Coronal Remodeling Potential of Pediatric Distal Radius Fractures

Age-dependent Sagittal Plane Remodeling of Pediatric Supracondylar Fractures

BACKGROUND

Current treatment guidelines for pediatric supracondylar fractures have not fully accounted for age-related variations in the remodeling potential. This study aimed to explore age-dependent sagittal plane remodeling in supracondylar fractures by assessing cases with residual deformities after treatment.

METHODS

This study included 62 patients under 16 years of age treated for supracondylar fractures at our institution from 2002 to 2022. The distance between the posterior and anterior aspects of the capitellar ossific nucleus (CON) was defined as the CON size, while the distance from the anterior humeral line to the posterior aspect of CON was termed DAP-CON. The value obtained by subtracting the DAP-CON on the unfractured side from the DAP-CON on the fractured side was divided by the CON size and multiplied by 100 and termed the displacement of CON (d-CON). The absolute value of the difference between d-CON after intervention and d-CON at the last follow-up was denoted as sagittal plane remodeling.

RESULTS

For this patient cohort, the mean age was 5.5 years (range, 1.4 to 14.6 years), and the mean follow-up period was 30.4 months (range, 12.0 to 137.1 months). Sagittal plane remodeling was more pronounced in children younger than 5 years (group I) compared with those older (group II) (P<0.001). In multiple regression analysis, only age at the time of injury was found to be a significant variable (P<0.001). The receiver operating characteristic curve analysis identified 4.2 years as the cutoff age for predicting >33% sagittal plane remodeling, with an area under the curve of 0.975.

CONCLUSIONS

Children below the age of 5 years exhibit sagittal plane remodeling, with a cutoff age identified at 4.2 years for achieving >33% of d-CON. This indicates that mild deformities (16.5%

LEVEL OF EVIDENCE

Level IV-retrospective study.

Collapse

Key Words Collapse

MESH Headings Collapse

Grants Collapse

Affiliation(s)

Yun Ki Kim Department of Orthopedic Surgery, Regional Rheumatoid and Degenerative Arthritis Center, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
Seung Hoo Lee Department of Orthopedic Surgery, Chungnam National University Sejong Hospital, Chungnam National University College of Medicine, Sejong, South Korea

Collapse

Surgically reducing displaced distal radial fractures in children

Displaced fractures of the distal radius in children are usually reduced under sedation or general anaesthesia to restore anatomical alignment before the limb is immobilized. However, there is growing evidence of the ability of the distal radius to remodel rapidly, raising doubts over the benefit to these children of restoring alignment. There is now clinical equipoise concerning whether or not young children with displaced distal radial fractures benefit from reduction, as they have the greatest ability to remodel. The Children's Radius Acute Fracture Fixation Trial (CRAFFT), funded by the National Institute for Health and Care Research, aims to definitively answer this question and determine how best to manage severely displaced distal radial fractures in children aged up to ten years.

Bony Remodeling of Adolescent Displaced Clavicle Fractures: A FACTS Study

BACKGROUND

Bony remodeling of displaced clavicle fractures in adolescents remains poorly understood.

PURPOSE

To evaluate and quantify clavicle remodeling in a large population of adolescents with completely displaced fractures, which were treated nonoperatively, to better understand the factors that may influence this process.

STUDY DESIGN

Case series; Level of evidence, 4.

METHODS

Patients were identified from the databases of a multicenter study group investigating the functional outcomes of adolescent clavicle fractures. Patients between the ages of 10 and 19 years with completely displaced middiaphyseal clavicle fractures that were treated nonoperatively and who had further radiographic imaging of the affected clavicle at a minimum of 9 months from initial injury were included. Fracture shortening, superior displacement, and angulation were measured on the injury and final follow-up radiographs using previously validated techniques. Furthermore, fracture remodeling was classified as complete/near complete, moderate, or minimal, using an original classification system found to have good to excellent reliability (interobserver reliability = 0.78, intraobserver reliability = 0.90). Classifications were subsequently analyzed quantitatively and qualitatively to determine the factors associated with deformity correction.

RESULTS

Ninety-eight patients (mean age, 14.4 ± 2.0 years) were analyzed at a mean radiographic follow-up of 3.4 ± 2.3 years. Fracture shortening, superior displacement, and angulation significantly improved during the follow-up period by 61%, 61%, and 31%, respectively (P < .001). Furthermore, while 41% of the population had initial fracture shortening >20 mm at final follow-up, only 3% of the cohort had residual shortening >20 mm. Fracture remodeling was found to be associated with follow-up time; those with longer follow-up time demonstrated more remodeling (P = .001). Eighty-five percent of patients aged <14 years and 54% of patients aged ≥14 years at time of injury with a minimum follow-up of 4 years underwent complete/near-complete remodeling.

CONCLUSION

Significant bony remodeling occurs in adolescent patients with completely displaced clavicle fractures, including older adolescents, and appears to continue over longer time intervals, even beyond the adolescent years. This finding may help explain the low rate of symptomatic malunions in adolescents, even in severely displaced fractures, and particularly when compared with rates reported in adult studies.

Clinical Follow-Up without Radiographs Is Sufficient after Most Nonoperatively Treated Distal Radius Fractures in Children

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.

Mini-invasive Osteotomy for Pediatric Distal Radius Malunion

Although most malunions after pediatric distal radius fractures will remodel as the child grows, adolescent patients with severe malunion and limited growth require reduction to restore alignment. The authors technique for a mini-invasive osteotomy is presented. The apex of the malunion is approached from a single 2 cm volar incision through the flexor carpi radialis sheath. Open wedge osteotomy is performed. The osteosynthesis is secured with an individually contoured T-plate. The procedure was used to correct a severe visible malunion in a 12-year-old girl. Normal alignment was achieved with no nerve or tendon injury or irritation, infection, refracture, or any other complication. Mini-invasive osteotomy with a volar plate is a feasible method for experienced hand surgeons for the treatment of distal radius malunion in adolescents.

Managing children's forearm fractures in the emergency department

Forearm fractures are the most common fractures among children and young people aged up to 19 years and these patients frequently present to the emergency department (ED). Many of these fractures can be treated in the ED without the need for inpatient admission. This article examines the assessment, diagnosis and management of forearm fractures. The authors also use a case study format to demonstrate best practice in the treatment of forearm fractures in this age group. The information in this article will enable ED nurses to enhance the experience of children and their families who present with forearm fractures.

[Typical liability damages of the upper extremities in childhood and their evaluation]

Legal appraisals of possible treatment errors in childhood and adolescence are rare, often refer to the treatment of trauma of the upper limbs and are frequently recognized. From the activity of the first author as an expert witness 31 expert opinions (25%) referred to the upper limbs. Supracondylar humeral fractures, radius neck fractures, radial condyle fractures and distal radius fractures were predominant. A primary treatment error was determined in 14 patients and a secondary error in 7 patients. This corresponds to a recognition rate of 68%. The aim of this study was the reflection and the development of a prevention strategy. Insufficient recognition of instability (radial condyle), inadequate reduction and inadequate stabilization (radius neck, supracondylar) as well as untreated malalignments and secondary dislocations (wrist) were the main reproaches. Poor communication and deficient documentation often aggravate the situation. Working along clear algorithms can help to avoid legal proceedings and assignment of guilt.