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.

Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency

PURPOSE

To analyze early to midterm radiographic results after forearm lengthening in children with radial longitudinal deficiency.

METHODS

We conducted a retrospective chart review of patients with radial longitudinal deficiency undergoing distraction osteogenesis with an Ilizarov device. We retrospectively reviewed 8 lengthening procedures in 6 children with respect to distraction details and assessed anteroposterior and lateral radiographs of the hand and forearm of the preoperative and postoperative follow-up investigations.

RESULTS

The mean age at time of ulna lengthening was 9.9 years (range, 6.3-14.0 y). The mean follow-up period was 4.7 years (range, 1.0-8.5 y). Mean lengthening of the ulna was 7.0 cm (range, 3.5-8.7 cm), and the mean length gain of the ulna compared with its preoperative length was 75% (range, 42% to 103%). The mean ulna bowing was 25° preoperatively (range, 7° to 42°), 6° after forearm distraction (range, 0° to 14°), and 17° at latest follow-up (range, 0° to 45°). The mean hand-forearm angle was 25° of radial deviation preoperatively (range, 15° ulnar to 60° radial deviation), 11° of radial deviation after distraction (range, 0° to 41°), and 23° at latest follow-up (range, 0° to 45°). We encountered 2 major complications: 1 ulna fracture after removal of the Ilizarov device and 1 insufficient bone regenerate during lengthening.

CONCLUSIONS

We achieved both deformity correction and improvement of limb length after distraction osteogenesis with an Ilizarov device. However, some of the deformity-in particular, ulnar bowing and radial deviation of the hand-recurred at midterm follow-up.

Growth from birth to adulthood and peak bone mass and density data from the New Delhi Birth Cohort

Growth in early life may predict adult bone health. Our data showed that greater height and body mass index (BMI) gain in utero and infancy are associated with higher peak bone mass, and greater BMI gain in childhood/adolescence with higher peak bone density. These associations are mediated by attained adult height and BMI.

INTRODUCTION

To study the relationship of height and BMI during childhood with adult bone mineral content (BMC), areal density (aBMD) and apparent density (BMAD, estimated volumetric density).

METHODS

Participants comprised 565 men and women aged 33-39 years from the New Delhi Birth Cohort, India, whose weight and height were recorded at birth and annually during infancy (0-2 years), childhood (2-11 years) and adolescence (11 years-adult). Lumbar spine, femoral neck and forearm BMC and aBMD were measured using dual X-ray absorptiometry; lumbar spine and femoral neck BMAD were calculated.

RESULTS

Birth length, and height and height gain during infancy, childhood and adolescence were positively correlated with adult BMC (p≤0.01 all sites except birth length with femoral neck). Correlations increased with height from birth to 6 years, then remained constant for later height measurements. There were no associations with BMAD. BMI at birth, and during childhood and adolescence was also positively correlated with BMC (p < 0.01 all sites). BMI at 11 years, and BMI gain in childhood and adolescence, were correlated with aBMD and BMAD (p < 0.001 for all); these correlations strengthened with increasing age of BMI measurement. The associations with height and BMI in early life became non-significant after adjustment for adult height and BMI.

CONCLUSIONS

Greater skeletal growth and BMI gain in utero and during infancy are associated with higher peak BMC, and greater BMI gain in childhood and adolescence is associated with higher peak aBMD and BMAD. These associations are mediated by the attainment of adult height and BMI, respectively.

[Osteogenesis in healthy children and in children with growth retardation depending on body constitution]

Somatometric and radiographic study of bones of the hand and of the distal forearm was performed in 258 healthy children and adolescents (148 boys and 110 girls) aged 11-17 years and in 115 children (84 boys and 31 girl) aged 13-16 years which were under the observation due to growth retardation. It was shown that within the groups of the same age children with various somatometric characteristics possessed different levels of skeletal (and therefore, biological) maturity. In the group of healthy children, different variants of skeletal maturation were established, which corresponded to the constitutionally stipulated rates of somatic development including accelerated, average and retarded. In children with growth retardation, the third (retarded) variant of somatic development rate was prevalent, which was also found in the group of healthy children and was accompanied with its peculiar osteogenesis characteristics. In the other cases, when such abnormalities of skeletal maturation as asymmetry in the appearance of ossification centers and synostoses as well as the presence of pseudoepiphyses, were observed, growth retardation could be caused by some endocrine pathology. Thus, the radiographic study enables the differentiated approach to the evaluation of the morphological status of children and adolescents and permits to avoid the unjustified administration of hormonal treatment.

Radiological aspects of the Poland syndrome and implications for treatment: a case study and review

Poland syndrome (PS) (OMIM 173800) is a rare congenital anomaly classically consisting of the combination of unilateral aplasia of the sternocostal head of the major pectoral muscle and an ipsilateral hypoplastic hand with simple syndactyly and short fingers. The aetiology is most probably a vascular disruption sequence of the subclavian arteries. In most cases, PS is sporadic. Familial occurrence suggests that genes exist which are involved in the pathogenesis as paradominant traits. The syndrome may include mammary hypoplasia and further muscle abnormalities which can be accurately defined by sonography and MRI. The evaluation of the vascular status can be performed using colour coded duplex sonography for peripheral arteries and contrast-enhanced MR-angiography for supra-aortic arteries.

CONCLUSION

We report a 7-year-old girl with unilateral right sided Poland syndrome with particular emphasis on the radiological investigations of vascular abnormalities. A review of the literature concerning the origin, outcome, and implications for treatment is given.

Daily physical activity program increases bone mineralization and growth in preterm very low birth weight infants

OBJECTIVE

A study of daily physical activity was performed with 32 preterm infants to evaluate changes in body weight and bone mineralization.

STUDY DESIGN

Subjects were matched by birth weight and gestational age and randomly assigned to the physical activity (PA; n = 16) or to the control (C; n = 16) program. PA consisted of range of motion against passive resistance to all extremities for 5 to 10 minutes daily. Peripheral dual-energy x-ray of the right forearm (ulna and radius); biomarkers of bone formation (serum type I collagen C-terminal propeptide [PICP]) and resorption (urine pyridinoline cross-links of collagen [Pyd]); serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), and 1, 25-(OH)(2) vitamin D; and urine levels of calcium, phosphate, and creatinine were obtained. All measurements were made at study entry and at 2.0 kg of body weight.

RESULTS

Despite a similar nutrient intake at advised levels for preterm infants, gains in body weight (g) and forearm bone length (cm), bone area (BA; cm(2)), bone mineral content (BMC; mg), and fat-free mass (g) were greater in PA infants. Forearm bone mineral density and fat mass gains did not differ between groups. Serum PICP levels remained constant in PA infants but decreased in C infants suggesting a slower rate of bone formation. Urine Pyd or bone resorption activity was similar between groups. A higher level of serum PTH was observed in PA infants at 2. 0 kg of body weight; however, the change from study entry to completion did not differ between groups. All other serum and urine values were similar and within normal limits.

CONCLUSION

A daily PA program promotes greater gains in body weight, forearm length, BA, BMC, and fat-free mass in premature infants.

[Ulnar lengthening in osteochondroma (multiple cartilagenous exostoses) of the forearm]

The osteochondroma is the most frequent bone tumor to occur during the period of growth. The multiple hereditary form often involves the forearms. Depending on localisation and size of the tumor, shortening of the bones in the forearm, angular malalignments and functional impairment of the wrist and elbow joints may result. Early diagnosis and surgery in the growing child can prevent these complications. 13 children were operated on altogether 15 forearms. In nine cases lengthening of the ulna was necessary to correct ulnar instability of the wrist as well as improving the support of the carpus and preventing dislocation of the radial head.

Reference data of forearm bone mineral density in healthy Japanese male and female subjects in the second decade based on calendar age and puberty onset: Japanese Population Based Osteoporosis (JPOS) study

Osteoporosis is a major public health problem in Japan. The second decade is an important period in which to attain a high peak bone mass. However, normal values of forearm bone mineral density (BMD) are not well known in children and adolescents. BMD at one-third of forearm length proximal to the ulnar end plate (BMD1/3) and the ultradistal forearm (BMDud) was measured using dual-energy X-ray absorptiometry (DXA) in 1207 (631 males, 576 females) Japanese subjects aged 9-18 years. Puberty onset was assessed by questionnaire, by obtaining the time that pubic hair appeared in males and the time that menstruation started in females. BMD1/3 and BMDud increased steadily with age in males. In relation to puberty development, these parameters also increased after puberty onset although the increase in BMD1/3 was not statistically significant after the fifth year from puberty onset and that of BMDud was not significant after the sixth year from puberty onset. BMD1/3 and BMDud increased with age and then plateaued in females. The increase in BMD1/3 was not statistically significant after 15-16 years of age and that of BMDud was not significant after 13-14 years of age. In relation to puberty development, the increase in BMD1/3 leveled out after the fourth year from puberty onset and that of BMDud also plateaued after the third year from puberty onset. We provide reference values of forearm BMD in Japanese children and adolescents by DXA according to calendar age and puberty development. Peak bone mass of the forearm may be in the late second decade in Japanese females.

Radial growth and function of the forearm after excision of the radial head. A study of growing macaque monkeys

In five immature macaque monkeys, the right radial head was excised and the left forearm served as a control. Growth of each radius, ulna, and proximal and distal physis was followed for eight years. Total radial growth was slightly less on the side that was operated on than it was on the control side. After excision of the radial head, 95 per cent of radial growth came from the distal physis, compared with 71 per cent on the control side. A regenerated radial head, which had an irregular surface of fibrocartilaginous tissue, accounted for the remainder of growth on the side that had been operated on. Incongruous contact of articular surfaces resulted in degenerative changes in the capitellum. The arms that had been operated on were left with a flexion contracture that was an average of 12 degrees greater than that of the normal elbows, and they had a carrying angle that was an average of 6 degrees greater than that on the normal side. The arc of pronation and supination was decreased for the forearms that had been operated on, but motion of the wrist was unaffected. In our study, excision of the radial head in growing monkeys resulted in minimum radial shortening, slight deformity of the elbow, and moderate impairment of rotation of the forearm.

Left subclavian flap aortoplasty for coarctation of the aorta: effects on forearm vascular function and growth

This study evaluated vascular function and growth of the forearm in nine children (mean age 9.2 years) who had undergone left subclavian flap aortoplasty for the infantile type of coarctation of the aorta many years (mean 9.0) earlier. Variables used to investigate bilateral forearm vascular function included forearm blood flow and resistance measured by strain gauge plethysmography under rest conditions, in response to 30 s of static handgrip exercise at 40% maximal voluntary contraction and in response to 10 min of forearm arterial occlusion (that is, the reactive hyperemic blood flow response). Forearm growth was ascertained by measuring right and left forearm volumes, lengths, circumferences and skinfold thickness. Mean arterial pressure at rest in the right and left arms differed by 9% (right 78.2 +/- 2.1, left 71.0 +/- 2.7 mm Hg; p less than 0.05). Forearm blood flow, however, was not significantly different between the surgically altered left arm and the normal right arm under any of the study conditions. Likewise, forearm vascular resistance was not statistically different under any conditions, although the left arm tended to have a lower resistance at rest (right 23.5 +/- 3.2, left 18.7 +/- 2.0 mm Hg.min.100 ml/ml; p = 0.057). Left forearm anthropometric measurements showed a 9% reduction in volume and a 3% reduction in circumference and length. In addition, skinfold thickness tended to be larger on the left arm, suggesting that this limb had a smaller muscle mass. In conclusion, early repair with a subclavian flap does not impair vascular function in the altered limb and is associated with only minor reductions in forearm growth variables. Hence, left subclavian flap aortoplasty appears to be a safe and effective procedure for repair of coarctation of the aorta.

[Longitudinal data of physical growth of healthy children. Lengths of trunk, hand, forearm, upper arm, whole arm, lower leg, thigh and whole leg of children aged 2,5 to 15 years. (author's transl)]

From 1968-78 a longitudinal study was performed concerning development of lengths of trunk, hand, forearm, upper arm, whole arm, lower leg, thigh and whole leg in 709 healthy boys and 711 girls aged 2,5 to 15 years. In boys the mean increase in lengths of trunk amounted to 17.7 cm, of hand to 8.1 cm, of forearm to 12.2 cm, of upper arm to 16.1 cm, of whole arm to 36.8 cm of lower leg to 21.5 cm, of thigh to 27.3 cm, and of whole leg to 54.0 cm. The corresponding lengths in girls amounted in 16.9 cm, 7.2 cm, 11.0 cm, 14.0 cm, 32.6 cm, 18.7 cm, 24.5 cm, and 46.4 cm. Lengths investigated increase almost linearly between 3 and 11 years of age both in boys and girls. Beginning with 12 years boys have an increased development of all lengths when compared with girls.

[Disturbed growth in height in multiple cartilaginous exostoses (author's transl)]

Basing on the hypothesis that reduced body height in patients with multiple cartilaginous exostoses would be mainly accounted for by shorter extremities, not by a shorter trunk, the authors clinically examined 19 exostosis patients in respect of thigh, lower leg, upper and lower arm, as well as height of the seated patient. The dimensions were compared by the method of matched pairs, with 19 volunteers without diseased skeleton, who corresponded with one of the exostosis patients in respect of age, sex and height of seated patient. Results were evaluated according to Wilcoxon's test. This showed a statistically significant reduction in length of the extremities in adults with multiple cartilaginous exostoses.

Long bone growth in Western Eskimo and Aleut skeletons

The pattern of long bone growth in Eskimo and Aleut juvenile skeletons reflects that in living Eskimos and Aleuts. There is a pre-adolescent growth spurt which is particularly intense in females. After age 14 male long bones supercede those of females in length. The characteristic Eskimo and Aleut adult body proportion is established early in childhood. Eskimos and Aleuts have shorter bones than whites at all ages. The difference in length of the forearm and lower leg in comparison with whites appears to increase especially at adolescence.

Correction with growth following diaphyseal forearm fracture

In 25 children with fracture of the shafts of the forearm an average angulation deformity of 20 degrees was recorded when the fracture had healed. At follow-up, which took place after the cessation of growth, and angulation deformity was reduced by half; there was, however, a large individual variation. Both severe and less severe deformities were found to be corrected. Correction was more likely in younger children than in older children, though again there were exceptions to this rule. The most common dysfunction recorded was a decreased pronation-supination. This was not very closely correlated with angular deformity.

Roentgen recognition of acute plastic bowing of the forearm in children

Traumatic bowing of one or both forearm bones in children represents an acute plastic deformation of bone. Plastic curvatures have been produced in the dog ulna, but have been recognized only recently in man. The biomechanics and histologic changes of the experimental model explain the roentgenological features found in children with traumatically bowed bones: (1) broad fixed curvatures which hold fractures in angulation and resist orthopedic reduction; (2) absence of periosteal new bone formation following the injury; and (3) partial correction of the plastic corvature by cortical remodeling in young children. In a series of 17 patients, eight children had bowing of the ulna with an angulated fracture of the radius, five had bowing of the radius with an angulated ulna fracture, and four children had both the radius and ulna bowed without fracture. Manipulative reduction in the majority of children with fractures failed to reduce the plastic curvature, causing partial loss of pronation and supination.