Extraphyseal distal radius fracture in children: is the cast always needed? A retrospective analysis comparing Epibloc system and K-wire pinning

Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study

BACKGROUND

Several methods have been used for the treatment of pediatric distal radius fractures, such as the elastic stable intramedullary nail (ESIN), Kirschner wire (K-wire), and plate, but there has been no consensus about the optimum method. The purpose of this study was to compare ESIN and K-wire techniques used in metaphyseal-diaphyseal junction (MDJ) fractures of the pediatric distal radius.

METHODS

The data of patients who were treated at a children's hospital affiliated with Shandong University between August 2018 and January 2022 were analyzed retrospectively. The children were divided into the ESIN and K-wire groups. Clinical outcomes were measured by the Gartland and Werley scoring system. Variables were analyzed using a statistical approach between the two groups.

RESULTS

The study included 26 patients, of whom 11 were treated with K-wire and 15 with ESIN. At the final follow-up, all of the fractures were healed. There were no differences in terms of age, sex, fracture location, or wrist function score. However, the ESIN was superior to K-wire in operative time, fluoroscopic exposure, and estimated blood loss (EBL).

CONCLUSIONS

K-wire and ESIN are both effective methods in the treatment of MDJ fractures of the pediatric distal radius. The use of the ESIN technique represents less EBL, fluoroscopy exposure, and operation time compared with K-wire. We recommend osteosynthesis by ESIN rather than K-wires in patients with MDJ fractures of the distal radius.

LEVEL OF EVIDENCE

III, a case-control study.

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.

Elastic stable intramedullary fixation using epibloc versus crossed kirschner wires fixation for distal forearm fractures in children: A retrospective analysis

BACKGROUND

Childrens' distal forearm fractures (DFFs) could be treated conservatively with closed reduction and immobilisation, but post-reduction displacements often occur. Displaced DFF should be surgically fixed, to avoid further displacement. Nevertheless, immobilisation after surgery is recommended. Epibloc system (ES), a system of stable elastic nail fixation, is widely used to stabilise adults extra-articular distal radius fractures, with advantages to not requiring post-surgical immobilisation. The present investigation represents a retrospective analysis of paediatric patients with DFF treated with ES applied with a minimal technical variation, to fix both ulna and radius fractures using a unique device.

MATERIALS AND METHODS

A retrospective analysis was performed on 44 children (age 6-11 years) who underwent closed reduction and internal fixation because of DFF (both ulna and radius). Group A (21 patients): ES fixation. Group B (23 patients): K-wires and short arm cast fixation. The primary outcome was the subsistence of reduction monitored through X-rays. The secondary outcome was the measurement of active range of motion (AROM) and the time of recovery.

RESULTS

No differences were observed comparing Group A and B in terms of the maintenance of reduction (P > 0.05). Seven days after the implant removal, patients in Group A reached significantly better results compared to patients in Group B in terms of AROM (P < 0.05). No differences were revealed in terms of complications between the two groups.

CONCLUSION

ES applied with a minimal technical variation is safe and effective in treating distal ulna and radius fractures, with minimal requirement of post-surgical rehabilitation.

Is it time to resume elective knee arthroplasty surgery? A multidisciplinary experience in a Sardinian center during the SARS-CoV-2 pandemic

Background

Starting in January 2020, the SARS-CoV-2 pandemic caused changes in the nation's health systems. The hospital's reorganization led to a near-total stop of non-urgent, elective surgeries across all specialties, including hip and knee arthroplasty. However, in May 2020, a gradual elective surgery restarting was possible. Considering the risk of COVID-19 infections, the European Knee Associates suggest the need to implement specific protocols for a safe return to orthopaedic elective surgery.

Methods

A retrospective analysis regarding all patients who underwent primary knee arthroplasty (TKA) between March 1st and October 1st, 2020 using an institutional database was performed. The study time was divided into 2 periods: Pandemic (from March 2020 to May 2020), Post Pandemic (from June 2020 to October 2020). A specific protocol was designed to safeguard the health of patients and healthcare workers during the SARS-CoV-2 pandemic.

Results

A total of 147 patients underwent total knee replacement surgery in the analyzed period. The mean surgical time was 77.6 (+/-18.9). The intraoperative mean blood loss was 54 (+/-28) ml. The mean hospital stay was 3-4 days. Among the treated patients no case of COVID-19 infection was observed.

Conclusion

The use of our protocol, developed ad hoc for the management of elective orthopedic patients, allowed the restart of elective orthopedic surgery in a safe and reproducible way with an average increase of 374% on surgical activity between the pandemic and post-pandemic periods without record cases of contagion among the treated patients.

Arthroscopic-assisted radiocarpal ligaments tensioning for dynamic radiocarpal instability

Background

Dynamic radiocarpal instability is one of the causes of post-trauma radial-sided wrist pain. It is not easy to diagnose and may possibly be overlooked. The key ligaments responsible for dynamic radiocarpal instability are the radioscaphocapitate (RSC) and long radiolunate (LRL) ligaments. Tensioning of these 2 ligaments could be a method of treatment for dynamic carpal instability. We proposed a method for arthroscopic thermal shrinkage of these 2 ligaments, and for setting a landmark arthroscopically to facilitate identification of these 2 ligaments during the combined open suture tensioning procedure.

Methods

Between January 2016 and May 2020, 12 patients treated with this method were enrolled. The mean age was 33.3 years (range, 18–57 years), and the mean duration from injury to operation was 7.8 months (range, 3–25 months). The diagnosis was mainly depended on the physical examinations and confirmed under arthroscopy. The mean follow-up was 17.7 months (range, 12–26 months).

Results

All the patients had marked improvement of pain, grip strength, the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH), and the radiocarpal stability. The wrist range of motion showed significant decrease around 5^o in both flexion and extension and around 4^o in the ulnar deviation at the final follow-ups. All patients were able to return to their previous full level of work and activities.

Conclusions

We conclude that arthroscopic thermal shrinkage combined with open suture tensioning can be effective in treating dynamic carpal instability, while the arthroscopic-assisted landmark setting can help identify the accurate location of the RSC and LRL ligaments without dissecting too much soft tissue.

Retrospective study of radial dome osteotomy with volar plate fixation versus K-wires in Madelung's deformity: long-term follow-up

PURPOSE

The emerging role of the locking plate improved the technique also in corrective osteotomies in Madelung's deformity, but there is a lack of analyses between the fixation techniques, as well as little information in functional outcomes and long-term follow-up. The current study compared the outcomes, pitfalls, and advantages of volar plate and screws fixation versus K-wires fixation in a long-term follow-up.

METHODS

Twenty-eight children presenting the "distal radius" variant of Madelung's deformity underwent Vickers ligament release and distal radial dome osteotomy between 2009 and 2015. Twenty-three children (20 females and 3 males, mean age 15 years and 7 months at surgery and 24 years and 8 moths at follow-up), with 26 operatively treated wrists, were available for follow-up. A retrospective two-cohort study, evaluating clinically and radiologically results, has been conducted with a mean eight years and seven months follow-up.

RESULTS

Bone union and pain relief were obtained in all cases, as well as improvements in wrist motion and radiographic indices. A statistically significant correlation was identified between the volar plate fixation and an improved lunate subsidence on X-ray, and a trend towards an improved DASH score in the cohort with plate and screws, as well as significant improvement in wrist extension and supination always in the plate fixation cohort.

CONCLUSIONS

The long-term follow-up enabled the patients to report on more definitive outcomes in terms of functional and cosmetic improvements. Volar plate fixation is an effective technique allowing for simple post-operative management and earlier rehabilitation program with improved clinical and radiographic outcomes.

Modified osteotomy for treatment of forearm deformities (Masada IIb) in hereditary multiple osteochondromas: a retrospective review

Purpose

Approximately 30% of patients with hereditary multiple osteochondromas (HMO) have forearm deformity and dysfunction. The aim of this retrospective study was to review our experience with the surgical treatment of children with HMO and Masada IIb forearm deformities.

Methods

Data of eight children treated for HMO Masada IIb forearm deformity at our hospital between 2015 and 2019 were collected from the hospital records and retrospectively reviewed. All patients underwent ulnar lengthening by distraction osteogenesis using either the Orthofix or Ilizarov external fixator. Range of movements at the elbow and wrist joints, and forearm supination/pronation, before and after the operation were recorded. Radiographs were evaluated by the Fogel method, and wrist joint function by the Krimmer method.

Results

Follow-up radiographs showed significant improvement in relative ulnar shortening after treatment (pre-operative 9.23 ± 5.21 mm; post-operative 0.33 ± 4.13 mm). Changes in radial articular angle (pre-operative 33.55° ± 3.88° to 32.78° ± 6.57°) and carpal slip (pre-operative 45.00% ± 19.09%; post-operative 43.13% ± 16.68%) were not significant. Elbow flexion and extension, wrist flexion and extension, ulnar and radial deviation at wrist, and forearm rotation were significantly improved after surgery. Wrist function was graded as excellent in seven patients and as good in one patient. One patient treated with the Ilizarov external fixator had poor radial head reduction.

Conclusion

Ulnar lengthening with distraction osteogenesis is an effective treatment for HMO Masada IIb deformities. The optimum site for ulnar osteotomy appears to be at the proximal one-third to one-fourth of the ulna.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12891-021-04829-x.

Single volar locking plating for the intra- and extra-articular distal radius fractures with dorsal metaphyseal comminution

BACKGROUND

Volar locking plating remains a popular method for the surgical management of distal radius fractures. Dorsal metaphyseal comminution (DMC) is a common fracture pattern which weakens the stability during fracture fixation. In this study, we aimed to compare the radiographic and functional outcome of the intra- and extra-articular distal radius fractures with DMC following single volar locking plate fixation.

MATERIALS AND METHODS

Patients suffered from a distal radius fracture with DMC were reviewed in the clinical database of the authors' institution between Jan 2016 and Jan 2020. The included patients were classified into the extra-articular (A3) group or the intra-articular (C2 and C3) group according to the AO/OTA system. The radiological parameters, wrist range of motion, and functional outcomes were evaluated following open reduction and volar locking plate fixation.

RESULTS

A total of 130 patients were included in this study with a mean follow-up length of 17.2 months. Compared with the A3 fracture group, no significant fracture re-displacement or reduced wrist ROMs was observed in the C2 fractures after 12-month's follow-up. However, significantly decreased volar tilt (P = 0.003) as well as the extension/flexion ROMs were observed in the C3 fractures comparing to the A3 fractures. Most of the patients achieved an excellent (n = 75) or good (n = 51) Gartland and Werley wrist score. Four patients with C3 fractures resulted in a fair functional outcome due to a significant loss of volar tilt during follow-up.

CONCLUSIONS

The single volar locking plate fixation provided sufficient stability for distal radius fractures with DMC, and resulted in similar radiological and functional outcomes in the intra-articular distal radius fractures with a simple articular component (C2 fractures) as those in the extra-articular fractures. Considering the intra-articular fractures with multifragmentary articular component (C3 fracture), despite of the subsequent loss of volar tilt, the majority of the patients achieved good to excellent wrist function following single volar locking plating.

TRIAL REGISTRATION

This study has been registered on the ClinicalTrials.gov.

Effect of a figure-of-eight cerclage wire with two Kirschner wires on fixation strength for transverse metacarpal shaft fractures: an in vitro study with artificial bone

BACKGROUND

Metacarpal shaft fractures are a common type of hand fracture. Despite providing strong fixation strength, plate fixation has numerous shortcomings. Concerning internal fixation with Kirschner wires (K-wires), although this approach is frequently used to treat metacarpal shaft fractures, the lack of functional stability may result in fixation failure.

OBJECTIVE

To evaluate the effect of figure-of-eight cerclage wire on fixation for transverse metacarpal shaft fractures using two K-wires.

MATERIALS AND METHODS

We used a saw blade to create transverse metacarpal shaft fractures in 14 fourth-generation artificial third metacarpal bones (Sawbones, Vashon, WA, USA), which were assigned to groups undergoing fixation with two K-wires (KP) or with two K-wires and figure-of-eight cerclage wire (KP&F8). All specimens were subjected to material testing, specifically cantilever bending tests. The maximum fracture force and stiffness of the two fixation types were determined on the basis of the force-displacement data. The Mann-Whitney U test was used to compare between-group differences in maximum fracture force and stiffness.

RESULTS

The maximum fracture force of the KP group (median ± interquartile range = 97.30 ± 29.70 N) was significantly lower than that of the KP&F8 group (153.2 ± 69.50 N, p < 0.05; Figure 5a), with the median of the KP&F8 group exceeding that of the KP group by 57.5%. Similarly, stiffness was significantly lower in the KP group (18.14 ± 9.84 N/mm) than in the KP&F8 group (38.25 ± 23.49 N/mm; p < 0.05; Figure 5b), with the median of the KP&F8 group exceeding that of the KP group by 110.9%.

CONCLUSION

The incorporation of a figure-of-eight cerclage wire increased the maximum fracture force and stiffness by 57.5 and 110.9%, respectively, compared with those achieved in standard two K-wire fixation. Therefore, hand surgeons are advised to consider the proposed approach to increase fixation strength.

A Single Intramedullary K-Wire Is Sufficient for the Management of Nonthumb Metacarpal Shaft Fractures

Objective

This study aims to evaluate the outcome after the internal fixation of diaphyseal metacarpal fractures by a single intramedullary K-wire.

Methods

In this prospective case series study, conducted from July 2017 to June 2019 in 23 adult patients with a single, unstable, diaphyseal metacarpal fracture, outcomes after internal surgical fixation using a single antegrade intramedullary K-wire were evaluated. The outcomes were evaluated by union rate, time to union, handgrip measurements at 6 and 12 months, and the modified Disabilities of the Arm, Shoulder, and Hand (DASH) score at 12 months.

Results

The study population consisted of 17 males and 6 females, with a mean patient age of 28.4 ± 8.5 years (range, 16–45 years). The median time to final follow-up was 14 ± 1.8 months (range: 12–24 months). The mean duration of the union was 7.3 ± 1.6 weeks (range: 5–11 weeks), with a union rate of 95.7% (22 cases). The mean handgrip strength was 68% ± 12.8% of the strength of the uninjured hand after 6 months and 92.7% ± 6.9% after 12 months. The mean modified DASH score was 2.6 ± 0.26 after 12 months (range: 0–5.8). There were no cases of malrotation or infection. In conclusion, using a single 1.8–2.0 mm K-wire gives excellent functional outcomes and union rate without significant complications when used to treat an unstable metacarpal shaft fracture.

Feasibility of Homodigital Flexor Digitorum Superficialis transposition, a new technique for A2-C1 pulleys reconstruction: A kinematic cadaver study

INTRODUCTION

Homodigital flexor digitorum superficialis transposition (HFT) is proposed as a new technique for A2-C1 pulley reconstruction. Flexor digitorum superficialis is transposed on the proximal phalanx and inserted on the pulley rims, crossing over flexor digitorum profundus and acting as a pulley.

MATERIALS AND METHODS

The kinematic feasibility was investigated in a cadaveric bowstring model (after A2 and C1 pulley removal) on 22 fingers (thumb excluded).

RESULTS

HFT was effective in restoring the correct flexion of proximal and distal interphalangeal joints, compared to bowstring model. No adverse events were registered.

CONCLUSION

HFT is a feasible technique. Clinical application is encouraged.