The evolution of hand function during remodelling in nonreduced angulated paediatric forearm fractures: a prospective cohort study

Improved forearm rotation even after early conversion to below-elbow cast for non-reduced diaphyseal both-bones forearm fractures in children: a secondary 7.5-year follow up of a randomized trial

BACKGROUND AND PURPOSE

previous RCT compared short-term results of above-elbow cast (AEC) with early conversion to below-elbow cast (BEC) in children with non-reduced diaphyseal both-bone forearm fractures. After 7 months both groups had comparable function. Our primary aim was to investigate whether forearm rotation improves or worsens over time. Secondary aims were loss of flexion and extension of the elbow and wrist, patient-reported outcomes measures, grip strength ratio, and radiographic assessment.

PATIENTS AND METHODS

We performed long-term follow-up (FU) of a previous RCT. All patients were invited again for the long-term FU measurements. Primary outcome was limitation of forearm rotation. Secondary outcomes were loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, the ABILHAND-Kids questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, grip strength ratio, and radiographic assessment.

RESULTS

The mean FU was 7.5 (4.4-9.6) years. Of the initial 47 children, 38 (81%) participated. Rotation improved in both groups over time, with no significant difference in the final forearm rotation: 8° (SD 22) for the AEC group and 8° (SD 15) for the BEC group with a mean difference of 0° (95% confidence interval -13 to 12). Secondary outcomes showed no statistically significant differences. Finally, children < 9 years almost all have full recovery of function.

CONCLUSION

Long-term follow-up showed that loss of forearm rotation after a non-reduced diaphyseal both-bone forearm fracture improved significantly compared with that at 7 months, independent of the initial treatment and children aged < 9 will have almost full recovery of function. This substantiates that the remaining growth behaves like a "friend" at long-term follow-up.

Functional recovery after reduced pediatric fractures of the forearm with respect to perceived limitations, common post-traumatic symptoms, range of motion, and dexterity: a prospective study

PURPOSE

Studies on functional recovery after pediatric forearm fractures are scarce. Outcome measures are usually (retrospectively) incorporated to compare treatments. How these parameters recover has only rarely fallen within the scope. Aim was to provide insight into "normal recovery" by evaluating how limitations, post-traumatic symptoms, range of motion (ROM) and dexterity recuperate.

MATERIALS AND METHODS

Prospective observational study regarding children 4 and 18 years with a reduced forearm fracture. Limitations, post-traumatic symptoms, ROM, and dexterity were evaluated 6 weeks, 3 and 6 months post-trauma. ROM of the unaffected side was used as a baseline.

RESULTS

Of 54 participants 25.9% and 5.9% perceived limitations after 3 respectively 6 months. Pain, swelling and hypertrichosis were common symptoms. Movements distal from the elbow were restrained 6 weeks post-trauma. Supination and palmar flexion were most affected, followed by dorsal flexion and pronation. Palmar flexion and pronation were still affected after 3 months and associated with treatment invasiveness. Dexterity was diminished at 6 weeks only.

CONCLUSIONS

Mild limitations are common. Further investigation of the association between pain, reduced sensitivity and hypertrichosis with treatment invasiveness is warranted. Regarding ROM supination, pronation, palmar and dorsal flexion should be incorporated in future studies. Dexterity is an unsuitable outcome measure.IMPLICATIONS FOR REHABILITATIONThis study relates to monitoring recovery from pediatric forearm fractures.Physicians ought to realize that one in four children experience limitations preceding 3 months post-trauma, in which case involvement of a hand therapist should be considered.Pain, swelling and especially hypertrichosis are common post-traumatic symptoms in children and should on itself not immediately raise concerns for complex regional pain syndrome (CRPS).To assess recovery of range of motion measuring pronation, supination, dorsal, and palmar flexion is sufficient.

Is three-point index reliable in the follow-up of the distal radius metaphys fractures in the pediatric age group?

Three-point index (TPI), which can be used in the follow-up of conservative treatment, is an important indicator and reveals objective results about the fracture redisplacement. The hypothesis of the current study was that an initial TPI value of 0.6-0.8 may also be dangerous as it has the potential to exceed over 0.8 before a sufficient consolidation occurs and a prompt revision of the cast may prevent an upcoming displacement. This prospective controlled study 84 patients between 4 and 16 years of age, with radius distal metaphyseal fractures with more than 30% displacement or more than 15° initial angulation, were included. All of the patients in the groups had no redisplacement at 5-7 days and had TPI between 0.6 and 0.8. The patients who had cast replacement and adjusted TPI below 0.6 were included Group 1. The patients who had no cast replacement were included in Group 2. Redisplacement was observed in 8 of 38 (21%) patients in the Group 1 and in 27 of 46 (58%) patients in the Group 2 ( P value 0.001). Redisplacement with cast revision was 2.8 times less ( P  < 0.005). The first reduction quality, fracture obliquity, renewed TPI values were found to be statistically significant for the prediction of redisplacement ( P  < 0.005). We recommend that the follow-up of the TPI is an important predictive factor in the conservative treatment of pediatric metaphyseal radius fractures. TPI may be renewed for protection of the fracture reduction when calculated in the gray zone which is 0.6-0.08.

Diametaphyseal Distal Forearm Fractures in Children: A STROBE Compliant Comparison of Outcomes of Different Stabilization Techniques Regarding Complications

Diametaphyseal forearm fractures are difficult to treat because standard methods for long-bone fracture stabilization in the metaphyseal or diaphyseal regions are less effective in this transition zone. We hypothesized that there is no difference in outcomes between conservative and surgical treatment of diametaphyseal forearm fractures. This retrospective analysis included 132 patients who had undergone treatment for diametaphyseal forearm fracture between 2013 and 2020 at our institution. The primary analysis compared complications occurring in patients treated conservatively with those occurring in patients managed surgically (ESIN, K-wire fixation, KESIN stabilization, or open reduction and plate osteosynthesis). In a subgroup analysis, we compared the two most frequently applied surgical stabilization techniques in distal forearm fractures (i.e., ESIN and K-wire) with conservative treatment. The mean age of the patients at the time of intervention was 9.43 ± 3.78 years (mean ± SD). Most patients were male (91; 68.9%), and 70 of 132 (53.1%) patients underwent surgical stabilization. The rate of re-intervention or complications was similar after conservative and surgical treatment, and ESIN or K-wire fixation achieved comparable complication rates. Recurrent displacement of fragments was the most frequent reason for re-interventions (13 of 15 patients; 86.6%). There was no permanent damage as a result of a complication. The median time of exposure to image intensifier radiation was comparable between ESIN (95.5 s) and K-wire fixation (85.0 s), but significantly lower during conservative treatment (15.0 s; p = 0.001).

Corrective Surgery for a Forearm Deformity in a Middle-Aged Patient with Multiple Hereditary Exostoses: A Case Report

CASE

A 48-year-old man underwent corrective surgery for a deformity of the left forearm because of multiple hereditary exostoses (MHE). The patient had no complaint of pain, the appearance of his forearm improved, and acceptable range of motion of the wrist and forearm were maintained at 14-month follow-up.

CONCLUSION

The esthetic forearm deformity in the middle-aged patient with MHE was successfully improved without sacrificing function. Although there is little evidence of forearm corrective surgeries for adult patients with MHE, this report could expand surgical indications for them.

Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature

PURPOSE

This narrative review intends to summarize the most important and relevant data on diagnosis and treatment of pediatric forearm fractures and to describe the characteristics and advantage of each therapeutic option.

METHODS

We conducted a literature research considering peer-reviewed papers (mainly clinical trials or scientific reviews) using the string "forearm fracture AND epidemiology" or "forearm fracture AND diagnosis or " forearm fracture AND treatment" or "forearm fracture AND casting" or "forearm fracture AND surgery". Studies were identified by searching electronic databases (MEDLINE and PubMed) till April 2020 and reference lists of retrieved articles. Only English-language articles were included in the review.

RESULTS

Conservative management with cast immobilization is a safe and successful treatment option in pediatric forearm fractures. Surgical indication is recommended when an acceptable reduction cannot be obtained with closed reduction and casting. Surgical treatment options are intramedullary nail, plating and hybrid fixation.

CONCLUSIONS

There is not a unique consensus about fracture management and treatment. Further studies are necessary to create univocal guidelines about optimal treatment, considering new techniques and available technologies.