Malunion of distal radius fractures in children

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.

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MESH Headings

• Humans
• Child
• Child, Preschool
• Male
• Adolescent
• Female
• Age Factors
• Humeral Fractures/surgery
• Infant
• Retrospective Studies
• Bone Remodeling
• Follow-Up Studies
• Fracture Fixation, Internal/methods

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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

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Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?

BACKGROUND

For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.

QUESTIONS/PURPOSES

In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?

METHODS

In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.

RESULTS

At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).

CONCLUSION

In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.

LEVEL OF EVIDENCE

Level I, therapeutic study.

Repurposing Spinal Distractor to Reduce Pediatric Wrist Fractures

Fracture geometry, particularly a jagged bone spike, can present a physical barrier in closed reduction of pediatric distal radius-ulna fractures. When closed reduction of the fracture is not possible, accepting an incomplete reduction and hoping for remodeling, or open reduction, which poses a greater risk for infection and potential physeal injury, are alternative treatment options. The objective of this study was to describe a technique, coined as Percutaneous Skeletal Traction Aided Reduction (P_STAR), for reducing these fractures, thereby eliminating the acceptance of an incomplete reduction and the risks associated with open reduction. In P_STAR, 2 distraction pins are placed 1.5 cm proximal and distal to the fracture site in clearance of the distal radial physis. A shadow-line spinal distractor is then used to distract the pins, reducing the fracture over the irregular impeding fracture geometry. After distraction is released, 1 or 2 K-wires can be percutaneously inserted to transfix the fracture. A video of the technique was also included as Supplemental Digital Content, http://links.lww.com/BTH/A188 . When performed on 18 children with distal radius-ulna fractures, P_STAR achieved near anatomic fracture alignment with no nerve or tendon injury, infection, or refracture.

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.

Paediatric distal radius fractures: an instructional review for the FRCS examination

An instructional review of the literature and guidelines relevant for the classification, management and prognosis of paediatric distal radius fractures. Aimed at the knowledge level required for the trauma and orthopaedic FRCS examination.

Outcomes and Cost of Reduction of Overriding Pediatric Distal Radius Fractures

BACKGROUND

This study compared radiographic outcomes of pediatric patients undergoing closed reduction of 100% displaced distal radius fractures to a historical, published cohort treated with casting alone. We also examined the expense associated with sedated reduction.

METHODS

Single-center, retrospective cohort study examining radiographic outcomes following reduction of 100% translated distal radius fractures in 50 consecutive pediatric patients. Radiographic outcomes were compared with a historical cohort published by Crawford and colleagues. Charges associated with emergency department (ED) and clinic visits were compared between the reduction cohort and a comparison cohort of 13 patients with fractures not requiring reduction.

RESULTS

Forty-nine children (mean age 4.7 y) were included in this study. Duration of casting averaged 51 days and ED visit duration was 6.6±2.5 hours. Mean sagittal and coronal angulation at time of injury were 16.4 and 15.6 degrees, respectively, and were 13.2 and 9.4 degrees at the time of final follow-up. All fractures achieved radiographic union. Eighteen patients underwent a total of 21 unexpected cast changes. No patients required repeat sedation or surgical management.Angulation after casting was significantly better in the reduction cohort compared with the casting-only cohort initially, however, at final follow-up, both coronal and sagittal angulation were significantly worse in the reduction cohort compared with the casting-only cohort (coronal angulation 8.59 vs. 0.75, P<0.0001; sagittal angulation 13.49 vs. 2.2, P<0.0001).Charge analysis compared 46 patients in the reduction cohort to 13 patients with unreduced fractures from the same institution during the same time period. Mean clinic charges were similar ($1957 vs. $2240, P=0.3008). ED charges were higher in the reduction cohort compared with the nonreduction cohort ($7331 vs. $3501, P<0.001), resulting in higher total charges in the reduction cohort ($9245.04 vs. $5740.99, P<0.001).

CONCLUSIONS

While closed reduction of 100% translated distal radius fractures in the pediatric population improves angulation initially, casting alone may provide similar or better radiographic outcomes, expedited care, reduced patient exposure to the risks of procedural sedation, and avoidance of ED charges associated with procedural sedation.

LEVEL OF EVIDENCE

Level III-therapeutic.

Casting Without Reduction Versus Closed Reduction With or Without Fixation in the Treatment of Distal Radius Fractures in Children: Protocol for a Randomized Noninferiority Trial

Background

Acute treatment for distal radius fractures, the most frequent fractures in the pediatric population, represents a challenge to the orthopedic surgeon. Deciding on surgical restoration of the alignment or cast immobilization without reducing the fracture is a complex concern given the remodeling potential of bones in children. In addition, the lack of evidence-based safe boundaries of shortening and angulation, that will not jeopardize upper-extremity functionality in the future, further complicates this decision.

Objective

The authors aim to measure functional outcomes, assessed using the Patient-Reported Outcomes Measurement Information System (PROMIS) Pediatric Physical Function v2.0 instrument. The authors hypothesize that outcomes will not be worse in children treated with cast immobilization in situ compared with those treated with closed reduction with or without percutaneous fixation. The authors also aim to compare the following as secondary outcomes: ulnar variance and fracture alignment in the sagittal and coronal planes, range of motion, pressure ulcers, pain control, radius osteotomy due to deformity, pseudoarthrosis cure, and remanipulation.

Methods

This is the protocol of a randomized noninferiority trial comparing upper-extremity functionality in children aged 5 to 10 years, after sustaining a distal radius fracture, treated with either cast immobilization in situ or closed reduction with or without fixation in a single orthopedic hospital. Functional follow-up is projected at 6 months, while clinical and radiographic follow-up will occur at 2 weeks, 3 months, and 9 months.

Results

Recruitment commenced in July 2021. As of January 2022, 23 children have been randomized. Authors expect an average of 5 patients to be recruited monthly; therefore, recruitment and analysis should be complete by October 2024.

Conclusions

This experimental design that addresses upper-extremity functionality after cast immobilization in situ in children who have sustained a distal fracture of the radius may yield compelling information that could aid the clinician in deciding on the most suitable orthopedic treatment.

Trial Registration

ClinicalTrials.gov NCT05008029; https://clinicaltrials.gov/ct2/show/NCT05008029

International Registered Report Identifier (IRRID)

DERR1-10.2196/34576

Post-traumatic Radioulnar Synostosis in Distal Forearm Fractures in Children: A Report of 2 Cases

CASES

Two pediatric cases of post-traumatic distal radioulnar synostosis are reported, accompanied by a literature review summarizing evidence on the management of these conditions. Radioulnar synostosis is a rare complication of distal forearm fractures, which impairs upper-extremity function. The numerous surgical procedures that have been described to treat this condition in adults typically involve synostosis resection and an interposition graft to reduce recurrence. The optimal treatment in children has not been established.

CONCLUSIONS

Post-traumatic radioulnar synostoses are rare conditions in pediatric patients who can be successfully treated with surgical excision of the synostoses and without the use of interposition grafting.

Do We Need to Stabilize All Reduced Metaphyseal Both-bone Forearm Fractures in Children with K-wires?

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.

Below-elbow cast sufficient for treatment of minimally displaced metaphyseal both-bone fractures of the distal forearm in children: long-term results of a randomized controlled multicenter trial

Background and purpose - We have previously shown that children with minimally displaced metaphyseal both-bone forearm fractures, who were treated with a below-elbow cast (BEC) instead of an above-elbow cast (AEC), experienced more comfort, less interference in daily activities, and similar functional outcomes at 7 months' follow-up (FU). This study evaluates outcomes at 7 years' follow-up.Patients and methods - A secondary analysis was performed of the 7 years' follow-up data from our RCT. Primary outcome was loss of forearm rotation compared with the contralateral forearm. Secondary outcomes were patient-reported outcome measures (PROMs) consisting of the ABILHAND-kids and the DASH questionnaire, grip strength, radiological assessment, and cosmetic appearance.Results - The mean length of FU was 7.3 years (5.9-8.7). Of the initial 66 children who were included in the RCT, 51 children were evaluated at long-term FU. Loss of forearm rotation and secondary outcomes were similar in the 2 treatment groups.Interpretation - We suggest that children with minimally displaced metaphyseal both-bone forearm fractures should be treated with a below-elbow cast.

Management of Distal Radius Fractures in Adolescent Patients

BACKGROUND

While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population.

METHODS

A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized.

RESULTS

Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes.

CONCLUSIONS

Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Remodelling in Children's Fractures and Limits of Acceptability

Remodeling follows inflammatory and reparative phases of bone healing and is very pronounced in children. Unlike adults, in growing children, remodeling can restore the alignment of initially malunited fractures to a certain extent, making anatomic reduction less essential. Remodeling is not universal and ubiquitous. Animal experiments and clinical studies have proven that in a malunited fracture, the angulation corrects maximally by physeal realignment (75%) and partly by appositional remodeling of the diaphysis also known as the cortical drift (25%). Remodeling potential reduces with the increasing age of the child; lower extremities have higher remodeling potential compared to the upper extremity. Remodeling is most pronounced at the growing end of the bone and in the axis of the adjacent joint motion. Correction of a very small amount of rotational malalignment is possible, but it is clinically not relevant. Overgrowth of the bone after a fracture occurs due to hyperaemia of fracture healing. Overgrowth is the most common after paediatric femur fractures, though it is reported after fractures of the tibia and humerus as well. The orthopaedic surgeon treating children's fractures should be familiar with regional variations of remodeling and limits of acceptance of angulation in different regions. Acceptability criteria for different bones are though well defined, but serve best as guidelines only. For the final decision-making patient's functional capacity, parents' willingness to wait until the completion of the remodeling process, and the experience of treating doctor should be considered concurrently. In case of the slightest doubt, a more aggressive approach should be taken to achieve a satisfactory result.

Coronal Remodeling Potential of Pediatric Distal Radius Fractures

BACKGROUND

Distal radius fractures in the pediatric population are common injuries with a remarkable capability to remodel. The degree of angulation that can reasonably be expected to remodel is controversial though, particularly when it comes to angulation in the coronal plane. The purpose of this study was to quantify the rate of coronal remodeling, via the distal radius physis, present in a retrospective cohort of skeletally immature patients with coronally angulated distal radius fractures.

METHODS

A retrospective chart review was performed to identify skeletally immature patients treated for an angulated distal radius fracture with over 10 degrees of angulation in the coronal plane during the healing process at a single institution by either a pediatric orthopaedic surgeon or an orthopaedic trauma surgeon from 2009 to 2018. Coronal angulation was measured at every visit where radiographs were available from time of injury to the final follow-up visit to determine the rate of remodeling.

RESULTS

In total, 36 patients with distal radius fractures with a mean age of 7.93 years (range, 4 to 12 y) at the time of injury were identified. The median peak angulation during the healing process in the coronal plane was 17 degrees (range, 12.4 to 30.4 degrees). The mean follow-up period was 6.4 months from the time of maximum angulation to the final visit. The median time from cast removal to final follow-up was 6.59 months (range, 2.5 to 8.72 mo). At final follow-up, the median coronal angulation was 3.35 degrees (range, 0.24 to 14.0 degrees). At the 95% confidence level, remodeling rates ranged from 2.00 to 2.59 degrees per month. The mean rate of coronal angulation remodeling from maximum angulation to final follow-up was 2.30 degrees per month.

CONCLUSIONS

Distal radius fractures have a large capacity to remodel in the pediatric population. This remodeling occurs in a predictable and reliable manner, even in the coronal plane. On the basis of this study, coronal angulation was shown to remodel at a rate of at least 2 degrees per month for the first 6 months following the injury, which should likely continue at a similar rate for the first year after the injury. Repeat manipulation is not indicated in skeletally immature patients where the maximum coronal angulation is <24 degrees, which provides a conservative estimate of the amount of remodeling that can be expected to occur in the first year after fracture.

LEVEL OF EVIDENCE

Level III-retrospective comparative study.

Displaced Distal Radius Fracture Treatment: A Survey of POSNA Membership

BACKGROUND

Distal radius fractures (DRFs) are the most common pediatric orthopaedic fracture, of which 20% are displaced injuries. Displaced metaphyseal DRFs are often treated with sedated or anesthetized reduction. The necessity of reduction treatment of displaced fractures to achieve good clinical outcomes is unclear. The purpose of this investigation was to determine the treatment preferences for DRFs among pediatric orthopaedic surgeons and to determine whether they were uncertain enough in their decisions to randomize treatment.

METHODS

Twenty-eight DRF scenarios in children aged 3 to 10 years were constructed in an electronic survey to represent a spectrum of age, angulation in sagittal and coronal planes, and displacement. The survey was disseminated to the full membership of the Pediatric Orthopaedic Society of North America (POSNA). Respondents could select either a treatment of (a) attempt anatomic reduction with sedation or (b) nonsedated immobilization. Respondents also denoted whether they would be willing to randomize the treatment of each injury scenario. Patient, fracture, and surgeon characteristics were analyzed to develop predictors of treatment recommendations and willingness to randomize treatment.

RESULTS

A total of 319 surgeons responded (23% of POSNA membership). Respondents were a characteristic representation of POSNA membership (well distributed by years in practice, 78% academic, 91% whose work is >80% pediatrics, and 84% work with residents). Predictors of sedated reduction were complete displacement [odds ratio (OR), 9.23; 95% confidence interval (CI), 2.27-37.51; P=0.002] and coronal angulation (per 1-degree increase, OR, 1.09; 95% CI, 1.02-1.17; P=0.016), Willingness to randomize was inversely related to larger coronal plane angulation (per 1-degree increase, OR, 0.96; 95% CI, 0.93-0.99; P=0.01). A majority of surgeons were willing to randomize 7 of the 8 scenarios involving complete displacement and shortening, and >64% of surgeons were willing to randomize 5 of these 8 scenarios.

CONCLUSIONS

POSNA members recommend sedated reduction of DRFs primarily based on existence of complete displacement. Although most completely displaced DRFs would undergo reduction, most surgeons would be willing to randomize the treatment of these injuries. This suggests that most POSNA members do not know whether their recommended treatment for displaced DRFs is necessary or correct. This survey establishes the groundwork for a randomized, prospective trial comparing nonsedated immobilization with sedated/anesthetized reduction in the treatment of displaced pediatric DRFs.

LEVELS OF EVIDENCE

Level II-survey study.

Displaced Physeal and Metaphyseal Fractures of Distal Radius in Children. Can Wire Fixation Achieve Better Outcome at Skeletal Maturity than Cast Alone?

Introduction

Redisplacement following fracture reduction is a known sequela during the casting period in children treated for distal radius fracture. Kirschner wire pinning can be alternatively used to maintain the reduction during fracture healing. This study was conducted to compare the outcomes at skeletal maturity of distal radius fractures in children treated with a cast alone or together with a Kirschner wire transfixation.

Material and Methods

This was a retrospective study involving 57 children with metaphyseal and physeal fractures of the distal radius. There were 30 patients with metaphyseal fractures, 19 were casted, and 11 were wire transfixed. There were 27 patients with physeal fractures, 19 were treated with a cast alone, and the remaining eight underwent pinning with Kirschner wires. All were evaluated clinically, and radiologically, and their overall outcome assessed according to the scoring system, at or after skeletal maturity, at the mean follow-up of 6.5 years (3.0 to 9.0 years).

Results

In the metaphysis group, patients treated with wire fixation had a restriction in wrist palmar flexion (p=0.04) compared with patients treated with a cast. There was no radiological difference between cast and wire fixation in the metaphysis group. In the physis group, restriction of motion was found in both dorsiflexion (p=0.04) and palmar flexion (p=0.01) in patients treated with wire fixation. There was a statistically significant difference in radial inclination (p=0.01) and dorsal tilt (p=0.03) between cast and wire fixation in physis group with a more increased radial inclination in wire fixation and a more dorsal tilt in patients treated with a cast. All patients were pain-free except one (5.3%) in the physis group who had only mild pain. Overall outcomes at skeletal maturity were excellent and good in all patients. Grip strength showed no statistical difference in all groups. Complications of wire fixation included radial physeal arrests, pin site infection and numbness.

Conclusion

Cast and wire fixation showed excellent and good outcomes at skeletal maturity in children with previous distal radius fracture involving both metaphysis and physis. We would recommend that children who are still having at least two years of growth remaining be treated with a cast alone following a reduction unless there is a persistent unacceptable reduction warranting a wire fixation. The site of the fracture and the type of treatment have no influence on the grip strength at skeletal maturity.

Radiographic Remodeling of the Proximal Phalangeal Head Using a Stretching Exercise in Patients With Camptodactyly

PURPOSE

The aims of this study were to verify proximal phalangeal head normalization after a stretching exercise in patients with infantile-type camptodactyly and to propose radiographic indices for quantifying bony deformities.

METHODS

Forty-eight fingers of 20 patients with camptodactyly were enrolled in this study. All patients and their parents received instruction on how to perform the stretching exercise. The qualitative assessments of proximal phalangeal head remodeling were conducted by consensus of 2 hand surgeons. Two radiographic parameters, head triangle ratio (HTR) and head angle (HA), were measured on finger lateral radiographs taken at the initial visit and at 12-month follow-up. The intra- and interobserver reliability of both parameters was assessed. Those parameters of the patients were compared with those of 177 fingers of 80 children without camptodactyly. The extent of proximal interphalangeal (PIP) joint flexion contracture was used to evaluate clinical outcomes resulting from nonsurgical treatment.

RESULTS

Qualitative assessments of proximal phalangeal head remodeling exhibited meaningful improvements. Both radiographic parameters showed significant change between their status before and after intervention and had excellent intra- and interobserver reliability. Average PIP joint flexion contracture significantly improved. In the noncamptodactyly group, neither parameter showed significant differences in accordance with finger types and age ranges.

CONCLUSIONS

Stretching improved movement within the proximal phalangeal joint and helped to restore proximal phalangeal head roundness and concentricity in patients with infantile-type camptodactyly. The HTR and HA would be useful indices for objectively assessing the degree of bony deformity in patients with camptodactyly.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

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

Forearm fractures are very common orthopaedic injuries in children. Most of these fractures are forgiving due to the unique and excellent remodelling capacity of the juvenile skeleton. However, significant evidence stating the limits of acceptable angulations and taking functional outcome into consideration is scarce. The aim of this study is, therefore, to get a first impression of the remodelling capacity in nonreduced paediatric forearm fractures based on radiological and functional outcome. Children aged 0-14 years with a traumatic angular deformation of the radius or both the radius and ulna, treated conservatively without reduction, were included in this prospective cohort study. Radiographs were taken and functional outcome was assessed at five fixed follow-up appointments throughout a period of one year. Outcome measurements comprised radiographic angular alignment, grip strength and wrist mobility. A total of 26 children (aged 3-13 years) with a traumatic angulation of the forearm were included. Mean dorsal angulation at the time of presentation amounted to 12° (5-18) and diminished after one year to a mean angulation of 4° (0-13). Grip strength, pronation and supination were significantly diminished compared to the unaffected hand up to 6 months after injury. After one year, no significant differences in function between the affected and the unaffected arm were found. Nonreduced angulated paediatric forearm fractures have the potential to remodel in time and have good radiographic and functional outcome one year after trauma, where pronation and grip strength take the longest to recover.

Resource Utilization for Patients With Distal Radius Fractures in a Pediatric Emergency Department

IMPORTANCE

Improvement of clinician understanding of acceptable deformity in pediatric distal radius fractures is needed.

OBJECTIVE

To assess how often children younger than 10 years undergo a potentially unnecessary closed reduction using procedural sedation in the emergency department for distal radial metaphyseal fracture and the associated cost implications for these reduction procedures.

DESIGN, SETTING, AND PARTICIPANTS

This retrospective cross-sectional study included 258 consecutive children younger than 10 years who presented to a single, level I, pediatric emergency department and who had a distal radius fracture with or without ulna involvement between January 1, 2016, and December 31, 2017. Reductions were deemed to be potentially unnecessary if the coronal and sagittal plane angulation of the radius bone measured less than 20° and shortening measured less than 1 cm on initial injury radiographs. Use of procedural sedation or transfer status to another facility was noted if present. Statistical analysis was performed from April 2019 to June 2019.

MAIN OUTCOMES AND MEASURES

Potentially unnecessary reduction was the primary outcome. Radiographic findings were measured to determine reduction necessity. Additional variables measured were age, sex, time in the emergency department, transfer status, required reduction procedure, use of sedation, and cost associated with care.

RESULTS

Of the 258 participants studied, 156 (60%) were male, with a mean (SD) age of 6.7 (2.3) years. Among 142 patients (55%) who underwent closed reduction with procedural sedation in the emergency department, 38 (27%) procedures were determined to be potentially unnecessary. Review of Common Procedural Terminology charges revealed an approximately $7000 difference between the stated cost of a reduction procedure in the emergency department vs a cast application in an outpatient orthopedic clinic for distal radial metaphyseal fractures. The mean (SD) maximal angulation in either plane for fractures that underwent appropriate reduction was 30.6° (10.3°) compared with 13.9° (4.5°) for those unnecessarily reduced (P < .001). Patients who were transfers from other facilities were more than twice as likely to undergo a potentially unnecessary reduction (odds ratio, 2.3; 95% CI, 1.1-5.0; P = .03).

CONCLUSIONS AND RELEVANCE

The findings suggest that improved awareness of these acceptable deformities in young children may be associated with limiting the number of children requiring reduction with sedation, improving emergency department efficiency, and substantially reducing health care costs.

The Community Orthopedic Surgeon Taking Trauma Call: Pediatric Distal Radius and Ulna Fracture Pearls and Pitfalls

Distal radius and ulna fractures are common injuries in children. Fractures typically involve the distal radius and ulna metaphysis or physis or a combination of the 2. The goals of treatment are aimed at achieving satisfactory anatomic alignment within defined parameters based on growth remaining. Nonoperative treatment approaches are recommended for most fractures, whereas surgical intervention is indicated for select cases. Potential issues with skeletal growth and bone remodeling are common. This article will offer evidence- and experience-based pearls regarding common closed fractures of the distal radius and ulna intended to benefit the community orthopaedic surgeon caring for children during the course of their on-call duties.

Is percutaneous pinning needed for the treatment of displaced distal radius metaphyseal fractures in children?: A systematic review

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.

When is it ok to use a splint versus cast and what remodeling can one expect for common pediatric forearm fractures

PURPOSE OF REVIEW

The purpose of this review is to provide an overview of common pediatric forearm fractures, clarify the descriptions used to identify and thereby appropriately treat them with a splint or cast, and explain osseous remodeling that is unique to the skeletally immature.

RECENT FINDINGS

Recent literature addresses the gap in standard treatment protocols. There is variability in the management of pediatric forearm fractures because of the multiple subspecialty physicians that care for children's fractures and a lack of well established guidelines.

CONCLUSION

The following review will expound upon the assortment of pediatric forearm fractures, address suitable treatment options, and illustrate the expected restoration of bony deformity in an effort to update practitioners of the most recent advances in research and clinical practice of this common orthopedic injury.

Malunion of the distal radius in children: accurate prediction of the expected remodeling

PURPOSE

Malunions of fractures in children have a natural tendency to remodel. However, quantitative data of this well-known process are scarce. The extent of the correction depends inter alia on the type of bone and the location of the deformity and growth remaining. The aim of this study was to quantify the remodeling process of distal radius malunions in children to allow better future prediction.

METHODS

Data were derived from two published patient series. Analysis included 63 malunions of distal radius fractures in 62 children (38 boys), with a mean age of 8.5 years (range 2-14.5 years).

RESULTS

The mean initial dorsovolar angulation was 25º [standard deviation (SD) 7.8°], remodeling time 22 (SD 18) months, and angulation at follow-up 6.7° (SD 5.8°). Based on these findings, the remodeling process can be described as an exponential function with angulation (A 0) as a factor and the remodeling time (RT) as a negative exponent of e (R (2) = 0.47). The function allows accurate prediction of the expected correction in over 76 % of the malunions. From this model, a formula was derived for calculation of the time needed for complete remodeling, but this formula lacked precision when compared to findings in the literature and needs to be validated.

CONCLUSIONS

The remodeling of distal radius malunions can be described as an exponential function with starting speed dependent on the initial angulation. The current model proves to be more accurate than models described previously in the literature. These findings allow for better patient information and optimal planning of eventual surgical intervention. The postulated model could serve as a basis for the description of correction of other malunions by adaptation of the coefficients in this model.