The aims of this study were i) to see if there is an association between poorly applied plasters and redisplacement of paediatric forearm fractures, and ii) to define reliable radiographic measurements to predict redisplacement of these fractures. The two radiographic measurements which were assessed were Cast Index and Padding Index which are a guide to plaster moulding and padding respectively. The sum of these was termed as the Canterbury Index. Case records and radiographs of 142 children who underwent a manipulation for a displaced fracture of forearm were studied. Angulation, translation displacement, Cast index and Padding index were measured on radiographs. Redisplacement was seen in 44 cases (32.3%). The means and 95 % Confidence intervals for cast index and padding index were 0.87 (0.84, 0.90) and 0.42 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redisplacement respectively. Initial displacement, Cast index, Padding index and Canterbury Index were significantly greater in the redisplacement group (p< 0.005). No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. We suggest that Cast Index > 0.8, Padding Index > 0.3 and Canterbury Index > 1.1 are significant risk factors for redisplacement of conservatively treated paediatric forearm fractures

We assessed two simple radiological methods of predicting redisplacement of forearm fractures in children: a) Cast Index (ratio of sagittal to coronal cast width at the fracture site), and b) Padding Index (ratio of padding thickness at the fracture site in the plane of the deformity to the maximum interosseous width). Case records and radiographs of 100 children who underwent a manipulation under general anaesthesia for a displaced fracture of forearm or wrist were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 50 percent of translational displacement on check radiographs at 1–2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. Cast index and Padding index were measured on the check radiographs. Good intra and inter observer reproducibility was observed for both these measurements. The cast index was validated in an experimental study. Redisplacement was seen in 29 cases. Of these 21 cases underwent a secondary procedure for redisplacement. Initial displacement, cast index and padding index were the three factors which were significantly higher in the redisplacement group (p< 0.05). The means and 95% Confidence intervals for cast index and padding index were 0.88 (0.84, 0.90) and 0.48 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redis-placement respectively. No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. Conclusion: cast index and padding index are simple and reliable radiographic measurements to predict the redisplacement of forearm fractures in children. A plaster with a cast index of> 0.9 and padding index of > 0.3 is prone to redisplacement

We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the cast index and padding index and correlated these measurements with the incidence of fracture redisplacement. Phase II assessed these indices for their value in clinical decision making. Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1

The purpose of the study was to identify risk factors that are associated with re-displacement of the hip after surgical reconstruction in cerebral palsy. Retrospective review of children with cerebral palsy who had hip reconstruction with proximal femoral varus derotation osteotomy (VDRO) and Dega-type pelvic osteotomy, between 2005–2012, at a UK and European institution, was performed. Patient demographics, GMFCS, clinical and radiological outcome were assessed as well as the presence of pelvic obliquity and significant scoliosis (Cobb angle > 10 degrees). Redisplacement was defined as Reimer's Migration Index (MI) >30% at final follow-up. Logistic regression analysis was used to assess which factors were predictive of redisplacement and adjusted for clustered variables (α = 0.05). Eighty hips were identified in 61 patients. The mean age at surgery was 8.8 years (± 3.3). Mean MI pre-op was 68% (± 23%) and post-op was 8% (± 12%). At a mean follow-up, of 3.2 years (± 2.0), 23 hips had a MI >30%. Of these; five were symptomatic, and one had required a salvage procedure. Metalwork removal was undertaken in 14 hips. Logistic regression demonstrated that the pre-operative MI and the percentage of acute correction were significant predictors of re-displacement. If the pre-operative MI was greater than 65 percent, the odds ratio (OR) for redisplacement was 5.99 (p = 0.04). If correction of the MI was less than 90% of the pre-operative MI, the OR for re-displacement was 4.6 (p = 0.03). Age at the time of surgery, GMFCS, pelvic obliquity and scoliosis were not predictive of re-displacement. These results, firstly, highlight the importance of hip surveillance in children with cerebral palsy to allow timely intervention to ensure adequate radiological outcomes. Secondly, as in developmental hip dysplasia, full concentric reduction is essential to reduce the risk of re-displacement, with its associated clinical consequences

Purpose

Distal metaphyseal radial fractures are common in the paediatric population and the management of these fractures is controversial. The incidence of re-displacement in the closed management of these fractures is as much as 30% in some studies. Various methods have been described with the view to predict fracture displacement of distal radial fractures in children. One of these indices is the three point index (TPI). This index seeks to assess the adequacy of 3 point moulding and thus predict fracture displacement. It is a calculated ratio that if above 0.8 states that there is an increased risk of fracture re-displacement. The purpose of this study is to assess the accuracy of this index in predicting displacement of distal radial fractures in children.

Distal radius and ulna fractures are a common paediatric injury. Displaced or angulated fractures require manipulation under anaesthetic (MUA) with or without Kirchner (K) wire fixation to improve alignment and avoid malunion. After treatment a proportion redisplace requiring further surgical management. This study aimed to investigate whether the risk of redisplacement could be reduced by introducing surgical treatment guidelines to ascertain whether MUA alone or the addition of K wire fixation was required. A cohort of 51 paediatric forearm fractures managed either with an MUA alone or MUA and K wire fixation was analysed to determine fracture redisplacement rates and factors which predisposed to displacement. Guidelines for optimal management were developed based on these findings and published literature and implemented for the management of 36 further children. A 16% post-operative redisplacement rate was observed within the first cohort. Redisplacement was predicted if an ‘optimal reduction’ of less than 5° of angulation and/or 10% of translation was not achieved and no K wire fixation utilised. Adoption of the new guidelines resulted in a significantly reduced redisplacement rate of 6%. Implementation of departmental guidelines have reduced redisplacement rates of children's forearm fractures at Great Western Hospital

Introduction: We aimed to assess a simple radiological method of predicting redisplacement of paediatric forearm fractures. The Cast Index (CI) is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. A CI of > 0.7 was used as the standard in predicting fracture redisplacement. The cast index has previously been validated in an experimental study. Methods: Case records and radiographs of 1001 children who underwent a manipulation under general anaesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 80 percent of translational displacement on check radiographs at 2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. The CI was measured on postoperative radiographs. Results: Fracture redisplacement was seen in 107 cases at 2 week follow up. Of the 752 patients (75%) with a CI of less than 0.7 the displacement rate was 5.58%. Of the 249 patients (25%) with a CI greater than 0.7 the redisplacement rate was 26%. The CI was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex or ethnicity. Nor were statistical differences noted in initial angular deformity, initial displacement and seniority of the surgeon. Good intra and inter observer reproducibility was observed. There was no statistical difference in patients with a cast index between 0.7 and 0.8. Conclusion: The cast index is a simple and reliable radiographic measurement to predict the redisplacement of forearm fractures in children. Previous studies have used a CI of > 0.7 as the predictor of redisplacement although this study suggests a plaster with a CI of < 0.81 is acceptable. A high cast index is associated with redisplacement of fractures and should therefore be considered when moulding casts in distal forearm fractures

We aimed to assess a simple radiological method of predicting redisplacement of paediatric forearm fractures. The Cast Index (CI) is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. CI of 0.7 was used as the benchmark in predicting fracture redisplacement. Case records and radiographs of 1001 children who underwent a manipulation under general anaesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 80 percent of translational displacement on check radiographs at 2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. The Cast index was measured on the check radiographs. Good intra and inter observer reproducibility was observed for both these measurements. The cast index has been previously validated in an experimental study. The adequacy of reduction after manipulation was estimated by the postreduction translation and angulation of the radius and ulna in anteroposterior and lateral plain film radiographs. The 1001 patients who qualified for the study, fracture redisplacement was seen in 107 cases at the all important two week follow up. Seven hundred and fifty-two patients had cast indices of 0.8 or less whilst 249 had casting indices of 0.81 or more. In patients with cast indices of 0.8 or less, the displacement rate was only 5.58%. However, in patients with cast indices of 0.81 or more, the displacement rate was 26%. Initial displacement, angulation and the post manipulation cast index were the three factors which were significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex or ethnicity. Nor were statistical differences noted in initial angular deformity, initial displacement and seniority of the surgeon. There was no statistical difference in patients with cast indices between 0.7 and 0.8. Cast index is a simple reliable radiographic measurement to predict the redisplacement of forearm fractures in children. A plaster with a CI of > 0.81 is prone to redisplacement. A high cast index is associated with redisplacement of fractures and should therefore be considered when moulding casts is distal forearm fractures

The aim of this study is to discuss the results of intramedullary devices in the management of paediatric radial neck fractures and to suggest methods to avoid the pitfalls of the technique. 30 patients with isolated Judet III and IV fractures were included in this retrospective study. The method of reduction was reviewed. The final results were graded using the Metaizeau functional scoring system and Oxford Elbow score. Intramedullary K wires were used in 10 patients and blunt tipped TENS nails in 20 patients. The complications seen were radiocapitellar joint penetration-6 cases at mean 4.87 weeks, redisplacement − 6, radial epiphyseal sclerosis − 5 and heterotopic ossification − 1 case. The functional result was good to excellent in 24 of 30 cases(80%). The mean Oxford Elbow score was 44.32. The mean follow-up was 40.11 months. Intramedullary K wires may result in radiocapitellar joint penetration. Blunt tipped devices should not be used as purely fixation devices as they may not prevent redisplacement. Minimal redisplacement does not affect the functional outcome. Regular follow-up until atleast 6 weeks is essential. Patients who have a Judet IV fracture and need open reduction should be closely followed up and given a guarded prognosis

Aim: To evaluate the outcome of displaced distal radius fracture in children & review our practice. Methods: A retrospective review of case notes and radiographs of all children requiring orthopaedic intervention under general anaesthetic for displaced distal radius in our hospital over a period of 18 months (January 2005 to June 2006) was carried out. We had treated 72 fractures of the distal radius in same number of children. All but 3 cases were treated by primary closed manipulation & plaster immobilisation. Average age was 11.7 years (range 5 to 16 years). We looked at the re-displacement rate amongst these children that required a second procedure. We also sought predictive factors for redisplacement if any. Results: There were 22 female & 50 male patients. All the fractures were closed injuries with no distal neuro-vascular deficit. Of the 72 cases, 16 cases showed more than 50% initial displacement and 6 were completely displaced (off-ended). 9 cases had volar angulation. Redisplacement of fracture after initial satisfactory reduction was seen in 9 cases (12.7%) & required a second procedure. The secondary procedure involved closed reduction and percutaneous K wire fixation in 4 patients and open reduction in 2 cases. 3 cases had closed remanipulation & change of plaster. We reviewed the factors responsible for re-displacement after a closed reduction such as initial displacement, angulation, adequacy of initial reduction, associated ulna fracture, type of plaster, and initial post-operative images. Average age has been 12.7 years. 3 out of 5 (60 %) completely displaced fractures treated by closed reduction and manipulation required a second procedure. Only 1 in 16 cases of incompletely displaced fracture required a second procedure. Volar angulated fractures tend to redisplace after closed reduction, 3 out of 7cases (42 %) required a second procedure. Associated ulna fracture (22.7%) increased the risks of redisplacement. 5 out of 24 epiphyseal injuries redisplaced but these were either severely displacement or had volar angulation. 3 out of 4 cases (75 %)that were severely displaced had inadequate primary closed reduction & underwent a second procedure. Conclusion: We would like to conclude that despite achieving a very good initial reduction, offended distal radius fractures & those with volar displacement have high risk of re-displacement. Inadequate primary reduction has invariably resulted in requiring a second procedure. It is advisable to treat such cases by primary open reduction and K wire fixation in order to prevent redisplacement. In management of paediatric distal radius fractures, primary reduction with percutaneous Kirschner wire has better outcome and lower incidence of redisplacement in selected cases with features of complete displacement and volar angulation especially in the older age group (> 11 years)

Purpose: To determine the need for routine serial radiographs in the management of forearm fractures in children. Material and Methods: A binational study was conducted in 202 consecutive children with closed forearm fractures. In the 91 patients with stable fractures that did not require reduction, clinical and radiographic examination was performed one week after the start of treatment and again on cast removal 4–6 weeks later. In the remaining 111 patients who underwent closed reduction, an additional X-ray was taken two weeks after cast placement. Outcome was defined as the occurrence of redisplacement. Results: Redisplacement occurred during the first 2 weeks of cast management in 9 of the children who required reduction and in none of the children who did not. Conclusion: Radiographs should be performed one week after cast placement for greenstick or complete fractures that do not require reduction, and repeated at 2 weeks from start of treatment for fractures that require reduction. They need not be performed on cast removal, if clinical examination does not show signs of nonunion or malalignment. The adoption of these recommendations will lead to more cost-effective management and will spare children unnecessary radiographic exposure

Purpose: Waterproof casts have been shown to be a safe and effective means of immobilization in children with minimally displaced fractures. The purpose of this study was to determine if waterproof Gore-Tex-lined casts are as effective as traditional cotton-lined casts in the immediate postoperative period after closed reduction of displaced distal radius fractures in children. Method: We performed a retrospective review of distal radius fractures that underwent closed reduction and application of a long-arm cast between June 2004 and December 2006. A total of 124 cases were included (55 Gore-Tex; 69 traditional cotton-lined). The primary outcome measure was redisplacement in the cast. The cast index was also used to assess the quality of cast molding. Data was analyzed using repeated measures ANOVA. Power analyses were also conducted. Results: There were no significant differences between the two groups with regards to translation of the radius or angulation of the radius on anterior-posterior (AP) and lateral radiographs at the time of injury, postreduction, or cast removal. Redisplacement as measured by the change in translation of the radius and angulation of the radius on AP and lateral radiographs from the time of reduction to cast removal was also not significantly different between the two groups. The mean cast index for the Gore-Tex and traditional cotton-lined groups was 0.882 and 0.873 respectively, which was not a significant difference. Conclusion: A waterproof Gore-Tex-lined cast will maintain fracture reduction as well as a cotton-lined cast for closed reductions of distal radius fractures in children in the immediate postreduction period. Waterproof casts also provide extensive benefits to the patient with regards to bathing, hygiene, and participation in aquatic activities

Background: Distal forearm fractures are common in children. Many studies have described high failure rate when treated by closed reduction and immobilization in plaster cast. Loss of reduced position in the cast has been shown to be the most important factor leading to malunion and failure of the treatment. Treating these fractures by closed reduction and percutaneous Kirsch-ner (K-) wiring has been recommended. Objective: This study aims at determining the value of management of distal forearm fractures in children by closed reduction and percutaneous K-wiring in avoiding treatment failure and improving the final outcome. Material and methods: A series of 70 displaced distal forearm fractures in children was studied. These children were randomly allocated to one of two treatment groups: either manipulation and cast alone, or manipulation and percutaneous K-wiring with cast. Both groups were followed up until union occurred. Looking at the incidence of redisplacement, the radiological position at union, and the functional results four months after injury. Results: Redisplacement occurred in 8 out of 35 patients in the cast group (23%), compared to none in the K-wiring group (the difference was statistically significant).The quality of reduction was significantly better in the K-wire group, both initially and at union. Only 59 patients (84%) were reviewed 4 months after injury, none of the children in both groups had functional deficit

Background: The epidemiology of fracture in children has been reported in detail by other authors. The most common mechanism in their study was a fall in or around the house onto an outstretched hand causing a fracture of the distal radius and ulna. These injuries accounted for 35.8% of all fractures in this age group and the annual incidence was estimated to be 16 per 1000 children in the UK. The controversial issues in the management of distal radius fracture involve what constitutes a degree of fracture displacement and angulation likely to be compensated by remodelling with growth over time, indications for fracture stabilisation with wires or other invasive methods compared with plaster casting alone, details of the position of the arm during immobilisation in a cast, and whether the cast should immobilise the wrist alone or both, the wrist and the elbow. The management of buckle fractures of the distal radius is relatively uncontroversial, involving splintage for symptomatic relief from pain. Some authors have advocated removable wrist supports, with discontinuation of splintage at the parents’ discretion. We performed a systematic review of all areas of the management of distal radius metaphyseal fractures in children. Growth plate injuries were not included for analysis. Methods: Any randomised or quasi-randomised controlled trials which compared types of immobilisation and the use of wire fixation for distal radius fractures in children were included. Types of outcome measures:. Radiological deformity. Effect of cast index. Complications of k-wiring. Remanipulation rates. Compliance with splintage. Cost of various forms of splintage. Effect of intact ulna. Upper limb function while immobilised. Wrist and elbow ROM. 10 studies complied with the inclusion criteria and were analysed using Review Manager software provided by the Cochrane Collaboration. Summary of Results:. Regarding displaced metaphyseal fractures:. K wire fixation reduces redisplacement. There is no proven increase in complications with k wires. Intact ulna favours redisplacement. Long casts do not reduce displacement. Short casts allow better early function. Regarding stable compression fractures:. Removable splints are not associated with displacement. Patients prefer removable splints for buckle fractures. Removable splints cause less discomfort and allow better early function

Introduction. Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures. Study Design. Consecutive radiographic analysis. Materials and methods. 156 consecutive paediatric patients (114M : 42F), with a mean age of 9.8 years (range 2-15 years), presenting with forearm fractures were studied. All patients were manipulated in OR and a moulded above elbow cast was applied. The cast index was measured on immediate post manipulation radiographs. Results. Displacement of the fracture within the original plaster cast occurred in 30 patients (19%), 22/114 males; 8/42 females. The cast index in the 30 patients requiring a second procedure (mean 0.92, SD=0.08) was significantly more than the cast index (mean 0.77, SD=0.07) in the others (p< .001). Discussion. A high cast index in post manipulation radiographs indicates increased risk of re-displacement of the fracture and these patients should be kept under close review. Conclusion. Cast index is a valuable tool to assess the quality of moulding of the cast following closed manipulation of distal radius fractures in children. The maximum acceptable cast index should be 0.82

To evaluate the efficacy of elastic stable intramedullary nailing (ESIN) for the treatment of forearm fractures in children and adolescents. Between June 2002 and August 2007, 28 patients (19 boys – 9 girls) with 28 forearm fractures were treated with ESIN in our department. The mean age was 12.88 years (range 10.9–4.82). Both forearm bones were affected in all cases. 13 patients were treated by intra-medullary splinting immediate after the accident whilst 15 children were operated after failure of conservative treatment and fracture redisplacement. The radius was nailed in a retrograde fashion in all cases. On the other hand antegrade nailing of the ulna was performed in 18 cases whilst retrograde nailing in 5 patients. In 8 cases closed reduction was possible whilst a small incision at the fracture site was necessary in 20 children. In all cases an above-elbow cast was applied for 5 – 6 weeks postoperatively. The healing process was determined on the basis of two-projection radiographs. At the latest follow-up elbow and forearm motion were also assessed. Mean follow-up was 16 months (range, 7 – 28). With the exception of one case all fractures healed within 9 weeks. No case of infection, cross-union or non-union occurred. At the latest follow-up all children presented with complete restoration of elbow movement but three of them had a deficit of pronation of 15–20 degrees. In those cases where an open reduction was required the results were the same as in other cases. Based on our results, retrograde, of both bones, nailing is recommended for the treatment of all displaced forearm fractures in children older than 7 years-old. Proper preoperative curving of the nails offers increased stability maintaining the anatomic relation of the forearm bones

Reduction and K-wiring is the most popular form of treating displaced supracondylar fractures of the humerus. Complications including redisplacement of the fracture, cubitus varus, iatrogenic nerve injuries and pin tract infection have been reported following surgery. For successful outcome with K-wiring of supracondylar fractures, strict adherence to protocols and surgical expertise are necessary. We have treated these fractures in straight arm traction since 1995, and the purpose of this study was to audit our practice. Between January 1995 and December 2000, 112 children with a closed displaced supracondylar fracture of the humerus, without neurovascular deficit, were managed by straight arm traction for a mean duration of 22 days. Final outcome was assessed using clinical (flex-ion-extension arc, carrying angle and residual rotational deformity) and radiographical (metaphyseal-diaphyseal angle and Humero-Capitellar angle) criteria. Our outcomes were compared with those of the recent large studies reporting results of surgical treatment. 71 (63%) patients had excellent, 33 (29%) patients good, 5 (4.4%) patients fair, and 3 (2.6%) patients poor outcome. All patients with fair or poor outcomes were older than 10 years. Elevated straight-arm traction is safe and effective in children younger than 10 years. It can be effectively used in an environment that has provision of paediatric medical care and general orthopaedic expertise with outcomes comparable to those fractures treated surgically in specialist centres

Aims: A retrospective study was done to examine the rate of failure. Methods: The most recent evaluation consisted of a medical papers and a radiographic examination. Between 1992 and 2000 in general orthopaedic unit 222 patients with an acute femoral neck fracture were managed by 180 primary prosthetic replacements and 42 cannulated screws internal fixations (25 percutaneosly and 17 open technique). The patients treated with cannulated screws had a mean age of 63,5 years (range,42 to 88 years) at the time of operation and were followed-up on average for 42 months (range, 12 to 102 months). There were 13 type B1 and 29 type B3 according to AO classification system. Results: Four patients had died early postoperatively (less than 6 months). Femoral neck fracture healed in 24 patients (57%). Osteonecrosis developed in 5 patients (12%). Redisplacement of the fracture and non-union were found in 16 patients (38%). Revision operation was done in 13 patients (10 total arthroplasties, 2 hemiar-throplasties and 1 corrective osteotomy). Conclusions: An acute subcapital desplaced fracture of the femoral neck still remains the so-colled “Unsolved fracture”

Percutaneous fixation is a well recognised technique in the treatment of three-part and four-part fractures of the proximal humerus. Minimal fixation of these fractures do show good functional outcome and may further reduce the incidence of avascular complications. We report a preliminary series of 11 patients who underwent percutaneous minimal fixation of such complex humeral fractures using a new technique. 11 consecutive patients (7 with three-part fractures and 4 with four-part fractures) treated by percutaneous limited fixation in our Hospital were involved in this retrospective study. There were 7 fractures with valgus displacement. Percutaneous technique was employed using small incisions and the fracture was reduced under image guidance. The three-part and the four-part fractures were essentially converted into two part fractures, i.e. only the greater and the lesser tuberosities were re-attached to head with AO cancellous screws after realignment of the fragments. The shaft of the humerus was not fixed to the head in any of the cases. All of these cases had a minimum follow-up of at least 6 months. The results were evaluated using the Constant -Murley Shoulder score. 1 out of 11 cases had to be converted to hemi-arthroplasty due to secondary redisplacement of the fracture. The remaining 10 cases showed good bony union although the greater tuberosity in 2 cases showed a residual superior displacement of 3mm and a residual valgus displacement in 2 out of 7 cases. There were no complications of avascular necrosis in any of the cases. Clinically, compared to the uninjured side the average constant score was 93.7% (range- 68.7% – 100%). 7 patients were very satisfied and 4 were satisfied with the operation. Percutaneous minimal fixation achieves good to very good functional outcome comparable to the conventional methods and theoretically reduces the incidence of infection, avascular necrosis and neurological complications

The majority of diaphyseal forearm fractures in children are treated by closed reduction and plaster immobilisation. There is a small subset of patients where operative treatment is indicated. Recent reports indicate that elastic intramedullary nailing (EIN) is gaining popularity over plate fixation. We report the results of EIN for diaphyseal fractures of the forearm in 44 children aged between 5 and 15 years during a three-year period. The indications were instability (26), redisplacement (14), and open fractures (4). Closed reduction and nailing was carried out in 18 cases. A single bone had to be opened in 16 cases and in 10 cases both bones were opened for achieving reduction. Out of the 39 both bone forearm fractures, 35 patients had stabilisation of both radius and ulna and in 4 cases only a single bone was nailed (Radius 3, Ulna 1). Union was achieved in all the 44 cases at an average time of 7 weeks with one delayed union. All patients regained full flexion and extension of the elbow and wrist. Pronation was restricted by an average of 20° in 30% patients. Complications were seen in 10 patients (20%). 4 patients had prominent metal work which required early removal. There was refracture in one case, which was treated by nail removal and re-fixation. Two patients developed post operative compartment syndrome requiring fasciotomy. EIN of the radius alone in a patient with fractures of both the bones of forearm, led to secondary displacement of the ulna. This resulted in ulnar malunion and a symptomatic distal radio-ulnar joint subluxation. This was successfully treated by ulnar osteotomy. Compared to forearm plating EIN involves minimal scarring, easier removal and less risk of nerve damage. We therefore recommend EIN for the treatment of unstable middle and proximal third forearm fractures