ORIGINAL ARTICLE

Comparison of Intramedullary Nailing to Plating for

Both-Bone Forearm Fractures in Older Children
Keith R. Reinhardt, MD,* David S. Feldman, MD, Daniel W. Green, MD,* Debra A. Sala, MS, PT,
Roger F. Widmann, MD,* and David M. Scher, MD*
Background: When operative stabilization of forearm fractures in
older children is necessary, the optimal method of xation is
controversial. This study compared the radiographic and functional
outcomes of intramedullary nailing to plating of forearm fractures in
children between 10 and 16 years of age.
Methods: Thirty-one patients who underwent operative xation of
midshaft radius and ulna fractures were divided into nailing and
plating groups and were compared retrospectively according to
perioperative data and patient outcome measures (fracture union at 3
and 6 months, loss of forearm rotation, restoration of radial bow
magnitude and location, and complication rates).
Results: The nailing group had 19 patients, with a mean age of 12.5
years (range, 10Y14.6 years), and the plating group had 12, with a
mean age of 14.5 years (range, 11.9Y16 years). Groups were similar
for sex, arm injured, fracture location, Arbeitsgemeinschaft fur
Osteosynthesefragen/Orthopaedic Trauma Association classication,
and number of open fractures. Duration of surgery and tourniquet use
were signicantly shorter in the nailing group (P = 0.037 and 0.001,
respectively). No differences were found between the groups for
fracture union at 3 or 6 months. At latest follow-up, radial bow
magnitude was similar for the 2 groups and restored to normal in
both. Radial bow location in the nailing group was signicantly
different from the reported normal values (P = 0.001). Despite this,
there was no difference in loss of forearm rotation between groups.
Complication rates were also similar between groups, with 1 ulna
nonunion, 1 compartment syndrome, and 2 refractures in the nailing
group and 1 radius and ulna nonunion, 1 broken plate, and 2
refractures in the plating group.
Conclusions and Significance: Based on similar functional and
radiographic outcomes, nailing of length-stable forearm fractures
remains an equally effective method of xation in skeletally immature
patients 10 to 16 years of age when compared with plating and is our
treatment of choice.
Level of Evidence: Therapeutic level IIIVretrospective comparative
study
Key Words: forearm fracture, both-bone, pediatric, intramedullary
nailing, open-reduction internal xation, children
(J Pediatr Orthop 2008;28:403Y409)

raditionally, most fractures of the forearm in children

younger than 10 years are treated nonoperatively with

From the *Hospital for Special Surgery; and NYU Hospital for Joint
Diseases, New York, NY.
None of the authors received financial support for this study.
Reprints: Keith R. Reinhardt, MD, Hospital for Special Surgery, 310 East 71st
St, Apt 2L, New York, NY 10021. E-mail: reinhardtk@hss.edu.
Copyright * 2008 by Lippincott Williams & Wilkins

J Pediatr Orthop

closed reduction and casting.1Y3 Although casting remains a

viable treatment option in children 10 years and older,4 the
criteria for an acceptable closed reduction in this older group
become more stringent because of their limited boneremodeling potential. No clear consensus as to the exact
amount of angulation or malrotation that is acceptable in this
age group has been reached. Furthermore, it is not clear that
residual deformity is associated with functional decit.
Nonetheless, current guidelines suggest that up to 30 degrees
of malrotation with up to 10 degrees of angulation is
acceptable.5,6 Operative intervention is indicated with open
fractures or when adequate alignment cannot be achieved or
maintained by closed means.7Y10 Surgical treatment usually
consists of open reduction and internal xation (ORIF) with
plates and screws9,10 or intramedullary (IM) nailing.11Y13
Although ORIF with plating is the treatment of choice
in adult forearm fractures,5,6,13,14 the surgical management
of forearm fractures in children is more controversial. In
children younger than 10 years, growth and bone remodeling lessen the need for surgical intervention because
malunions will more likely correct themselves.15 However,
surgical intervention in the young child is still indicated for
open fractures, fractures slightly before skeletal maturity,
irreducible fractures with or without soft-tissue interposition,
and unstable fractures after closed reduction.6 In these cases of
surgical xation in children younger than 10 years, previous
authors generally agree that IM nailing is a safe, less invasive
alternative to plating with similar functional and radiographic
outcomes.13,14,16Y19
Greater controversy exists regarding the optimal method
of xation in children between the ages of 10 and 16 years.
Fractures in this age group that cannot be maintained in
acceptable alignment with closed reduction can be treated with
either IM nails or ORIF with plates. The advantages of IM
xation over plating include small incisions, shorter duration
of anesthesia, limited soft-tissue dissection, rapid union, and
excellent recovery of range of motion.11,20Y22 However, open
reduction and plating allow a more anatomic repair for most
fractures.8,23,24 This may result in more accurate restoration
of the radial bow, which, although unproven, may more
completely restore forearm rotation.
Several studies on IM nailing and plating of forearm
fractures have included children spanning a wide range of
ages, from early childhood to late adolescence,9,12,21 but none
have exclusively studied older children. The purpose of this
study was to compare the radiographic and functional results
of IM nailing to plate and screw xation in treating both-bone
forearm fractures in skeletally immature older children and
adolescents from 10 to 16 years of age.

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Reinhardt et al

METHODS
Between 1996 and 2005, 31 patients, with a mean
age of 13.2 years (range, 10Y16 years), had a both-bone
forearm fracture that was treated by either ORIF with a
plate and screws or IM nailing of both the radius and ulna
by 1 of 4 fellowship-trained pediatric orthopaedic surgeons.
All fractures were as follows: (1) in the middle third of the
forearm with greater than 10 degrees of angulation or 30
degrees of malrotation after attempted closed reduction or (2) a
middle third open both-bone forearm fracture. Exclusion
criteria were as follows: xation of only 1 bone, xation of
1 bone with nails and the other with plates, bilateral forearm
injuries, previous forearm injuries in either arm, concomitant
wrist or humerus fracture (eg, Galeazzi, Monteggia, and
radial head fractures), and underlying bone pathology (eg,
pathologic fractures and osteogenesis imperfecta).

Perioperative and Follow-up Analyses

Patients_ charts were reviewed for age at time of injury,
sex, mechanism of injury, side and location of injury,
indication for surgery, type of xation, date of removal of
hardware when applicable, type of fracture (closed or open
fracture with open fractures graded using the GustilloAnderson classication25), and complications. Perioperative
data included the duration of surgery, duration of tourniquet
use, estimated blood loss, and complications.
Preoperative and latest follow-up standard anteroposterior (AP) and lateral radiographs of the forearm were reviewed.
Radiographic measurements, using a marking pencil and
goniometer, included angulation at the fracture site, percent
translation of the distal segment, and position of the ulnar
fracture relative to that of the radius. Radial malrotation was
assessed as the amount of deviation from the normal
orientation between the radial (bicipital) tuberosity and the
radial styloid on an AP view.6 The presence or absence of the
thumb sesamoid was noted, corresponding to the skeletal age
of 11 years in girls and 13 years in boys. All fractures were
classied according to the AO/OTA classication of diaphyseal fractures.26 Restoration of the radial bow was evaluated
on latest follow-up AP radiographs by using the technique
described by Firl and Wunsch27 to measure and calculate the
magnitude and location of the maximum radial bow, both as a
percentage of radial length (Fig. 1). These values were then

FIGURE 1. The method of Firl and Wunsch27 for measuring

the magnitude and location of the maximum radial bow,
expressed as a percent of radial length. Reprinted and modied
with permission from Schemitsch EH, Richards RR. The effect
of malunion on functional outcome after plate xation of
fractures of both bones of the forearm in adults. J Bone
Joint Surg [Am]. 1992;74(7):1068Y1078.

404

& Volume 28, Number 4, June 2008

TABLE 1. Perioperative Data

Plating (n = 12)

IM Nailing (n = 19)

Mean

Range

Mean

Range

Duration of surgery, min 132.6

Tourniquet use, min
89.5
Estimated blood loss, mL3 21.5

95Y175
54Y126
10Y75

103.4
35.6
22.9

47Y185 0.037
0Y100 0.001
10Y50 0.844

compared with the normal values of 60.39% for bow location

and 7.21% for bow magnitude in children.27 Patients were
followed until at least the time of fracture union, dened as the
presence of a bridging callus across 3 cortices of bone seen on
standard AP and lateral radiographs and nontender fracture
sites. Union beyond 3 months was dened as Bdelayed union[
and beyond 6 months as Bnon-union.[ Complications during
the follow-up period were classied as either major (long-term
sequelae or return to the operating room) or minor (resolved
with minimal treatment).
At the latest follow-up visit, patients were assessed for
injured arm range of motion, as compared with the contralateral uninjured arm, including forearm pronation and
supination as well as elbow and wrist exion and extension.
A loss of forearm rotation was dened as a loss of greater than
10 degrees of supination or pronation compared with the
contralateral uninjured arm.

Statistical Analysis
The t test for independent samples was used to compare
the 2 groups for age at time of injury, duration of surgery,
duration of tourniquet use, blood loss, maximum radial bow
magnitude and location (both as percentage of radial length),
and radial angulation. The Fisher exact test was calculated to
compare the groups for presence of the thumb sesamoid bone,
presence of normal magnitude of radial bow, fracture union at 3
and 6 months, loss of rotation, major and minor complications,
and fracture type. The 1-sample t test was used to compare the
location of the maximum radial bow of each group to a
previously reported normal value.27 For all analyses, a P G 0.05
was considered signicant. Statistical analyses were performed
using SPSS 10.0 (SPSS Inc, Chicago, Ill).

RESULTS
Nineteen patients, 13 boys and 6 girls, were treated
with IM nailing and 12 patients, 10 boys and 2 girls, with
plating. The mean age at the time of injury of the plating
group (14.4 years; range, 11.9Y16 years) was signicantly
greater (P = 0.004) than that of the IM nailing group
(12.5 years; range, 10.0Y14.6 years). Despite this, the
presence of the thumb sesamoid bone did not differ
signicantly (P = 0.24; 11 IM nailing patients and 10 plating
patients). In the nailing group, 12 patients underwent closed
IM nailing, and 7 patients underwent open nailing with direct
visualization of the fracture site. In the IM nailing group, the
fracture was on the right in 9 patients and the left in 10, and in
the plating group, on the right in 6 and the left in 6. For
AO/OTA fracture geometry, the IM nailing group had no
complex fractures (18 patients with 22-A3.2 and 1 patient
with 22-B3.2), whereas the plating group had only 1
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& Volume 28, Number 4, June 2008

Comparison of Intramedullary Nailing to Plating

TABLE 2. Radiographic Outcome, Functional Outcome, and

Complications

Union at 3 mo
Union at 6 mo
Loss of forearm rotation
Major complications
Minor complications

Plating (n = 12)

Nailing (n = 19)

No. Patients (%)

No. Patients (%)

7 (58.3)
11 (91.7)
4 (33.3)
4 (33.3)
4 (33.3)

13 (68.4)
17 (89.5)
2 (10.5)
4 (21.1)
8 (42.1)

0.705
1.000
0.174
0.676
0.717

complex fracture, 22-C1.3 (9 patients with 22-A3.2 and 1

each with 22-B3.1 and 22-B3.2). The number of open
fractures, 2 in the IM nailing group (both grade 1) and 5 in
the plating group (4 grade 1, 1 grade 2), was not
signicantly different (P = 0.078). The most common
mechanism of injury was a fall onto an outstretched hand
for both groups, 17 of 19 patients in the IM nailing group

and 9 of 12 in the plating group. Residual angulation after

failed closed reduction was the most frequent indication for
surgery, 14 of 19 patients in the IM nailing group and 7 of
12 in the plating group.

Perioperative Data
The mean duration of surgery was signicantly shorter
(P = 0.037) for the IM nailing group, 103.4 minutes (range,
47Y185 minutes), than that for the plating group, 132.6
minutes (range, 95Y175 minutes). A tourniquet was used
intraoperatively for signicantly less time (P = 0.001) in the
IM nailing group versus the plating group (35.6 minutes vs
89.5 minutes). The estimated blood loss during surgery was
similar for the 2 groups (Table 1).

Radiographic Outcomes
No statistically signicant differences were found
between the groups for fracture union at 3 (P = 0.705) or 6
months (P = 1.00; Table 2). At latest follow-up (mean, 1.15

FIGURE 2. Injury (A) and postoperative (B) radiographs of a 13-year-10-month-old girl who underwent IM nailing. The nails
were removed 6 weeks postoperatively because the exposed nail tips were painful, and 4 weeks later, she presented with a reinjury
(C). She underwent closed reduction under conscious sedation and casting for 3 months (D) with subsequent union (E). Of note,
this case was done early in our series before the surgical technique was modied to bury the tips of the nails beneath the skin.
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& Volume 28, Number 4, June 2008

FIGURE 3. Injury (A) and postoperative (B) radiographs of a 14-year-7-month-old boy who underwent ORIF with plate and screw
xation. The fracture had not united at 3.5 months postoperatively, qualifying it as a delayed union, when he fell and refractured
through the plate (C). He subsequently underwent revision ORIF with plating and iliac crest bone grafting of the ulna and went on to
union (D) with full recovery of range of motion at latest follow-up.

years; range, 6 monthsY3.9 years), no patients in either group

had residual angulation, translation about the fracture sites, or
radial malrotation (Figs. 2 and 3). The magnitude of the
maximum radial bow as a percentage of radial length was not
signicantly different (P = 0.984) between the groups, with a
mean of 6.8% in the IM nailing group and a mean of 6.7% in

TABLE 3. Radial Bow

Plating (n = 12)
Radial bow magnitude*
Radial bow location*

Mean

Range

Mean

6.7
62.1

5.5Y8.6
51Y72

6.8
69.3

*Expressed as % of radial length.

406

IM Nailing (n = 19)
Range

3.1Y13 0.984
59Y84.8 0.007

the plating group (Table 3). Overall, 18 of 19 patients in the IM

nailing group, and all of the patients in the plating group, had a
radial bow magnitude within the normal range at latest followup. No difference was found in the ability of either xation
technique to restore a normal radial bow magnitude. However,
the location of the maximum radial bow in the IM nailing
group, 69.3% (range, 59.0%Y84.8%), was signicantly
different from both the plating group (P = 0.007), 62.1%
(range, 51.0%Y72.0%), and the established normal value
described by Firl and Wunsch27 (P = 0.001; Table 3). No
signicant difference was found for radial bow location
between the plating group and the normal value (P = 0.371).

Functional Outcomes
On latest follow-up examination, when compared with
the contralateral uninjured forearm, 4 patients in the plating
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J Pediatr Orthop

& Volume 28, Number 4, June 2008

group and 2 patients in the IM nailing group had a loss of

forearm rotation. In the plating group, 3 patients had a loss of
pronation and 1 patient had a loss of both pronation and
supination. In the IM nailing group, 2 patients had a loss of
pronation. However, Fisher exact test indicated that the loss of
forearm rotation was not signicantly different between the
groups (P = 0.174; Table 2). All patients in both groups had
full exion and extension of the elbow and wrist at latest
follow-up.

Complications
The IM nailing group had 4 major complications (2
refractures, 1 ulna nonunion, and 1 compartment syndrome)
and 8 minor complications (4 delayed unions, 3 supercial
wound infections, and 1 bursitis over olecranon). One
refracture was in a 14-year-5-month-old boy with a grade 1
open 22-A3.2 index injury who fell onto his arm nearly
3.5 years after the index operation and more than 3 years
after the hardware was removed. He was treated with
ORIF and plating and subsequently healed completely with
full recovery of range of motion after 6 months. The other
refracture occurred in a 13-year-10-month-old girl with a
closed 22-A3.2 index injury who presented with angulation of the radius and pain 4 weeks after the hardware
was removed 6 weeks postoperatively for painful nail tip
sites (Fig. 2). She healed fully after closed reduction under
conscious sedation and casting for 3 months but continued
to have loss of pronation of 15 degrees at latest follow-up.
In all other nailing patients, all the nails were removed
electively without related complications. All the IM nailing
delayed unions occurred in 22-A3.2 injuries, 3 of which
were closed and 1 grade 1 open.
The plating group had 4 major complications (2
refractures, 1 nonunion, and 1 broken plate), and 4 minor
complications (4 delayed unions). One refracture was of the
radius adjacent to the plate in an 11-year-11-month-old boy
who fell playing football 2.5 years after experiencing a grade 1
open 22-A3.2 index injury. He was healed after casting for
4 weeks. The broken plate occurred in a 14-year-7-month-old
boy who fell 3.5 months after plating for a closed 22-A3.2
index fracture. The refracture occurred in the setting of a
delayed union (Fig. 3) because it was not yet united at
3.5 months postoperatively. The revision required ORIF with
plating and iliac crest bone grafting of the ulna. The fracture
subsequently went on to union (Fig. 3) with full recovery of
forearm range of motion. Other than the removal of this ulna
plate for revision plating, the hardware was not removed in any
of the other plating patients. Overall, neither major nor minor
complication rates were signicantly different between the
nailing and plating groups (P = 0.676 and 0.716, respectively;
Table 2). Furthermore, there was no difference in the number
of healing complications between the open and closed nailing
subgroups (28.6% vs 25%, respectively; P 9 0.05).

DISCUSSION
Although plating is generally accepted as the operative
treatment of choice for forearm fractures in adults, the optimal
treatment method is less clear among children undergoing
operative xation of similar injuries. The options for surgical

Comparison of Intramedullary Nailing to Plating

intervention in children include IM nailing and plate and screw

xation. Fixation with either IM nails or plating has been
shown to be an effective method for the treatment of unstable
forearm fractures in children.5,8Y12,14
Smaller incisions, shorter surgical times, and minimal
dissection at the fracture site have been described as
advantages of nailing over plating in children.8,10,11,28 Most
reports have included children of wide age ranges and have not
exclusively looked at children older than 10 years. Recently, in
64 children, aged 3 to 14 years, who were treated with IM
nailing or plating, Fernandez et al20 found similar functional
and radiographic results between the groups, but better
cosmesis and shorter operative times in the nailing group.
Similarly, in the current study of children older than 10 years,
the duration of surgery and intraoperative tourniquet usage
were signicantly shorter in the IM nailing group.
Other authors have suggested that plating more correctly
restores the anatomical bow of the radius,23,24 which could
possibly lead to improved forearm rotation. In our study, the
radial bow was measured in terms of its magnitude and
location as a percentage of radial length as described by
Schemitsch and Richards23 in adults, and adapted by Firl and
Wunsch27 to children. We found that both IM nailing and plate
and screw xation in children older than 10 years were
similarly effective at restoring the magnitude of the radial bow.
However, it has been suggested that the restoration of the
location of the bow is more important in maintaining the range
of forearm rotation.23 When compared with the normal values
reported by Firl and Wunsch27 for the mean location of the
radial bow, only the plating group restored the location of the
bow to normal.
Schemitsch and Richards23 proposed an association
between residual bow deformity and functional decit in
forearm rotation, but this was not supported by our ndings in
older children. In fact, the plating group, which had better
anatomical correction of the location of the radial bow, had a
greater percentage of patients with a loss of rotation, although
no statistically signicant difference between the groups could
be demonstrated. It should be noted that it is possible this
study lacked the statistical power to detect a true difference in
loss of rotation between the groups. Alternatively, the
statistical difference between groups in restoration of the
radial bow location may have been a statistical aberrancy that
would normalize with a larger sample size. A larger,
prospective study would appropriately address these issues.
In addition, the ideal comparison for the radial bow at latest
follow-up would have been radiographs of the contralateral,
uninjured arm in each child, which was not available for the
current study.
Healing complications in forearm fractures in children
have been shown to be rare in several previous studies.8,10Y12
Those treated with IM nailing healed within 3 months in 80
children, aged 4 to 16 years12 and by 6 weeks in a group of
20 adolescent patients.11 Using plate xation, Ortega et al8 did
not have any delayed unions or nonunions in 16 patients
younger than 13 years. In addition, all forearm fractures of 26
skeletally immature 4 to 16 year olds, treated with either IM
nailing or ORIF with plates and screws, healed with a mean
time to union of 3.5 months.10 Similarly, in our group of

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Reinhardt et al

exclusively older children and adolescents, aged 10 to 16

years, we found no signicant differences between IM nailing
and plating in terms of fracture union at 3 and 6 months
after surgery. All delayed unions were completely healed by
6 months. The single nonunion in the IM nailing group,
which involved the ulna, subsequently healed during the
seventh postoperative month without further treatment. In the
plating group, the nonunion was an ulna wedge fracture that
healed 8 weeks after revision plating and 32 weeks after the
index operation with full recovery of forearm range of
motion at 14-month follow-up.
Compared with standard closed reduction and casting, a
higher complication rate is associated with operative intervention. Although IM nailing was reported to have a higher
overall complication rate than plating (42% vs 33%) in 50
children between the ages of 4 and 17 years, these
complications were less likely to be classied as major
complications.22 We found similar complication rates between
our 2 study groups. In the IM nailing group, a smaller
percentage of complications was major, but this difference was
not statistically signicant. The case illustrated in Figure 2 was
done early in our series, and the nails were left prominent
through the skin. This technique necessitated earlier hardware
removal which may have been responsible for this patient_s
susceptibility to refracture. We now bury the tips of the nails
beneath the skin with the goal of leaving the hardware in place
until the fracture callus has fully matured and the medullary
canal recannalized. Hardware removal is typically performed a
minimum of 6 months postoperatively, except in cases where
skin irritation at the proximal tip of the ulna nail necessitates
earlier removal.
As has been previously demonstrated in patient populations of wide age ranges, our study indicated that IM nailing
and plate and screw xation yield similar surgical and
functional results in children older than 10 years. One
shortcoming of our study is the age discrepancy between the
groups. The mean age for plating was 1.9 years older than that
for nailing. Due to the fact that this was a retrospective study,
we were unable to control for age and this could confound the
results because the surgeons may have had a selection bias
toward plating in older children. However, on the routine injury
x-rays, we were able to note the presence of the thumb
sesamoid, corresponding to a bone age of 11 in girls and 13 in
boys. Using this variable as an indicator of physiologic maturity,
there was not a statistical difference in the distribution between
the 2 groups. In addition, IM nailing has the advantages of
shorter surgical times, less intraoperative tourniquet use, and
better cosmetic outcomes with smaller scars.
Seven of the 19 patients treated by nailing required open
reductions, most commonly because of an inability to pass the
nail across the fracture site secondary to either soft tissue
interposition or an inadequate reduction. One might postulate
that this could increase the risk for healing complications;
however, we did not nd this to be the case in our series.
Clearly, one would rst try to perform a closed nailing, if
possible, without opening the fracture sight. However, our data
suggest that if an adequate reduction cannot be obtained and
the nails cannot be passed, then opening the fracture sight does
not alter the outcome. Future research with larger numbers

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J Pediatr Orthop

& Volume 28, Number 4, June 2008

focusing on open versus closed reductions in IM nailing would

help to further validate this nding.
Another important factor in the decision-making
process surrounding operative technique is one_s philosophy
toward removing hardware. A clear benet in the use of IM
nailing is the ease of hardware removal. When removing
plates, one must consider the risk of refracture, and it is
commonly agreed upon that signicant and prolonged
activity restrictions must be advised. In contrast, because
of the absence of stress shielding and the cortical continuity
after nail removal, minimal activity restrictions are necessary
after the removal of nails. Other than that which was
necessary for revision surgery, none of the hardware in our
plating patients was removed. Conversely, the hardware was
electively removed in all nailing patients without related
complications, except that illustrated in Figure 2, which
occurred before altering our nailing practices. Overall, these
factors make a compelling argument for the use of IM nails,
in light of the fact that radiographic and functional outcomes
are similar.
We conclude that IM nailing of length-stable forearm
fractures in skeletally immature patients between the ages of
10 and 16 years is an equally effective treatment when
compared with plate and screw xation and is our treatment
of choice.
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