Is Obesity a Risk Factor for Loss of Reduction in Children with Distal Radius Fractures Treated Conservatively?

Modified Kapandji technique in pediatric displaced distal radius fractures: results in 195 patients

PURPOSE

The modified Kapandji technique has been proposed for fracture reduction in pediatric displaced distal radius fractures (DDRFs), but evidence is sparse. The purpose of this study was to evaluate our outcomes and complications, critically and systematically, when performing the modified Kapandji technique in pediatric DDRFs. Using this technique since 2011, we asked: (1) What is the quality of fracture reduction using this technique? (2) How stable is fracture alignment with this technique? (3) What are the postoperative complications and complication rates?

METHODS

Retrospective observational study of 195 pediatric patients treated with the modified Kapandji technique. Quality of fracture reduction, fixation type (intrafocal, combined, or extrafocal), and coronal/sagittal angulation were recorded at surgery and healing. Perioperative complications were graded. Patients were stratified by fracture (metaphyseal or Salter-Harris) and fixation type, as well as age (≤ 6 years; 6 to 10 years; > 10 years).

RESULTS

Fracture reduction was 'good' to 'anatomical' in 85% of patients. 'Anatomical' fracture reduction was less frequent in metaphyseal fractures (21% vs. 51%; p < .001). Mean angulation change was higher in metaphyseal fractures in both the sagittal (p = .011) and coronal (p = .021) planes. Metaphyseal fractures showed a higher mean change in sagittal angulation during fracture healing for the 'intrafocal' group. We observed a 15% overall complication rate with 1% being modified Sink Grade 3.

CONCLUSION

The modified Kapandji technique for pediatric DDRFs is a safe and effective treatment option. Metaphyseal fractures that do not involve the physis should be treated with extrafocal or combined wire fixation. Complications that require additional surgical treatment are rare.

LEVEL OF EVIDENCE

Level of evidence IV.

The Slipper Fracture: Revisited

Objectives The term "slipper fracture" is used to describe a fracture of the radius at the junction of the metaphysis and diaphysis. This fracture has an "evil" reputation because it often angulates in the cast. Historically, there have been differing opinions on the optimal way to cast slipper fractures either with a long arm cast in pronation or a long arm cast in supination to prevent angulation. The purpose of this study is to report the outcomes of "slipper fractures" treated with casting. Methods Sixteen slipper fractures were retrospectively reviewed. Electronic medical records (EMRs) and radiographs were analyzed to gather data on body weight, cast type, cast position, cast index, loss of reduction, cast wedging, repeat reduction, surgery, and amount of remodeling. Results The average age of the patients was eight years old. The average body weight was 30.4 kg. Initial casting included 14 long arm casts in neutral, one short arm cast, and one sugar tong splint. The average cast index was 0.87. Only one cast had a cast index of less than 0.8. This fracture was treated with a long arm cast and did not displace. Of the fractures, 94% lost reduction in the cast and angulated an average of 26 degrees. Two cases were treated with a cast wedge; 13 were observed. Remodeling occurred at an average rate of 2.7 degrees/month. The average remodeling measured at the last follow-up was 15 degrees. Conclusion Slipper fractures are difficult to treat due to the angulation of the fracture in the cast. The current study indicates that a long arm cast, appropriate cast index, and cast position are key to preventing the loss of reduction or angulation of a slipper fracture.

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

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

Analysis of Physeal Fractures from the United States National Trauma Data Bank

Background: Pediatric long-bone physeal fractures can lead to growth deformities. Previous studies have reported that physeal fractures make up 18–30% of total fractures. This study aimed to characterize physeal fractures with respect to sex, age, anatomic location, and Salter–Harris (SH) classification from a current multicenter national database. Methods: A retrospective cohort study was performed using the 2016 United States National Trauma Data Bank (NTDB). Patients ≤ 18 years of age with a fracture of the humerus, radius, ulna, femur, tibia, or fibula were included. Results: The NTDB captured 132,018 patients and 58,015 total fractures. Physeal fractures made up 5.7% (3291) of all long-bone fractures, with males accounting for 71.0% (2338). Lower extremity physeal injuries comprised 58.6% (1929) of all physeal fractures. The most common site of physeal injury was the tibia comprising 31.8% (1047), 73.9% (774) of which were distal tibia fractures. Physeal fractures were greatest at 11 years of age for females and 14 years of age for males. Most fractures were SH Type II fractures. Discussion and Conclusions: Our analysis indicates that 5.7% of pediatric long-bone fractures involved the physis, with the distal tibia being the most common. These findings suggest a lower incidence of physeal fractures than previous studies and warrant further investigation.

Vitamin D and Forearm Fractures in Children Preliminary Findings: Risk Factors and Correlation between Low-Energy and High-Energy Fractures

Background: The forearm is the most common fracture site in childhood, accounting for every fourth pediatric fracture. It is well described that vitamin D is involved in the regulation of bone mineralization and skeletal homeostasis by the regulation of calcium absorption. The aim of our study was to determine the influence of 25-hydroxyvitamin D levels on forearm fracture falls in a pediatric population, depending on level of energy impact. Additionally, we also aimed to evaluate the correlation between 25-hydroxyvitamin D levels and other tested risk factors for pediatric fractures. Methods: We evaluated 50 eligible children aged 3 to 12 years with a forearm fracture. According to energy impact, patients were grouped into low-energy fractures (LEF) and high-energy fractures (HEF) groups. The general characteristics of the patients included age, gender, sport participation, and fractured bone and its localization. We analyzed 25-hydroxyvitamin D, parathyroid hormone (PTH), calcium, magnesium, phosphate, C-reactive protein (CRP) levels, and body mass index (BMI). Results: There is a significant difference in the 25-hydroxyvitamin D levels distribution between LEF and HEF (p < 0.001) and PTH levels (p = 0.002). For magnesium levels, calcium levels, phosphate levels, and CRP levels, there were no significant differences in their frequency distribution. For the group of patients with LEF, there is a significantly positive correlation between 25-hydroxyvitamin D and calcium levels (p = 0.019) and a borderline significantly positive correlation between 25-hydroxyvitamin D and magnesium levels (p = 0.050). For the group of patients with HEF, there was only a significantly positive correlation between 25-hydroxyvitamin D and PTH levels (p < 0.001). Conclusions: Children with LEF were more frequently insufficient in 25-hydroxyvitamin D levels but had normal calcium levels, compared to the ones with HEF. These findings suggest that LEF and HEF in children might to a certain degree have different pathophysiological mechanisms.