{"paper_id":"37a38580-b512-4c2c-be59-4d7dedbdf521","body_text":"Elastic stable intramedullary nailing (ESIN) in paediatric diaphyseal forearm fractures – retrospective analysis of 201 cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Elastic stable intramedullary nailing (ESIN) in paediatric diaphyseal forearm fractures – retrospective analysis of 201 cases Katarzyna Kwas, Marcin Mostowy, Klaudia Szatanik, Krzysztof Małecki This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4159221/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Forearm shaft fractures are common injuries, often caused by falling from a fully upright standing position or falling off while riding a bike. These injuries can be treated nonoperatively or surgically with intramedullary nailing or plates. According to the literature, the method of choice for treating pediatric forearm shaft fractures is the application of elastic stable intramedullary nailing (ESIN)|. The study aimed to carry out a radiological assessment of ESIN use in pediatric patients with forearm shaft fractures, as well as an analysis of the etiology of the injury and the complication rate. Patients aged 1 to 17 years, diagnosed with a fracture of the forearm shaft treated surgically with ESIN, with a set of X-ray pictures and a minimum 6-month follow-up qualified for the study. The evaluation of the axial alignment was carried out retrospectively in anatomical (AP) and lateral (LAT) positions. 402 radiographs of 201 patients (30,5% women, 69,5% men) with a mean age of 9.1 years (SD = 3.2) were analyzed. 68% of fractures occurred during sports activity. 75% of fractures involved both the radius and the ulna. The union was observed in 100% of cases. Mean axial alignment values in AP and LAT X-ray or both the ulna and radius were proper according to the literature. Axial alignment values were not influenced significantly by the age, type of surgery carried out or the type of fracture. Plaster cast application (9,8% of cases) significantly influenced the values of radius axial alignment. Complications rate equaled 11.4% (n=23). The etiology of the injury did not affect axial alignment values. Significantly more complications were observed in the ORIF group (p = 0,0025). The ESIN technique is an effective treatment for forearm diaphyseal fractures in children, with good radiological results regarding reduction and bone healing. Health sciences/Anatomy Health sciences/Health occupations Health sciences/Risk factors forearm fractures pediatrics fractures ESIN technique intramedullary nailing Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Diaphyseal forearm fractures rank among the most common types of injury in pediatric cases and mainly occur in boys aged 10–14. Their annual incidence constitutes 13–40% of all childhood fractures, positioning them as the third most frequent among pediatric fractures [1,2]. Typically caused by falls, sports or play, the management of these fractures is based on factors such as age, fracture type, and displacement. While conservative treatment, involving closed reduction and plaster cast immobilization, is successful for many diaphyseal forearm fractures, surgical intervention becomes necessary for unstable, open, or combined fractures, or those at high risk of malunion or malreduction. While conservative treatment, involving closed reduction and plaster cast immobilization is successful for many diaphyseal forearm fractures, surgical intervention becomes necessary for unstable, open, or combined fractures, or those at high risk of malunion or malreduction. Literature suggests that the optimal nonconservative treatment is not clearly defined. One commonly used surgical technique, established in the late '70s by Jean Prevot and Jean Paul-Metaizeau, involves closed reduction and the implantation of elastic stable intramedullary nailing (ESIN). Alternatives to ESIN application include the use of K-wires, plates, or external fixators. However, due to its minimally invasive application, the potential for early mobilization, and satisfactory postsurgical functional outcomes, ESIN is a common primary choice for surgical treatment in diaphyseal forearm fractures [1–3]. Nevertheless, the use of ESIN is associated with multiple complications, such as wound infection, skin perforation, bursitis, nonunion, tendon rupture, or compartment syndrome. The general complication rate ranges from 10–67%, with varied results reported in different studies [4–6]. Complications may occur after ESIN implantation, during the procedure, or after nail removal. Aim of the study This research aimed to evaluate the axial alignment and bone union, etiology of injury and complications of forearm fracture treatment with elastic stable intramedullary nailing (ESIN) in pediatric cases. Materials and methods A retrospective analysis was conducted on 201 pediatric patients with operatively treated diaphyseal forearm fractures. Inclusion criteria comprised patients aged 1-17 years, admission to the clinic between 01.2018 and 01.2022, a minimum six-month follow-up, diaphyseal forearm fracture, ESIN surgery, and completed anterior-posterior (AP) and lateral (LAT) X-ray views. Selection criteria excluded patients over 17 years and those with less than six months of follow-up, epiphyseal or metaphyseal fractures or insufficient documentation. Patients' data were extracted from the hospital database, including basic information, injury etiology, type of ESIN used, and post-surgical complications. X-rays of 201 patients aged between 1 and 17 years were analyzed. The mean age of the study group was 9.1 years (SD=3.2), with a mean follow-up of 9.1 months (SD=2.8). Fractures involved the isolated radius (23%), ulna (2%), or both bones (75%), predominantly on the left side (54.3%). Most fractures occurred in the distal 1/3 of the forearm (61%), followed by the middle 1/3 (36%) and the proximal 1/3 (3%). Closed reduction internal fixation (CRIF) was performed in 92.7% of fractures, while open reduction internal fixation (ORIF) was used in 9.3% of cases. 90.7% of fractures were closed. A cast was applied in 9.8% of cases for 2 to 4 weeks in younger children to alleviate post-surgery pain. All patients underwent ESIN (diameter 1.5mm – 3.0mm) application [Figure no. 1]. In further analysis, patients were divided into three age groups: 1 to 7 years old, 7 to 13 years old, and 14 to 17 years old. Union and alignment of radius and ulna were assessed on X-rays using RadiAnt software. Statistical analysis was performed using Statistica 13.1. The experiment was approved by the institutional review board of the Polish Mother’s Memorial Hospital as well as so the research was performed in accordance with relevant guidelines and regulations. Informed consent was obtained from all legal guardians of participants. Results Obtained study group observations were presented in the graph no.1. Bone union was achieved in all cases. Age dependence of axial alignment Mean values of axial alignment of patients in age from 1 to 7 were as follows: AP radius=2,2 o (SD=3,2 min =0 max=16), AP ulna=1,1 o (SD=1,8, min=0, max=7), LAT radius=1,9 o . (SD=2,6,min=0, max=12), LAT ulna=1,4 o (SD=2,1, min =0 max=13). In age from 8 to 13: AP radius=2,8 o , AP ulna=1,9 o , LAT radius=2,6 o , LAT ulna=1,8 o . In age from 14 to 17: AP radius=2,4 o , AP ulna=1,3 o , LAT radius=0,75 o , LAT ulna=1,06 o . These differences are caused by the anatomical variations of bone shape resulting from the different age of the patients and all the obtained axial alignment mean values were appropriate since none of them exceeded 10 degrees. All the results are presented in the table no. 1. In further analysis, the dependence between values of axial alignment and age groups was performed. Results are presented in figure no. 2 and figure no. 3. None of these results were statistically significant. However as observed, both AP and LAT of ulna values are lower than LAT and AP values of radius which is an outcome of the natural curvature of the radius. Influence of ESIN diameter on axial alignment In 87% of cases, the ESIN with a diameter of 2.0mm were used. In further research, the diameter of ESIN was correlated with the axial alignment of both the ulna and radius. However, there was no dependence of ESIN diameter on axial alignment in the ulna, since p equals 0,123 (r=0,160) in AP and p = 0,5 (r=0,064) in LAT. In radius, p was 0,093 (r=0,341) in AP and p = 0,133 (r=0,542) in LAT. None of these results were statistically significant, as presented in figure no.4. Etiology of diaphyseal forearm fractures Further analysis of the research also included the etiology of forearm fractures in the study group. As it was stated, 32% of the fractures were caused by a fall from a standing position onto an outstretched hand. 29% of cases were caused by sport and recreation, in which 16% were accidents on the scooter and 12% on the trampoline. 25% of the accidents occurred while cycling, 7% during PE lessons and 4% happened during a football game. Cycling was excluded from the list of recreational activities to emphasize the importance of these disciplines in causing fractures. The data described is presented in figure no. 5. The etiology did not influence the axial alignment since none of the p values calculated was statistically significant. In further analysis, the dependence between axial alignment values of both the radius and ulna and the type of treatment, type of fracture and type of plaster cast used were assessed. Mean values of axial alignment were calculated for all the groups as well as the possible influence of complication on these values. The results are presented in table no.2. As stated below, when a plaster cast is used, there is an influence on axial alignment values of radius in AP and LAT views since p values are as follows: p =0.036 and p =0.035. Such a result may be a consequence of the treatment of patients who had a plaster cast used due to its analgetic effect, a Monteggia fracture, a coexisting epiphyseal fracture or refracture. In this research, most of the patients with a plaster cast had the above-mentioned injury, which may explain why such statistically significant values were obtained. Table 1- Influence on p values and axial alignment. Ulna AP [ o ] Radius AP [ o ] Ulna LAT [ o ] Radius LAT [ o ] ORIF/ CRIF p value 2,18 (SD=2,04) 1,53 (SD=1.87) p=0.186 1,27 (SD=1,56) 2,76 (SD=3,31) p=0.178 1,27 (SD=1,74) 1,69 (SD=2,22) p=0.065 0,91 (SD=1,38) 2,33(SD=2,68) p=0.548 Open/ close fracture p value 2,08 (SD=1,75) 1,53 (SD=1,90) p=0.194 3,08 (SD=3,59) 2,56 (SD=3,19) p=0.789 1,23 (SD=3,35) 1,70 (SD=2,26) p=0.784 2,62 (SD=2,50) 2,18 (2,49) p=0.835 Plaster cast (n=19) p value 1,55 (SD=1,88) p=0.630 3,69 (SD=2,89) p=0.036 1,67 (SD=2,30) p=0.725 4,22 (SD=2,43) p=0.035 Complications of the treatment Complications occurred in 9,5% (n=19) of patients. The most common complication was oedema of an implantation side which was presented by 9 patients. Less common was refracture which appeared in 5 cases, neuropraxia of the ulnar nerve was observed in 3 patients and skin puncture of the TEN stub occurred in 2 cases. Further analysis considered the influence of possible complication-related factors with developed side effects as presented in Table No. 2. The presence of complications was correlated with the type of surgery performed, type of fracture and type of plaster cast application. The dependence of open reduction internal fixation on side effects occurrence was statistically significant ( p = 0,0025). The type of fracture or plaster cast application did not influence the development of the complications due to a lack of statistical significance. Table 2 – Possible complication dependence Study group [%] Complications p-value ORIF 7,2 Yes (n=11) p = 0,025 Open fracture 9,3 Yes (n=2) p = 0,571 Plaster cast 9,8 Yes (n=4) p = 0,252 Discussion Axial alignment values This research presents mean axial alignment values of ESIN implantation in three age groups, calculated for both ulna and radius, in AP and LAT views. The exact value of acceptable axial alignment or angulation has not yet been ascertained and remains controversial. The work of Papermanikou et al. reports this value as less than 15 degrees in the distal and middle 1/3 of the diaphyseal and less than 10 degrees for the proximal diaphyseal. Flynn et al. defined acceptable alignment up to 10-20 degrees in patients younger than 10 years old and less than 10 degrees in patients aged over 10 years old. Other authors report this permissible value as less than 15 degrees for distal diaphyseal [6-8]. Taking into consideration the above statements, all mean values obtained in this research, (ranging from 0,75 to 2,8 degrees) are proper values of axial alignment, since our study represents a smaller alignment than the acceptable values listed above. Similar results were achieved by Du et al. where the mean angulation of the ulna in AP and LAT views fluctuated around 2,20 to 2,80 degrees in double ESIN implantation and 5,50 to 6,04 degrees in single ESIN use. Comparable outcomes were reported by Korhonen et al. , with mean postoperative displacement at follow-up equal to 7,6 degrees for radius and 1,8 degrees for ulna. Slightly different observations have been presented by Papamerkouriou et al. since the authors obtained an angulation of around 10 to 12 degrees [6,9,10]. Such outcomes may be the result not only of different techniques and radiological assessment programmes but also due to anatomical variations in the radius curvature which inhibit proper analysis of angulation and its reference to normal values. Nevertheless, the literature is still insufficient regarding the effectiveness of using ESIN in forearm fractures regarding the axial alignment, meaning that further studies are needed to find optimal and acceptable values. Cause of injury Among our patients, the most common fracture etiology was a fall from an upright standing position (32%), the second most common was sport and recreation (29%). The available literature is consistent with our findings. Data reported by Papamerkouriou et al. clearly showed that the most frequent mechanism of injury was when a patient had fallen onto an outstretched hand from an upright standing position. Our results are related also to the work of Lyman et al. where the most common mechanism of injury was a fall onto an outstretched hand, followed by sport injuries. Vopat et al. reported that the most common mechanism is falling from an upright standing position (83%), however, the injury was reported to occur most frequently in playground areas. In this study, less common injury causes included bicycle, scooter and trampoline use [2,6]. Work of Papamerkouriou et al. listed similar observations, since less frequent causes combined vehicle or playground accidents, falling from a tree or trampoline. The available literature is quite consistent with our etiology results, and despite slight differences, most of the studies suggest that the most crucial mechanism of pediatric forearm fractures is falling onto an outstretched hand which is coherent with the mechanism of adults’ forearm fractures. Complications The incidence of complications is diverse in the available literature. In our study, the complication rate was 9,5% and the most common side effect observed was implantation side oedema of the wound area (n=9). Less frequent was refracture (n=5) and ulnar nerve neuropraxia (n=3). No complications regarding the delayed union or malunion were observed in the study. In the work of Fernandez et al. the complication rate was equal to 14,6% and the most common complication was refracture, lesion of the radial nerve and delayed union. In Pogorelić’s et al. work, the main complication was superficial skin irritation, which was not observed in our study. Flynn et al . reported a 14,6% complication rate; the most common side effect being delayed union (6/15 cases), other complications included compartment syndrome, tendon laceration and infection [4,6-9,11]. Korhonen et al. reported delayed or lacking union as the most frequent complication. It was also found that open reduction was associated with an increased risk of ulna nonunion. This finding is relevant to our observations since in our work the dependence of open reduction on complication presence was stated. Furthermore, ulna nonunion in the work of Korhonen et al. was also reported to be the result of using thicker nails and the distal location of the fracture. Despite that, authors assumed that the ESIN implantation procedure shows satisfactory healing. Peterlein et al. observed a refracture rate of 3,3% and described long-term results of ESIN use in forearm fractures as convincing. What is more, current literature indicates that the use of ESIN is associated with a lower number of refractures when compared to conservative treatment [7,22,23]. On the other hand, Lyman et al. reported a 24% complication rate among which the most common was ulnar or radial nerve dysfunction described by the author as a postoperative complication and tendon rupture. Other side effects observed were compartment syndrome and implant migration requiring early removal [2,3,9,12,14,15]. Despite all the complications observed, the authors of the studies were satisfied with the functional results of ESIN use [17,22,23]. Surgical treatment indications According to the literature, common indications for surgical treatment of diaphyseal forearm fracture in children include unstable fractures and dislocations, open fractures, fractures that failed to reduce and were irreducible as well as refractures and fractures with neurovascular defects. It is also crucial to consider the impact of the rotation and angulation of the fractures on the type of treatment and functional ability in children. The loss of function can be diminished by restoring the proper axial alignment and rotation. However, the direct acceptable values of malalignments remain controversial, leaving the final decision about treatment up to the surgeon. However, when analyzing angulation in the child population, it is vital to mention that it may be restored by remodelling. As Price and other authors reported, even with less than 20 degrees of angulation, 50% of correction may be expected to remodel when children aged less than 8 years. In older children (>8 years old) the acceptable angle is less than 10 degrees. Nevertheless, the rotational deformities are not expected to be remodelled completely and may be difficult to examine. The literature values of acceptable rotational values differ among the studies and range from 0 to 45 degrees. In both younger and older children, the acceptable malrotation is 30 degrees [2,11, 13, 18,19] meaning that in the case of patients with such values, no manipulation of the fracture is needed. In other cases, whether closed or open reduction is required depends on the surgeon’s assessment. In cases where surgical treatment is unavoidable, the use of the ESIN as a preferred technique is one possibility. Nail removal Not many researchers specified the time after ESIN should be removed. Most of the literature states, that removing ESIN is a relatively easy surgery with a low rate of complications, however, the accurate time and possible complications are not addressed. An available study by Pogorelić et al . reports that nails were removed at a median time of 5 months (4-9 months) and all patients were reported to have regained full limb function. Moreover, all the complications that occurred during the hospitalization were resolved after the nail removal. Patients with ulnar injuries regained their function. As Lieber et al. stated the mean time of ESIN removal was 4 months, with a low, 3,4% complication rate including temporary loss of sensation, tendon rupture, refracture and superficial wound infection. In the work of Furlan et al., the median time of ESIN removal was 6 months [11,13,15-21]. However, in our study, the time of implant removal also was not stated since not all of our patients have had it removed. In the majority of cases, ESINs were taken out at the parent’s request on average after a year. Conclusions Elastic stable intramedullary nailing may be considered a satisfactory method of surgical treatment of pediatric forearm fractures with acceptable axial alignment values and a low rate of complications. According to the results of this study and literature, ESIN should be considered as the method of choice for displaced forearm fractures in the pediatric population. Declarations Conflict of Interest The authors declare no conflicts of interest related to this study. Author Contribution K.K. - gathered the data, prepared the manuscipt, prepared the figures and tablesM.M. - performed the statistics analysisK.Sz.- gathered the data, prepared the figures and tablesK.M. - suggested the topic of the research, supervised the data gathering and the whole manuscript preparation. Data Availability Data supporting the findings of this study are available from the corresponding author upon reasonable request. 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Han B, Wang Z, Li Y, Xu Y, Cai H. (2019) Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing. Int Orthop.;43(9):2093-2097.doi: 10.1007/s00264-018-4184-4 (1998). Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {\"props\":{\"pageProps\":{\"initialData\":{\"identity\":\"rs-4159221\",\"acceptedTermsAndConditions\":true,\"allowDirectSubmit\":true,\"archivedVersions\":[],\"articleType\":\"Article\",\"associatedPublications\":[],\"authors\":[{\"id\":294118665,\"identity\":\"ad762d1c-a510-4759-b248-1f23090a48e0\",\"order_by\":0,\"name\":\"Katarzyna Kwas\",\"email\":\"data:image/png;base64,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\",\"orcid\":\"\",\"institution\":\"Polish Mother’s Memorial Hospital Research Institute\",\"correspondingAuthor\":true,\"prefix\":\"\",\"firstName\":\"Katarzyna\",\"middleName\":\"\",\"lastName\":\"Kwas\",\"suffix\":\"\"},{\"id\":294118666,\"identity\":\"ab1755d5-0073-4319-b755-473292cc2736\",\"order_by\":1,\"name\":\"Marcin Mostowy\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Polish Mother’s Memorial Hospital Research Institute\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Marcin\",\"middleName\":\"\",\"lastName\":\"Mostowy\",\"suffix\":\"\"},{\"id\":294118667,\"identity\":\"742a67bb-2f99-43d2-a3e8-4c2d588560f8\",\"order_by\":2,\"name\":\"Klaudia Szatanik\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Polish Mother’s Memorial Hospital Research Institute\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Klaudia\",\"middleName\":\"\",\"lastName\":\"Szatanik\",\"suffix\":\"\"},{\"id\":294118668,\"identity\":\"7d50e0c2-9237-43ab-9b4d-0a0f8f238dd5\",\"order_by\":3,\"name\":\"Krzysztof Małecki\",\"email\":\"\",\"orcid\":\"\",\"institution\":\"Polish Mother’s Memorial Hospital Research Institute\",\"correspondingAuthor\":false,\"prefix\":\"\",\"firstName\":\"Krzysztof\",\"middleName\":\"\",\"lastName\":\"Małecki\",\"suffix\":\"\"}],\"badges\":[],\"createdAt\":\"2024-03-24 18:59:24\",\"currentVersionCode\":1,\"declarations\":\"\",\"doi\":\"10.21203/rs.3.rs-4159221/v1\",\"doiUrl\":\"https://doi.org/10.21203/rs.3.rs-4159221/v1\",\"draftVersion\":[],\"editorialEvents\":[],\"editorialNote\":\"\",\"failedWorkflow\":false,\"files\":[{\"id\":55535515,\"identity\":\"faed6672-673b-4a84-a276-a66b32fce032\",\"added_by\":\"auto\",\"created_at\":\"2024-04-29 16:24:45\",\"extension\":\"jpg\",\"order_by\":1,\"title\":\"Figure 1\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":61041,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eStudy group characteristics.\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"1.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/d5244ce23e2e79f6d752a80d.jpg\"},{\"id\":55535514,\"identity\":\"627ec14d-58c3-47c2-9ed8-81f6a0d379c6\",\"added_by\":\"auto\",\"created_at\":\"2024-04-29 16:24:44\",\"extension\":\"jpg\",\"order_by\":2,\"title\":\"Figure 2\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":61590,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eMean values of axial alignment in particular age groups\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"2.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/2e7bfcf619f022503d66b48a.jpg\"},{\"id\":55535517,\"identity\":\"e2e4ac97-0c42-43ae-9833-4f8a7e777c92\",\"added_by\":\"auto\",\"created_at\":\"2024-04-29 16:24:45\",\"extension\":\"jpg\",\"order_by\":3,\"title\":\"Figure 3\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":70938,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eInfluence of age on axial alignment values\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"3.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/7a94dade3d3d12848d0e69f2.jpg\"},{\"id\":55535516,\"identity\":\"07af613b-e8c8-4f11-a0fc-44025180c4a7\",\"added_by\":\"auto\",\"created_at\":\"2024-04-29 16:24:45\",\"extension\":\"jpg\",\"order_by\":4,\"title\":\"Figure 4\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":52480,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eESIN diameter versus axial alignment\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"4.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/e42888b6104e7f86653155b4.jpg\"},{\"id\":55535513,\"identity\":\"c853b7ad-9766-4a7d-bd2c-1b9ccfed0d4f\",\"added_by\":\"auto\",\"created_at\":\"2024-04-29 16:24:44\",\"extension\":\"jpg\",\"order_by\":5,\"title\":\"Figure 5\",\"display\":\"\",\"copyAsset\":false,\"role\":\"figure\",\"size\":57202,\"visible\":true,\"origin\":\"\",\"legend\":\"\\u003cp\\u003eEtiology of injuries in the study group\\u003c/p\\u003e\",\"description\":\"\",\"filename\":\"5.jpg\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/6b88b3e6bce45eeaac0ee80b.jpg\"},{\"id\":59468856,\"identity\":\"c340aaa1-3b0e-416a-a528-85066bac2cc5\",\"added_by\":\"auto\",\"created_at\":\"2024-07-02 07:12:13\",\"extension\":\"pdf\",\"order_by\":0,\"title\":\"\",\"display\":\"\",\"copyAsset\":false,\"role\":\"manuscript-pdf\",\"size\":695091,\"visible\":true,\"origin\":\"\",\"legend\":\"\",\"description\":\"\",\"filename\":\"manuscript.pdf\",\"url\":\"https://assets-eu.researchsquare.com/files/rs-4159221/v1/6ae667d3-a6e5-4635-aa69-96607264e889.pdf\"}],\"financialInterests\":\"No competing interests reported.\",\"formattedTitle\":\"Elastic stable intramedullary nailing (ESIN) in paediatric diaphyseal forearm fractures – retrospective analysis of 201 cases\",\"fulltext\":[{\"header\":\"Introduction\",\"content\":\"\\u003cp\\u003eDiaphyseal forearm fractures rank among the most common types of injury in pediatric cases and mainly occur in boys aged 10\\u0026ndash;14. Their annual incidence constitutes 13\\u0026ndash;40% of all childhood fractures, positioning them as the third most frequent among pediatric fractures [1,2]. Typically caused by falls, sports or play, the management of these fractures is based on factors such as age, fracture type, and displacement. While conservative treatment, involving closed reduction and plaster cast immobilization, is successful for many diaphyseal forearm fractures, surgical intervention becomes necessary for unstable, open, or combined fractures, or those at high risk of malunion or malreduction. While conservative treatment, involving closed reduction and plaster cast immobilization is successful for many diaphyseal forearm fractures, surgical intervention becomes necessary for unstable, open, or combined fractures, or those at high risk of malunion or malreduction. Literature suggests that the optimal nonconservative treatment is not clearly defined. One commonly used surgical technique, established in the late '70s by Jean Prevot and Jean Paul-Metaizeau, involves closed reduction and the implantation of elastic stable intramedullary nailing (ESIN). Alternatives to ESIN application include the use of K-wires, plates, or external fixators. However, due to its minimally invasive application, the potential for early mobilization, and satisfactory postsurgical functional outcomes, ESIN is a common primary choice for surgical treatment in diaphyseal forearm fractures [1\\u0026ndash;3]. Nevertheless, the use of ESIN is associated with multiple complications, such as wound infection, skin perforation, bursitis, nonunion, tendon rupture, or compartment syndrome. The general complication rate ranges from 10\\u0026ndash;67%, with varied results reported in different studies [4\\u0026ndash;6]. Complications may occur after ESIN implantation, during the procedure, or after nail removal.\\u003c/p\\u003e\\n\\u003ch3\\u003eAim of the study\\u003c/h3\\u003e\\n\\u003cp\\u003eThis research aimed to evaluate the axial alignment and bone union, etiology of injury and complications of forearm fracture treatment with elastic stable intramedullary nailing (ESIN) in pediatric cases.\\u003c/p\\u003e\"},{\"header\":\"Materials and methods\",\"content\":\"\\u003cp\\u003eA retrospective analysis was conducted on 201 pediatric patients with operatively treated diaphyseal forearm fractures. Inclusion criteria comprised patients aged 1-17 years, admission to the clinic between 01.2018 and 01.2022, a minimum six-month follow-up, diaphyseal forearm fracture, ESIN surgery, and completed anterior-posterior (AP) and lateral (LAT) X-ray views. \\u0026nbsp;Selection criteria excluded patients over 17 years and those with less than six months of follow-up, epiphyseal or metaphyseal fractures or insufficient documentation.\\u003c/p\\u003e\\n\\u003cp\\u003ePatients\\u0026apos; data were extracted from the hospital database, including basic information, injury etiology, type of ESIN used, and post-surgical complications. X-rays of 201 patients aged between 1 and 17 years were analyzed. The mean age of the study group was 9.1 years (SD=3.2), with a mean follow-up of 9.1 months (SD=2.8). Fractures involved the isolated radius (23%), ulna (2%), or both bones (75%), predominantly on the left side (54.3%). Most fractures occurred in the distal 1/3 of the forearm (61%), followed by the middle 1/3 (36%) and the proximal 1/3 (3%).\\u003c/p\\u003e\\n\\u003cp\\u003eClosed reduction internal fixation (CRIF) was performed in 92.7% of fractures, while open reduction internal fixation (ORIF) was used in 9.3% of cases. 90.7% of fractures were closed. A cast was applied in 9.8% of cases for 2 to 4 weeks in younger children to alleviate post-surgery pain. All patients underwent ESIN (diameter 1.5mm \\u0026ndash; 3.0mm) application [Figure no. 1].\\u003c/p\\u003e\\n\\u003cp\\u003eIn further analysis, patients were divided into three age groups: 1 to 7 years old, 7 to 13 years old, and 14 to 17 years old. Union and alignment of radius and ulna were assessed on X-rays using RadiAnt software. Statistical analysis was performed using Statistica 13.1.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eThe experiment was approved by the institutional review board of the Polish Mother\\u0026rsquo;s Memorial Hospital as well as so the research was performed in accordance with relevant guidelines and regulations.\\u003c/p\\u003e\\n\\u003cp\\u003eInformed consent was obtained from all legal guardians of participants.\\u003c/p\\u003e\"},{\"header\":\"Results\",\"content\":\"\\u003cp\\u003eObtained study group observations were presented in the graph no.1.\\u003c/p\\u003e\\n\\u003cp\\u003eBone union was achieved in all cases.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAge dependence of axial alignment\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eMean values of axial alignment of patients in age from 1 to 7 were as follows: AP radius=2,2\\u003csup\\u003eo\\u003c/sup\\u003e (SD=3,2 min =0 max=16), AP ulna=1,1\\u003csup\\u003eo\\u003c/sup\\u003e (SD=1,8, min=0, max=7), \\u0026nbsp;LAT radius=1,9\\u003csup\\u003eo\\u003c/sup\\u003e. (SD=2,6,min=0, max=12), \\u0026nbsp;LAT ulna=1,4\\u003csup\\u003eo\\u003c/sup\\u003e (SD=2,1, min =0 max=13).\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eIn age from 8 to 13: AP radius=2,8\\u003csup\\u003eo\\u003c/sup\\u003e, AP ulna=1,9\\u003csup\\u003eo\\u003c/sup\\u003e, LAT radius=2,6\\u003csup\\u003eo\\u003c/sup\\u003e, LAT ulna=1,8\\u003csup\\u003e\\u0026nbsp;o\\u003c/sup\\u003e. In age from 14 to 17: AP radius=2,4\\u003csup\\u003e\\u0026nbsp;o\\u003c/sup\\u003e, AP ulna=1,3\\u003csup\\u003e\\u0026nbsp;o\\u003c/sup\\u003e, LAT radius=0,75\\u003csup\\u003e\\u0026nbsp;o\\u003c/sup\\u003e, LAT ulna=1,06\\u003csup\\u003e\\u0026nbsp;o\\u003c/sup\\u003e. These differences are caused by the anatomical variations of bone shape resulting from the different age of the patients and all the obtained axial alignment mean values were appropriate since none of them exceeded 10 degrees.\\u003c/p\\u003e\\n\\u003cp\\u003eAll the results are presented in the table no. 1. In further analysis, the dependence between values of axial alignment and age groups was performed. Results are presented in figure no. 2 and figure no. 3. None of these results were statistically significant. However as observed, both AP and LAT of ulna values are lower than LAT and AP values of radius which is an outcome of the natural curvature of the radius. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eInfluence of ESIN diameter on axial alignment\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eIn 87% of cases, the ESIN with a diameter of 2.0mm were used. In further research, the diameter of ESIN was correlated with the axial alignment of both the ulna and radius. However, there was no dependence of ESIN diameter on axial alignment in the ulna, since \\u003cem\\u003ep\\u003c/em\\u003e equals 0,123 (r=0,160) in AP and \\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e= 0,5 (r=0,064) in LAT. In radius, \\u003cem\\u003ep\\u003c/em\\u003e was 0,093 (r=0,341) in AP and \\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e= 0,133 (r=0,542) in LAT. None of these results were statistically significant, as presented in figure no.4. \\u0026nbsp;\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eEtiology of diaphyseal forearm fractures\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eFurther analysis of the research also included the etiology of forearm fractures in the study group. As it was stated, 32% of the fractures were caused by \\u0026nbsp;a fall from a standing position onto an outstretched hand. 29% of cases were caused by sport and recreation, in which 16% were accidents on the scooter and 12% on the trampoline. \\u0026nbsp;25% of the accidents occurred while cycling, 7% during PE lessons and 4% happened during a football game. Cycling was excluded from the list of recreational activities to emphasize the importance of these disciplines in causing fractures. The data described is presented in figure no. 5. The etiology did not influence the axial alignment since none of the \\u003cem\\u003ep\\u003c/em\\u003e values calculated was statistically significant.\\u003c/p\\u003e\\n\\u003cp\\u003eIn further analysis, the dependence between axial alignment values of both the radius and ulna and the \\u0026nbsp;type of treatment, type of fracture and type of plaster cast used were assessed. Mean values of axial alignment were calculated for all the groups as well as the possible influence of complication on these values. The results are presented in table no.2.\\u003c/p\\u003e\\n\\u003cp\\u003eAs stated below, when a plaster cast is used, there is an influence on axial alignment values of radius in AP and LAT views since p values are as follows: \\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e=0.036 and \\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e=0.035. Such a result may be a consequence of the treatment of patients who had a plaster cast used due to its analgetic effect, a Monteggia fracture, a coexisting epiphyseal fracture or refracture. In this research, most of the patients with a plaster cast had the above-mentioned injury, which may explain why such statistically significant values were obtained.\\u003c/p\\u003e\\n\\u003cp\\u003eTable 1- Influence on p values and axial alignment. \\u0026nbsp;\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"605\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"14.214876033057852%\\\" valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"20.165289256198346%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUlna\\u003cbr\\u003e AP [\\u003csup\\u003eo\\u003c/sup\\u003e]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRadius\\u003cbr\\u003e\\u0026nbsp;AP\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003e[\\u003csup\\u003eo\\u003c/sup\\u003e]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eUlna\\u003cbr\\u003e\\u0026nbsp;LAT\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003e[\\u003csup\\u003eo\\u003c/sup\\u003e]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"24.958677685950413%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003eRadius\\u003cbr\\u003e\\u0026nbsp;LAT\\u0026nbsp;\\u003c/strong\\u003e\\u003cstrong\\u003e[\\u003csup\\u003eo\\u003c/sup\\u003e]\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"14.214876033057852%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eORIF/\\u003cbr\\u003e\\u0026nbsp;CRIF\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep value\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.165289256198346%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2,18 (SD=2,04)\\u003cbr\\u003e\\u0026nbsp;1,53 (SD=1.87)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep=0.186\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1,27 (SD=1,56)\\u003cbr\\u003e\\u0026nbsp;2,76 (SD=3,31)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp;p=0.178\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1,27 (SD=1,74)\\u003cbr\\u003e\\u0026nbsp;1,69 (SD=2,22)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep=0.065\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"24.958677685950413%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e0,91 (SD=1,38)\\u003cbr\\u003e\\u0026nbsp;2,33(SD=2,68)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep=0.548\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"14.214876033057852%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eOpen/\\u003cbr\\u003e\\u0026nbsp;close fracture\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep value\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.165289256198346%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2,08 (SD=1,75)\\u003cbr\\u003e\\u0026nbsp;1,53 (SD=1,90)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp;p=0.194\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3,08 (SD=3,59)\\u003cbr\\u003e\\u0026nbsp;2,56 (SD=3,19)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; p=0.789\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1,23 (SD=3,35)\\u003cbr\\u003e\\u0026nbsp;1,70 (SD=2,26)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; p=0.784\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"24.958677685950413%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e2,62 (SD=2,50)\\u003cbr\\u003e\\u0026nbsp;2,18 (2,49)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003e\\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; \\u0026nbsp; p=0.835\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"14.214876033057852%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePlaster cast\\u003cbr\\u003e\\u0026nbsp;(n=19)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep value\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.165289256198346%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1,55 (SD=1,88)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep=0.630\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e3,69 (SD=2,89)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ep=0.036\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"20.330578512396695%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e1,67 (SD=2,30)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep=0.725\\u003c/em\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"24.958677685950413%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e4,22 (SD=2,43)\\u003c/p\\u003e\\n \\u003cp\\u003e\\u0026nbsp;\\u003c/p\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ep=0.035\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eComplications of the treatment\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eComplications occurred in 9,5% (n=19) of patients. The most common complication was oedema of an implantation side which was presented by 9 patients. Less common was refracture which appeared in 5 cases, neuropraxia of the ulnar nerve was observed in 3 patients and skin puncture of the TEN stub occurred in 2 cases. Further analysis considered the influence of possible complication-related factors with developed side effects as presented in Table No. 2. The presence of complications was correlated with the type of surgery performed, type of fracture and type of plaster cast application. The dependence of open reduction internal fixation on side effects occurrence was statistically significant (\\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e= 0,0025). The type of fracture or plaster cast application did not influence the development of the complications due to a lack of statistical significance.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003eTable 2 \\u0026ndash; Possible complication dependence\\u003c/p\\u003e\\n\\u003ctable border=\\\"0\\\" cellspacing=\\\"0\\\" cellpadding=\\\"0\\\" width=\\\"631\\\"\\u003e\\n \\u003ctbody\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"24.603174603174605%\\\" valign=\\\"top\\\"\\u003e\\u003cbr\\u003e\\u003c/td\\u003e\\n \\u003ctd width=\\\"26.349206349206348%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eStudy group [%]\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eComplications\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.38095238095238%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ep-value\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"24.603174603174605%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eORIF\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.349206349206348%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e7,2\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes (n=11)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.38095238095238%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003cstrong\\u003e= 0,025\\u003c/strong\\u003e\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"24.603174603174605%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eOpen fracture\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.349206349206348%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e9,3\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes (n=2)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.38095238095238%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep\\u003c/em\\u003e = 0,571\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003ctr\\u003e\\n \\u003ctd width=\\\"24.603174603174605%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003ePlaster cast\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.349206349206348%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e9,8\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"26.666666666666668%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003eYes (n=4)\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003ctd width=\\\"22.38095238095238%\\\" valign=\\\"top\\\"\\u003e\\n \\u003cp\\u003e\\u003cem\\u003ep\\u0026nbsp;\\u003c/em\\u003e= 0,252\\u003c/p\\u003e\\n \\u003c/td\\u003e\\n \\u003c/tr\\u003e\\n \\u003c/tbody\\u003e\\n\\u003c/table\\u003e\"},{\"header\":\"Discussion\",\"content\":\"\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eAxial alignment values\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThis research presents mean axial alignment values of ESIN implantation in three age groups, calculated for both ulna and radius, in AP and LAT views.\\u003c/p\\u003e\\n\\u003cp\\u003eThe exact value of acceptable axial alignment or angulation has not yet been ascertained and remains controversial. The work of \\u003cem\\u003ePapermanikou et al.\\u003c/em\\u003e reports this value as less than 15 degrees in the distal and middle 1/3 of the diaphyseal and less than 10 degrees for the proximal diaphyseal. \\u003cem\\u003eFlynn et al.\\u003c/em\\u003e defined acceptable alignment up to 10-20 degrees in patients younger than 10 years old and less than 10 degrees in patients aged over 10 years old. Other authors report this permissible value as less than 15 degrees for distal diaphyseal [6-8]. Taking into consideration the above statements, all mean values obtained in this research, (ranging from 0,75 to 2,8 degrees) are proper values of axial alignment, since our study represents a smaller alignment than the acceptable values listed above. Similar results were achieved by \\u003cem\\u003eDu et al.\\u003c/em\\u003e where the mean angulation of the ulna in AP and LAT views fluctuated around 2,20 to 2,80 degrees in double ESIN implantation and 5,50 to 6,04 degrees in single ESIN use. Comparable outcomes were reported by \\u003cem\\u003eKorhonen et al.\\u003c/em\\u003e, with mean postoperative displacement at follow-up equal to 7,6 degrees for radius and 1,8 degrees for ulna. Slightly different observations have been presented by\\u0026nbsp;\\u003cem\\u003ePapamerkouriou et al.\\u0026nbsp;\\u003c/em\\u003esince the authors obtained an angulation of around 10 to 12 degrees [6,9,10]. Such outcomes may be the result not only of different techniques and radiological assessment programmes but also due to anatomical variations in the radius curvature which inhibit proper analysis of angulation and its reference to normal values.\\u003cbr\\u003e\\u0026nbsp;Nevertheless, the literature is still insufficient regarding the effectiveness of using ESIN in forearm fractures regarding the axial alignment, meaning that further studies are needed to find optimal and acceptable values.\\u0026nbsp;\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eCause of injury\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Among our patients, the most common fracture etiology was a fall from an upright standing position \\u0026nbsp;(32%), the second most common was sport and recreation (29%). The available literature is consistent with our findings. Data reported by \\u003cem\\u003ePapamerkouriou et al.\\u003c/em\\u003e clearly showed that the most frequent mechanism of injury was when a patient had fallen onto an outstretched hand from an upright standing position. Our results are related also to the work of \\u003cem\\u003eLyman et al.\\u0026nbsp;\\u003c/em\\u003ewhere the most common mechanism of injury was a fall onto an outstretched hand, followed by sport injuries.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cem\\u003eVopat et al.\\u003c/em\\u003e reported that the most common mechanism is falling from an upright standing position (83%), however, the injury was reported to occur most frequently in playground areas. In this study, less common injury causes included bicycle, scooter and trampoline use [2,6]. Work of\\u003cem\\u003e\\u0026nbsp;Papamerkouriou et al.\\u0026nbsp;\\u003c/em\\u003elisted similar observations, since less frequent causes combined vehicle or playground accidents, falling from a tree or trampoline.\\u003c/p\\u003e\\n\\u003cp\\u003eThe available literature is quite consistent with our etiology results, and despite slight differences, most of the studies suggest that the most crucial mechanism of pediatric forearm fractures is falling onto an outstretched hand which is coherent with the mechanism of adults\\u0026rsquo; forearm fractures.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eComplications\\u0026nbsp;\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eThe incidence of complications is diverse in the available literature. In our study, the complication rate was 9,5% and the most common side effect observed was implantation side oedema of the wound area (n=9). Less frequent was refracture (n=5) and ulnar nerve neuropraxia (n=3). No complications regarding the delayed union or malunion were observed in the study. \\u0026nbsp;In the work of \\u003cem\\u003eFernandez et al.\\u003c/em\\u003e the complication rate was equal to 14,6% and the most common complication was refracture, lesion of the radial nerve and delayed union. In \\u003cem\\u003ePogorelić\\u0026rsquo;s et al.\\u0026nbsp;\\u003c/em\\u003ework, the main complication was superficial skin irritation, which was not observed in our study. \\u003cem\\u003eFlynn et al\\u003c/em\\u003e. reported a 14,6% complication rate; the most common side effect being delayed union (6/15 cases), other complications included compartment syndrome, tendon laceration and infection [4,6-9,11]. \\u003cem\\u003eKorhonen et al.\\u0026nbsp;\\u003c/em\\u003ereported delayed or lacking union as the most frequent complication. It was also found that open reduction was associated with an increased risk of ulna nonunion. This finding is relevant to our observations since in our work the dependence of open reduction on complication presence was stated. Furthermore, ulna nonunion in the work of \\u003cem\\u003eKorhonen et al.\\u0026nbsp;\\u003c/em\\u003ewas also reported to be the result of using thicker nails and the distal location of the fracture. Despite that, authors assumed that the ESIN implantation procedure shows satisfactory healing. \\u003cem\\u003ePeterlein et al.\\u003c/em\\u003e observed a refracture rate of 3,3% and described long-term results of ESIN use in forearm fractures as convincing. What is more, current literature indicates that the use of ESIN is associated with a lower number of refractures when compared to conservative treatment [7,22,23]. On the other hand, \\u003cem\\u003eLyman et al.\\u003c/em\\u003e reported a 24% complication rate among which the most common was ulnar or radial nerve dysfunction described by the author as a postoperative complication and tendon rupture. Other side effects observed were compartment syndrome and implant migration requiring early removal [2,3,9,12,14,15]. Despite all the complications observed, the authors of the studies were satisfied with the functional results of ESIN use [17,22,23].\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eSurgical treatment indications\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003eAccording to the literature, common indications for surgical treatment of diaphyseal forearm fracture in children include unstable fractures and dislocations, open fractures, fractures that failed to reduce and were irreducible as well as refractures and fractures with neurovascular defects.\\u003c/p\\u003e\\n\\u003cp\\u003eIt is also crucial to consider the impact of the rotation and angulation of the fractures on the type of treatment and functional ability in children. The loss of function can be diminished by restoring the proper axial alignment and rotation. However, the direct acceptable values of malalignments remain controversial, leaving the final decision about treatment up to the surgeon. However, when analyzing angulation in the child population, it is vital to mention that it may be restored by remodelling. As\\u0026nbsp;\\u003cem\\u003ePrice\\u0026nbsp;\\u003c/em\\u003eand other authors reported, even with less than 20 degrees of angulation, 50% of correction may be expected to remodel when children aged less than 8 years. In older children (\\u0026gt;8 years old) the acceptable angle is less than 10 degrees. Nevertheless, the rotational deformities are not expected to be remodelled completely and may be difficult to examine. The literature values of acceptable rotational values differ among the studies and range from 0 to 45 degrees. In both younger and older children, the acceptable malrotation is 30 degrees \\u0026nbsp;[2,11, 13, 18,19] meaning that in the case of patients with such values, no manipulation of the fracture is needed.\\u0026nbsp;\\u003cbr\\u003e\\u0026nbsp;In other cases, whether closed or open reduction is required depends on the surgeon\\u0026rsquo;s assessment. In cases where surgical treatment is unavoidable, the use of the ESIN as a preferred technique is one possibility.\\u003c/p\\u003e\\n\\u003cp\\u003e\\u003cstrong\\u003e\\u003cem\\u003eNail removal\\u003c/em\\u003e\\u003c/strong\\u003e\\u003c/p\\u003e\\n\\u003cp\\u003e\\u0026nbsp;Not many researchers specified the time after ESIN should be removed. Most of the literature states, that removing ESIN is a relatively easy surgery with a low rate of complications, however, the accurate time and possible complications are not addressed. An available study by \\u003cem\\u003ePogorelić et al\\u003c/em\\u003e. reports that nails were removed at a median time of 5 months (4-9 months) and all patients were reported to have regained full limb function. Moreover, all the complications that occurred during the hospitalization were resolved after the nail removal. Patients with ulnar injuries regained their function. As \\u003cem\\u003eLieber et al.\\u0026nbsp;\\u003c/em\\u003estated the mean time of ESIN removal was 4 months, with a low, 3,4% complication rate including temporary loss of sensation, tendon rupture, refracture and superficial wound infection. In the work of \\u003cem\\u003eFurlan et al., the\\u0026nbsp;\\u003c/em\\u003emedian time of ESIN removal was 6 months [11,13,15-21]. However, in our study, the time of implant removal also was not stated since not all of our patients have had it removed. In the majority of cases, ESINs were taken out at the parent\\u0026rsquo;s request on average after a year.\\u003c/p\\u003e\"},{\"header\":\"Conclusions\",\"content\":\"\\u003cp\\u003eElastic stable intramedullary nailing may be considered a satisfactory method of surgical treatment of pediatric forearm fractures with acceptable axial alignment values and a low rate of complications. According to the results of this study and literature, ESIN should be considered as the method of choice for displaced forearm fractures in the pediatric population.\\u003c/p\\u003e\"},{\"header\":\"Declarations\",\"content\":\"\\u003cp\\u003e \\u003ch2\\u003eConflict of Interest\\u003c/h2\\u003e \\u003cp\\u003eThe authors declare no conflicts of interest related to this study.\\u003c/p\\u003e \\u003c/p\\u003e\\u003ch2\\u003eAuthor Contribution\\u003c/h2\\u003e\\u003cp\\u003eK.K. - gathered the data, prepared the manuscipt, prepared the figures and tablesM.M. - performed the statistics analysisK.Sz.- gathered the data, prepared the figures and tablesK.M. - suggested the topic of the research, supervised the data gathering and the whole manuscript preparation.\\u003c/p\\u003e\\u003ch2\\u003eData Availability\\u003c/h2\\u003e\\u003cp\\u003eData supporting the findings of this study are available from the corresponding author upon reasonable request.\\u003c/p\\u003e\"},{\"header\":\"References\",\"content\":\"\\u003col\\u003e\\n\\u003cli\\u003eVopat ML, Kane PM, Christino MA, Truntzer J, McClure P, Katarincic J, Vopat BG. Treatment of diaphyseal forearm fractures in children. Orthop Rev (Pavia);6(2):5325. doi: 10.4081/or.2014.5325 (2014).\\u003c/li\\u003e\\n\\u003cli\\u003eLyman A, Wenger D, Landin L. Pediatric diaphyseal forearm fractures: epidemiology and treatment in an urban population during a 10-year period, with special attention to titanium elastic nailing and its complications. J Pediatr Orthop B;25(5):439-46. doi: 10.1097/BPB.0000000000000278 (2016).\\u003c/li\\u003e\\n\\u003cli\\u003ePeterlein CD, Modzel T, Hagen L, Ruchholtz S, Kr\\u0026uuml;ger A. Long-term results of elastic-stable intramedullary nailing (ESIN) of diaphyseal forearm fractures in children. Medicine (Baltimore);98(11):e14743. doi: 10.1097/MD.0000000000014743 (2019).\\u003c/li\\u003e\\n\\u003cli\\u003eFernandez FF, Langend\\u0026ouml;rfer M, Wirth T, Eberhardt O. Failures and complications in intramedullary nailing of children\\u0026rsquo;s forearm fractures. J Child Orthop;4:159\\u0026ndash;67 (2010).\\u003c/li\\u003e\\n\\u003cli\\u003eSalonen A, Salonen H, Pajulo O. A critical analysis of postoperative complications of antebrachium TEN-nailing in 35 children. Scand J Surg;101:216\\u0026ndash;21 (2012).\\u003c/li\\u003e\\n\\u003cli\\u003ePapamerkouriou YM, Christodoulou M, Krallis P, Rajan R, Anastasopoulos J. Retrograde Fixation of the Ulna in Pediatric Forearm Fractures Treated With Elastic Stable Intramedullary Nailing. \\u003cem\\u003eCureus\\u003c/em\\u003e.;12(5):e8182. doi:10.7759/cureus.8182 (2020).\\u003c/li\\u003e\\n\\u003cli\\u003eFlynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop.;30(4):313-9. doi:10.1097/BPO.0b013e3181d98f2c (2010).\\u003c/li\\u003e\\n\\u003cli\\u003eBa\\u0026scaron;ković M. Acceptable angulation of forearm fractures in children Rev Esp Cir Ortop Traumatol. 9:S1888-4415(22)00151-5. doi: 10.1016/j.recot.2022.06.003 (2022).\\u003c/li\\u003e\\n\\u003cli\\u003eKorhonen L, Lutz N, Sinikumpu JJ. The Association of Metal Frame Construct of ESIN and radiographic bone healing of pediatric forearm fractures. Injury.;51(4):856-862. doi: 10.1016/j.injury.2020.03.028. (2020).\\u003c/li\\u003e\\n\\u003cli\\u003eDu SH, Feng YZ, Huang YX, Guo XS, Xia DD. Comparison of Pediatric Forearm Fracture Fixation Between Single- and Double-Elastic Stable Intramedullary Nailing. Am J Ther; 23(3):e730-6. doi: 10.1097/MJT.0000000000000031 (2016).\\u003c/li\\u003e\\n\\u003cli\\u003ePogorelić Z, Gulin M, Jukić M, Bili\\u0026scaron;kov AN, Furlan D. Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases. \\u003cem\\u003eActa Orthop Traumatol Turc\\u003c/em\\u003e;54(4):378-384. doi:10.5152/j.aott.2020.19128 (2020).\\u003c/li\\u003e\\n\\u003cli\\u003eKruppa C, Bunge P, Schildhauer TA, Dudda M. Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases. Medicine (Baltimore). 96(16):e6669. doi: 10.1097/MD.0000000000006669 (2017).\\u003c/li\\u003e\\n\\u003cli\\u003eBowman EN, Mehlman CT, Lindsell CJ, Tamai J. Nonoperative treatment of both-bone forearm shaft fractures in children: predictors of early radiographic failure. J Pediatr Orthop.; 31(1):23-32. doi: 10.1097/BPO.0b013e318203205b (2011).\\u003c/li\\u003e\\n\\u003cli\\u003eMakki D, Matar HE, Webb M, Wright DM, James LA, Ricketts DM. Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications. J Pediatr Orthop B. 26(5):412-416. doi: 10.1097/BPB.0000000000000408 (2017).\\u003c/li\\u003e\\n\\u003cli\\u003eMazzini PJ, Martin RJ. Paediatric forearm and distal radius fractures: risk factors and re-displacement--role of casting indices. Int Orthop. 34(3):407-12. doi: 10.1007/s00264-009-0904-0 (2010).\\u003c/li\\u003e\\n\\u003cli\\u003eColaris JW et al. Which factors affect limitation of pronation/supination after forearm fractures in children? A prospective multicentre study. Injury;45(4):696-700. doi: 10.1016/j.injury.2013.09.041 (2014).\\u003c/li\\u003e\\n\\u003cli\\u003eCaruso G, Caldari E, Sturla FD, Caldaria A, Re DL, Pagetti P, Palummieri F, Massari L. Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature. Musculoskelet Surg.;105(3):225-234. doi: 10.1007/s12306-020-00684-6 (2020).\\u003c/li\\u003e\\n\\u003cli\\u003eKamat AS, Pierse N, Devane P, Mutimer J, Horne G. Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures. J Pediatr Orthop.;32(8):787-91. doi: 10.1097/BPO.0b013e318272474d. (2012).\\u003c/li\\u003e\\n\\u003cli\\u003eNoonan KJ, Price CT. (1998) Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998 May-Jun;6(3):146-56. doi: 10.5435/00124635-199805000-00002 (1998).\\u003c/li\\u003e\\n\\u003cli\\u003eFurlan D, et al. Elastic stable intramedullary nailing for pediatric long bone fractures: experience with 175 fractures. Scand J Surg;100(3):208-15. doi: 10.1177/145749691110000313 (2011).\\u003c/li\\u003e\\n\\u003cli\\u003eLieber J, Dietzel M, Scherer S, Sch\\u0026auml;fer JF, Kirschner HJ, Fuchs J. Implant removal associated complications after ESIN osteosynthesis in pediatric fractures. Eur J Trauma Emerg Surg. 2022 Oct;48(5):3471-3478. doi: 10.1007/s00068-021-01763-4 (2021).\\u003c/li\\u003e\\n\\u003cli\\u003eRichter D, Ostermann PA, Ekkernkamp A, Muhr G, Hahn MP. Elastic intramedullary nailing: a minimally invasive concept in the treatment of unstable forearm fractures in children. J Pediatr Orthop. \\u003c/li\\u003e\\n\\u003cli\\u003eHan B, Wang Z, Li Y, Xu Y, Cai H. (2019) Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing. Int Orthop.;43(9):2093-2097.doi: 10.1007/s00264-018-4184-4 (1998).\\u003c/li\\u003e\\n\\u003c/ol\\u003e\"}],\"fulltextSource\":\"\",\"fullText\":\"\",\"funders\":[],\"hasAdminPriorityOnWorkflow\":false,\"hasManuscriptDocX\":true,\"hasOptedInToPreprint\":true,\"hasPassedJournalQc\":\"\",\"hasAnyPriority\":false,\"hideJournal\":true,\"highlight\":\"\",\"institution\":\"\",\"isAcceptedByJournal\":false,\"isAuthorSuppliedPdf\":false,\"isDeskRejected\":\"\",\"isHiddenFromSearch\":false,\"isInQc\":false,\"isInWorkflow\":false,\"isPdf\":false,\"isPdfUpToDate\":true,\"isWithdrawnOrRetracted\":false,\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true},\"keywords\":\"forearm fractures, pediatrics fractures, ESIN technique, intramedullary nailing\",\"lastPublishedDoi\":\"10.21203/rs.3.rs-4159221/v1\",\"lastPublishedDoiUrl\":\"https://doi.org/10.21203/rs.3.rs-4159221/v1\",\"license\":{\"name\":\"CC BY 4.0\",\"url\":\"https://creativecommons.org/licenses/by/4.0/\"},\"manuscriptAbstract\":\"\\u003cp\\u003eForearm shaft fractures are common injuries, often caused by falling from a fully upright standing position or falling off while riding a bike. These injuries can be treated nonoperatively or surgically with intramedullary nailing or plates. According to the literature, the method of choice for treating pediatric forearm shaft fractures is the application of elastic stable intramedullary nailing (ESIN)|. The study aimed to carry out a radiological assessment of ESIN use in pediatric patients with forearm shaft fractures, as well as an analysis of the etiology of the injury and the complication rate. \\u003cstrong\\u003e\\u003cbr\\u003e\\n\\u003c/strong\\u003ePatients aged 1 to 17 years, diagnosed with a fracture of the forearm shaft treated surgically with ESIN, with a set of X-ray pictures and a minimum \\u0026nbsp;6-month follow-up qualified for the study. The evaluation of the axial alignment was carried out retrospectively in anatomical (AP) and lateral (LAT) \\u0026nbsp;positions.\\u003cstrong\\u003e \\u003c/strong\\u003e402 radiographs of 201 patients (30,5% women, 69,5% men) with a mean age of 9.1 years (SD = 3.2) were analyzed. 68% of fractures occurred during sports activity. 75% of fractures involved both the radius and the ulna. The union was observed in 100% of cases. Mean axial alignment values in AP and LAT X-ray or both the ulna and radius were proper according to the literature.\\u003cbr\\u003e\\nAxial alignment values were not influenced significantly by the age, type of surgery carried out or the type of fracture. Plaster cast application (9,8% of cases) significantly influenced the values of radius axial alignment. Complications rate equaled 11.4% (n=23). The etiology of the injury did not affect axial alignment values. Significantly more complications were observed in the ORIF group (p = 0,0025).\\u003cstrong\\u003e\\u003cbr\\u003e\\n\\u003c/strong\\u003eThe ESIN technique is an effective treatment for forearm diaphyseal fractures in children, with good radiological results regarding reduction and bone healing.\\u003c/p\\u003e\",\"manuscriptTitle\":\"Elastic stable intramedullary nailing (ESIN) in paediatric diaphyseal forearm fractures – retrospective analysis of 201 cases\",\"msid\":\"\",\"msnumber\":\"\",\"nonDraftVersions\":[{\"code\":1,\"date\":\"2024-04-29 16:24:37\",\"doi\":\"10.21203/rs.3.rs-4159221/v1\",\"editorialEvents\":[{\"type\":\"communityComments\",\"content\":0}],\"status\":\"published\",\"journal\":{\"display\":true,\"email\":\"info@researchsquare.com\",\"identity\":\"researchsquare\",\"isNatureJournal\":false,\"hasQc\":true,\"allowDirectSubmit\":true,\"externalIdentity\":\"\",\"sideBox\":\"\",\"snPcode\":\"\",\"submissionUrl\":\"/submission\",\"title\":\"Research Square\",\"twitterHandle\":\"researchsquare\",\"acdcEnabled\":true,\"dfaEnabled\":false,\"editorialSystem\":\"\",\"reportingPortfolio\":\"\",\"inReviewEnabled\":false,\"inReviewRevisionsEnabled\":true}}],\"origin\":\"\",\"ownerIdentity\":\"e3dbc0a4-77eb-4f3e-9446-d9a1d8de7925\",\"owner\":[],\"postedDate\":\"April 29th, 2024\",\"published\":true,\"recentEditorialEvents\":[],\"rejectedJournal\":[],\"revision\":\"\",\"amendment\":\"\",\"status\":\"posted\",\"subjectAreas\":[{\"id\":31001855,\"name\":\"Health sciences/Anatomy\"},{\"id\":31001856,\"name\":\"Health sciences/Health occupations\"},{\"id\":31001857,\"name\":\"Health sciences/Risk factors\"}],\"tags\":[],\"updatedAt\":\"2024-07-02T07:12:05+00:00\",\"versionOfRecord\":[],\"versionCreatedAt\":\"2024-04-29 16:24:37\",\"video\":\"\",\"vorDoi\":\"\",\"vorDoiUrl\":\"\",\"workflowStages\":[]},\"version\":\"v1\",\"identity\":\"rs-4159221\",\"journalConfig\":\"researchsquare\"},\"__N_SSP\":true},\"page\":\"/article/[identity]/[[...version]]\",\"query\":{\"redirect\":\"/article/rs-4159221\",\"identity\":\"rs-4159221\",\"version\":[\"v1\"]},\"buildId\":\"qtupq5eGEP_6zYnWcrvyt\",\"isFallback\":false,\"isExperimentalCompile\":false,\"dynamicIds\":[84888],\"gssp\":true,\"scriptLoader\":[]}","source_license":"CC-BY-4.0","license_restricted":false}