ESIN

Most of the ulnar fractures are in the proximal 1/3 so retrograde nailing of both bones is recommended.

The ESIN method involves closed reduction and internal fixation of both fractures with elastic nails or K-wires.

It can be used in any age group and any combination of fracture types.

Note: The risk of avascular necrosis of the radial head is higher after open reduction which should be avoided if possible.

The ulna is treated first.

The radial neck fracture may spontaneously reduce after anatomical reduction and fixation of the ulna.

The radial neck fracture should also be fixed with an intramedullary nail to prevent redisplacement and to allow early joint mobilization.

This procedure is normally performed with the patient in a supine position.

The steps for ulnar fracture fixation are described in the following ESIN procedure:

• ESIN for complete fracture (22u-D/4 and 22u-D/5)

The steps required for proximal radial fracture fixation are described in the ESIN procedures for each fracture type:

• ESIN for Salter-Harris I (21r-E/1.1)
• ESIN for Salter-Harris II (21r-E/2.1 and 21r-E/2.2)

Check the completed osteosynthesis with image intensification. These images should be retained for documentation or alternatively an x-ray should be obtained before discharge.

Make sure that the desired reduction has been achieved and the nails are of appropriate length.

Whilst the child remains in bed, the forearm should be elevated on pillows to reduce swelling and pain.

They should be encouraged to use the arm.

Cast immobilization is not necessary and hinders early recovery of joint movement.

For Monteggia lesions treated with ulnar nailing, the forearm may be immobilized in a cast in the position of maximum stability of the radiocapitellar joint for 2-4 weeks.

Ibuprofen and paracetamol should be administered regularly during the first 4-5 days of injury, with additional oral narcotic medication for breakthrough pain.

If pain is increasing the child should be examined.

The child should be examined regularly, to ensure finger range of motion is comfortable and adequate.

Neurological and vascular examination should also be performed.

Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which are a late phenomenon.

See also the additional material on postoperative infection.

Compartment syndrome is a possible early postoperative complication that may be difficult to diagnose in younger children.

The presence of full passive or active finger extension, without discomfort, excludes muscle compartment ischemia.

If there are signs of a compartment syndrome:

1. If the child is in a cast, split the cast, along its full length down to skin level.
2. Elevate the limb.
3. Encourage active finger movement.
4. Reexamine the child after 30 min.

If a definitive diagnosis of compartment syndrome is made, then a fasciotomy should be performed without delay.

Discharge from hospital follows local practice and is usually possible after 1-3 days.

The parent/carer should be taught how to assess the limb.

They should also be advised to return if there is increased pain or decreased range of finger movement.

It is important to provide parents with the following additional information:

• The warning signs of compartment syndrome, circulatory problems and neurological deterioration
• Hospital telephone number
• Information brochure

For the first few days, the elbow and forearm can be elevated on a pillow, until swelling decreases and comfort returns.

The arm can be placed in a sling for a few days until the patient is pain free. Many children are more comfortable without support.

Early movement of the forearm should be encouraged as soon as the patient is pain free.

Physiotherapy is normally not indicated.

The first clinical and radiological follow-up depends on the age of the child and is usually undertaken 4-6 weeks postoperatively.

At this point, the child should be able to move the forearm almost fully with some limited rotation caused by callus formation.

AP and lateral x-rays are required.

See also the additional material on healing times.

Nail removal is delayed until the fracture has modelled completely and can be performed as a day case, under general anesthesia.

The nail end in the proximal ulna can often be easily palpated.

In the distal radius and ulna, the nail end may slip under tendons and nerves. This may irritate the soft tissues and make it difficult to palpate the nail tip.

Exposure of the nail end should be performed under direct vision with small retractors.

In most cases, a small bursa has formed. Once this bursa is opened, the end of the nail can be seen.

The nail can be removed with the extraction pliers, or a similar clamp. A strong needle holder is also useful.