pronation and supination loss between radius-only and ulna-only fixation from all of the analyzed studies, similar percentages were found in each group (Table 5).



The studies evaluated the outcomes of single-bone intramedullary fixation of pediatric both-bone forearm fractures. Our results show that despite variations in methodological strategies, single-bone fixation may be comparable to both-bone fixation. The rising incidence of and debate around this technique highlights the importance of a systematic review that specifically focuses on single-bone intramedullary nailing of both-bone forearm fractures.

Eight out of the 11 studies included in our review demonstrated low rates of pronation and supination loss and radiologic angulation in single-bone cohorts. There was no obvious difference in outcome between radius and ulna only stabilization. Others have suggested that the radius has the more complicated function, so fixation of the radius stabilizes the forearm and improves alignment of the ulna. (22) Previous reports have also shown that IMN of the radius produces a significantly more stable construct than IMN of the ulna. (23)

Study Limitations

Due to the retrospective design of all but two studies in this review, selection bias was prevalent. For instance, unstable fracture configurations may not be amenable to single-bone fixation, which may not have been included in retrospective reviews. The majority of studies that conclude that single-bone fixation maintains adequate reduction are based on a selection of children who sustained a both-bone forearm fracture that remained aligned and stable after initial single-bone fixation. Skeletal maturity was only implied through age cut-offs but not specifically mentioned.

A number of studies examined surgical outcomes from a large group of surgeons. This was another limitation of the retrospective design: it is not possible to control for who performs the operations. The inclusion of numerous surgeons may have introduced some variety in outcomes. Lee and associates (8) noted that the interpretation of when to proceed with single-bone fixation was often left up to the individual surgeon, and the interpretation may have been inconsistent. The different stages of training among the surgeons may have also affected surgical results.

Studies often used a variety of intramedullary nailing materials, another factor that could not be controlled for in retrospective design. These materials included Kirschner wiring, Rush rods, Steinmann pins, and ESIN, sometimes all used in the same study. There are a number of differences among these materials that could have introduced variability in outcomes. The elastic stable intramedullary nail has been purported to have a theoretical advantage for maintaining the radial bow in both-bone forearm fractures due to its flexibility. Kirschner wires and Rush nails are rigid and difficult to insert through the metaphysis of children's bones. (5) However, previous literature has shown that ESIN has no definite advantage over stiff material, such as K-wires. (24,25) This pattern was consistent with the results of our review, given the positive outcomes from Yung and colleagues (4)

Another trend was the lack of clearly reported statistical parameters and measures of precision. Two papers in the review did not report explicit pronation, supination, or angulation outcomes, which complicated efforts to conduct pooled quantitative estimates, such as a meta-analysis. This difficulty was compounded by studies that did not explicitly specify whether certain outcomes were from both-bone or single-bone fixation cohorts and from ulna-only or radius-only fixation cohorts. Clearly, defined statistical parameters and measures of precision are important tools to gauge the spread of the data and should be included in all analysis.

We did not find evidence for systematic publication or reporting bias across studies. Our review was limited by the fact that the majority of included studies were retrospective cohort studies. Only one study, by Colaris and coworkers, (16) was a prospective randomized controlled trial.


In conclusion, single-bone IMN has been reported to have comparable outcomes to both-bone IMN, and this may be due to proper selection of inherently stable fractures. In cases where single-bone IMN was used, similar results were seen in radius and ulna-only fixation.

Disclosure Statement

None of the authors have a financial or proprietary interest in the subject matter or materials discussed, including, but not limited to, employment, consultancies, stock ownership, honoraria, and paid expert testimony.


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(2.) Kapoor V, Theruvil B, Edwards SE, et al. Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children. Injury. 2005 Oct;36(10):1221-5.

(3.) Smith VA, Goodman HJ, Strongwater A, et al. Treatment of pediatric both-bone forearm fractures: A comparison of operative techniques. J Pediatr Orthop. 2005 May-Jun;25(3):309-13.

(4.) Yung PS, Lam CY, Ng BK, et al. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fractures in children. J Pediatr Orthop. 2004 Jan-Feb;24(1):7-12.

(5.) Ali AM, Abdelaziz M, El-Lakanney MR. Intramedullary nailing for diaphyseal forearm fractures in children after failed conservative treatment. J Orthop Surg (Hong Kong). 2010 Dec;18(3):328-31.

(6.) Richter D, Ostermann PA, Ekkernkamp A, et al. Elastic intramedullary nailing: A minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop. 1998 Jul-Aug;18(4):457-61.

(7.) Antabak A, Luetic T, Ivo S, et al. Treatment outcomes of both-bone diaphyseal paediatric forearm fractures. Injury. 2013 Sep;44 Suppl 3:S11-5.

(8.) Lee S, Nicol RO, Stott NS. Intramedullary fixation for pediatric unstable forearm fractures. Clin Orthop Relat Res. 2002 Sep;(402):245-50.

(9.) Shah AS, Lesniak BP, Wolter TD, et al. Stabilization of adolescent both-bone forearm fractures: A comparison of intramedullary nailing versus open reduction and internal fixation. J Orthop Trauma. 2010 Jul;24(7):440-7.

(10.) Egol K, Koval K, Zuckermann J. Radius and ulna shaft. In: Handbook of Fractures. Philadelphia: Lippincott Williams & Wilkins, 2010, pp. 257-268.

(11.) Malik S, Malik S. Intramedullary Nail II. Orthopaedic Biomechanics Made Easy. Cambridge, UK: University Press, 2015, pp. 178-179.

(12.) Barry M, Paterson JMH. Flexible intramedullary nails for fractures in children. J Bone Joint Surg Br. 2004 Sep;86(7):947-53.

(13.) Dietz JF, Bae DS, Reiff E, et al. 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 Jul-Aug;30(5):420-4.

(14.) Flynn JM, Waters PM. Single-bone fixation of both-bone forearm fractures. J Pediatr Orthop. 1996 Sep-Oct;16(5):655-9.

(15.) PRISMA. The PRISMA checklist. Available at: Accessed August 10, 2015.

(16.) Colaris J, Reijman M, Allema JH, et al. Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicenter randomised controlled trial. Arch Orthop Trauma Surg. 2013 Aug;133(8):1079-87.

(17.) Houshian S, Bajaj SK. Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases. Injury. 2005 Dec;36(12):1421-6.

(18.) Alnaib M, Taranu R, Lakkol S, et al. Radius-only intramedullary nailing for both-bones diaphyseal forearm fractures in children. Acta Orthop Belg. 2011 Aug;77(4):458-63.

(19.) Shoemaker SD, Comstock CP, Mubarak SJ, et al. Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children. J Pediatr Orthop. 1999 May-Jun;19(3):329-37.

(20.) Luhmann SJ, Gordon JE, Schoenecker PL. Intramedullary fixation of unstable both-bone forearm fractures in children. J Pediatr Orthop. 1998 Jul-Aug;18(4):451-6.

(21.) Cullen MC, Roy DR, Giza E, et al. Complications of intramedullary fixation of pediatric forearm fractures. J Pediatr Orthop. 1998 Jan-Feb;18(1):14-21.

(22.) Kirkos JM, Beslikas T, Kapras EA, et al. Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius. Injury. 2000 Oct;31(8):591-6.

(23.) Jones D, Henley M, Schemitsch E, et al. A biomechanical comparison of two methods of fixation of fractures of the forearm. J Orthop Trauma. 1995 Jun;9(3):198-206.

(24.) Calder PR, Achan P, Barry M. Diaphyseal forearm fractures in children treated with intramedullary fixation: Outcome of K-wire versus elastic stable intramedullary nail. Injury. 2003 May;34(4):278-82.

(25.) Battle J, Carmichael KD, Morris RP. Biomechanical comparison of flexible intramedullary nailing versus crossed Kirschner wire fixation in a canine model of pediatric forearm fractures J Pediatr Orthop B. 2006 Sep;15(5):370-5.

Chang-Yeon Kim, M.D., Mark Gentry, M.A., M.L.S., Debra A. Sala, M.S., P.T., and Alice Chu, M.D.

Chang-Yeon Kim, M.D., Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Cleveland, Ohio. Mark Gentry, M.A., M.L.S., Harvey Cushing/John Hay Whitney Medical Library, Yale University, New Haven, Connecticut. Debra A. Sala, M.S., P.T., and Alice Chu, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, New York, New York.

Correspondence: Alice Chu, M.D., Department of Orthopaedic Surgery, NYU Hospital for Joint Diseases, 301 East 17th Street, New York, New York 10003;

Caption: Figure 1 Search flow diagram.
Table 1 Study Eligibility Form

Inclusion criteria for review
  Published in a peer-reviewed journal?
  Analyzes intramedullary nailing?
  Analyzes diaphyseal both-bone forearm fractures?
  Primary study?
  Population < 18 years old?
  Compares single-bone versus both-bone fixation?
  Article in English?
Study characteristic
  Year of publication
  Type of study
  Follow-up period
  Study size
  Inclusion criteria
Sources of bias
  Controlled for selection bias
    If yes, how?
  Appropriate assumptions for statistical tests?
    If yes, how?
  Included measures of precision?
    If yes, which measure?
  Controlled for confounding variables?
    If yes, how?
  Outlined process for data exclusion?
    If yes, how?
Primary outcome
  Outcome used for evaluation
  Reported outcome
    Number in each cohort
    Outcome of each cohort
    Results of significance testing
  Secondary outcomes

Table 2 Search Strategy

 A.  Medline
 1.  exp Fracture Fixation, Intramedullary/
 2.  exp Ulna Fractures/su [Surgery]
 3.  exp Radius Fractures/su [Surgery]
 4.  1 and 2 and 3
 6.  both bone forearm fracture*.tw.
 7.  1 and (5 or 6)
 8.  exp Bone Wires/
 9.  exp Bone Nails/
10.  (8 or 9) and (5 or 6)
11.  (8 or 9) and (2 and 3)
12.  4 or 7 or 10 or 11
13.  (single adj2 bone*).tw.
14.  (both adj2 bone*).tw.
15.  exp Forearm/su [Surgery]
16.  forearm injuries/
17.  1 or 8 or 9
18.  15 or 16
19.  17 and 18
20.  12 or 19
21.  limit 20 to "all child (0 to 18 years)"
22.  13 or 14
23.  21 and 22
24.  21 not 23

 B.  Embase
 1.  exp Fracture Fixation, Intramedullary/
 2.  exp Ulna Fractures/su [Surgery]
 3.  exp Radius Fractures/su [Surgery]
 4.  1 and 2 and 3
 6.  both bone forearm fracture*.tw.
 7.  1 and (5 or 6)
 8.  exp Bone Wires/
 9.  exp Bone Nails/
10.  (8 or 9) and (5 or 6)
11.  (8 or 9) and (2 and 3)
12.  4 or 7 or 10 or 11
13.  (single adj2 bone*).tw.
14.  (both adj2 bone*).tw.
15.  exp Forearm/su [Surgery]
16.  forearm injuries/
17.  1 or 8 or 9
18.  15 or 16
19.  17 and 18
20.  12 or 19
21.  13 or 14
22.  limit 20 to (child or preschool child < 1 to 6 years > or
     school child < 7 to 12 years > or adolescent < 13 to 17
     years >)
23.  21 and 22

Table 3 Characteristics of Study

Study              Type of Study     IMN Technique    Bone Fixed

Colaris et al.,    Prospective       ESIN (Nancy)     7 radius only
2013 (16)          randomized                         6 ulna only
                   controlled trial                   11 both bones
Houshian and       Prospective       ESIN (Nancy)     17 radius
Bajaj, 2005 (17)                                      3 ulna
Yung et al.,       Retrospective     K-wire           25 radius only
2004 (4)                                              2 ulna only
                                                      37 both bones
Lee et al.,        Retrospective     K-wire           3 radius
2002 (8)                                              22 ulna
                                                      24 both bone
Myers et al.,      Retrospective     ESIN (C-nail)    18 radius only
2004 (1)                                              7 ulna only
                                                      25 both bone
Flynn and          Retrospective     K-wire           1 radius only
Waters, 1996 (14)                                     9 ulna only
Dietz et al.,      Retrospective     32 K-wire        38 ulna
2010 (13)                            4 ESIN (Nancy)
                                     2 Rush rods
Alnaib et al.,     Retrospective     ESIN (Titanium)  29 radius
2011 (18)
Shoemaker et       Retrospective     28 K-wire        9 radius only
al., 1999 (19)                       4 Steinmann      1 ulna only
                                                      22 both bone

Luhmann et         Retrospective     K-wire           7 radius only
al., 1998 (20)                       Rush rods        5 ulna only
                                                      13 both bone
Cullen et al.,     Retrospective     K-wire           2 radius only
1998 (21)                            Rush rods        8 ulna only
                                                      7 both bone

Study              Follow-up   Time of Cast and Hardware Removal

Colaris et al.,    9 months    Cast removed at 3 weeks
2013 (16)                      Nail removed at 2 and 8 months
                   20 months   Cast removed at 3 weeks
Houshian and                   Nail removed at median 19 weeks
Bajaj, 2005 (17)               (range:16-24)
Yung et al.,       70 months   Cast and K-wire removed at average of 5
2004 (4)                       weeks (range: 4-7)
Lee et al.,        10 weeks    Cast removed at 6-8 weeks
2002 (8)                       Unclear when K-wire was removed
Myers et al.,      2.75 years  Cast removed at 4 to 6 weeks
2004 (1)                       Unclear when nail was removed
Flynn and          16.8        Unclear when cast and K-wire were removed
Waters, 1996 (14)  months
Dietz et al.,      4 months    Cast removed average of 60 days (range:
2010 (13)                      25-111)
                               Hardware removed median 45 days (range:
Alnaib et al.,     6.8 months  Cast removed at 4-6 weeks
2011 (18)                      Nail removed at 10-12 weeks
Shoemaker et       13 months   Cast removed at average of 8.4 weeks
al., 1999 (19)                 (range: 3.9-16.6)
                               Hardware removed at average of 5.2 and
                               average of 15.2 weeks
Luhmann et         31.0 weeks  Cast removed at avg 7.3 weeks (range:
al., 1998 (20)                 4.4-11.6)
                               Hardware removed at avg 11.8 weeks
                               (range: 4.3-44.7)
Cullen et al.,     10 months   Unclear when cast was removed
1998 (21)                      Hardware removed at average of 16 weeks
                               (range: 6-34)

Table 4 Outcomes

Study             Limitation of Pronation and Supination

Colaris et al.,   SBF: 5 > 10[degrees] limitation
2013 (16)         BBF: 4 > 10[degrees] limitation
Houshian and      Full pronation and supination in all
Bajaj, 2005 (17)  patients
Yung et al.,      1 with 20[degrees] pronation loss and
2004 (4)          10[degrees] supination loss
Lee at al.,       Not reported; angulation was primary
2002 (8)          outcome
Myers et al.,     SBF: 5 with pronation or supination loss
2004 (1)          BBF: 6 with pronation or supination loss
Flynn and         2 ulna-only with 5[degrees] pronation
Waters,           loss
1996 (14)
Dietz et al.,     3 with pronation or supination loss
2010 (13)
Alnaib et al.,    Full pronation and supination in all
2011 (18)         patients
Shoemaker et      SBF: 2 with pronation or supination loss
al., 1999 (19)    in radius-only
                  BBF: 2 with pronation or supination loss
Luhmann et        SBF: pronation or supination loss in 3
al., 1998 (20)    radius-only, 2 ulna-only
                  BBF: 3 with pronation or supination loss
Cullen et al.,    SBF: 1 pronation and supination loss in
1998 (21)         ulna-only
                  BBF: 1 pronation and supination loss

Study             Elbow and Wrist Movement,  Notes
                  Angulation, Complications

Colaris et al.,   SBF: 4 redisplaced         SBF: median limitation
2013 (16)         BBF: 0 redisplaced         5[degrees]-10[degrees]
                                             BBF: median limitation
Houshian and      No deficits
Bajaj, 2005 (17)
Yung et al.,      6 with residual radius or  Unclear which patients had
2004 (4)          ulna angulation [greater   outcome deficits
                  than or equal to]
                  18 with reduced handgrip
                  1 with forearm shortening
Lee at al.,       SBF: 7 with radial
2002 (8)          reangulation in
                  ulnar-only group, leading
                  to 2 reoperations BBF:
                  all < 5[degrees]
Myers et al.,     No deficits                Radius-only SBF: 4 loss of
2004 (1)                                     pronation or supination
                                             Ulna-only SBF: 1 loss of
                                             pronation or supination
Flynn and         No deficits
1996 (14)
Dietz et al.,     Ulna angulation: all <
2010 (13)         10[degrees]
                  Radial angulation: 11
                  with 10[degrees] to
                  20[degrees], 2 with
                  > 20[degrees] of
                  1 refracture of both
Alnaib et al.,    Full radiological union
2011 (18)         in all patients
Shoemaker et      SBF: 3 with loss of
al., 1999 (19)    reduction

Luhmann et        1 delayed union in         Mean supination loss =
al., 1998 (20)    ulna-only                  13[degrees]
                                             Mean pronation loss =
                                             3 with pronation or
                                             supination loss >
                                             15[degrees] (2 in SBF, 1
                                             in BBF)
Cullen et al.,    SBF: 2 loss of reduction
1998 (21)         BBF: 2 delayed union

SBF = single-bone fixation; BBF = both-bone fixation.

Table 5 Frequency of Loss of Pronation or Supination in Single-Bone

Study                      Radius Only        Ulna Only

Colaris et al., 2013 (16)  Unspecified        Unspecified
Houshian and Bajaj, 2005   0/17 (0%)           0/3 (0%)
Yung et al., 2004 (4)      Unspecified        Unspecified
Lee et al., 2002 (8)       0/3 (0%)            7/21 (33%) (*) ([dagger])
Myers et al., 2004 (1)     4/18 (22%)          1/7 (14%)
Flynn and Waters, 1996     0/1 (0%)            2/9 (22%)
Dietz et al., 2010 (13)    None                3/38 (8%)
Alnaib et al., 2011 (18)   0/29 (0%)          None
Shoemaker et al., 1999     2/8 (25%)[dagger]   0/1 (0%)
Luhmann et al., 1998 (20)  3/7 (43%)           2/5 (40%)
Cullen et al., 1998 (21)   0/2 (0%)            1/8 (13%)
TOTAL                      9/85 (17%)         16/92 (17%)

(*) Reangulation of radial fracture; ([dagger]) one patient lost to
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Author:Kim, Chang-Yeon; Gentry, Mark; Sala, Debra A.; Chu, Alice
Publication:Bulletin of the NYU Hospital for Joint Diseases
Date:Oct 1, 2017
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