Treating Displaced Distal Forearm Fractures in Children

Early complications of percutaneous K-wire fixation in pediatric distal radius fractures-a prospective cohort study

INTRODUCTION

Distal radius fractures (DRF) are the most common pediatric fractures, but the current evidence for management remains inconclusive. Closed reduction and percutaneous pinning (CRPP) provide excellent stability but are not complications-free. Therefore, a thorough evaluation of their adverse events is necessary to provide reliable information on risks and benefits in different clinical scenarios. The current literature lacks studies conducted with rigorous grading systems and uniform follow-up protocols on this topic. This prospective cohort study used a validated grading scheme to analyze complications associated with CRPP in an unselected pediatric population with displaced, unstable distal third radius fractures.

MATERIALS AND METHODS

One hundred and nineteen DRFs (one hundred and sixteen patients) treated with CRPP were enrolled in the study. All patients were followed 4 weeks, 5 weeks, 3 months, and 6 months after the surgery. The same protocol, comprising structured history, physical and radiological assessment, was used throughout the study. All data were prospectively abstracted. The Clavien-Dindo-Sink grading system was used to assess the complications and the Dahl score to evaluate the pin sites.

RESULTS

Forty-two wrists (35,3%) had CDS grade I or II complications, and two (1,7%) had a grade III complication. The general complication rate for the study group was 37% (44 complications). Two patients required repeated surgery-deep bone pin-track infection treated with the Masquelet technique and surgical removal of a migrated pin. Among minor complications, pin-site inflammations were the most common-40 wrists (33,6%).

CONCLUSIONS

The CRPP is a safe treatment method for DRF in pediatric patients, with a low major complication rate. However, minor adverse events are frequent and can significantly burden the patient's postoperative well-being. The application of rigorous definitions and grading systems should not only lead to the obtainment of high-quality data but also to higher awareness of possible pin tract infections and therefore allow for better therapeutic decisions.

Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children

AIM OF THE WORK

This study was designed to highlight internal fixation by intramedullary K-wires for displaced distal forearm fractures among children and analyze the results of this technique. We hypothesize that physis-sparing intramedullary fixation prevents displacement with a lower complication rate.

METHODS

This prospective case series involving 47 patients was conducted between February 2018 and December 2019. All patients with open physis presented with recent displaced distal forearm fractures were included, and all of them were treated with an intramedullary k-wire fixation for both bones with the assessment of the union rate, union time, suspected complication, radiographic evaluation, and functional outcome.

RESULTS

The study population consisted of 31 boys (66%) and 16 girls (34%). The mean age of the patients was 10.68 ± 2.728 years (range, 7-15 years). All fractures were united in a median of 6 weeks (range, 4-8 weeks), The functional outcome after 12 months was normal in 42 patients (89.4%), whereas, in five patients (10.6%), the functional parameters were minimally reduced. The median preoperative angulation improved from 36° (range, 24°-52°) preoperatively to 4° (range, 0°-10°) on immediate postoperative radiographs. After 12 months, the median angulation was 2° (range, 0°-7°) (p < 0.001). The angulation of the distal radius immediately after surgery and at the final follow-up was statistically correlated with the functional outcome (p < 0.001 and 0.002, respectively).

CONCLUSION

This technique provides a good result with less susceptibility to re-displacement and low complication rates.

LEVEL OF EVIDENCE

Level IV.

Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: A case-control study

Purpose

Flexible intramedullary nailing is regularly applied for pediatric displaced unstable forearm fractures. When compared to closed reduction and casting (orthopedic treatment), flexible intramedullary nailing decreases malalignment, shortens immobilization time, and should decrease follow-up controls. Comparing flexible intramedullary nailing and orthopedic treatment in the clinical, radiological, and financial managements of these fractures was performed.

Methods

Retrospective 5 years study of pediatric cases in two pediatric orthopedic university departments. Treatment method, post-operative course, and radiological follow-up were reviewed. Number of radiographs, follow-up controls, type and duration of immobilization, final bone angulation, and reported complications were compared. Extensive financial analysis was completed.

Results

Of 73 girls and 168 boys included in the study, 150 were treated by flexible intramedullary nailing and 91 by orthopedic treatment. No difference was noted with regard to total number of radiographs (7.3 vs 7.2, respectively). Total number of follow-ups was 6.4 and 5.5, respectively. Malalignment occurred in two flexible intramedullary nailing and sixteen orthopedic treatments. The least expensive cost was ambulatory orthopedic treatment.

Conclusion

Flexible intramedullary nailing treated children had similar numbers of radiographs or follow-up consultation, but less malunion when compared to orthopedic treatment. Orthopedic management was systematically cheaper than flexible intramedullary nailing. Unless post-operative management guidelines decreasing the number of radiographs and follow-ups are implemented, flexible intramedullary nailing will remain a costly procedure when compared to conventional orthopedic treatment.

Level of evidence

level III case-control retrospective study.

Epidemiology, Treatment, and Treatment Quality of Overriding Distal Metaphyseal Radial Fractures in Children and Adolescents

BACKGROUND

The incidence of completely displaced overriding distal metaphyseal radial fractures in children is unknown, and the optimal treatment is controversial.

METHODS

All completely displaced distal metaphyseal radial fractures in patients <16 years old treated in our tertiary-level institution from 2014 to 2019 were identified with use of the Kids' Fracture Tool Helsinki. Etiology, fracture characteristics, management, and quality of treatment were assessed. A telephone interview with the guardian of the patient was performed for 100 (89%) of 112 patients at 1.5 to 7.2 years (median, 4.6 years) after the injury. Pain during the last month and forearm function were recorded. Treatment satisfaction was assessed with use of a 7-point Likert scale.

RESULTS

A total of 113 completely displaced overriding distal metaphyseal radial fractures in 112 patients (81 of whom were residents of Helsinki) were treated during the 6-year-long study period. The mean annual incidence was 1.42 per 10,000 population. Most (73%) of these fractures occurred in children <11 years old, and most fractures were dorsally displaced and located nearly as far proximally from the distal radial physis as the maximum width of the distal metaphysis. Closed manipulation was attempted in two-thirds of cases in the emergency department, with a failure rate of 46%. Strong opioids were administered in 70 of 112 patients. None of the 26 patients whose fractures were immobilized in an overriding position had secondary interventions, pain, or functional disability. The mean satisfaction with treatment on the Likert scale was 6.2.

CONCLUSIONS

The annual incidence of overriding distal metaphyseal radial fractures patients <16 years old was shown to vary between 0.72 and 2.01 per 10,000 population. Opioids, local and general anesthesia, hospital admission, and secondary interventions can be avoided in prepubescent patients by casting these fractures in an overriding position while the patient is in the emergency department.

LEVEL OF EVIDENCE

Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

A systematic review of displaced paediatric distal radius fracture management: Plaster cast versus Kirschner wiring

Displaced distal radius fractures involving the metaphysis are common childhood injuries requiring intervention. Patients frequently undergo operative treatment for these injuries. The aim of our study was to systematically review the literature comparing manipulation under anaesthesia (MUA) and Kirschner wire fixation(K wire). PRISMA guidelines were followed throughout. Medline and Cochrane databases were searched for comparative randomised controlled trials (RCTs) and cohort studies. Quality assessment was undertaken using the Jadad score, Cochrane assessment of bias tool and the Newcastle-Ottawa Scale. Data extraction was performed with customised forms. 2 RCTs and 4 cohort studies were included. There was significant variation in their methodologies, which included their inclusion criteria and threshold for remanipiulation. Re-operation rates for MUA varied from 14% to 91%. There were no recorded re-operations following K-wiring. There was a 2.2% infection rate and 4.5% rate of wire migration. There were no adverse long-term sequelae reported. All studies showed a higher re-operation rate with MUA alone. Further studies are required to identify which fracture subtypes are most susceptible to re-displacement. Current evidence suggests the use of a k-wire to stabIlise these fractures following manipulation.

Risk factors for fracture redisplacement after reduction and cast immobilization of displaced distal radius fractures in children: a meta-analysis

PURPOSE

Displaced distal radius fractures in children are common and often reduced if necessary and immobilized in cast. Still, fracture redisplacement frequently occurs. This can be prevented by fixation of fracture fragments with K-wires, but until now, there are no clear guidelines for treatment with primary K-wire fixation. This meta-analysis aimed to identify risk factors for redisplacement after reduction and cast immobilization of displaced distal radius fractures in children, and thereby determine which children will benefit most of primary additional K-wire fixation.

METHODS

Eight databases were searched to identify studies and extract data on the incidence of and risk factors for redisplacement of distal radius fractures after initial reduction and cast immobilization in children.

RESULTS

Twelve studies, including 1256 patients, showed that initial complete displacement (odds ratio [OR] 4.69, 95% confidence interval [CI] 2.98-7.39) and presence of a both-bone fracture (OR 1.95, 95% CI 1.34-2.85) were independent risk factors for redisplacement. Anatomical reduction reduced the redisplacement risk (OR 0.14, 95% CI 0.05-0.40). No significant influence on redisplacement risk could be established for female sex, experience level of the attending surgeon, Cast Index < 0.8, Three-Point Index < 0.8 and patient's age.

CONCLUSIONS

For children with a displaced distal radius fracture, the presence of a both-bone fracture, complete displacement of the distal radius and non-anatomical reduction are risk factors for redisplacement after reduction of their initially displaced distal radius fracture. Children with one or more of these risk factors probably benefit most of reduction combined with primary K-wire fixation.