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Galán-Olleros M, Mayans-Sanesteban J, Martínez-Álvarez S, Miranda-Gorozarri C, Ramírez-Barragán A, Egea-Gámez RM, Alonso-Hernández J, Martínez-Caballero I. Is reduction necessary in overriding metaphyseal distal radius fractures in children under 11 years: a systematic review and meta-analysis of comparative studies. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:2225-2234. [PMID: 38594456 DOI: 10.1007/s00590-024-03936-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
OBJECTIVE To determine the necessity of reduction in the treatment of overriding metaphyseal distal radius fractures (DRF) in children under 11 years. METHODS In this systematic review and meta-analysis, PubMed, Embase, and Cochrane databases were searched to retrieve studies published from inception to 2023. Two reviewers independently screened for studies with observational or randomized control design comparing two treatments for overriding metaphyseal DRF in patients under 11 years: simple casting without reduction (SC group) versus closed reduction plus casting or pin fixation (CRC/F group); with varying outcomes reported (CRD471761). The risk of bias was assessed using the ROBINS-I tool. RESULTS Out of 3,024 screened studies, three met the inclusion criteria, 180 children (mean age 7.1 ± 0.9 years) with overriding metaphyseal DRF: SC-group (n = 79) versus CRC/F-group (n = 101). Both treatment groups achieved 100% fracture consolidation without requiring further manipulation. The SC-group showed significantly fewer complications (mean difference [MD] 0.08; 95% CI [0.01, 0.53]; I2 = 22%; P < 0.009) and trends towards better sagittal alignment (MD 5.11; 95% CI [11.92, 1.71]; I2 = 94%; P < 0.14), less reinterventions (MD 0.31; 95% CI [0.01, 8.31]; P < 0.48), and fewer patients with motion limitation at the end of follow-up (MD 0.23; 95% CI [0.03, 1.98]; P < 0.18), although these findings were not statistically significant. CONCLUSIONS Despite a limited number of studies comparing SC versus CRC/F in overriding DRF in children under 11 years, this study suggests that anatomical reduction is not necessary. Treating these fractures with SC, even when presenting with an overriding position, leads to reduced complications, shows a trend towards fewer reinterventions, improved sagittal alignment, and less limitation in patient motion. LEVEL OF EVIDENCE Level III, Systematic review of Level-III studies.
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Affiliation(s)
- María Galán-Olleros
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain.
| | - Jorge Mayans-Sanesteban
- Orthopaedic Surgery and Traumatology Department, Hospital Universitario de La Ribera, Alzira, Valencia, Spain
| | - Sergio Martínez-Álvarez
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
| | - Carlos Miranda-Gorozarri
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
| | - Ana Ramírez-Barragán
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
| | - Rosa M Egea-Gámez
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
| | - Javier Alonso-Hernández
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
| | - Ignacio Martínez-Caballero
- Orthopaedic Surgery and Traumatology Department, Hospital Infantil Universitario Niño Jesús, Avenida Menéndez Pelayo 65, 28009, Madrid, Spain
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Horoz L, Cakmak MF, Kircil C. Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique. BMC Musculoskelet Disord 2024; 25:228. [PMID: 38509566 PMCID: PMC10956287 DOI: 10.1186/s12891-024-07358-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/13/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation. PATIENTS AND METHODS A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up. RESULT There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients. CONCLUSION In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.
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Affiliation(s)
- Levent Horoz
- Faculty of Medicine Orthopedics and Traumatology Clinic, Kırşehir Ahi Evran University, Kirsehir, Turkey.
| | - Mehmet Fevzi Cakmak
- Faculty of Medicine Orthopedics and Traumatology Clinic, Kırşehir Ahi Evran University, Kirsehir, Turkey
| | - Cihan Kircil
- Faculty of Medicine Orthopedics and Traumatology Clinic, Kırşehir Ahi Evran University, Kirsehir, Turkey
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Rava A, Alberghina F, Cravino M, Canavese F, Andreacchio A. Closed reduction and cast immobilization of overriding distal forearm fractures under nitrous oxide as conscious sedation without the use of imaging control. Musculoskelet Surg 2023; 107:413-421. [PMID: 37273144 DOI: 10.1007/s12306-023-00785-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/02/2023] [Indexed: 06/06/2023]
Abstract
PURPOSE The management of overriding distal forearm fractures is still controversial. This study aimed to evaluate the efficacy of immediate closed reduction and cast immobilization (CRCI) at the emergency department (ED) using equimolar nitrous oxide (eN2O2) as conscious sedation, and without the use fluoroscopic assistance. METHODS Sixty patients with overriding distal forearm fracture were included in the study. All procedures were performed in the ED without fluoroscopic assistance. Antero-posterior and lateral wrist radiographs were taken after CRCI. Follow-up radiographs were taken 7 and 15 days post-reduction, and at cast removal to evaluate callus formation. Depending on the radiological outcome, two groups of patients could be identified: Group 1 (satisfactory reduction and maintenance of alignment) and Group 2 (poor reduction or secondary displacement requiring further manipulation and surgical fixation). Group 2 was additionally divided into Group 2A (poor reduction) and Group 2B (secondary displacement). Pain was assessed using Numeric Pain Intensity (NPI) score, while functional outcome was measured according to Quick DASH questionnaire. RESULTS Mean age at the time of injury was 9.2 ± 2.4 years (range, 5-14). Twenty-three (38%) patients were aged between 4 and 9 years old, 20 (33%) patients between 9 and 11, 11 (18%) patients between 11 and 13, and 6 (10%) patients between 13 and 14. The mean follow-up time was 45.6 ± 12 months (range, 24-63). Satisfactory reduction with maintenance of alignment was achieved in 30 (50%) patients (Group 1). Re-reduction was performed in the remaining 30 (50%) patients (Group 2) due to poor reduction (Group 2A) or secondary displacement (Group 2B). No complications related to the administration of eN2O were recorded. No statistically significant difference could be identified between the three groups for any clinical variable (Quick DASH and NPI). CONCLUSION Overriding distal forearm fractures may be safely treated with CRCI at ED using eN2O2 as conscious sedation. However, fluoroscopic assistance during CRCI might significantly improve the quality of reduction thus avoiding further treatment as the lack of relaxed muscle can restrain reduction.
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Affiliation(s)
- A Rava
- Orthopedic Surgery Department, Ospedale Degli Infermi, Via Rivalta 29, 10098, Rivoli, Italy
| | - F Alberghina
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy
| | - M Cravino
- Pediatric Orthopedic Surgery Department, Regina Margherita Children's Hospital, Piazza Polonia 94, 10126, Turin, Italy
| | - F Canavese
- Dept. of Pediatric Orthopedic Surgery, Lille University Center, Jeanne de Flandre Hospital, Av. Eugène Avinée, 59000, Lille, France
| | - A Andreacchio
- Pediatric Orthopedic Surgery Department, Vittore Buzzi Children's Hospital, Via Lodovico Castelvetro 32, 20154, Milan, Italy.
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Abulsoud MI, Mohammed AS, Elmarghany M, Elgeushy A, Elzahed E, Moawad M, Elshal EA, Elhalawany MF, Hassanein YA, Fouad AA, Zakaria AR. Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children. BMC Musculoskelet Disord 2023; 24:746. [PMID: 37735419 PMCID: PMC10512509 DOI: 10.1186/s12891-023-06875-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 09/12/2023] [Indexed: 09/23/2023] Open
Abstract
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.
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Affiliation(s)
- Mohamed I Abulsoud
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt.
| | - Ahmed Saied Mohammed
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohammed Elmarghany
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed Elgeushy
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ehab Elzahed
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Moawad
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ehab A Elshal
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed F Elhalawany
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Yahia A Hassanein
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Amr A Fouad
- Department of Orthopedic Surgery, Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Ahmed R Zakaria
- Department of Orthopedic Surgery, Helwan University, Helwan, Egypt
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Perhomaa M, Stöckell M, Pokka T, Lieber J, Niinimäki J, Sinikumpu JJ. Clinical Follow-Up without Radiographs Is Sufficient after Most Nonoperatively Treated Distal Radius Fractures in Children. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020339. [PMID: 36832469 PMCID: PMC9955157 DOI: 10.3390/children10020339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 01/31/2023] [Accepted: 02/03/2023] [Indexed: 02/12/2023]
Abstract
Distal forearm fractures are common in children and are usually treated nonoperatively. No consensus has been reached on how to perform clinical and radiographic follow-up of these fractures. Our aim was to study whether radiographic and clinical follow-up is justified. We included 100 consecutive patients with non-operatively treated distal forearm fractures who were treated at Oulu University Hospital in 2010-2011. The natural history of the fractures during the nonoperative treatment was analyzed by measuring the potential worsening of the alignment during the follow-up period. The limits of acceptable fracture position were set according to the current literature using "strict" or "wide" criteria for alignment. We determined the rate of worsening fracture position (i.e., patients who reached the threshold of unacceptable alignment). In relation to splinting, we evaluated how many patients benefited from clinical follow-up. Most of the fractures (98%) preserved acceptable alignment during the entire follow-up period when wide criteria were used. The application of stricter criteria for alignment in radiographs showed loss of reduction in 19% of the fractures. Worsening of the alignment was recognized at a mean of 13 days (range 5-29) after the injury. One in three (32%) patients needed some intervention due to splint loosening or failure. Radiographic follow-up of nonoperatively treated distal forearm fractures remains questionable. Instead, clinical follow-up is important, as 32% of patients needed their splints fixed.
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Affiliation(s)
- Marja Perhomaa
- Research Unit of Clinical Medicine, Medical Research Center, Oulu Childhood Fracture and Sports Injury Study, Division of Pediatric Surgery and Orthopedics, Department of Children and Adolescents, (MRC) Oulu, Oulu University Hospital, Oulu University, 90220 Oulu, Finland
- Research Unit of Health Sciences and Technology, Department of Radiology, Oulu University Hospital, Oulu University, 90220 Oulu, Finland
- Correspondence:
| | - Markus Stöckell
- Research Unit of Clinical Medicine, Medical Research Center, Oulu Childhood Fracture and Sports Injury Study, Division of Pediatric Surgery and Orthopedics, Department of Children and Adolescents, (MRC) Oulu, Oulu University Hospital, Oulu University, 90220 Oulu, Finland
| | - Tytti Pokka
- Research Service Unit, Research Unit of Clinical Medicine, Oulu University Hospital, 90220 Oulu, Finland
| | - Justus Lieber
- Department of Pediatric Surgery and Pediatric Urology, University Children’s Hospital of Tübingen, 72076 Tübingen, Germany
| | - Jaakko Niinimäki
- Research Unit of Health Sciences and Technology, Department of Radiology, Oulu University Hospital, Oulu University, 90220 Oulu, Finland
| | - Juha-Jaakko Sinikumpu
- Research Unit of Clinical Medicine, Medical Research Center, Oulu Childhood Fracture and Sports Injury Study, Division of Pediatric Surgery and Orthopedics, Department of Children and Adolescents, (MRC) Oulu, Oulu University Hospital, Oulu University, 90220 Oulu, Finland
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Leuba A, Ceroni D, Tabard-Fougère A, Lutz N. Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: A case-control study. J Child Orthop 2022; 16:220-226. [PMID: 35800656 PMCID: PMC9254019 DOI: 10.1177/18632521221106380] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 04/20/2022] [Indexed: 02/03/2023] Open
Abstract
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.
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Affiliation(s)
- Aline Leuba
- Pediatric Trauma and Orthopaedic Unit,
University Hospital of Lausanne, Switzerland,Aline Leuba, Pediatric Trauma and
Orthopaedic Unit, University Hospital of Lausanne, La Haute Route 77, 2502
Bienne, Switzerland.
| | - Dimitri Ceroni
- Service of Pediatric Orthopaedics,
University Hospital of Geneva, Geneva, Switzerland
| | - Anne Tabard-Fougère
- Service of Pediatric Orthopaedics,
University Hospital of Geneva, Geneva, Switzerland
| | - Nicolas Lutz
- Pediatric Trauma and Orthopaedic Unit,
University Hospital of Lausanne, Switzerland
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Laaksonen T, Kosola J, Nietosvaara N, Puhakka J, Nietosvaara Y, Stenroos A. Epidemiology, Treatment, and Treatment Quality of Overriding Distal Metaphyseal Radial Fractures in Children and Adolescents. J Bone Joint Surg Am 2022; 104:207-214. [PMID: 34780389 DOI: 10.2106/jbjs.21.00850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
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.
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Affiliation(s)
- Topi Laaksonen
- Department of Pediatric Orthopedics and Traumatology, Helsinki New Children's Hospital, Helsinki, Finland
| | - Jussi Kosola
- Department of Pediatric Orthopedics and Traumatology, Helsinki New Children's Hospital, Helsinki, Finland
| | - Nicolas Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, Helsinki New Children's Hospital, Helsinki, Finland
| | - Jani Puhakka
- Department of Spine Surgery, Schulthess Klinik, Zürich, Switzerland
| | - Yrjänä Nietosvaara
- Department of Pediatric Orthopedics and Traumatology, Helsinki New Children's Hospital, Helsinki, Finland.,Department of Pediatric Surgery, Kuopio University Hospital, Kuopio, Finland
| | - Antti Stenroos
- Department of Pediatric Orthopedics and Traumatology, Helsinki New Children's Hospital, Helsinki, Finland
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8
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Diederix LW, Roth KC, Edomskis PP, Musters L, Allema JH, Kraan GA, Reijman M, Colaris JW. Do We Need to Stabilize All Reduced Metaphyseal Both-bone Forearm Fractures in Children with K-wires? Clin Orthop Relat Res 2022; 480:395-404. [PMID: 34533477 PMCID: PMC8747480 DOI: 10.1097/corr.0000000000001980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 08/26/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Short-term follow-up studies have shown that reduced metaphyseal both-bone forearm fractures in children should be treated with K-wires to prevent redisplacement and inferior functional results. Minimum 5-year follow-up studies are limited. Range of motion, patient-reported outcome measures, and radiographic parameters at minimum 5-year follow-up should be evaluated because they could change insights into how to treat pediatric metaphyseal forearm fractures. QUESTIONS/PURPOSES (1) Does K-wire stabilization of reduced metaphyseal both-bone forearm fractures in children provide better forearm rotation at minimum 5-year follow-up? (2) Do malunions (untreated redisplaced fractures) of reduced metaphyseal both-bone forearm fractures in children induce worse functional results? (3) Which factors lead to limited forearm rotation at minimum 5-year follow-up? METHODS We analyzed the extended minimum 5-year follow-up of a randomized controlled trial in which children with a reduced metaphyseal both-bone forearm fracture were randomized to either an above-elbow cast (casting group) or fixation with K-wires and an above-elbow cast (K-wire group). Between January 2006 and December 2010, 128 patients were included in the original randomized controlled trial: 67 in the casting group and 61 in the K-wire group. For the current study, based on an a priori calculation, it was determined that, with an anticipated mean limitation in prosupination (forearm rotation) of 7° ± 7° in the casting group and 3° ± 5° in the K-wire group, a power of 80% and a significance of 0.05, the two groups should consist of 50 patients each. Between January 2014 and May 2016, 82% (105 of 128) of patients were included, with a mean follow-up of 6.8 ± 1.4 years: 54 in the casting group and 51 in the K-wire group. At trauma, patients had a mean age of 9 ± 3 years and had mean angulations of the radius and ulna of 25° ± 14° and 23° ± 18°, respectively. The primary result was limitation in forearm rotation. Secondary outcome measures were radiologic assessment, patient-reported outcome measures (QuickDASH and ABILHAND-kids), handgrip strength, and VAS score for cosmetic appearance. Assessments were performed by the first author (unblinded). Multivariable logistic regression analysis was performed to analyze which factors led to a clinically relevant limitation in forearm rotation. RESULTS There was a mean limitation in forearm rotation of 5° ± 11° in the casting group and 5° ± 8° in the K-wire group, with a mean difference of 0.3° (95% CI -3° to 4°; p = 0.86). Malunions occurred more often in the casting group than in the K-wire group: 19% (13 of 67) versus 7% (4 of 61) with an odds ratio of 0.22 for K-wiring (95% CI 0.06 to 0.80; p = 0.02). In patients in whom a malunion occurred (malunion group), there was a mean limitation in forearm rotation of 6° ± 16° versus 5° ± 9° in patients who did not have a malunion (acceptable alignment group), with a mean difference 0.8° (95% CI -5° to 7°; p = 0.87). Factors associated with a limited forearm rotation ≥ 20° were a malunion after above-elbow casting (OR 5.2 [95% CI 1.0 to 27]; p = 0.045) and a refracture (OR 7.1 [95% CI 1.4 to 37]; p = 0.02). CONCLUSION At a minimum of 5 years after injury, in children with a reduced metaphyseal both-bone forearm fracture, there were no differences in forearm rotation, patient-reported outcome measures, or radiographic parameters between patients treated with only an above-elbow cast compared with those treated with additional K-wire fixation. Redisplacements occurred more often if treated by an above-elbow cast alone. If fracture redisplacement is not treated promptly, this leads to a malunion, which is a risk factor for a clinically relevant (≥ 20°) limitation in forearm rotation at minimum 5-year follow-up. Children with metaphyseal both-bone forearm fractures can be treated with closed reduction and casting without additional K-wire fixation. Nevertheless, a clinician should inform parents and patient about the high risk of fracture redisplacement (and therefore malunion), with risk for limited forearm rotation if left untreated. Weekly radiographic monitoring is essential. If redisplacement occurs, remanipulation and fixation with K-wires should be considered based on gender, age, and direction of angulation. Future research is required to establish the influence of (skeletal) age, gender, and the direction of malunion angulation on clinical outcome. LEVEL OF EVIDENCE Level I, therapeutic study.
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Affiliation(s)
- Leon W. Diederix
- Department of Orthopaedic Surgery, Elkerliek Hospital, Helmond, the Netherlands
| | - Kasper C. Roth
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Pim P. Edomskis
- Department of General Surgery, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Linde Musters
- Department of Orthopaedic Surgery, Noordwest Ziekenhuis Groep, Alkmaar, the Netherlands
| | - Jan Hein Allema
- Department of General Surgery, Haga Hospital, The Hague, the Netherlands
| | - Gerald A. Kraan
- Department of Orthopaedic Surgery, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Max Reijman
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
| | - Joost W. Colaris
- Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands
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Uppalapati VK, Kundu N, Nag DS, Shukla R. Blunt Injury Forearm Debridement Under Ultrasound-Guided Regional Anesthesia for a Marfan Syndrome Patient. Cureus 2021; 13:e12729. [PMID: 33614332 PMCID: PMC7883574 DOI: 10.7759/cureus.12729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/15/2021] [Indexed: 11/05/2022] Open
Abstract
Marfan syndrome is an autosomal dominant connective tissue disorder with anomalies involving the musculoskeletal system, cardiovascular system, skin, eyes, and teeth. Patients with Marfan syndrome are especially prone to cardiovascular complications, which increases the risk multifold under general anesthesia. This is a case of a 37-year-old Marfan syndrome male patient with cardiac manifestations and his anesthesia course during emergency wound debridement.
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Affiliation(s)
| | | | | | - Rajiv Shukla
- Anesthesiology, Tata Main Hospital, Jamshedpur, IND
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10
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van Delft EA, Vermeulen J, Schep NW, van Stralen KJ, van der Bij GJ. Prevention of secondary displacement and reoperation of distal metaphyseal forearm fractures in children. J Clin Orthop Trauma 2020; 11:S817-S822. [PMID: 32999562 PMCID: PMC7503138 DOI: 10.1016/j.jcot.2020.07.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 10/23/2022] Open
Abstract
BACKGROUND Metaphyseal distal forearm fractures are common in paediatric patients and treating these fractures by reduction and cast immobilization alone is under debate, since secondary displacement is a frequent complication that often warrants re-intervention. This study was conducted to invest the incidence of secondary displacement and re-intervention for non-displaced and displaced fractures, with or without fixation. MATERIAL AND METHODS A retrospective cohort study was conducted analysing all consecutive paediatric patients under the age of 16 with distal metaphyseal forearm fractures throughout a 2-year period. Data were recorded on radiographic characteristics, OTC/AO-classification, type of treatment, reduction technique, surgical interventions and removal of hardware and complications. RESULTS 200 Patients with displaced metaphyseal forearm fractures were included of which 139 were primarily treated in the emergency room, the other 61 patients were primarily treated in the operating room. 83% Of the patients had a satisfactory reduction in the emergency room and 94% of these patients were treated successfully with casting alone. A total of 84 patients were treated in the operating room of whom 30% underwent reduction and K-wire fixation, and 70% underwent reduction and casting only. 47% Of the patients treated with closed reduction without K-wire fixation in the operating room suffered from secondary displacement, of which 80% needed re-intervention. CONCLUSION Metaphyseal forearm fractures can be treated with a very high success rate by closed reduction and casting alone in the emergency room. Reduction and casting of displaced metaphyseal forearm fractures in children that needed treatment in the operating room however, resulted in unacceptable high rate of secondary displacement and commonly required re-intervention. Those patients should therefore be treated by reduction and K-wire fixation.
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Affiliation(s)
- Eva A.K. van Delft
- Amsterdam UMC, Vrije Universiteit Amsterdam Department of Trauma Surgery, Amsterdam Movement Sciences, Spaarne Gasthuis, Department of Trauma Surgery Boelelaan 1117, Amsterdam, The Netherlands Boerhaavelaan 22, 2035RC, Haarlem, the Netherlands,Corresponding author.
| | - Jefrey Vermeulen
- Trauma Surgeon, Maasstad Hospital, Department of Trauma Surgery, Maasstadweg 21, 3079 DZ, Rotterdam, the Netherlands
| | - Niels W.L. Schep
- Trauma Surgeon, Maasstad Hospital, Department of Trauma Surgery, Maasstadweg 21, 3079 DZ, Rotterdam, the Netherlands
| | - Karlijn J. van Stralen
- Spaarne Gasthuis Academy, Spaarne Gasthuis, Boerhaavelaan 22, 2035RC, Haarlem, the Netherlands
| | - Gerben J. van der Bij
- Trauma Surgeon, Spaarne Gasthuis, Department of Trauma Surgery, Boerhaavelaan 22, 2035RC, Haarlem, the Netherlands
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11
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Passiatore M, De Vitis R, Perna A, D'Orio M, Cilli V, Taccardo G. Extraphyseal distal radius fracture in children: is the cast always needed? A retrospective analysis comparing Epibloc system and K-wire pinning. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1243-1250. [PMID: 32405758 DOI: 10.1007/s00590-020-02698-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 05/07/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Closed reduction and internal fixation are a widespread surgical treatment for pediatrics displaced extraphyseal distal radius fractures. Post-surgical cast immobilization is usually needed. Epibloc system (ES) is a device used to fix Colles fractures in adults, not requiring post-surgical immobilization. The aim of the study is to investigate the effectiveness of ES in a pediatric population suffering from displaced extraphyseal distal radius fractures. METHODS We retrospectively analyzed 52 patients (age 8-12 years) who underwent CRIF. Patients were divided into two groups. Group A (25 patients): ES osteosynthesis. Group B (27 patients): K-wires and short arm cast osteosynthesis. The primary outcome is the maintenance of reduction in radiographs (displacement on frontal and lateral view). The secondary outcome is the reaching of the complete active range of motion recovery (compared with the contralateral side) and the time needed to obtain it. The need of further additional treatment (physiotherapy) and the presence of complication were also assessed. RESULTS Reduction was equally maintained in both groups (p > 0.05). Physiotherapy was mandatory for 11 patients in group B; only for 3 patients in group A, the difference was statistically significant (p = 0.03) according to Fisher test. Otherwise, the difference was not statistically significant regarding complications. (p > 0.05). At the last follow-up, complete functional recovery was reached in all patients. CONCLUSIONS Functional recovery is faster, and postoperative physiotherapy is rarely required with ES. This device allows us to go beyond the traditional concept of mandatory postoperative immobilization after pediatric wrist fractures surgery.
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Affiliation(s)
- Marco Passiatore
- Istituto Di Clinica Ortopedica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via Giuseppe Moscati 31, 00168, Roma, Italia.
| | - Rocco De Vitis
- Istituto Di Clinica Ortopedica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italia
| | - Andrea Perna
- Istituto Di Clinica Ortopedica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via Giuseppe Moscati 31, 00168, Roma, Italia
| | - Marco D'Orio
- Istituto Di Clinica Ortopedica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Via Giuseppe Moscati 31, 00168, Roma, Italia
| | - Vitale Cilli
- Chirurgie de La Main, CHIREC Site Delta, Bruxelles, Belgium
| | - Giuseppe Taccardo
- Istituto Di Clinica Ortopedica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Roma, Italia
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12
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Kocaoğlu H, Kalem M, Kavak M, Şahin E, Başarır K, Kınık H. Comparison of operating time, fluoroscopy exposure time, and functional and radiological results of two surgical methods for distal forearm fractures of both-bones in pediatric patients: Is it necessary to fix both bones? ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2020; 54:155-160. [PMID: 32254031 DOI: 10.5152/j.aott.2020.02.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE The aim of this study was to compare the functional results of internal fixation of both forearm bones versus fixation of the radius alone in the treatment of distal both-bone forearm fractures in children. METHODS This study included a total of 34 children who were treated for distal forearm both-bone fracture. Patients were divided into two groups according to the technique used, which depended on the date of their surgery. Group 1 consisted of 18 children (14 males and four females; mean age: 10.3 years; age range: 7-16 years) who underwent both-bone fracture fixation using closed reduction and percutaneous pinning; Group 2 consisted of 16 children (12 males and four females; mean age: 10.1 years; age range: 6-15 years) who underwent only radius fracture fixation. The average follow-up was 65.6 months in Group 1 and 38.9 months in Group 2. Operating time, fluoroscopy exposure time, functional results (Mayo Wrist Score, visual analogue scale score, and range of motion), radiological results (time to union and malunion), and complications were recorded as outcome parameters. RESULTS The mean operating time was 35 min (range: 30-45 min) in Group 1 and 19 min (range: 10-25 min) in Group 2 (p<0.001). The mean fluoroscopy exposure time was 54 sec (range: 40-70 sec) in Group 1 and 18 sec (range: 10-26 sec) in Group 2 (p<0.001). Only three patients in Group 1 and four patients in Group 2 exhibited <10° of limitation in pronation and supination. No significant differences were determined between the groups with respect to functional scores (p=1.000). Final follow-up radiographs showed no malalignment in either group. In terms of time to union, there was no significant difference between groups (p=1.000). Additionally, only three minor complications associated with the pin track (two patients in Group 1 and one patient in Group 2) were noted. CONCLUSION In children with distal both-bone fractures, fixation of the radius fracture alone may be considered as an alternative method of treatment to fixation of both forearm bones as it results in satisfactory functional and radiographic outcomes. LEVEL OF EVIDENCE Level III, Therapeutic study.
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Affiliation(s)
- Hakan Kocaoğlu
- Department of Orthopedics and Traumatology, İbn-i Sina Hospital, Ankara University, School of Medicine, Ankara, Turkey
| | - Mahmut Kalem
- Department of Orthopedics and Traumatology, İbn-i Sina Hospital, Ankara University, School of Medicine, Ankara, Turkey
| | - Mustafa Kavak
- Department of Orthopedics and Traumatology, Eskişehir Osmangazi University, School of Medicine, Eskişehir, Turkey
| | - Ercan Şahin
- Department of Orthopedics and Traumatology, Bülent Ecevit University School of Medicine, Zonguldak, Turkey
| | - Kerem Başarır
- Department of Orthopedics and Traumatology, İbn-i Sina Hospital, Ankara University, School of Medicine, Ankara, Turkey
| | - Hakan Kınık
- Department of Orthopedics and Traumatology, İbn-i Sina Hospital, Ankara University, School of Medicine, Ankara, Turkey
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13
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Rai P, Haque A, Abraham A. A systematic review of displaced paediatric distal radius fracture management: Plaster cast versus Kirschner wiring. J Clin Orthop Trauma 2020; 11:275-280. [PMID: 32099293 PMCID: PMC7026543 DOI: 10.1016/j.jcot.2019.03.021] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2018] [Revised: 03/24/2019] [Accepted: 03/26/2019] [Indexed: 10/27/2022] Open
Abstract
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.
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14
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Sengab A, Krijnen P, Schipper IB. Displaced distal radius fractures in children, cast alone vs additional K-wire fixation: a meta-analysis. Eur J Trauma Emerg Surg 2018; 45:1003-1011. [PMID: 30276723 PMCID: PMC6910898 DOI: 10.1007/s00068-018-1011-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/17/2018] [Indexed: 11/27/2022]
Abstract
Purpose Displaced distal radius fractures in children are common and often treated by reduction and cast immobilization. Redisplacement occurs frequently and may be prevented by additional treatment with K-wire fixation after initial reduction. This meta-analysis aims to summarize available literature on this topic and determine if primary K-wire fixation is the preferred treatment for displaced distal radius fractures in children. Methods A search in eight databases identified studies that compared cast immobilization alone to additional K-wire fixation as treatment for displaced paediatric distal radius fractures. The primary outcome was the redisplacement rate. Secondary outcomes were secondary reduction rate, range of motion and complications. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement. Results Three RCTs and 3 cohort studies, analysing 197 patients treated with cast immobilization alone and 185 with additional K-wire fixation, were included in this meta-analysis. Redisplacement occurred less frequently after additional K-wire fixation than after cast alone (3.8 versus 45.7%; OR 0.07, 95% CI 0.03–0.15). Secondary reduction was performed in 59.8% of the redisplaced fractures. Complications, other than redisplacement, occurred more often after additional K-wire fixation than after cast alone (15.7 versus 3.6%). Range of motion did not differ after both treatments. Conclusions Additional K-wire fixation is a suitable treatment to prevent redisplacement and secondary operations after initial reduction of displaced distal radius fractures in children, but is associated with post-procedural complications. Additional K-wire fixation does not result in a better range of motion than cast immobilization alone. More research is needed to identify those patients who will benefit the most from K-wire fixation as a treatment for displaced distal radius fractures in children. Electronic supplementary material The online version of this article (10.1007/s00068-018-1011-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Alysia Sengab
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands.
| | - Pieta Krijnen
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
| | - Inger Birgitta Schipper
- Department of Trauma Surgery, Leiden University Medical Center, Post zone K6-R, P.O. Box 9600, 2300 RC, Leiden, The Netherlands
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15
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Zeng ZK, Liang WD, Sun YQ, Jiang PP, Li D, Shen Z, Yuan LM, Huang F. Is percutaneous pinning needed for the treatment of displaced distal radius metaphyseal fractures in children?: A systematic review. Medicine (Baltimore) 2018; 97:e12142. [PMID: 30200107 PMCID: PMC6133581 DOI: 10.1097/md.0000000000012142] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Distal radius metaphyseal (DRM) fractures are very frequent childhood fractures. Whether additional percutaneous pinning improves the outcome remains controversial. In this review, we tried to systematically evaluate the effect of percutaneous pinning on re-displacement, secondary reduction, radiographs, function, and complications in children with displaced DRM fractures. METHODS PubMed, Medline, Embase, Cochrane Library, and Web of Science databases were explored systematically to identify randomized controlled trials (RCTs) and clinical controlled trials (CCTs) comparing cast immobilization alone or following reduction to additional percutaneous pinning in the treatment of pediatric displaced DRM fractures. Two reviewers independently screened eligible articles and extracted relevant information from each article. The methodological quality of eligible articles was evaluated using the Cochrane Collaboration risk assessment tool (RCTs) and modified Jadad scale (CCTs). RESULTS A total of 4 RCTs and 3 CCTs met the inclusion criteria, with a total patient count of 1144 children. The results showed that additional percutaneous pinning significantly reduced the rate of re-placement (Chi-square tests, P < .001) and complications (Chi-square tests, P = .030). The superior results, both radiographically and functionally seemed to be temporary. No difference was found between the 2 groups after longer-term follow-up. CONCLUSIONS This systematic review suggested that compared with casting following reduction, percutaneous pinning had a positive effect on maintaining the initial reduction and reducing fracture complication rate of displaced DRM fractures in children, but with no significant improvement in function and radiographic outcome at the long-term follow-up. We suggest clinicians think twice before percutaneous pinning of displaced pediatric DRM fractures.
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Affiliation(s)
- Zhi-Kui Zeng
- Department of Orthopedics, The Affiliated Hospital of Jiangxi University of Chinese Medicine (Jiangxi Provincial Hospital of Chinese Medicine), Nanchang
| | - Wei-Dong Liang
- Department of Orthopedics, The Affiliated Hospital of Jiangxi University of Chinese Medicine (Jiangxi Provincial Hospital of Chinese Medicine), Nanchang
| | - You-Qiang Sun
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou
| | - Ping-Pin Jiang
- Department of Orthopedics, Xinyu Chinese Medicin Hospital Affiliated to Jiangxi University of Chinese Medicine, Xinyu
| | - Ding Li
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Zhen Shen
- First School of Clinical Medicine, Guangzhou University of Chinese Medicine, Guangzhou City, China
| | - Ling-Mei Yuan
- Department of Orthopedics, The Affiliated Hospital of Jiangxi University of Chinese Medicine (Jiangxi Provincial Hospital of Chinese Medicine), Nanchang
| | - Feng Huang
- Department of Orthopaedics, The First Affiliated Hospital of Guangzhou University of Chinese Medicine, Guangzhou
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16
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Roth KC, Denk K, Colaris JW, Jaarsma RL. Think twice before re-manipulating distal metaphyseal forearm fractures in children. Arch Orthop Trauma Surg 2014; 134:1699-707. [PMID: 25288028 DOI: 10.1007/s00402-014-2091-8] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2014] [Indexed: 11/28/2022]
Abstract
BACKGROUND Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided. METHODS Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1-8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire. RESULTS Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups. CONCLUSION Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9-<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.
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Affiliation(s)
- Kasper C Roth
- Erasmus University (Faculty of Medicine and Health Sciences) and Erasmus Medical Centre, Rotterdam, The Netherlands
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