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Surgical interventions for diaphyseal fractures of the radius and ulna in children

  1. Alwyn Abraham1,*,
  2. Sujit Kumar2,
  3. Samena Chaudhry3,
  4. Talal Ibrahim4

Editorial Group: Cochrane Bone, Joint and Muscle Trauma Group

Published Online: 9 NOV 2011

Assessed as up-to-date: 6 JUN 2011

DOI: 10.1002/14651858.CD007907.pub2


How to Cite

Abraham A, Kumar S, Chaudhry S, Ibrahim T. Surgical interventions for diaphyseal fractures of the radius and ulna in children. Cochrane Database of Systematic Reviews 2011, Issue 11. Art. No.: CD007907. DOI: 10.1002/14651858.CD007907.pub2.

Author Information

  1. 1

    Leicester Royal Infirmary, Department of Paediatric Orthopaedics, Leicester, UK

  2. 2

    The County Hospital, Department of Trauma and Orthopaedics, Hereford, UK

  3. 3

    Selly Oak Hospital, Department of Trauma and Orthopaedics, Birmingham, UK

  4. 4

    Leicester Royal Infirmary, Department of Orthopaedic Surgery, Leicester, UK

*Alwyn Abraham, Department of Paediatric Orthopaedics, Leicester Royal Infirmary, Ward 14, Infirmary Square, Leicester, LE1 5WW, UK. alwyn.abraham@uhl-tr.nhs.uk. alwynabraham2010@gmail.com.

Publication History

  1. Publication Status: New
  2. Published Online: 9 NOV 2011

SEARCH

 

Background

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

In children, diaphyseal or shaft fractures of one or both of the two forearm bones (radius and ulna) usually result from falling onto an outstretched hand (Worlock 1986). A large epidemiological study of fractures in children aged 12 and under in Nottingham, UK in 1981 reported that diaphyseal fractures of the radius and ulna constituted 6.5% of fractures in this population (Worlock 1986). A more recent epidemiological study conducted in Edinburgh reported a rate of 5.4% of all fractures in children under 16 years of age (Rennie 2007). This study reported around twice as many males as females sustained these fractures, at an average age of 7.8 years.

 

Description of the condition

A fracture of the forearm is an acute painful condition requiring pain relief and plaster cast splintage. Pain reduces gradually over the course of two weeks. Splintage also helps to prevent increasing deformity while the fracture unites. Once fracture union occurs and motion at the fracture site ceases, splintage can be discontinued and function of the forearm is gradually restored.

Fracture of the ulna shaft can occur with dislocation of the radial head proximally at the elbow (Monteggia fracture). Reduction of the ulna deformity allows relocation of this dislocation. A similar dislocation of the distal radio-ulnar joint can occur with fractures of the distal radius (Galeazzi fracture).

The forearm functions as a joint allowing for forward rotation (pronation: palm faces downwards) or backward rotation (supination: palm faces upwards) (Gray 1918). This increases the functions a hand can perform, such as turning a key to lock or unlock a door. This ability to pronate and supinate depends, amongst other things, on the shape of the radial diaphysis. Interventions for radius and ulna diaphyseal fractures which restore the pre-fracture shape of these bones should therefore result in better forearm pronation-supination function than interventions that result in residual deformity.

In children, a deformed bone can remodel with growth over time. This remodelling potential is greatest in children under the age of five, where remodelling up to 30 degrees of deformity in the forearm is possible. The potential for bone remodelling is considerably reduced in older children, especially as they approach skeletal maturity. The extent of deformity and anticipated capacity for remodelling are likely to influence the treatment decisions.

 

Description of the intervention

Surgical intervention is aimed at reduction and then surgical stabilisation of the fracture.

Fracture reduction reduces the deformity following a fracture by normalising the alignment of the radius and ulna. Reduction can either be closed (externally by manipulation under X-ray control) or open (by surgical exposure, visualisation and instrumentation).

Surgical stabilisation of the fracture involves holding the reduction such that the restored alignment following reduction is maintained. Devices for surgical stabilisation can be either internal to the forearm or external such as an external fixator. Internal devices can either be intramedullary nails, typically nowadays these are elastic stable intramedullary nails (ESIN), or a combination of plates and screws.

In children, the trend has generally been to remove orthopaedic implants once the operated bone has fully healed. This is usually undertaken a year or so after operation before new bone formation buries the implant completely. Removal of intramedullary nails is much easier than plates or other implants that are fixed to the bone. Access to the ends of intramedullary nails is usually in safe zones, where neurovascular structures (nerves and blood vessels) are not at risk. Conversely plate removal requires a surgical dissection though inter-nervous or inter-muscular planes. These planes are often scarred and less discrete following previous open reduction and internal fixation. Thus repeat surgery, for the removal of plates and screws, requiring dissection may endanger neurovascular structures and result in complications.

 

How the intervention might work

Surgical stabilisation prevents motion at the fracture site, thereby preventing displacement and recurrence of deformity at the fracture site. Anatomical restoration should help to maximise function of the forearm once rehabilitation from the injury is complete.

Generally intramedullary nailing consists of a manipulation (closed reduction) with percutaneous insertion (through a small incision in the skin) of the Elastic Stable Intramedullary Nail (ESIN). This technique allows for the formation of callus from the fracture haematoma which subsequently ossifies. The fracture ends are manipulated to approximate the shape of the pre-fracture radial shaft before being secured using an ESIN.

Open reduction and internal fixation (ORIF) involves surgical dissection and exposure of the fracture. The two ends of the fractured bone are perfectly matched like a jigsaw. This type of reduction is both macroscopic and microscopic allowing for the restoration of the microscopic, cellular and matrix bone anatomy, without the need for bridging callus. The reduced bone is then stabilised using an implant, typically a plate with screws.

 

Why it is important to do this review

The indications for surgical interventions, for diaphyseal fractures of the radius and ulna in children, are not clear. Similarly, the relative effects of various methods of surgery, particularly intramedullary nailing and plate fixation are not established.

 

Objectives

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We aimed to evaluate the evidence from randomised and quasi-randomised controlled trials comparing the effects (benefits and harms) of a) surgical versus non-surgical interventions, and b) different surgical interventions for the fixation of fractures of the forearm in children.

 

Methods

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Criteria for considering studies for this review

 

Types of studies

We planned to include any randomised or quasi-randomised (for example, allocation by date of birth or alternation) controlled trials which compared a) surgical versus non-surgical interventions and b) different surgical interventions for fractures of the forearm in children.

 

Types of participants

Children (babies, infants, young children or adolescents) who had a displaced diaphyseal fracture of the radius or ulna diagnosed radiographically. In addition, planned for inclusion were children with diaphyseal fractures of both bones. Excluded were Monteggia and Galeazzi fractures. Fractures of the distal radius and ulna were excluded also: these are reviewed in Abraham 2008.

 

Types of interventions

Realignment of displaced fractures (reduction) can be achieved by closed (manipulation) or open (surgical exposure) means. Non-surgical or conservative treatment usually comprises immobilisation using splints or casts. Methods of surgical stabilisation include external fixation, such as with an external fixator, or internal fixation, such as intramedullary nailing or a combination of plates and screws.

 

Types of outcome measures

We sought the following outcome measures:

 

Primary outcomes

1. Function including activities of daily living and impairments such as loss of forearm rotation and wrist range of motion
2. Complications from treatment including refracture/periprosthetic fracture, infection and nerve or tendon injuries
3. Secondary treatment including surgery for implant removal

 

Secondary outcomes

1. Quality of life measures
2. Resource use and other costs
3. Redisplacement and residual deformity
4. Patient (child) satisfaction and adherence (compliance); parent satisfaction and adherence to treatment plan

 

Search methods for identification of studies

 

Electronic searches

We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2011), the Cochrane Central Register of Controlled Trials (The Cochrane Library, Wiley Online Library 2011 Issue 1), MEDLINE (OvidSP 1948 to February week 4 2011) and EMBASE (OvidSP 1980 to 2011 Week 09). In MEDLINE, the subject specific search was combined with the sensitivity-maximizing version of the Cochrane Highly Sensitive Search Strategy for identifying randomised trials (Lefebvre 2008) (see Appendix 1). This strategy was modified for use in the Cochrane Central Register of Controlled Trials and EMBASE (see Appendix 1).

We also searched Current Controlled Trials and the WHO International Clinical Trials Registry for ongoing and recently completed trials (May 2011) (see Appendix 1).

No language restrictions were applied.

 

Searching other resources

We searched reference lists of articles and contacted researchers in this field.

 

Data collection and analysis

 

Selection of studies

The initial searches were carried out by all authors, assisted by the Cochrane Bone, Joint and Muscle Trauma Group's editorial base. All authors assessed potentially eligible trials for inclusion and any disagreement was resolved through discussion. Titles of journals, names of authors or supporting institutions were not masked at any stage.

 

Data extraction and management

Should trials be included in a future update, all authors will independently perform data extraction using a pre-piloted form. Any disagreement will be resolved through discussion.

 

Assessment of risk of bias in included studies

We had planned for all authors to independently assess the risk of bias of the included studies using The Cochrane Collaboration's 'Risk of bias' tool (Higgins 2008). This tool incorporates assessment of randomisation (sequence generation and allocation concealment), blinding (participants, personnel and outcome assessors), completeness of outcome data, selection of outcomes reported and other sources of bias. We will consider also other sources of bias, specifically bias from major imbalances in key baseline characteristics (e.g. age, gender, and concomitant ulna shaft fracture); and performance bias from systematic differences in the care provided (e.g. care provider experience, and rehabilitation). Risk of bias associated with a) blinding and b) completeness of outcomes for patient-reported outcomes and objective outcomes would have been done separately.

 

Measures of treatment effect

When quantitative data become available, we plan to calculate risk ratios with 95% confidence intervals for dichotomous outcomes, and mean differences with 95% confidence intervals for continuous outcomes.

 

Unit of analysis issues

The unit of randomisation in these trials is usually the individual patient. Exceptionally, as in the case of trials including children with bilateral fractures, data for trials are presented for fractures or limbs rather than individual patients. In future updates, where such unit of analysis issues arise and appropriate corrections have not been made, we will consider presenting the data for such trials only where the disparity between the units of analysis and randomisation is small. Where data are pooled, we plan to perform a sensitivity analysis to examine the effects of pooling these incorrectly analysed trials with the other correctly analysed trials.

 

Dealing with missing data

Where appropriate, we would have performed intention-to-treat analyses to include all children randomised to the intervention groups. We would have investigated the effect of drop outs and exclusions by conducting worse and best scenario analyses. We indicated that we would be alert to the potential mislabelling or non-identification of standard errors and standard deviations, and, unless missing standard deviations could be derived from confidence interval data, we would not assume values in order to present these in the analyses.

 

Assessment of heterogeneity

Should this be relevant in a future update, we intend to assess heterogeneity by visual inspection of the forest plot (analysis) along with consideration of the test for heterogeneity and the I² statistic (Higgins 2003).

 

Assessment of reporting biases

If sufficient data become available, we will attempt to assess publication bias by preparing a funnel plot. Our search of 'grey literature' and pursuit of trials listed in clinical trial registers should help to address publication bias.

 

Data synthesis

If possible in future and considered appropriate, results of comparable groups of trials will be pooled. Initially we will use the fixed-effect model and 95% confidence intervals. We will also consider using the random-effects model, especially where there is unexplained heterogeneity.

 

Subgroup analysis and investigation of heterogeneity

Our pre-specified subgroup analyses are by age (under 5 years; 5 to 10 years; 11 years or above), gender and the presence of a fracture of the ulna. To test whether the subgroups are statistically significantly different from one another, we will test the interaction using the technique outlined in Altman 2003 or use the test for subgroup differences facility in RevMan.

 

Sensitivity analysis

In future updates, and where possible, we plan sensitivity analyses examining various aspects of trial and review methodology, including the effects of missing data, risk of bias (specifically relating to allocation concealment, outcome assessor blinding and reportage of surgical experience), and inclusion of trials only reported in abstracts.

 

Results

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Description of studies

See: Characteristics of excluded studies; Characteristics of ongoing studies.

 

Results of the search

We screened 162 citations up to March 2011 from the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register (10 records), The Cochrane Library (17), MEDLINE (82) and EMBASE (53). A search of the Current Controlled Trials platform yielded one further trial (Colaris). Only 15 studies were considered potentially eligible after initial screening. Of these, two were RCTs (Agarwal 2004; Colaris). We have been unable to find the full paper by Agarwal despite help from the Cochrane Group and have also been unsuccessful in obtaining data or further information on trial methods from the listed authors. Efforts to contact the main author failed and the co-author does not have the data (Hammer 2010). This study (Agarwal 2004) therefore has been excluded. The Colaris study is not yet complete at the time of writing and has therefore been included in the Characteristics of ongoing studies, to be assessed for future updates of this review.

 

Included studies

None of the completed and published studies identified in the detailed searches fulfilled the inclusion criteria.

 

Excluded studies

Fourteen studies were excluded (see the Characteristics of excluded studies for details).

 

Risk of bias in included studies

There were no completed studies included in this review.

 

Effects of interventions

There were no completed studies included in this review.

 

Discussion

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

A thorough search of the medical literature failed to reveal any completed and published randomised or quasi-randomised trials comparing different methods, whether surgical or non-surgical, for the treatment of radius and ulna diaphyseal fractures in children. We, however, identified one completed randomised controlled trial (Agarwal 2004), which compared elastic intramedullary nailing with plate fixation of long bone fractures in 66 children, of whom 49 had forearm fractures, that was reported only in conference abstracts. Regrettably, it seems very unlikely that a full report of this trial will ever become available. This leaves us with our other find of an ongoing randomised controlled trial (Colaris), which has completed recruitment but failed to make its recruitment target. Nonetheless, we anticipate that a full report of this study, which compares one versus two elastic stable intramedullary nails, will be available for a future update of this review.

While it is possible that there may be other randomised trials on this topic that remain unpublished and have gone unnoticed in our search, we suggest that the submission for publication of such rare studies would be unlikely to meet with rejection from editors of most orthopaedic journals. We strongly encourage all trialists to publish the results of their trials in full.

 

Authors' conclusions

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

 

Implications for practice

We would like to emphasise our finding of a lack of evidence from randomised controlled trials to inform on the available choices for treatment of diaphyseal fractures of the radius and ulna in children. Specifically, there is no best quality evidence to inform practice in terms of when to operate and on the choice of method of surgical stabilisation.

 
Implications for research

Diaphyseal fractures in children are common and there remains a need for studies to help inform key treatment decisions. Ideally such studies would be well conducted randomised trials with adequate follow-up to assess for healing, functional recovery, refracture rates and the complications associated with implant removal. Such studies should be preceded by evidence-based discussions amongst specialists and other stakeholders in this area that aim to establish the priority topics in current practice that would merit investigation in multi-centre randomised controlled trials. It should be noted that treatment outcomes of single bone forearm fractures (isolated radius or ulna diaphyseal fractures) may be importantly different from those for fractures of both forearm bones. Thus, at minimum, all studies with mixed populations should present separate data for these different fracture populations.

 

Acknowledgements

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Lindsey Elstub has been extremely supportive to the authors during the lengthy process from conception to finish. We wish to acknowledge the advice, feedback and administration she has provided. The searches with updates were provided by Lesley Gillespie and Joanne Elliott, for which we are very grateful.

We also like to thank the following for their help with feedback during editorial and external review of the protocol and review: Helen Handoll, Alastair Murray, Ben Vandemeer and Janet Wale.

 

Data and analyses

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

This review has no analyses.

 

Appendices

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Appendix 1. Search strategies

 

The Cochrane Central Register of Controlled Trials (Wiley Online Library)

#1 MeSH descriptor Radius, this term only (117)
#2 MeSH descriptor Ulna, this term only (28)
#3 (#1 OR #2) (670)
#4 MeSH descriptor Fractures, Bone, this term only (748)
#5 MeSH descriptor Fracture Fixation explode all trees (237)
#6 MeSH descriptor Fracture Healing, this term only (129)
#7 (#4 OR #5 OR #6) (1382)
#8 (#3 AND #7) (22)
#9 MeSH descriptor Radius Fractures, this term only (150)
#10 MeSH descriptor Ulna Fractures, this term only (27)
#11 ((forearm or radius or radial or ulna*) near3 fractur*) (356)
#12 (#8 OR #9 OR #10 OR #11) 396)
#13 (shaft or diaphys*) (481)
#14 (#12 AND #13) in Clinical Trials (17)

 

MEDLINE (OvidSP)

1     Radius/ or Ulna/ or Forearm Injuries/ (10940)
2     Fractures, Bone/ or exp Fracture Fixation/ or Fracture Healing/ (75992)
3     and/1-2 (1778)
4     Radius Fractures/ or Ulna Fractures/ (6805)
5     or/3-4 (7942)
6     ((forearm or radius or radial or ulna$1) adj3 fractur$).tw. (4551)
7     or/5-6 (9024)
8     (forearm or shaft or midshaft or diaphys$).tw. (41160)
9     and/7-8 (2654)
10     exp Pediatrics/ (37196)
11     exp Infant/ (832486)
12     exp Child/ (1359668)
13     Adolescent/ not exp Adult/ (416670)
14     (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw. (1176311)
15     or/10-14 (2173073)
16     and/9,15 (872)
17     Randomized controlled trial.pt. (300417)
18     Controlled clinical trial.pt. (81837)
19     randomized.ab. (207921)
20     placebo.ab. (122109)
21     Drug therapy.fs. (1427896)
22     randomly.ab. (151069)
23     trial.ab. (214457)
24     groups.ab. (1009219)
25     or/17-24 (2634820)
26     exp Animals/ not Humans/ (3543352)
27     25 not 26 (2233968)
28     and/16,27 (82)

 

EMBASE (OvidSP)

1     Radius/ or Ulna/ (9773)
2     Fracture/ or exp Fracture Fixation/ or exp Fracture Healing/ (101940)
3     1 and 2 (1671)
4     Radius Fracture/ or Ulna Fracture/ (6636)
5     3 or 4 (7777)
6     ((forearm or radius or radial or ulna$1) adj3 fractur$).tw. (5355)
7     5 or 6 (9741)
8     (shaft or diaphys$).tw. (19550)
9     7 and 8 (893)
10     exp Pediatrics/ (57963)
11     exp Infant/ (457420)
12     exp Child/ (1449902)
13     Adolescent/ not exp Adult/ (402011)
14     (paediatr$ or pediatr$ or neonate$ or bab$3 or infant$ or child$ or teenage$ or adolescen$).tw. (1357992)
15     10 or 11 or 12 or 13 or 14 (2135713)
16     9 and 15 (291)
17     exp Randomized Controlled trial/ (290476)
18     exp Double Blind Procedure/ (101826)
19     exp Single Blind Procedure/ (13968)
20     exp Crossover Procedure/ (30289)
21     Controlled Study/ (3460885)
22     or/17-21 (3527135)
23     ((clinical or controlled or comparative or placebo or prospective$ or randomi#ed) adj3 (trial or study)).tw. (535863)
24     (random$ adj7 (allocat$ or allot$ or assign$ or basis$ or divid$ or order$)).tw. (132542)
25     ((singl$ or doubl$ or trebl$ or tripl$) adj7 (blind$ or mask$)).tw. (130488)
26     (cross?over$ or (cross adj1 over$)).tw. (55289)
27     ((allocat$ or allot$ or assign$ or divid$) adj3 (condition$ or experiment$ or intervention$ or treatment$ or therap$ or control$ or group$)).tw. (158921)
28     or/23-27 (803148)
29     or/22,28 (3901636)
30     limit 29 to human (2361931)
31     30 and 16 (53)

 

Current Controlled Trials

  1. children AND fracture
  2. paediatric AND fracture
  3. pediatric AND fracture

 

WHO International Clinical Trials Registry

Advanced Search facility: multiple searches carried out in both the ‘Title’, or ‘Condition’ fields (separately), limiting to ‘Clinical trials in children’

Recruitment status: all.

  1. forearm and fracture
  2. torus and fracture
  3. buckle and fracture
  4. radius and fracture
  5. ulna and fracture

 

History

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Protocol first published: Issue 3, 2009
Review first published: Issue 11, 2011

 

Contributions of authors

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

Alwyn Abraham:

  1. Conception and design of study
  2. Analysis and interpretation of data.
  3. Drafting the review
  4. Guarantor of the review

Sujit Kumar:

  1. Conception and design of study
  2. Commenting on the draft critically for intellectual content
  3. Final approval of the document to be published.

Sameena Chaudhry:

  1. Analysis and interpretation of data
  2. Commenting on the draft critically for intellectual content
  3. Final approval of the document to be published.

Talal Ibrahim:

  1. Analysis and interpretation of data.
  2. Commenting on it critically for intellectual content.
  3. Final approval of the document to be published.

 

Declarations of interest

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

None known.

 

Sources of support

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms
 

Internal sources

  • Leicester Royal Infirmary, Leicester, UK.

 

External sources

  • No sources of support supplied

 

Differences between protocol and review

  1. Top of page
  2. Background
  3. Objectives
  4. Methods
  5. Results
  6. Discussion
  7. Authors' conclusions
  8. Acknowledgements
  9. Data and analyses
  10. Appendices
  11. History
  12. Contributions of authors
  13. Declarations of interest
  14. Sources of support
  15. Differences between protocol and review
  16. Index terms

We used the Cochrane Highly Sensitive Search Strategy in the MEDLINE sensitivity-maximizing version for identifying randomised trials.

* Indicates the major publication for the study

References

References to studies excluded from this review

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Agarwal 2004 {published data only}
  • Agarwal A, Hammer A, Deep K, Morar Y, Jones CB, Nascone JW. Is elastic intramedullary nailing technique better in children? A prospective randomised trial [abstract]. American Academy of Orthopaedic Surgeons Annual Meeting; 2006 Mar 22-26; Chicago. 2006.
  • Agarwal A, Hammer AJ, Deep D, Morar Y. Is elastic intramedullary nailing technique better in children? A prospective randomized trial [abstract]. European Journal of Trauma 2004;30(3):214.
  • Agarwal A, Selven, Hammer AJ, Deep K, Morar Y. Is elastic intramedullary nailing technique better in children? A prospective randomised trial [abstract]. Journal of Bone and Joint Surgery - British Volume 2006;88 Suppl 1:119.
  • Hammer A. Personal correspondence 2010.
Bhaskar 2001 {published data only}
  • Bhaskar AR, Roberts JA. Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate?. Journal of Bone and Joint Surgery - British Volume 2001;83(2):253-8.
Collinge 2000 {published data only}
  • Collinge CA, Herscovici D Jr. Open reduction and plating vs. intramedullary nailing for diaphyseal forearm fractures: A prospective randomized study [abstract]. Journal of Orthopaedic Trauma 2000;14(2):121.
Fernandez 2005 {published data only}
  • Fernandez FF, Egenolf M, Carsten C, Holz F, Schneider S, Wentzensen A. Unstable diaphyseal fractures of both bones of the forearm in children: Plate fixation versus intramedullary nailing. Injury 2005;36(10):1210-6.
Hertlein 2000 {published data only}
  • Hertlein H. Aidelsburger P. Huber A. Hartl WH. Andress HJ. Unstable pediatric femoral and forearm shaft fractures. Comparison between conservative treatment and stable intramedullary nailing [Instabile kindliche Femur- und Unterarmschaftfrakturen. Vergleich zwischen konservativer Behandlung und stabiler intramedullarer Schienung]. Zentralblatt fur Chirurgie 2000;125(9):756-62.
Johari 1999 {published data only}
Jubel 2005 {published data only}
  • Jubel A, Andermahr J, Isenberg J, Bergmann H, Prokop A, Rehm KE. Elastic stable intramedullary nailing (ESIN) for forearm fractures in children [Die elastisch stabile intramedullare nagelung (ESIN) instabiler kindlicher unterarmfrakturen]. Aktuelle Traumatologie 2004;34(3):111-6.
  • Jubel A, Andermahr J, Isenberg J, Issavand A, Prokop A, Rehm KE. Outcomes and complications of elastic stable intramedullary nailing for forearm fractures in children. Journal of Pediatric Orthopaedics Part B 2005;14(5):375-80.
Kucukkaya 2004 {published data only}
  • Kucukkaya M, Kabukcuoglu Y, Tezer M, Eren T, Kuzgun U. The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures. Journal of Orthopaedic Trauma 2002;16(5):340-4.
Lascombes 2005 {published data only}
  • Lascombes P, Hamel A, Geffroy L, Sales De Gauzy J, Abid A, Gicquel P, et al. Forearm shaft fractures. Revue de Chirurgie Orthopedique et Reparatrice de l'Appareil Moteur 2005;91(5 Suppl):2S97-2S135.
Luhmann 1998 {published data only}
Majed 2007 {published data only}
Myers 2004 {published data only}
  • Myers GJC, Gibbons PJ, Glithero PR. Nancy nailing of diaphyseal forearm fractures: Single bone fixation for fractures of both bones. Journal of Bone and Joint Surgery - British Volume 2004;86(4):581-4.
Roy 1990 {published data only}
Schmittenbecher 2008 {published data only}
  • Schmittenbecher PP, Fitze G, Godeke J, Kraus R, Schneidmuller D. Delayed healing of forearm shaft fractures in children after intramedullary nailing. Journal of Pediatric Orthopaedics 2008;28(3):303-6.

References to ongoing studies

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Colaris {unpublished data only}
  • Colaris, J. Treatment of unstable both-bone midshaft forearm fractures in children: A randomized trial between 1 and 2 elastic stable intramedullary nails. http://clinicaltrials.gov/show/NCT00314587 (accessed 31 March 2011).
  • Colaris J. personal communication June 23 2011.

Additional references

  1. Top of page
  2. AbstractRésumé
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Acknowledgements
  10. Data and analyses
  11. Appendices
  12. History
  13. Contributions of authors
  14. Declarations of interest
  15. Sources of support
  16. Differences between protocol and review
  17. Characteristics of studies
  18. References to studies excluded from this review
  19. References to ongoing studies
  20. Additional references
Abraham 2008
Altman 2003
Gray 1918
  • Gray H. Anatomy of the Human Body. http://www.bartleby.com/107/pages/page324.html. New York: bartleby.com, 2000. Philadelphia: Lea & Febiger, 1918.
Hammer 2010
  • Hammer A. Personal correspondence 2010.
Higgins 2003
Higgins 2008
  • Higgins JPT, Altman DG, editors. Assessing risk of bias in included studies. Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]; Chapter 8. http://www.cochrane-handbook.org/ (accessed 17 Nov 2008).
Lefebvre 2008
  • LeFebvre C, Manheimer E, Glanville J. Chapter 6.4.11 Box 6.4.c: Cochrane Highly Sensitive Search Strategy for identifying randomized trials in MEDLINE: sensitivity-maximizing version. In: Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.1 (updated September 2008). The Cochrane Collaboration, 2008. Available from www.cochrane-handbook.org.
Rennie 2007
Worlock 1986