Considerations and Challenges of Resorbable Intramedullary Nailing in Pediatric Forearm Fractures

Abstract

Background: Pediatric diaphyseal forearm fractures, often caused by sports or leisure activities, require treatment based on fracture stability. While stable fractures can be managed conservatively, unstable fractures typically require surgery, with elastic stable intramedullary (IM) nailing (ESIN) being the gold standard. Bioabsorbable IM nails (BINs) offer an alternative by eliminating the need for implant removal surgery. Methods: Between May 2023 and January 2025, we consecutively managed 161 children with poly-L-lactic-co-glycolic acid (PLGA) BINs in two healthcare centers for diaphyseal forearm fracture and evaluated every reported difficulty and complication of resorbable IM nails. Results: Seven unique peri- or postoperative events occurred during the study period. Even with a high success rate, some complications occurred during the study period. Difficulties and complications were mainly dependent on the surgical technique. Iatrogenic complications such as bone cortex perforation and implant end split were evaluated, along with anatomical variations like focal and general medullary cavity stenosis narrowings that affected implant insertion. Secondary malalignment, one early (2 months) refracture, and one recurrent fracture (2 years) were also noted. Conclusions: Although BINs reduce the need for a second surgery, careful planning, technique, and follow-up are crucial for optimal outcomes. Further research is needed to assess long-term results and complications.

Keywords: PLGA; complication; diaphyseal; forearm; fracture; intramedullary; pediatric; resorbable.

Figure 1

Primary X-rays of a distal diaphyseal forearm fracture from (A) anteroposterior (AP) and (B) lateral views. After the insertion of the dilator (blue line), the opposite cortical was perforated (red line). Following this intraoperative complication, elastic nails were inserted, and both bones were stabilized with ESINs. Postoperative X-ray demonstrates good alignment (C).

Figure 2

Preoperative X-rays from AP (A) and lateral (B) aspects of a left-sided both-bone diaphyseal forearm fracture. A red arrow marks the origin of the magnified image (C) showing the measurement of the medullary canal both distal and proximal to the fracture. Both bones were stabilized with ESINs, visible from AP (D) and lateral (E) views.

Figure 3

Initial X-rays of the diaphyseal forearm fracture (lateral (A), AP (B)) and the split end of the resorbable IM nail (C). Postoperative images (lateral (D), AP (F)) show good alignment of the bones. However, the red arrow highlights an area from Figure 3D, where the magnified AP view (E) demonstrates a two mm displacement of the radius, which caused the injury of the implant. A yellow circle shows the β-TCP tip and location where it left the medullary cavity.

Figure 4

Postoperative X-rays (AP (A), lateral (B)) depict the fracture stabilization in good alignment. The β-TCP marker is visible in the right radius at the level of the diaphysis, two cm proximal to the fracture site. The cause is visible in the magnified image (C), where the medullary cavity narrows, creating a sandglass effect, marked by the red circle.

Figure 5

Preoperative (from AP (A) and lateral (B) views), and immediately postoperative (AP (C), lateral (D)), control radiographs. Follow-up X-rays were taken one week (AP (E), lateral (F)), eight weeks (AP (G), lateral (H)), and six months postoperatively (AP (I), lateral (J)), exhibiting good callus formation and remodeling. Left wrist supination showed a 10° deficit (K), with no discrepancy in pronation range (L).

Figure 6

Control X-rays four weeks postoperatively showed good alignment from AP (A) and lateral (B) aspects. Radiographs at re-presentation eight weeks postoperatively, indicated refracture (AP (C), lateral (D)). Control X-rays after cast application upon re-presentation with refracture, showing good alignment (AP (E), lateral (F)). Follow-up radiographs taken six months postoperatively indicate adequate fracture healing (AP (G), lateral (H)).

Figure 7

Markers are visible in both bones two years after the primary treatment with BINs (lateral (A), AP (B)). Postoperative X-rays show the perfect alignment of the forearm, stabilized with ESINs (AP (C), lateral (D)).