Remodeling of angulated distal forearm fractures in children

Seventy children treated for distal forearm fractures were clinically and roentgenologically reexamined with a median follow-up time of 3.5 years (range, 1.5-6.0 years). The angulation of the fractures and of the epiphyseal plates was measured at the time of healing and at the follow-up examination. The patients were divided into three age groups of 0-5 years, 6-10 years, and 11-15 years at the time of fracture. In children younger than 11 years of age with residual angulation after distal forearm fractures, the change of orientation of the epiphyseal plate toward normal seemed to account for nearly all the actual correction at the site of fracture, up to 28 degrees. In children older than 11 years of age the capacity of correction of the orientation of the epiphyseal plate was preserved, but its influence upon the correction of distal forearm fractures decreased. This did not prevent correction of possible residual angulation at the fracture site--up to 18 degrees. This may be because, in this age group, appositional bone formation and resorption are the most important remodeling factors. The importance of the orientation of the epiphyseal plate is related to the distance between the fracture site and the epiphyseal plate and by the age of the patient.     

Epidemiology of distal forearm fractures in Danish children

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.     

Epidemiology of distal forearm fractures in Danish children

We recorded all the distal forearm fractures in inhabitants under 20 years of age in Frederiksborg County, Denmark, throughout 1985. The population at risk was 97,791 persons, and fractures occurred in 269 boys and 205 girls. The peak incidence in girls occurred at ages 10-12 (105 per 10,000) and in boys at ages 12-14 (100 per 10,000). Fractures occurred more often in the autumn than in the spring.     

Remodelling of angular deformity after femoral shaft fractures in children.

We reviewed 28 children with unilateral middle-third fractures of the femoral shaft who had an angular deformity after union of 10 degrees to 26 degrees. At an average follow-up of 45 months (20 to 66), we measured remodelling of the proximal physis, the distal physis and the femoral shaft. The average correction was 85% of the initial deformity. We found that 74% of correction occurred at the physes and only 26% at the fracture site. Neither the direction nor the magnitude of the angulation much influenced the degree of remodelling. Younger children remodelled only a little better than older children. We conclude that in children under 13 years of age, malunion of as much as 25 degrees in any plane will remodel enough to give normal alignment of the joint surfaces.     

The effect of alendronate on bone mass after distal forearm fracture.

Fracture and immobilization of an extremity lead to bone loss at the fracture and at adjacent sites. We conducted a 1-year, single-center, prospective, randomized, double-blind study to determine whether bone loss would occur in the distal radius after a Colles' fracture and whether this loss could be prevented using an antiresorptive drug (alendronate). Thirty-seven women with a recent fracture of the distal forearm and low bone mineral density (BMD) of the lumbar spine were randomized to receive either 10 mg alendronate daily or placebo. BMD of both forearms was measured at baseline and after 3, 6, and 12 months. The results of four women who developed reflex sympathetic dystrophy were not included in the analysis. In the placebo group, there was a significant reduction at 3 months and 6 months in BMD of total radius (p < 0.01), one-third distal radius (p < 0.01), middistal radius (p < 0.05), and ultradistal radius (p < 0.01) on the fractured side. The loss in BMD at one-third distal radius remained significant at month 12 (p < or = 0.001). In the alendronate group BMD of total distal radius, one-third distal radius, and middistal radius at the fractured side remained unchanged. BMD of ultradistal radius increased significantly at months 3, 6, and 12, compared with baseline (p < 0.05). The difference between the two treatment groups was significant at 3 months and 6 months and borderline significant (p = 0.054) after 1 year in total distal radius. In ultradistal radius the differences were significant at all time points. We conclude that BMD of the distal radius of a recently fractured forearm decreases significantly in the 6 months after fracture and the resulting deficit remains evident at least 1 year after fracture. This bone loss can be prevented by alendronate.     

The etiology of valgus angulation after metaphyseal fractures of the tibia in children

We conducted a retrospective study of proximal metaphyseal fractures of the tibia in children who developed valgus deformities. We reviewed the cases in an effort to determine the most likely etiology of post-fracture tibia valga, which occurs despite careful treatment and follow-up. We reviewed seven major theories presented in the literature regarding the etiology of this problem. Our conclusion was that all the theories were not prerequisites for the development of valgus angulation, but rather may be secondary mechanisms. We suggest that the most likely primary mechanism is an increased vascular response causing an asymmetric growth stimulation of the medial metaphysis of the proximal tibia.     

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.     

The removal of forearm plates in children

Routine removal of forearm plates in children remains controversial. The aim of the study was to assess if risks of complications associated with removal of forearm plates in children warrant routine removal of these plates. A total of 43 children (mean age 10.6 years old at time of fracture fixation) who had forearm plates removed after fracture fixation in our unit over a 10-year period were reviewed. There were three cases of re-fractures (two in the same child), all of which occurred following an episode of trauma and the use of Dynamic Compression Plates (DCP). One case of superficial infection was successfully treated with oral antibiotics. Low rates of complications from routine removal of metalwork after forearm plating in children may be achieved.     

Redisplacement after closed reduction of forearm fractures in children

Reangulation and displacement after closed reduction of pediatric forearm fractures were reviewed in 90 patients treated with 1978-1984. All fractures were remanipulated and followed to union. No complications occurred and all had a functionally satisfactory result. Both intrinsic and extrinsic factors were identified as contributing to the complication of reangulation/displacement. Nonepiphyseal fractures were safely remanipulated up to 24 days postfracture, with the majority at 1-2 weeks. We conclude that 7% of pediatric forearm fractures treated by closed reduction are subject to reangulation and/or displacement following routine acceptable primary treatment, and that remanipulation provides a safe, effective means to obtain and maintain reduction.     

The impact of residual angulation on patient reported functional outcome scores after non-operative treatment for humeral shaft fractures

PurposeTo determine if residual angular deformity following non-operative treatment of humeral diaphyseal fractures correlates with patient reported outcomes.MethodsSkeletally mature patients treated by one of three orthopaedic trauma surgeons at a level 1 trauma centre with humeral shaft fractures treated without surgery were retrospectively identified over a 7 year period. After inclusion and exclusion criteria, 42 patients were eligible for the study. Disabilities of the Arm, Shoulder, and Hand (DASH); Simple Shoulder Test (SST); General health questionnaire SF-12 physical component summary (SF-12 PCS) and mental component summary (SF-12 MCS) were obtained from study participants. Healed angular deformity was obtained from patient charts.ResultsThirty two subjects were successfully recruited (32/42 or 76%). Average age was 45 ± 22 with average study follow up being 47 ± 29 months. Average outcome scores were DASH 12 ± 16, SST 10 ± 2.7, SF-12 PCS 50 ± 7.9, and SF-12 MCS 54 ± 8.8. Healed sagittal plane deformity averaged 8 ± 5.7° [range 0−18], and 15 ± 7.9° [range 2−27] in the coronal plane. There was no correlation between residual sagittal or coronal plane deformity and outcome scores (DASH and SST for both p > 0.05). Patients with at least 20° (n = 7; 22%) of healed coronal deformity had similar outcomes to those with <20° ([DASH (13.2 ± 18.7 vs 11.7 ± 16.1; p = 0.83]; [SST (10.3 ± 2 vs 10.0 ± 2.9; p = 0.81]). Higher SF-12 PCS and MCS scores correlated with better DASH and SST scores (p < 0.05 for all).ConclusionResidual angular deformity ranging from 0 to 18° in the sagittal plane and from 2 to 27° in the coronal plane after non-operative treatment for humeral shaft fractures had no correlation with patient reported DASH scores, SST scores, or patient satisfaction. Instead, overall physical and mental health status as measured by the SF-12 significantly correlated with patient reported outcomes.     

Tibial fractures involving the ankle in children. The so-called triplane epiphyseal fracture.

Triplane fractures of the distal end of the tibia in fifteen children (average age, thirteen years) represented 6 per cent of 237 consecutive epiphyseal fractures of the ankle. Thirteen children were treated by closed methods (including manipulation) and two had open reduction of the fractures. At an average of twenty-six months after injury, three of fourteen patients showed roentgenographic evidence of premature symmetrical epiphyseal closure with less than 0.5 centimeter of shortening and no angular deformity. Of twelve children examined clinically, three had a 5 to 10-degree external rotation deformity and one patient also had an articular incongruity due to inadequate reduction. In the five cases in which tomograms were used to the medial malleolus, and the anteromedial part of the epiphysis. The lateral fragment included the remainder of the epiphysis together with a piece of posterior metaphysis with attached fibula.     

Open fractures of the forearm in children

OBJECTIVE: To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children. DESIGN: Retrospective review of patients treated according to protocol. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records. INTERVENTION: All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast. MAIN OUTCOME MEASUREMENTS: Time to union, angular alignment at union, and incidence of complications. RESULTS: The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously. CONCLUSIONS: Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.     

Above and below-the-elbow plaster casts for distal forearm fractures in children. A randomized controlled trial

BACKGROUND: Closed fractures of the distal third of the forearm are the most common fractures of childhood, but the method of immobilization after closed reduction is controversial. This study was undertaken to determine whether below-the-elbow casts are as effective as above-the-elbow casts in immobilizing these types of fractures and to identify patient and treatment considerations that are related to loss of reduction. METHODS: We designed a blinded, randomized, controlled trial. The criteria for reduction and remanipulation were set a priori. The primary outcome measure was fracture immobilization as reflected by reangulation in the cast and by the need for remanipulation. Exploratory analysis with use of stepwise logistic regression analysis was undertaken to search for factors predictive of loss of reduction. RESULTS: A total of 102 children were enrolled in the study and were allocated to two groups: the above-the-elbow cast group (fifty-six children) and the below-the-elbow cast group (forty-six children). The mean age was 8.6 years, and sixty-one patients were boys. The groups did not differ with respect to the initial fracture angulation, postreduction angulation, reangulation during cast immobilization, and angulation of the fracture at the time of cast removal. In the above-the-elbow cast group, twenty-three (42%) of fifty-five children with adequate radiographs met the criteria for remanipulation compared with fourteen (31%) of forty-five children with adequate radiographs in the below-the-elbow cast group (p = 0.27); only four of these thirty-seven children actually underwent remanipulation. Children with fractures of both the radius and ulna (p = 0.01) and those with residual angulation after reduction (p = 0.0001) were at the highest risk of meeting the criteria for remanipulation. The rates of complications related to the cast did not differ between the groups. CONCLUSIONS: Below-the-elbow casts perform as well as above-the-elbow casts in maintaining reduction of fractures in the distal third of the forearm in children, and the complication rates are similar. Factors that are associated with a higher risk of loss of reduction include combined radial and ulnar fractures and residual angulation of the fracture after the initial reduction.     

The incidence of distal forearm fractures in Zaragoza (Spain)

We present the results of a retrospective study of the epidemiology of distal forearm fractures in patients over 15 years of age in Zaragoza (Spain) during 1998-1999. We analysed a total of 2506 fractures of the distal forearm. Fractures were classified according to age, sex, Frykman classification and mechanism of injury. Fractures were Frykman type III in 23.5% of cases, Frykman II in 17.9%, Frykman IV in 14.5% and Frykman I in 12.8%. The rest of fractures were distributed homogeneously between the remaining fracture types. The mechanisms of injury was low energy in 78.2% of cases and high in 21.8%. Analysis of the age distribution showed an increase in the incidence of this type of fracture over 50 years of age, with a peak between 60 and 69 years as a result of accidental falls. We found an increased incidence in males below 49 years of age, as a result of traffic accidents, and a predominance of females over 50 years of age due to osteoporosis and an increased number of falls.     

Comparing the effectiveness of modified forearm and conventional minidose intravenous regional anesthesia for reduction of distal forearm fractures in children

BACKGROUND: Minidose intravenous regional anesthesia (IVRA) and modified forearm IVRA have been used for closed reduction of forearm fractures and for hand surgery in children. METHODS: Children (5-17 years old) with forearm fractures presenting to a pediatric emergency department were enrolled in a randomized controlled trial to test if modified forearm and minidose IVRA together would provide improved analgesia with reduced risk of anesthetic toxicity compared with conventional minidose IVRA. Pain was assessed using a visual analog scale (FACES) and an objective pain scale (OPS) score at baseline and at critical times. Spearman rank correlation and repeated-measures analysis of variance were used to compare interobserver pain measures and detect differences between the groups over time. RESULTS: Among the 62 patients in the study, no significant differences were observed between groups in objective measures of blood pressure, oxygen saturation, and heart rate at baseline, 5 minutes after IVRA, during surgical reduction, and 15 minutes after reduction. Nurses reported patients experienced a reduction in pain of 2.5 (SD, 3.1) on FACES and 2.3 (SD, 3.1) on OPS at 5 minutes after sedation (P < 0.001 for both). From time of reduction to 15 minutes after the procedure, FACES score declined 1.7 (SD, 3.4) (P = 0.001), and OPS declined 2.1 (SD, 3.6) (P = 0.002). No significant differences were found between experimental arms. CONCLUSION: The modified forearm minidose IVRA procedure is an acceptable alternative for the relief of pain that usually accompanies the manipulation and reduction of forearm fractures but does not appear to provide additional pain relief compared with conventional minidose IVRA. LEVEL OF EVIDENCE: Level I, therapeutic study.     

The small AO external fixator in the treatment of unstable distal forearm fractures

Sixteen patients with severely comminuted displaced fractures of the distal radius and ulna, who were treated with a small AO external fixator, have been reviewed at an average of 2.2 years after injury. Removal of the fixator, at an average of 4.9 weeks, was followed by significant alteration in position in some cases. The external fixator should be retained for eight weeks to reduce the risk of loss of position. In those cases with a good or excellent anatomical result on radiological assessment after removal of the fixator, the functional results were good or excellent in 80%.     

Delayed healing of forearm shaft fractures in children after intramedullary nailing

BACKGROUND: In displaced and unstable forearm shaft fractures, elastic stable intramedullary nailing represents the current treatment of choice. Delayed healing has been observed in single cases, but the incidence of healing disturbances remains unclear. METHODS: Retrospective analysis of all patients with forearm shaft fractures and open epiphyseal plates, treated with elastic stable intramedullary nailing between 2000 and 2004 in 5 pediatric trauma units, was conducted. Evaluation of cases with insufficient consolidation 90 days after osteosynthesis was performed. RESULTS: Ten (1.9%) of 532 cases showed delayed healing. Mean age (12.3 years), part of open fractures (30%), and part of open reductions (60%) were clearly higher than in a nonselected collective; the ulna was concerned in 70%. One refracture, 1 local soft tissue infection, and 1 small sequestration were found. In 5 children, nails were extracted with (2x) or without (3x) local surgical intervention. In the other 5 children, the nails were left in place. All fractures healed within 13 months posttrauma without relevant functional restrictions. CONCLUSIONS: Delayed healing is possible especially in open fractures or open reduced fractures of the ulna in older children, but healing takes place up to 13 months. Therefore, no change of treatment principles is necessary. Protection of ulna periost has to remain in the center of surgical focus. LEVEL OF EVIDENCE: Retrospective comparative study, Level III.     

Angulated greenstick fractures of the distal forearm in children: closed reduction by pronation or supination

The purpose of this study was to evaluate a reduction method that is based on the theory of Evans to reduce angulated greenstick fractures of the distal forearm with a rotation manoeuvre, to evaluate an immobilisation technique and to evaluate a brief survey on surgeon practice for treatment of these fractures. A retrospective study was performed on 21 patients. Fractures were reduced with a pronation or supination manoeuvre depending on the angulation of the fracture and were immobilised in pronation or supination. A good reduction was achieved in all patients. Six weeks after manipulation a loss of reduction was seen in 6 out of 21 patients, but with a reangulation of less than 15 degrees. There was no significant difference between fractures immobilized in pronation or in supination. There was no need for remanipulation. At the 2008 Osteosynthesis and Trauma Care Foundation (OTC) meeting, a brief informal survey was performed concerning the reduction method and the use of K-wires after reduction. No surgeons indicated they would perform only a rotation manoeuvre.