Selected Instructional Course Lecture   |    
Management of Fractures in Adolescents
Shital N. Parikh, MD1; Lawrence Wells, MD2; Charles T. Mehlman, DO, MPH1; Susan A. Scherl, MD3
1 Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, ML 2017, Cincinnati, OH 45229. E-mail address for S.N. Parikh: Shital.Parikh@cchmc.org. E-mail address for C.T. Mehlman: Charles.Mehlman@cchmc.org
2 Department of Orthopaedic Surgery, The Children's Hospital of Philadelphia, 34th Street and Civic Center, Wood Building, Floor 2, Philadelphia, PA 19104-4399. E-mail address: WellsL@email.chop.edu
3 Department of Orthopaedics, University of Nebraska, 10506 Burt Circle, Omaha, NE 68114. E-mail address: sscherl@unmc.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons
Printed with permission of the American Academy of Orthopaedic Surgeons. This article, as well as other lectures presented at the Academy's Annual Meeting, will be available in February 2011 in Instructional Course Lectures, Volume 60. The complete volume can be ordered online at www.aaos.org, or by calling 800-626-6726 (8 a.m.-5 p.m., Central time).

Copyright © 2010 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Dec 15;92(18):2947-2958
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Adolescence is defined as a transition phase between childhood and adulthood. It encompasses puberty (a period of rapid growth and hormonal changes), which includes an acceleration phase of growth (for about two years), a peak (peak height velocity), and a deceleration phase (for one to two years). The mean age at the time of the peak height velocity is twelve years (typical range, ten to fourteen years) for girls and fourteen years (typical range, twelve to sixteen years) for boys. Typically, girls who are more than fourteen years of age and boys who are more than sixteen years of age are considered skeletally mature and can undergo treatment similar to that for their adult counterparts. For the sake of this article, girls from eight to fourteen years old and boys from ten to sixteen years old will be considered adolescents1,2.
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    Shital N. Parikh, MD
    Posted on February 11, 2011
    Dr. Parikh and colleagues respond to Dr. Khan
    Orthopaedic Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio

    We appreciate the comments by Dr. Khan but would respectfully disagree on the issue of early (6-8 weeks) removal of implants after elastic nailing of displaced forearm fractures.

    Elastic nails should be removed only after fracture healing is confirmed by bridging callus across all four cortices in both bones and obliteration of the fracture line (1). Radius and ulna shaft fractures have the highest rates of refracture (2). The pioneers of the technique of elastic nailing of forearm shaft fractures in children reported their series of 85 patients with an average age of 11 years 4 months and a mean follow-up of 3 years and 6 months (3). In their first 50 patients, the nails were removed 4.25 months after the initial surgery, but due to three cases of refracture, they recommended nail removal between 10 months and 1 year after initial surgery. Besides refracture, delayed healing (4) and nonunion (5) have been reported after nailing of forearm shaft fractures, typically associated with open fractures or open reduction of fractures. In such cases the presence of intramedullary nail would help to stabilize the fracture until healing has been completed or definitive treatment has been performed.

    We agree with Dr. Khan that removal of nails can be difficult at times, especially if significant growth has occurred after fracture fixation or in noncompliant patients who have missed follow-up visits. The nails are usually cut about 10 mm from the bone (3) to facilitate easy removal. Since the annual growth of distal radius and proximal ulna are 7.5 mm and 2.2 mm respectively (6), removal of nails, even one year after initial surgery, should not be problematic.

    The last point that Dr. Khan makes is about the second period of recovery. The recovery following removal of nails is significantly less compared to the index procedure with most patients being able to return to full activities in 2-3 weeks. We do recommend a forearm splint for 6 weeks after removal of nails to avoid the risk of refracture. We don’t believe that the benefit of trying to avoid a second period of recovery would outweigh the risk of refracture and hence would not recommend early removal of elastic nails in forearm fractures.


    1. Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkin's fractures in children. 6th ed. Philadelphia: Lippincott Williams & Wilkins; 2006. p 399-441.

    2. Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B. 1997;6:79-83.

    3. Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop. 1990;10:167-71.

    4. Schmittenbecher PP, Fitze G, Gödeke J, Kraus R, Schneidmüller D. Delayed healing of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop. 2008;28:303-6.

    5. Fernandez FF, Eberhardt O, Langendörfer M, Wirth T. Nonunion of forearm shaft fractures in children after intramedullary nailing. J Pediatr Orthop B. 2009;18:289-95.

    Imran A. Khan, MD
    Posted on January 14, 2011
    Forearm Fractures in Adolescents
    Orthopaedic Surgeon, Countryside Orthopaedics, Leesburg, Virginia

    To the Editor:

    I appreciated the review of fractures in adolescents provided by Parikh et al. in, "Management of Fractures in Adolescents" (2010;92:2947-58). My experience with regard to displaced shaft fractures of the forearm has been that removing the implants at 6-8 weeks after initial treatment provides no increased risk for re-fracture and easier removal, soon after the patient has been removed from the long arm cast. This also allows the patient to have only one period of recovery, rather than a second period of reduced activity 6-8 months later. Removal at 6 months or later will likely make removal more difficult, without providing any significant benefit to the patient.

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