REFRACTURE OF THE FOREARM IN CHILDREN

[Greenstick fractures of the forearm shaft-Is it obligatory or facultative to break the cortex?]

BACKGROUND

To break or not to break-That is the question that has been asked in pediatric traumatology for many years regarding the treatment of greenstick fractures of the diaphyseal forearm shaft.

OBJECTIVE

The frequency of greenstick fractures of the forearm shaft in children and adolescents; the influence of breaking the fracture on the refracture rate.

METHODS

Analysis and discussion of relevant articles, analysis of the refracture rate of pediatric greenstick fractures of the forearm shaft in our own patient population.

RESULTS

Greenstick fractures frequently occur in the area of the forearm shaft and incomplete consolidation leads to an increased refracture rate. In the patient collective of the authors of 420 children with greenstick fractures of the diaphyseal forearm, there was a refracture rate of 9.5%; however, the rate for non-completed fractures was significantly higher compared to the group with completed fractures (15.2% vs. 3%). While in the subgroup of conservatively treated fractures (n = 234), breaking the intact cortex significantly reduced the refracture rate, breaking the intact cortical bone during surgical treatment with elastic stable intramedullary nailing (ESIN) did not change the refracture rate.

CONCLUSION

As part of the conservative treatment of greenstick fractures of the diaphyseal forearm, completing the fracture can be recommended in order to lower the refracture rate. Completing the fracture does not appear to be necessary during surgical treatment using ESIN.

How common are refractures in childhood?

Aims

The aim of this study was to describe the incidence of refractures among children, following fractures of all long bones, and to identify when the risk of refracture decreases.

Methods

All patients aged under 16 years with a fracture that had occurred in a bone with ongoing growth (open physis) from 1 May 2015 to 31 December 2020 were retrieved from the Swedish Fracture Register. A new fracture in the same segment within one year of the primary fracture was regarded as a refracture. Fracture localization, sex, lateral distribution, and time from primary fracture to refracture were analyzed for all long bones.

Results

Of 40,090 primary fractures, 348 children (0.88%) sustained a refracture in the same long bone segment. The diaphyseal forearm was the long bone segment most commonly affected by refractures (n = 140; 3.4%). The median time to refracture was 147 days (interquartile range 82 to 253) in all segments of the long bones combined. The majority of the refractures occurred in boys (n = 236; 67%), and the left side was the most common side to refracture (n = 220; 62%). The data in this study suggest that the risk of refracture decreases after 180 days in the diaphyseal forearm, after 90 days in the distal forearm, and after 135 days in the diaphyseal tibia.

Conclusion

Refractures in children are rare. However, different fractured segments run a different threat of refracture, with the highest risk associated with diaphyseal forearm fractures. The data in this study imply that children who have sustained a distal forearm fracture should avoid hazardous activities for three months, while children with a diaphyseal forearm fracture should avoid these activities for six months, and for four and a half months if they have sustained a diaphyseal tibia fracture.

Prescribing braces after forearm fractures does not decrease refracture rate

Refracture is one of the most common complications of pediatric forearm fractures. One way to decrease this risk is to extend immobilization with a brace after the cast has been removed to allow for a range of motion exercises. The purpose of this study was to examine whether prescribing a brace after casting was discontinued decreased the risk of refracture. A retrospective, cohort study was performed at one level I trauma center. Girls under 10 years and boys under 12 years who sustained a forearm fracture from January 2013 to December 2018 were included. Patients with open fractures, fractures that required operative intervention, fractures involving the physis, fracture-dislocations, floating elbows, fractures in children with endocrine abnormalities, and fractures in patients lost to follow-up were excluded. The primary endpoint was a refracture within 6 months of the original injury that extended through the original fracture site. In total 2093 patients met the inclusion criteria. There were 19 refractures (0.9%). There was no statistically significant difference in the refracture rate between the braced (11/1091) and unbraced (8/1002) cohorts (Fisher exact value 0.65 at P  < 0.05). The most common fracture type that went on to refracture was greenstick fractures. This large, retrospective study aimed to examine whether prescribing a brace had any significant effect on the refracture rate. Bracing after the cast is removed may help ease family anxiety and extend the period of immobilization while allowing for hygiene and range of motion, but it does not significantly decrease the rate of refracture.

Risk Factors for Upper Extremity Refractures in Children

BACKGROUND

Multiple descriptive studies have been published on refracture patterns, particularly for forearm fractures. However, few large cohorts have been analyzed quantitatively including the odds of refracture, and with a comprehensive assessment of the possible predictive factors associated with refracture. This study aimed to assess the frequency and timing of upper extremity refracture in a large pediatric orthopaedics practice, and to evaluate the strength of association of various patient-level and fracture-related factors with refracture.

METHODS

Medical records were reviewed retrospectively for patients 1 to 18 years of age with at least 1 upper extremity fracture (ICD-9 codes 810 to 819) between June 1, 2010 and May 31, 2011. Characteristics of patients and fractures were assessed for the association with refracture using bivariate analysis and multivariable logistic regression.

RESULTS

Among 2793 patients with a total of 2902 upper extremity fractures, 2% were treated for refracture within 2 years, at a median of 6 months (188 d) after the initial injury. Midshaft location, and characterization of the fracture as angulated or buckle, were associated with being more likely to refracture. Eighty percent of refractures were the result of a fall, with almost 25% involving a high-energy mechanism and about 15% from monkey bars or other playground equipment. The adjusted odds of refracture were 4 times higher if noncompliance with treatment recommendations was documented, when controlling for insurance type and number of days before orthopaedic evaluation. Forearm fractures were almost 4 times more likely to refracture compared with other bones, controlling for midshaft location, days immobilized, and buckle or torus characterization of the fracture.

CONCLUSIONS

Our practice saw a refracture occurrence in 2% of patients, with median time to refracture of ~6 months. The factors most strongly associated with refracture were midshaft fracture location, forearm fracture as opposed to clavicle or humerus, and noncompliance as defined in the study. Falls and high energy activities, such as use of wheeled devices, skis, or trampolines, were important mechanisms of refracture.

LEVEL OF EVIDENCE

This study is a Level II prognostic study. It is a retrospective study that evaluates the effect of patient and fracture characteristics on the outcome of upper extremity refracture.

Re-fractures of the paediatric radius and/or ulna: A systematic review

BACKGROUND

Fractures of the radius and/or ulna are one of the most common injuries in children. Evidence identifying risk factors for refracture, however, has not been summarised in a systematic review. Guidance for counselling patients and parents to minimise the risk of refracture is limited. The aims of this study are to 1) to determine if casting time 6 weeks or less is a risk factor for refracture after paediatric radius and/or ulna fractures, 2) to identify other risk factors for refracture after paediatric radius and/or ulna fractures and 3) to develop more accurate guidelines for counselling parents after a radius and/or ulna fracture in their child.

METHODS

A thorough search was performed in accordance with the Joanna Briggs Institute (JBI) guidelines for systematic review. JBI Critical Appraisal checklists were used for risk of bias assessment.

RESULTS

Diaphyseal both-bone fractures treated non-surgically should be casted for longer than 6 weeks. Surgically treated patients can be casted for less than 6 weeks. Diaphyseal and greenstick fractures have a higher risk of refracture. Residual angulation and incomplete healing in greenstick fractures may lead to a higher risk of refracture. Gender does not affect refracture risk. Falls, use of wheeled vehicles, playground activities and trampolining confer high-risk of refracture. Refracture risk is greatest up to 9 months from initial fracture.

CONCLUSION

Further case-controlled studies with sub-group analysis are required to further investigate risk factors for refracture after radius and/or ulna fractures in children.

Refracture of pediatric both-bone diaphyseal forearm fracture following intramedullary fixation with Kirschner wires is likely to occur in the presence of immature radiographic healing

PURPOSE

Refracture of pediatric both-bone diaphyseal forearm fractures (PBDFFs) may occur, even if the fractures are treated with intramedullary nailing. The purpose of this study was to investigate the risk of refracture of PBDFFs treated with intramedullary Kirschner wires (K-wires), which are commonly used in our clinic.

METHODS

The present multicenter retrospective study included 60 consecutive patients with 60 PBDFFs who were treated with intramedullary K-wires at 5 hospitals between 2007 and 2016. The age of the patients at the time of the primary fracture ranged from 2 to 15 years. The characteristics of the primary fractures and treatment course were evaluated.

RESULTS

Refracture occurred in 6 patients (10.0%). Three of the patients were young girls; the other 3 were adolescent boys. Refractures were caused by falling or during sports activity. The duration from primary fracture to refracture ranged from 46 to 277 days, and in 5 of the 6 patients refractures occurred within 6 months. Although we were unable to identify factors significantly contributing to refracture (e.g. fracture type or treatment procedures), radiographs at the latest visit before refracture demonstrated findings of immature healing in five of six patients. Both K-wires and external immobilization had been removed before complete fracture healing in a large proportion of patients with refracture (80.0%).

CONCLUSIONS

Refracture of PBDFF may occur several months after treatment with intramedullary K-wires if the primary fracture shows immature healing. Physicians should pay special attention when judging radiographic fracture healing, even when the fracture is deemed to have clinically healed.

Buried intramedullary implants for paediatric forearm fractures. Does the refracture rate improve?

INTRODUCTION

Unstable forearm fractures may require surgical management by reduction and osteosynthesis with intramedullary needles. This fixation should be removed early if it has been left exposed, but this could increase the risk of refracture in a bone in the period of remodelling. As an alternative we can keep the needles, buried subcutaneously, for a longer time, to protect the bone callus.

OBJECTIVE

To assess whether there are differences between using exposed needles with respect to burying them in paediatric patients with forearm fractures. Our hypothesis is that by burying the needles we keep them longer by reducing forearm refractures.

MATERIAL AND METHODS

We present a cohort of 75 paediatric patients with a forearm fracture between 2010 and 2016. Demographic data, surgical technique, complications and patient follow-up were collected.

RESULTS

The implants were left exposed in 50 patients and 25 buried. The average time of removal of the exposed implants was 6.8weeks and 17.6weeks in the buried ones. No significant differences were found in terms of consolidation (P=.19) or immobilization time (P=.22). Regarding refractures, a greater number was observed in the exposed osteosynthesis group (4patients) compared to only one case with buried osteosynthesis, but there were no significant differences (P=.49). No postsurgical complications were detected and the functionality was excellent at the end of the follow-up in both groups.

CONCLUSION

Leaving implants buried in relation to skin exposed does not cause a decrease in the number of refractures or other complications, with adequate patient functionality in both cases.

Is there a standard treatment for displaced pediatric diametaphyseal forearm fractures?: A STROBE-compliant retrospective study

To review our institutional results and assess different surgical and non-surgical techniques for the treatment of displaced diametaphyseal forearm fractures in children and adolescents.Thirty-four children (25M, 9F) with a total of 36 diametaphyseal forearm fractures who underwent treatment under general anesthesia between July 2010 and February 2016 were recruited to this retrospective study. From October 2016 until March 2018 patients and/or parents were contacted by telephone and interviewed using a modified Pediatric Outcomes Data Collection Instrument (PODCI).Median age at the time of injury was 9.1 years (range, 1.9-14.6 years). Initial treatment included manipulation under anesthesia (MUA) and application of plaster of Paris (POP) (n = 9), elastic stable intramedullary nailing (ESIN) (n = 10), percutaneous insertion of at least one Kirschner wire (K-wire) (n = 16), and application of external fixation (n = 1). Eleven children (32%) experienced a total of 22 complications. Seven complications were considered as major, including delayed union (n = 1) and extensor pollicis longus (EPL) tendon injury (n = 1) following ESIN, as well as loss of reduction (n = 2) and refractures (n = 3) after MUA/POP. The median follow-up time was 28.8 months (range, 5.3-85.8 months). In 32 out of 34 cases (94%) patients and/or parents were contacted by telephone and a PODCI score was obtained. Patients who experienced complications in the course of treatment had a significantly lower score compared with those whose fracture healed without any sequelae (P = .001). There was a trend towards an unfavorable outcome following ESIN compared with K-wire fixation (P = .063), but not compared with POP (P = .553). No statistical significance was observed between children who were treated initially with a POP and those who had K-wire fixation (P = .216).There is no standard treatment for displaced pediatric diametaphyseal forearm fractures. Management with MUA/POP only is associated with an increased refracture rate. Based on our experience K-wire fixation including intramedullar positioning of at least one pin seems to be favorable compared with ESIN.

Risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing

PURPOSE

This study aims to investigate risk factors for refracture of the forearm in children treated with elastic stable intramedullary nailing (ESIN).

METHODS

Clinical data of 267 patients who had been treated for forearm fractures by ESIN in our hospital from January 2010 to December 2014 were retrospectively reviewed. Risk factors for forearm refractures were determined using logistic regression analysis.

RESULTS

Forearm refractures occurred in 11 children. Univariate analysis revealed that age, body weight, number of fractures, open fracture, nail diameter, and immobilization time were not associated with refractures. However, gender (male, P = 0.042) and fracture location (lower third, P = 0.007) were significantly associated with refractures. Multivariate analysis revealed that fracture location was an independent risk factor for forearm refractures (P = 0.031).

CONCLUSION

Forearm refracture is uncommon in children treated with ESIN. Fracture location is an independent risk factor for forearm refractures in these patients.

Exposed versus buried intramedullary implants for pediatric forearm fractures: a comparison of complications

BACKGROUND

The purpose of this study was to compare the rate of complications between buried and exposed intramedullary implants after fixation of pediatric forearm fractures.

METHODS

A retrospective comparative cohort study of 339 children treated with intramedullary fixation for displaced forearm fractures between 2004 and 2009 was performed. Implants were left exposed in 128 patients (37.8%) and buried beneath the skin in 208 patients (61.4%); 3 patients had buried and exposed hardware (0.9%). Data on demographics, injury, surgical technique, and complications were analyzed.

RESULTS

The buried implant group was older (mean 10.3 vs. 8.5 y; P < 0.001), heavier (mean 38.6 vs. 31.9 kg; P < 0.001), and had fewer open injuries (23% vs. 41%; P < 0.001) than the exposed implant group. The buried group had their implants removed later than the exposed group (median 3.5 vs. 1.2 mo; P < 0.001). There was no difference between time to removal for patients with refracture and those without (median 1.3 vs. 2.0 mo; P = 0.78). A total of 36.2% of exposed implants were successfully removed in the office. Complications were seen in 56 patients (16.5%). There were 16 patients (4.7%) with refracture and 12 patients (3.5%) with infection. The buried and exposed implant groups did not differ significantly with respect to refracture (3.1% vs. 7.0%; P = 0.20), infection (3.5% vs. 2.3%; P = 0.66), or overall complications (14.5% vs. 17.2%; P = 0.87). There was also no difference between groups with respect to loss of reduction, nondelayed or delayed union, loss of motion, hypertrophic granuloma, or tendon rupture. Buried implants were also associated with penetration through the skin (3.9%). Injury to the dominant arm and need for open reduction were significant predictors of complication (OR = 1.01; 95% CI, 1.001-1.012; P = 0.02 and OR = 0.51; 95% CI, 0.264-0.974; P = 0.04, respectively).

CONCLUSIONS

There were no significant differences seen in number of infections, refractures, or overall complications based on whether implants were left exposed or buried beneath the skin after surgery.

LEVEL OF EVIDENCE

Level III, therapeutic.

Pediatric refracture rates after angulated and completely displaced clavicle shaft fractures

OBJECTIVES

The purpose of this study was to assess refracture rates after angulation-only and completely displaced clavicle shaft fractures in children.

DESIGN

Retrospective chart review.

SETTING

Level 1 pediatric trauma center.

PATIENTS

Computerized medical records searches identified children treated nonoperatively for clavicle shaft fractures at our institution. Inclusion criteria were age less than 18 years and a minimum of 1-year radiographic follow-up. Statistical methods included Fisher exact test with significant probability values being defined as less than 0.05.

RESULTS

Of the 120 angulation-only patients and 41 completely displaced patients meeting criteria for inclusion in our study, we identified a statistically higher (P = 0.002) refracture rate (18%, 21/120) in angulation-only fractures as compared with 0% (0/41) for completely displaced fractures. Subgroup analysis of the angulation-only fractures revealed that fractures angulated less than 40 degrees refractured at a 26% rate (18/69) versus 6% (3/51) of fractures with greater angulation (P = 0.004).

CONCLUSIONS

We found that angulation-only shaft fractures had a significantly higher refracture rate than completely displaced fractures. Furthermore, subgroup analysis demonstrated that less-angulated fractures had a higher refracture rate than the more-angulated ones. We feel this somewhat paradoxical finding is analogous to fractures of the forearm shaft, for which greenstick fractures refracture at a higher rate than complete forearm shaft fractures due to less-exuberant callus formation.

LEVEL OF EVIDENCE

Prognostic level III. See instructions for authors for a complete description of levels of evidence.

Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial

INTRODUCTION

This multicentre randomised controlled trial was designed to explore whether 6 weeks above-elbow cast (AEC) or 3 weeks AEC followed by 3 weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children.

MATERIALS AND METHODS

Children were randomly allocated to 6 weeks AEC or to 3 weeks AEC followed by 3 weeks BEC. The primary outcome was limitation of pronation and supination after 6 months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs.

RESULTS

A group of 23 children was treated with 6 weeks AEC and 24 children with 3 weeks AEC and 3 weeks BEC. The follow-up rate was 98 % with a mean follow-up of 7.0 months. The mean limitation of pronation and supination was 23.3 ± 22.0 for children treated with AEC and 18.0 ± 16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups.

CONCLUSIONS

Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children.

LEVEL OF EVIDENCE

Multicentre randomised controlled trial, Level II.

Complications and radiographic outcome of children's both-bone diaphyseal forearm fractures after invasive and non-invasive treatment

BACKGROUND

The incidence of paediatric forearm fractures and their invasive operative treatment is increasing. Evidence supporting increased interest in internal fixation of forearm fractures has been controversial. We studied radiographic outcome and complications of both-bone diaphyseal middle-third forearm fractures according to the type of treatment. The purpose of the study was to determine if there is an advantage in invasive treatment over non-invasive treatment that supports the increasing trend towards invasive surgery.

MATERIALS AND METHODS

All children and adolescents (<16 years) with both-bone diaphyseal middle-third forearm fractures in a geographic area with 86,000 children in 2000-2009 were included. There were 168 patients. The types of primary fractures and their malalignment and displacement rates were analysed. The fractures were classified as 'severe' or 'mild' according to radiographic findings. Radiographic fracture healing and alignment and the rate of complications were compared as regards invasive versus non-invasive surgery.

RESULTS

Just over a third of all patients suffered from some complication during follow-up. The overall complication rate was highest in the non-invasive treatment group (58%) and lowest in the intramedullary nailing group (24%) (P < 0.001). The difference was significant as regards both mild and severe fractures. Nearly a third of the fractures in the non-invasive treatment group were re-reduced during follow-up. Two third of them were finally fixed invasively. Re-reduction after invasive fixation was rare (1.4%, P = 0.001). Re-fracture was equally uncommon (7.1%) in both the invasive and non-invasive groups. Non-union was unusual (1.2%) and it was related to high-energy trauma or chronic disease. Nerve co-morbidity, scar problems, soft-tissue complications and compartmental syndrome were not problems in the study population despite the type of treatment.

CONCLUSIONS

We found that the complication rate of diaphyseal forearm fractures was twice as common after non-invasive than after invasive treatment. The need of re-reduction after non-invasive treatment was remarkable. Nevertheless, bone healing was equally good despite the treatment. We conclude that intramedullary fixation of both-bone forearm fractures is a good mode of primary treatment of mild and severe middle-third diaphyseal both-bone forearm fractures.

An update on the epidemiology of pediatric fractures

Despite public health measures to prevent childhood injuries, the incidence of pediatric fractures is increasing. This fracture incidence is dependent on many demographic factors, the various contributors to bone health, and an individual's risk-taking behavior. Although traditional play activities continue to be the prevalent causes for fractures, there is an evolving array of new sport and recreation activities that carry significant fracture risk. The following review article outlines the developing epidemiology of pediatric fractures by analyzing some of the individual risk factors that influence fracture incidence as well as the variety of activities that are associated with these fractures.

Paediatric diaphyseal forearm refractures after greenstick fractures: operative management with ESIN

BACKGROUND

One of the complications of forearm shaft fracture is refracture. Elastic stable intramedullary nailing represents an alternative method for refracture treatment to cast immobilisation for another five to seven weeks. Operative treatment often necessitates an open reduction in most cases due to blocked or narrowed medullary canals. The purpose of this study was to examine the expense of the operative procedure, technique (closed or open intramedullary nailing) and postoperative complications in diaphyseal forearm refractures.

METHODS

We retrospectively examined the expense of operative procedure in 21 children with diaphyseal forearm refractures treated with ESIN.

RESULTS

In 18 cases, closed reduction with nailing was possible; three required an open reduction. In nine patients a closed medullary cavity was present; only two of them needed an open reduction. None of the patients had complications (wound healing, osteomyelitis, rupture of the extensor pollicus longus). Swelling appeared in four patients, paraesthesia of the thumb in one. Free functional movement was achieved in all children. Long term results: No re-refracture occurred. One patient suffered from meteorosensitivity. Twelve are able to do the same sporting activities as before injury.

CONCLUSION

ESIN seems to be one choice for treatment in refracture of the forearm, as in most cases the operative reduction can be performed in a closed way by means of "tricks and hints".

Open intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children

PURPOSE

To compare the outcomes of intramedullary Kirschner wire versus screw and plate fixation for unstable forearm fractures in children aged older than 10 years.

METHODS

Records of 32 children aged 10 to 15 (mean, 12) years with displaced fractures of the radius and ulna were retrospectively reviewed. 17 boys and 4 girls underwent intramedullary Kirschner wiring, whereas 10 boys and one girl underwent plating. All patients had been initially treated with closed reduction and casting. Indications for surgical intervention were fractures with angulation of >10 degrees and total displacement. Patients were followed up for a mean of 24 (range, 13-40) months. Angulation and range of movements of the elbow, wrist, and forearm, as well as clinical and cosmetic results were compared.

RESULTS

Both treatments achieved excellent clinical outcomes, but intramedullary Kirschner wiring resulted in better cosmesis, shorter operating times, easier hardware removal, and lower implant costs.

CONCLUSION

Intramedullary Kirschner wiring is a better option than plating for the treatment of unstable forearm fractures in older children.

Are frequent radiographs necessary in the management of closed forearm fractures in children?

INTRODUCTION

A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China.

METHODS

The sample consisted of 202 consecutive children (mean age 7 years; range 3-12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4-6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15 degrees ) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal.

RESULTS

Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15 degrees on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients.

CONCLUSIONS

On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.

The healing forearm fracture: a matched comparison of forearm refractures

BACKGROUND

Forearm fractures in children usually heal rapidly after closed treatment. Recent studies report forearm refracture rates of 5%. The purpose of this study was to identify risk factors for refracture based on radiographic variables.

METHODS

We performed a retrospective review of patients that sustained a second forearm fracture (refracture) between 1998 and 2005. Refractures were defined as having a second fracture of the same forearm within 18 months of the original fracture. A comparison group of single-fracture patients followed in a capitated insurance plan were included and matched based on age and sex. Radiographic assessment included initial/final angulation, displacement, and fracture-line visibility at latest follow-up.

RESULTS

Sixty-three refractures were compared with 132 age- and sex-matched single-fracture patients. Time to refracture averaged 10 months. Thirty-eight percent of the initial fractures in the refracture group occurred in the proximal or middle third of the forearm compared with 15% for the single-fracture patients (P < 0.001). Because location of the fracture was found to be a risk factor for refracture, a secondary analysis was performed with refracture patients matched to single-fracture patients based on age, sex, bone fractured, fracture location, and treatment method. Fracture-line visibility of the radius at latest follow-up was clearly visible in 48% of refractures compared with 21% of controls (P = 0.05). Initial fracture severity and residual deformity were not significantly different.

CONCLUSIONS

Proximal and middle one third forearm fractures are at greater risk of refracture compared with distal one third forearm fractures. There was a trend toward incomplete healing seen more commonly in those that refractured, emphasizing the importance of longer immobilization in these fractures.

LEVEL OF EVIDENCE

Prognostic study, level III, case-control study.

Paediatric forearm refractures with retained plates managed with flexible intramedullary nails

During the past 18 months we have managed four paediatric patients who have sustained forearm refractures associated with retained plates that were used to treat their original fracture. Although this complication is not new, most literature regarding paediatric forearm refracture relates to refractures that occur after closed treatment or after removal of metalwork. We treated the patients in this small series with plate removal and intramedullary stabilisation using elastic stable intramedullary nails (Nancy, Depuy, UK) as opposed to revision plating. Treatment of this complication by this method has not previously been described.

Refractures of the upper extremity in children

PURPOSE

To investigate the etiologic factors related to refractures of the upper extremity in children.

PATIENTS AND METHODS

Eighteen refractures were divided into three groups according to the location of the initial fractures. They were analyzed in terms of the type of refractures, fracture patterns, and the existence of an underlying deformity.

RESULTS

Of nine supracondylar fractures of the humerus, two involved refractures at the supracondylar region, and the other seven involved the lateral condyle. Underlying cubitus varus was present in six cases. Of three lateral condylar fractures of the humerus, one had a refracture at the supracondylar region, and two cases involved the lateral condyle. One had an underlying cubitus varus. All but one case in the humeral fractures group were late refractures, and were treated with surgery. Of six repeat forearm fractures, five were early type and occurred at the original site within nine weeks, four at the diaphysis of both bones of the forearm, and one at the diaphysis of the ulna. All cases in the forearm fractures group, save one, had volar angulation before the refracture, and were treated conservatively.

CONCLUSION

In the humerus, the underlying cubitus varus was the most important predisposing factor for refractures and lateral condyle fractures were common. In the forearm, volar angulation of the diaphysis was related to refractures, and complete and circular consolidation of the primary fracture of the forearm was thought to be important in prevention.

Acceptance of angulation in the non-operative treatment of paediatric forearm fractures

Forearm fractures are the most common injury in paediatric traumatology. The unique properties of the juvenile skeleton make it possible to cope well with traumatic deformities such as angulation, apposition and displacement. While we make use of these properties, the exact mechanism and degree of healing remains obscure. Different types of forearm fractures require specific treatment options, each with its limitations. A meta-analysis of recent literature was carried out, and together with the opinions of 18 international experts an effort was made to provide insight into the limits of acceptance of angular deformation in the non-operative treatment of paediatric forearm fractures. With this information we constructed graphs (age versus angulation) for each of the eight types of paediatric forearm fractures. In the absence of proper trials, it is our opinion that the presented Isala graphs can provide useful support in the decision-making process of acceptance of angular deformities in paediatric forearm fractures.

A genetic approach to fracture epidemiology in childhood

The purpose of this report is to provide a review of both childhood fracture epidemiology and known heritable causes for fracture predisposition to the Medical Geneticist, who is frequently consulted to assess children with multiple or unexplained fractures for a physiologic etiology. A detailed knowledge of the clinical and laboratory evaluation for osteogenesis imperfecta (OI) and other single-gene disorders is obviously essential to complete a useful evaluation of such children. The experienced clinician will immediately recognize that single gene disorders represent only a small fraction of these patients. In infants, non-accidental trauma (NAT) unfortunately is the likely explanation for the fracture pattern, but in some infants, and certainly in older children with recurrent fractures, no medical explanations can be found. Recent studies in which bone mineral density (BMD) has been associated with genetic variation at a number of candidate genes are promising but these studies are too premature yet to be used clinically. Nonetheless, we do expect that in the future whole-genome approaches in conjunction with key clinical and epidemiological variables may be combined through an informatics approach to create better predictors of fracture susceptibility for these populations of patients.

Refracture of the clavicle in an infant: case report and review of clavicle fractures in children

Perinatal clavicle fractures typically heal without complication, and subsequent refracture of the same clavicle during infancy or toddlerhood has not been reported. This is a case report of a fracture of the clavicle in a 9-month-old child who had previously suffered a fracture of the same clavicle at birth. A review of the evaluation and management of neonatal and post-neonatal clavicle fractures is also presented.

Regulatory fit and persuasion: transfer from "Feeling Right."

The authors propose that when a message recipient "feels right" from regulatory fit (E. T. Higgins, 2000), this subjective experience transfers to the persuasion context and serves as information for relevant evaluations, including perceived message persuasiveness and opinions of the topic. Fit was induced either by strategic framing of message arguments in a way that fit/did not fit with the recipient's regulatory state or by a source unrelated to the message itself. Across 4 studies, regulatory fit enhanced perceived persuasiveness and opinion ratings. These effects were eliminated when the correct source of feeling right was made salient before message exposure, supporting the misattribution account. These effects reversed when message-related thoughts were negative, supporting the claim that fit provides information about the "rightness" of one's (positive or negative) evaluations.

The application of open intramedullary fixation in the treatment of pediatric radial and ulnar shaft fractures

OBJECTIVES

This retrospective review evaluates the efficiency of standard intramedullary Kirschner wires for the treatment of unstable diaphyseal forearm fractures in children.

DESIGN

Retrospective review.

SETTING

Large teaching and research hospital in Turkey.

PATIENTS

Thirty-one patients with diaphyseal forearm fractures were treated by surgical method between 1988 and 1998. The mean age was 12.3 years (range 7 to 17 years). The mean follow-up period was 4.2 years (1 to 6.2 years).

INTERVENTION

The method of treatment of each forearm fracture was open reduction and intramedullary Kirschner wire fixation using a mini-incision.

MAIN OUTCOME MEASUREMENTS

Fracture union, growth disturbance of the forearm, and complications were evaluated.

RESULTS

Union was obtained in all cases except two (6.4 percent). No forearm inequality was observed.

CONCLUSIONS

Intramedullary fixation is a useful technique for unstable shaft fractures of the forearm in children that can not be treated by closed manipulation.

Refractures of the radius and ulna in children

Seven hundred and sixty-eight children with displaced forearm fractures requiring reduction were studied retrospectively. Of 38 refractures (incidence 4.9%), 34 occurred within nine months at the original fracture site. The median time to refracture was eight weeks after discontinuing cast immobilisation. Diaphyseal fractures were eight times more likely to refracture than metaphyseal fractures. The risk of refracture was inversely proportional to the duration of cast immobilisation. Cast immobilisation for a minimum of six weeks reduces the risk of refracture by a factor of between four and six. Midshaft forearm fractures are at risk of refracture for sixteen weeks from cast removal.