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The data has been wholly included in the manuscript .



To investigate whether close decrease and home obsession ( CRIF ) with titanium elastic nails ( TENs ) is a feasible alternate treatment in proximal radial fractures .


In Kaohsiung Veterans General Hospital, from November 2013 to April 2015, five adult male patients with forearm injuries ( average age 43 years ; range 35–64 years ) were treated for proximal radial shaft fractures. CRIF with TENs for radial shaft fractures was performed in these five patients. Radiographs ; scope of motions ; ocular analogue scale ( VAS ) ; quick disabilities of the arm, shoulder, and hand ( Quick DASH ) questionnaire ; and time to union were evaluated in our study.


average follow-up period was 30 months ( range 28–36 months ). average time of spoke union was 7.3 months ( range 6–10 months ). Functional outcomes 1 year after operation revealed an average immediate DASH grade of 7.92 ( range 4.5–25 ), an average VAS of 1.5 ( range 1–3 ), and average forearm supination and pronation of 69.2° ( range 45°–75° ) and 82.5° ( range 80°–85° ). No major complication was noted .


CRIF with TEN for adult proximal radial fractures is a method acting to avoid extensive exposure or boldness wound during ORIF, particularly in multiple trauma patients who require inadequate running time, uremia patients with ipsilateral forearm AV shunt, hard easy tissue swelling due to direct muscle contusion or hard energy before surgery, extensive radial fracture, and those in pursuit of cosmetic outcomes. Keywords:

Proximal radial fracture, Titanium elastic nail, TEN, Radial intramedullary nail, Radial interlocking nail


Diaphyseal forearm fractures are considered intraarticular fractures. Anatomic decrease with plates and screw obsession serves as the gold standard as it is significant to restore rotational constancy and continue double bone duration [ 1, 2 ]. however, extensive surgical photograph and periosteal denudation during exposed reduction surgery may increase the risks of neurovascular injuries, soft tissue injuries, intraoperative fractures, muscle intumescence, and even postoperative compartment syndrome [ 3 – 5 ]. To avoid iatrogenic injuries, non-locked intramedullary nail treatment for forearm fractures has been previously reported [ 5 ]. It is worth noting that the precontoured elastic stable intramedullary collar ( such as titanium elastic pinpoint ( TEN ) fixation for radial shot fractures ) is widely used in children as it is safer and more efficient compared with plating [ 6 ]. This technique preserves the periosteum, allowing bone healing within a close and entire biological environment [ 7, 8 ]. By contrast, adult bone mend properties are diminished compared with that of children. Osteoblasts in the inner cellular layer of the child ’ south blockheaded periosteum become dilutant with age, and the bone healing process is besides prolonged with aging. The biomechanical chief of the TEN is based on the symmetrical brace action of elastic nails inserted into the metaphysis, which bears against the inner bone at three points [ 9 ]. This method has the benefits of early contiguous constancy to the involved bone segment, which permits early mobilization and returns to the normal activities of the patients, with very gloomy complication rate [ 10 ]. TENs lack axile and rotational stability but they are relatively stable with secondary bone mend. There are few reports evaluating the consumption of elastic stable intramedullary nails in adult proximal radial fractures [ 11, 12 ]. The proximal radius is surrounded by abundant forearm muscle, particularly the supinator and pronator teres, and the posterior interosseous boldness ( PIN ) besides crosses the proximal radius. The intramedullary breeze through method has advantages such as closed application, less easy tissue wound, avoidance of boldness injury, and cosmetic benefits. In particular, the application of the TEN for pornographic proximal radial cheat fractures has not been extensively investigated. The underlying hypothesis of this study was that limited surgical dissection to treat pornographic proximal radial shaft fractures can avoid neuromuscular wound, reduce lineage loss, enhance fracture curative, and yield better cosmetic results compared with the criterion routine of receptive reduction with plate and screw arrested development. Toward this end, this discipline evaluated the functional outcomes and efficiency of TENs in the surgical treatment of adult proximal radial shaft fractures .


The methodology of our study is a retrospective cohort sketch. The institutional review board of Kaohsiung General Veterans Hospital approved this retrospective cogitation and inform consents were taken from all the patients. This study assessed patients with proximal radial rotating shaft fractures who undergo fixation with TENs ( DePuy Synthes, Johnson & Johnson Family of Companies, MA, USA ) from November 2013 to April 2015. In full, five patients ( six radial fractures ) were included and anteroposterior ( AP ) and lateral forearm radiogram were obtained on first entree following trauma. All fracture patterns were recorded according to the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association ( AO/OTA ) fracture classification organization. All distal radial ulnar joint ( DRUJ ) stability was evaluated with radiogram and physical examinations before operation. Postoperative DRUJ stability and neurological assessment were evaluated, and stove of gesture at the wrist, elbow, and forearm supination and pronation were recorded. Numbness or wrist drop indicated iatrogenic boldness injury. The details of evaluation of crop of movement ( ROM ) of the forearm with the elbow flexed at 90° were measured by a goniometer [ 13 ]. primary coil consequence measurement is the compass of motion of forearm supination and pronation, and the junior-grade consequence measurements include the time to achieve cram union and the functional questionnaire to evaluate the function of diseased limb at 12 months postoperatively. In this study, one patient had bilateral extensive proximal-third radial shaft fractures ( Fig. ), one patient had only a right proximal-third radial shaft comminuted fracture ( Fig. ), and three patients had left proximal-third radial and ulnar shaft fractures ( Fig. ). All patients were male, and the average old age was 43 years ( range 30–64 years ). Etiologically, all fractures were sustained during traffic accidents while riding a motorcycle .An external file that holds a picture, illustration, etc.
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Surgical technique

After initiation of appropriate anesthesia, the patient was placed in the supine position and a compression bandage was placed at the upper branch for the reduction of rake loss. The arm was placed on a radiolucent arm board or suspended vertically in traction. surgical intervention began first with receptive reduction and inner obsession ( ORIF ) with plate arrested development for ulnar cheat fractures to preserve forearm duration if there were combine radio-ulnar fractures, and then radial fractures were treated via shut reduction and internal fixation ( CRIF ) with TEN arrested development under the help of an image intensifier ( OEC Fluorostar 7900 Digital Mobile C-arm, GE Healthcare, UK ). The diameters of the pinpoint are about two thirds of the medullary isthmus of radius. In our report, a nail diameter of 2.5 millimeter is largely used, whereas 3.0 millimeter breeze through is besides used. The TENs were pre-bent into a “ C ” shape with the nail tap pointing toward the concave side of the bandy nail down. A 1.5-cm skin incision was made below the radial styloid. The introduction point was created proximal to the first gear dorsal component to avoid kidnapper pollicis longus and extensor muscle pollicis brevis injuries. Penetrating near the cerebral cortex with the exercise sting and using a rotate awl, the awl was then slowly lowered to an angle of 45° relative to the quill axis and was advanced at this angle until it reached the medullary canal. An adequate length of TEN outside the hide was then temporarily fixed into a Synthes Universal Chuck with T-handle ( DePuy Synthes, Johnson & Johnson Family of Companies, MA, USA ). Using oscillating hand movements, the unreamed TEN was lightly advanced manually in a retrograde manner until it reached the fracture site. The breeze through was introduced into the proximal shard by indirect handling of the fragment under fluoroscopy. The breeze through was carefully advanced manually throughout the integral implantation procedure to avoid penetrating the cerebral cortex, specially in osteoporotic cram, until it rested at the radial tuberosity. When the nails were correctly positioned, the protruding complete ends were cut approximately 1 centimeter from the bone and then were pushed into their concluding positions using the impactor, with 5 millimeter of the nail end left beyond the cerebral cortex. TEN ends were left longer and placed sufficiently far outside the tendon compartment to avoid constant friction and tendon rupture. All TENs were removed after bone union .

Postoperative care and follow-up

Postoperative care included ( 1 ) immobilization for each affected role with a long-arm splint/cast in a forearm supination place for 4 weeks ( splint for the first workweek postoperatively due to the soft tissue swell, after the soft tissue swelling improved, casting from the second gear to fourthly weeks postoperatively ) ; ( 2 ) active/passive apparent motion of the elbow and forearm rotation reclamation after removal of the mold ; and ( 3 ) TENs removal when bone union was confirmed. All patients were followed up for at least 2 years postoperatively. close follow-up at our outpatient department included radiogram of the forearm to evaluate fault heal and the record of functional outcomes using the ocular analogue scale ( VAS ) for pain, the Quick Disabilities of the Arm, Shoulder, and Hand ( Quick DASH ) questionnaire [ 14 ], and the maximal ROM at the forearm using a goniometer was measured with supination and pronation at 12 months postoperatively .


According to the AO/OTA fracture classification system, one patient had bilateral type A2 fractures, one patient had a type C2 fracture, and three patients had a unilateral type A3 fracture. none of the patients had DRUJ instability. One affected role with bilateral external oblique muscle fractures had decreased operative clock time and piano tissue dissection. Another affected role was a victim of multiple trauma, with multiple rib fractures, pneumothorax, a maxillary fracture of the confront, and pectoral aortal transection so it was important to decrease operative time after chest of drawers operation. dangerous muscle swell was noted because of direct contusion wound in three patients. demographic information and radiological and clinical outcomes are shown in Table. The average follow-up period was 30 months ( range 28–36 months ). The average surgical time was 48 min ( range 35–65 minute ). The average measure of blood loss during operating room was 27 milliliter ( range 10–40 milliliter ). median time to union for each spoke was 7.3 months ( range 6–10 months ) .

Table 1

No. Age Sex Side Indication for TENs Type of reduction Operative time (min) Blood loss (ml) Duration of hospitalization (days) Time to clinical union (month) Supination/pronation
VAS Quick DASH score Follow-up period (month)
1 35 M L Severe soft tissue swelling Ulna ORIF + radius CRIF 55 30 4 6 75/85 1 4.5 28
2 30 M L Bilateral long oblique fracture to avoid long plate and soft tissue dissection Radius CRIF 40 10 4 6 L 75/85 1 4.5 28
R Radius CRIF 6 R 70/80 1 4.5
3 43 M L Severe soft tissue swelling Radius CRIF 65 30 2 8 75/80 2 4.5 30
4 64 M L Multiple trauma with the need to shorten operative time Ulna ORIF + radius CRIF 35 40 26 10 45/85 3 25 36
5 43 M R Comminuted fracture with severe soft tissue swelling Ulna ORIF + radius CRIF 45 25 2 8 75/80 1 4.5 28

Open in a separate window One patient achieved clinical union without pain or any clinical symptom at approximately 10 months postoperatively. Radiographic bone union was achieved at 18 months postoperatively, which may have resulted from the thick cortical bone and less cancellate bone as shown on the radiogram. immobilization with long-arm splint was performed after surgery, and the cast was removed 4 weeks late, followed by active and passive ROM of the elbow. evaluation of functional results according to the Quick DASH scores and ROM of elbow and forearm were completed 1 class after operation. Full ROM in flexion-extension of elbow and supination-pronation of forearm was noted in all patients expect one patient with restrict ROM on forearm rotation.

The average Quick DASH score of all six injured forearms was 7.92 ( range 4.5–25 ). The patient with the highest quick DASH score of 25 with limited ROM was a 64-year-old male whose multiple injury resulted in delay rehabilitation. It was particularly unmanageable for him to wash his back and turn a key. All patients were annoyance rid and returned to their previous oeuvre approximately 4.5 months after injury except the victim of multiple injury who retired after his accident. All patients received close reduction, and there was no iatrogenic injury of nerves, vessels, tendons, or intraoperative fractures. During the follow-up period, none of the patients received secondary interventions such as cram graft or shock wave discussion. There were neither implant failures nor synostosis in our patients ; however, two patients experienced skin pique over the pinpoint tails. average supination and pronation of each forearm were 69.2° ( range 45°–75° ) and 82.5° ( range 80°–85° ), respectively. According to these postoperative results, most patients successfully achieved functional recovery of the previously injured forearm, with the exception of the affected role with multiple injury, who entirely achieved 45° at supination of his forearm .


We performed CRIF in five pornographic patients with proximal radial shaft fractures using TENs to avoid cleave of the pronator teres muscle around the fracture web site vitamin a well as to minimize PIN wound. Our results indicated that this is an option treatment for patients with hard muscleman swelling around the fracture locate after injury, as this choice efficaciously avoids postoperative soft tissue swelling attributed to the elevation or detachment of muscles and reduces the incidence of postoperative apathy and wrist spend. forearm fractures are regarded as intraarticular fractures ; consequently, ORIF with plate fixation remains the gold standard of discussion [ 1 ]. It is sometimes unmanageable to perform ORIF at sealed locations of the forearm, such as the proximal radial quill, where the pronator teres and supinator are inserted and the posterior interosseous steel crosses. The injury mechanism underlying forearm fractures is much the consequence of direct bruise with austere gentle tissue swelling. The pronator teres and supinator surrounded by the fracture locate are vulnerable to transection during surgical approach. If surgeons decide to perform ORIF for proximal radial shaft fracture, the voiced tissue dissection is certain to cause extensive end. The PIN is besides at risk due to retraction rather of transection during surgery. The Henry approach provides conduct palmar visual image for radial fracture decrease at the forearm supination situation, with transection of pronator teres and some divide of the common flexors. The Thomson approach may offer less destruction during soft tissue dissection when confronting the forearm fracture ; however, the PIN is susceptible during this dorsal approach to the proximal radial fracture, and rotational deformity may besides occur with loss of full supination of the forearm [ 3, 4 ]. broadly, TENs are popularly applied to pediatric fractures due to the midst periosteum and the increased potential for bone recast in children, but they are not routinely used in adults because of miss of resistance to rotational storm and axial load [ 7, 8 ]. however, TENs are allow for the stabilization of proximal forearm fractures, which spares the massive easy tissue dissection and avoids the possibility of PIN injury. Unlike the lower extremity with its necessitate for system of weights have a bun in the oven, axile load may not remain a trouble for the upper arm. In our study, one pre-bent nail down was inserted, which then became constrained by the medullary canal of the spoke through 3-point pressure on the cram. The radial bowing of the radius promotes attainment of 3-point arrested development on the inner aspect of the bony cortex with a individual pre-contoured ten. Because of the 3-point atmospheric pressure on the bone, the pre-bent bow form of the TEN is less probably to back out. In our cohort, the rotational force out was resisted with postoperative farseeing sleeve frame over 4 weeks at the forearm supination position for radial paralleling the ulna, and pre-bent TENs are designed in a ice hockey joint shape with the breeze through tap inserted into the radial head for rotational constancy [ 15, 16 ]. According to the AO principles, ORIF with plate arrested development is the direct reduction of a fracture site for the purpose of absolute stability and takes approximately 3 to 4 months to achieve radiographic primary bone union. Internal obsession with an intramedullary nail provides the relative stability necessity to achieve junior-grade bone union, and callus formation should be discovered at 3 months postoperatively during follow-up. In our study, a small sum of callus was noted on the radiographic series approximately 3 to 4 months postoperatively, which may be attributed to the little sum of cancellate bone and thick cortical bone contentedness at the radio-ulnar shot. Clinical bone union was achieved approximately 6 months postoperatively at the time of about painless, broad compass of gesticulate, and come back to previous bring in our patients. In our opinion, the time of implant removal in our patients was at least 8 months postoperatively. The patients with devious and grind fractures who received CRIF with TENs demonstrated acceptable alignment of their reduction, and those patients with a cross character fracture model revealed unsatisfactory anatomic reduction of the radial arch, even though there was no significant difference in functional outcomes, or supination and pronation movement between them. The TEN is a type of non-locked intramedullary breeze through which provides relative stability over a fracture locate. The CRIF with a non-locked intramedullary collar technique for proximal radial fractures causes less damage to the soft tissues and less neurovascular injuries than ORIF with plate, arsenic well as sparing the risk of re-fracture after plate removal [ 17 ]. however, the CRIF may not adequately achieve anatomic reduction, specially in radial shaft metameric fractures [ 16, 18, 19 ]. The try sharing behavior and interfragmentary micro-motion of intramedullary implants could give raise to secondary periosteal callus formation [ 20 ]. recently, new intramedullary radial lock nails for radial and ulnar fractures were designed [ 5 ]. The lock intramedullary collar technique offers the advantages of preventing shorten and rotation in metaphyseal, comminuted, and metameric diaphyseal forearm fractures. however, CRIF with the radial interlock nails requires screws which lock at both ends, and there is the potential risk of PIN injury during the proximal lock in procedure and the gamble of extensor muscle pollicis longus and/or superficial radial heart injuries while performing distal locking [ 21 ]. In accession, as compared with our study, the diameter of the engagement nails is by and large larger than that of the TENs, and the insertion of an interlock complete takes more meter and requires a more experience surgical technique, concerning the preoperative plan and the intraoperative decision about the depth and width of the radial canal. interim, without a compression bandage, the medullary canal is enlarged via a reamer to allow interpolation of the intramedullary interlock smash, which is likely to cause more rake loss than a childlike TEN interpolation via fluent oscillating movements. Locked intramedullary complete is a technically more demand procedure that involves an excessive amount of x-ray acquisition [ 22, 23 ]. In our know, CRIF with interlocking nails normally requires more radiation exposure than with non-locked intramedullary nails in order to precisely apply the lock screw. The efficiency of the operation for patients plays an important function. TENs application is suggested for patients with the following conditions : ( 1 ) patients with multiple trauma who require short operative fourth dimension ; ( 2 ) uremia patients with an ipsilateral forearm arteriovenous shunt who should avoid indulgent weave dissection and extreme blood loss ; ( 3 ) those with preoperative easy tissue swelling due to direct muscle bruise or strong muscularity ; ( 4 ) extensive fracture of the forearm which necessitates a very long plate for ORIF ; and ( 5 ) those in pastime of cosmetic outcomes with circumscribed soft tissue dissection. TENs can be of great benefit to the aforesaid patient populations .


This study had several limitations including its retrospective nature and modest sample size. In accession, there was a miss of a manipulate group of patients treated via ORIF with plate obsession and difficulties in calculating the private detective time of radial fractures due to the combined ulnar fracture decrease with plate arrested development in some of our cases. In summation, we could not properly quantify radiation exposures .


rigid home plate arrested development is calm the amber standard for pornographic forearm fracture treatment. The use of TENs provides an alternative means for home obsession of adult proximal radial fractures. With limited soft tissue dissection, we can avoid neuromuscular injury and produce good cosmetic outcomes. however, the lack of absolute anatomic reduction and mechanical stability from the use of TENs necessitates 4 weeks of long-arm casting immobilization and more time for bone union. Most patients in our study achieved desirable functional outcomes, with degrees of postoperative supination and pronation that were near the normal range. A defect of our survey was the little sample size. Future comparative analyses of CRIF with TENs and ORIF with plates to treat adult proximal radial fractures, with bombastic, consecutive patient cohorts, are warranted .


We thank Dr. Shan-Wei Yang ( Kaohsiung Veteran General Hospital, Taiwan ) for his critical reading and modification of the manuscript .


This research received no specific allow from any fund agency in the public, commercial, or nonprofit organization sectors .

Availability of data and materials

The datum has been wholly included in the manuscript .


AO/OTA Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association
CRIF Closed reduction and internal fixation
DRUJ Distal radial ulnar joint
ORIF Open reduction and internal fixation
PIN Posterior interosseous nerve
Quick DASH Quick Disabilities of the Arm, Shoulder, and Hand questionnaire
ROM Range of motion
TEN Titanium elastic nail
VAS Visual analog scale

Authors’ contributions

All authors made substantive intellectual contributions to this report to qualify as authors. Y-CH, Y-WT, and J-HR designed the report. An initial draft of the manuscript was written by Y-CH. Y-WT re-drafted parts of the manuscript and provided helpful advice on the final examination rewrite. All authors were involved in writing the manuscript. All authors read and approved the final manuscript .


Ethics approval and consent to participate

The institutional review board ( IRB ) of Kaohsiung General Veterans Hospital approved this survey.

Consent for publication

All images for publication informed consents were taken from all the patients .

Competing interests

The authors declare that they have no competing interests .

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