Exposed versus buried intramedullary implants for pediatric forearm fractures: A comparison of complications

Background: The purpose of this study was to compare the rate of complications between buried and exposed intramedullary implants after fixation of pediatric forearm fractures.

Methods: A retrospective comparative cohort study of 339 children treated with intramedullary fixation for displaced forearm fractures between 2004 and 2009 was performed. Implants were left exposed in 128 patients (37.8%) and buried beneath the skin in 208 patients (61.4%); 3 patients had buried and exposed hardware (0.9%). Data on demographics, injury, surgical technique, and complications were analyzed.

Results: The buried implant group was older (mean 10.3 vs. 8.5 y; P<0.001), heavier (mean 38.6 vs. 31.9 kg; P< 0.001), and had fewer open injuries (23% vs. 41%; P< 0.001) than the exposed implant group. The buried group had their implants removed later than the exposed group (median 3.5 vs. 1.2 mo; P< 0.001). There was no difference between time to removal for patients with refracture and those without (median 1.3 vs. 2.0 mo; P =0.78). A total of 36.2% of exposed implants were successfully removed in the office. Complications were seen in 56 patients (16.5%). There were 16 patients (4.7%) with refracture and 12 patients (3.5%) with infection. The buried and exposed implant groups did not differ significantly with respect to refracture (3.1% vs. 7.0%; P =0.20), infection (3.5% vs. 2.3%; P=0.66), or overall complications (14.5% vs. 17.2%; P= 0.87). There was also no difference between groups with respect to loss of reduction, nondelayed or delayed union, loss of motion, hypertrophic granuloma, or tendon rupture. Buried implants were also associated with penetration through the skin (3.9%). Injury to the dominant arm and need for open reduction were significant predictors of complication (OR=1.01; 95% CI, 1.001-1.012; P=0.02 and OR =0.51; 95% CI, 0.264-0.974; P = 0.04, respectively).

Conclusions: There were no significant differences seen in number of infections, refractures, or overall complications based onwhether implants were left exposed or buried beneath the skin after surgery.