Atrophic non-union with severe osteolysis of the radius in a healthy child: successful rescue surgery. Management with fibular allograft and autograft growth factors in a paediatric patient

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Abstract


Background. Forearm fractures are the most frequent fractures in children and adolescents and they are more common in males than in females. In the last 20 years the increase of surgical indications have resulted in more complications, among them the non-unions, considered extremely rare and severe in children, have increased in incidence. We report a successful treatment of misdiagnosed forearm atrophic non-union with severe osteolysis using fibula allograft and autograft growth factors in a previously healthy 4-year-old child.

Clinical case. A 4 year-old boy presented to our hospital with massive bone loss and a negative bone biopsy for Gorham-Stout Syndrome, he also showed reactive bone tissue with abnormal vascularity, necrotic osteocartilaginous fragments and giant mononucleated cells. Other lab tests did not show any modifications, so all the causes of paediatric osteolysis were ruled out. He had already undergone a few surgeries on that fracture and we performed others before achieving a good result, obtained with an autologous fibula graft with medullary growth factors stabilized with Kirschner wire. At the follow up 28 months later, the patient showed total consolidation of the initial area of non- union, no neurovascular deficit and no joint deficiency.

Discussion. Non-union in paediatric patients is rare and therefore difficult to treat and diagnose. Since all of our tests ruled out the main causes of paediatric non-union, we managed the case with strategies usually applied to adult patients, carefully respecting the growth plates.

Conclusion. Although this is a single-case report, it underlines the importance of early diagnosis, the difficulty to rule out some pediatric causes of bone loss and the complicances of a wrong diagnosis/treatment. It also shows that the use of allograft bone and autograft growth factors in a pediatric patient, who has undergone multiple surgeries, can lead to excellent results


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About the authors

Daniele Priano

University of Milan

Email: daniele.priano@gmail.com
ORCID iD: 0000-0002-5123-4478

Italy, Milano

MD, Resident

Mario D'Errico

University of Milan

Author for correspondence.
Email: orto.derrico@gmail.com

Russian Federation, Milano

MD, Resident

Laura Peretto

G. Pini Institute

Email: laura.peretto@gmail.com
ORCID iD: 0000-0001-5664-3687

Russian Federation, Milano

MD, Orthopaedic Surgeon, Department of Pediatric Orthopedic Surgery

Antonio Memeo

G. Pini Institute

Email: antonio.memeo@asst-pini-cto.it

Russian Federation, Milano

MD, Orthopaedic Surgeon, Chief of Department of Pediatric Orthopedic Surgery

References

  1. Song KS, Lee SW, Bae KC, et al. Primary nonunion of the distal radius fractures in healthy children. J Pediatr Orthop B. 2016;25(2):165-169. https://doi.org/10.1097/BPB.0000000000000257.
  2. Saini P, Meena S, Shekhawat V, Kishanpuria TS. Nonunion of forearm fracture: A rare instance in a toddler. Chin J Traumatol. 2012;15(6):379-381. https://doi.org/10.3760/cma.j.issn.1008-1275.2012.06.015.
  3. De Raet J, Kemnitz S, Verhaven E. Nonunion of a pediatric distal radial metaphyseal fracture following open reduction and internal fixation: A case report and review of the literature. Eur J Trauma Emerg Surg. 2008;34(2): 173-176. https://doi.org/10.1007/s00068-007-6168-8.
  4. Lyons RA, Delahunty AM, Kraus D, et al. Children’s fractures: A population based study. Inj Prev. 1999;5(2):129-132. https://doi.org/10.1136/ip.5.2.129.
  5. Yeo JH, Jung ST, Kim MC, Yang HY. Diaphyseal nonunion in children. J Orthop Trauma. 2018;32(2):e52-e58. https://doi.org/10.1097/BOT.0000000000001029.
  6. Di Gennaro GL, Stilli S, Trisolino G. Post-traumatic forearm nonunion in healthy skeletally immature children: A report on 15 cases. Injury. 2017;48(3):724-730. https://doi.org/10.1016/j.injury.2017.01.023.
  7. Sinikumpu JJ, Lautamo A, Pokka T, Serlo W. The increasing incidence of paediatric diaphyseal both-bone forearm fractures and their internal fixation during the last decade. Injury. 2012;43(3):362-366. https://doi.org/10.1016/j.injury.2011.11.006.
  8. Kwa S, Tonkin MA. Nonunion of a distal radial fracture in a healthy child. J Hand Surg. 2016;22(2):175-177. https://doi.org/10.1016/s0266-7681(97)80056-3.
  9. Zura R, Kaste SC, Heffernan MJ, et al. Risk factors for nonunion of bone fracture in pediatric patients: An inception cohort study of 237,033 fractures. Medicine (Baltimore). 2018;97(31):e11691. https://doi.org/10.1097/MD.0000000000011691.
  10. Memeo A, Verdoni F, De Bartolomeo O, et al. A new way to treat forearm post-traumatic non-union in young patients with intramedullary nailing and platelet-rich plasma. Injury. 2014;45(2):418-423. https://doi.org/10.1016/j.injury.2013.09.021.
  11. Hardegger F, Simpson LA, Segmueller G. The syndrome of idiopathic osteolysis. Classification, review, and case report. J Bone Joint Surg Br. 1985;67(1):88-93. https://doi.org/10.1302/0301-620X.67B1.3968152.
  12. El-Kouba G, de Araújo Santos R, Pilluski PC, et al. Gorham-Stout syndrome: Phantom bone disease. Rev Bras Ortop. 2010;45(6):618-622. https://doi.org/10.1016/s2255-4971(15)30313-x.
  13. Zacharia B, Chundarathil J, Meethal KC, et al. Gorham’s disease of the fibula: A case report. J Foot Ankle Surg. 2009;48(3):347-352. https://doi.org/10.1053/j.jfas. 2009.01.004.
  14. Pedrazzini A, Bastia P, Bertoni N, et al. Distal radius nonunion after epiphyseal plate fracture in a 15 years old young rider. Acta Biomed. 2018;90(1-S):169-174. https://doi.org/10.23750/abm.v90i1-S.7999.
  15. Choma ND, Biscotti CV, Bauer TW, et al. Gorham’s syndrome: A case report and review of the literature. Am J Med. 1987;83(6):1151-1156. https://doi.org/10.1016/0002-9343(87)90959-4.
  16. Cannata G, De Maio F, Mancini F, Ippolito E. Physeal fractures of the distal radius and ulna: Long-term prognosis. J Orthop Trauma. 2003;17(3):172-179; discussion 179-180. https://doi.org/10.1097/00005131-200303000-00002.
  17. Zhen P, Lu H, Gao MX, et al. Successful management of atrophic nonunion of a severely osteoporotic femoral shaft in a child. J Pediatr Orthop B. 2012;21(6):592-595. https://doi.org/10.1097/BPB.0b013e328352d546.
  18. Rampoldi M, Palombi D, Artale AM, Marsico A. Pseudartrosi dell’avambraccio: Sintesi interna rigida e innesto osseo autologo. Giot. 2008;34:77-85.
  19. Bray CC, Walker CM, Spence DD. Orthobiologics in pediatric sports medicine. Orthop Clin North Am. 2017;48(3):333-342. https://doi.org/10.1016/j.ocl. 2017.03.006.
  20. Fioravanti C, Frustaci I, Armellin E, et al. Autologous blood preparations rich in platelets, fibrin and growth factors. Oral Implantol (Rome). 2015;8(4):96-113. https://doi.org/10.11138/orl/2015.8.4.096.
  21. Thevarajan K, Teo P. Free non-vascularized fibular graft for treatment of pediatric traumatic radial bone loss: A case report. Malays Orthop J. 2013;7(2):37-40. https://doi.org/10.5704/MOJ.1307.003.

Supplementary files

Supplementary Files Action
1.
Figure: 1. Re-fracture after 3 months.

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2.
Figure: 2. On the X-ray there are minor signs of bone consolidation, but the metal was removed and the forearm was immobilized with a new plaster cast

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3.
Figure: 3. In the area of fractures - signs of local bone resorption

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4.
Figure: 4. X-ray before and after tissue excision, autologous fibula with bone marrow growth factors, autograft stabilized with intramedullary Kirschner wire

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5.
Figure: 5. Absence of consolidation of the autologous fibula on the radiograph

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6.
Figure: 6. Radiograph after sanitation of the nonunion focus and cadaveric bone graft with bone marrow growth factor stabilized with Kirschner wires

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7.
Figure: 7. X-ray after removal of the Kirschner wire after 28 months. after injury

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8.
Figure: 8. The clinical picture after 28 months. after injury

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Copyright (c) 2021 Priano D., D'Errico M., Peretto L., Memeo A.

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