Angular remodeling of midshaft forearm fractures in children

Thirty-six children treated for angulated midshaft forearm fractures were roentgenographically reexamined after a median time of four years (range, two to 5.8 years). The angulation of the fractures and epiphyseal plates was measured at the time of healing and at the follow-up examination. In children younger than 11 years of age, there was a significant correlation between fracture correction and change in epiphyseal plate angulation, with the highest degree of correction being 13 degrees. In children older than 11 years, no correlation was found, and the degree of fracture correction was unpredictable. The study points to an important influence of the epiphyseal plate on fracture remodeling, which decreases in late childhood.     

Remodeling of forearm fractures in children

A prospective study of 42 children with forearm fractures, treated by closed reduction and plaster, was conducted to assess the remodeling capacity of the radial epiphyseal plate after union of fracture with angulation. The children's ages ranged from 3 to 15 years. The effect of residual angulation of the healed fracture on the distal radial epiphyseal plate was examined radiographically over a median follow-up time of 3 years and 2 months, to observe the behavior of the distal radial epiphyseal plate during remodeling and to identify the factors that influenced this process. On the basis of these findings, guidelines are proposed for the treatment of forearm fractures that have healed with residual angulation. The inclinations of the distal radial epiphyseal plate on the fractured and normal forearms were compared on anteroposterior and lateral radiographs, at union and at final follow-up, in both the radioulnar and the dorsovolar planes. An alteration of inclination was seen in all patients with dorsovolar angulation of the radial growth plate, which always tended toward a correction of the abnormal inclination. In diaphyseal fractures, the distal radial epiphyseal plate realigned well only in children aged < or = 10 years, whereas with distal radial fractures, realignment of the epiphyseal plate and restoration of function was uniformly good up to age 15. Diaphyseal fractures, with radioulnar angulation in the growth plate, did not seem to remodel completely and were associated with loss of motion, whereas in distal fractures, irrespective of the final inclination of the epiphyseal plate, the range of motion returned completely at the end of follow-up. Abnormal angulation in the radioulnar plane was poorly corrected in all patients. These results could be helpful in the treatment of forearm fractures that are positioned or have healed in residual angulation.     

Remodelling after Distal Forearm Fractures in Children: I. The Effect of Residual Angulation on the Spatial Orientation of the Epiphyseal Plates

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured.

The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course.

The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

Remodelling after distal forearm fractures in children. I. The effect of residual angulation on the spatial orientation of the epiphyseal plates

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured. The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course. The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

Antti Alho: 1935-2000

The effect of residual fracture angulation on the distal radial and ulnar epiphyseal plates was studied in children aged 1 to 15 years. Thirty-eight fractures located in the distal fifth of the forearm bones were observed for 1 to 25 months after the fractures had healed. The forearms were examined radiographically on two to five occasions and the inclinations of the epiphyseal plates in relation to the long axis of the proximal fragments were measured.

The results showed that an abnormal inclination of the epiphyseal plate after healing of a distal forearm fracture induced an alteration of growth in the epiphyseal plate. The redistribution of growth tended to correct the abnormal inclination. The rate of correction followed an exponential course.

The age of the child at the time of the fracture and the distance from the fracture to the epiphyseal plate did not influence the capacity for correction.     

58-year follow-up of a vitallium mold hip arthroplasty: A case report and literature review

In 39 children the steric orientation of both the distal and the proximal epiphyseal plates of the radius was evaluated 4 months to 10 years after distal forearm fractures that had healed with residual angulation.

A residual fracture angulation was found to induce a change in orientation of both the distal and proximal epiphyseal plates. The final result of the reorientation was a normalization of the inclination of the plates in relation to the long axis of the bone. The proximal epiphyseal plate attained practically a normal orientation. The distal epiphyseal plate tended towards overcorrection.

In two of the four cases with a primary angulation exceeding 20 degrees considerable normalization occurred, but a “normal” state was not reached. This indicates an upper limit for angulations permitting normalization of the orientation of the distal epiphyseal plate of the radius.     

弹性髓内钉去弹性化治疗儿童桡骨干远段骨折

目的 应用弹性髓内钉去弹性化技术治疗儿童桡骨干远段骨折,观察临床疗效、放射学结果 及预后功能情况.方法 自2006至2008年,应用闭合复位、弹性髓内钉去弹性化技术治疗儿童桡骨干远段骨折18例,男13例,女5例;年龄5～15岁,平均9岁8个月.所有病例均为闭合性骨折,从受伤到接受手术治疗的时间为1～9d.骨折部位均位于桡骨干远段1/3,15例合并同侧尺骨骨折,另外3例为单纯桡骨骨折.复位方式均为"C"型臂X线机透视下闭合复位.术后常规长臂功能位石膏管型固定3～周.结果 最短随访时间12个月,平均骨折完全愈合时间为5个月(3～7个月).术后骨折对位正位平均93.2%±5.9%,侧位平均95.7%±7.1%;术后成角正位平均2.7°±1.5°,侧位平均1.4°±1.2°.94%(17/18)的患儿最终恢复了完全的前臂旋转功能,1例患儿存在10°以内的前臂旋转受限,随着随访时间延长,逐步好转中.并发症包括1例患儿出现髓内钉钉尾软组织激惹症状,1例患儿进钉部位手术瘢痕皮肤敏感.结论 弹性髓内钉去弹性化技术对于治疗儿童桡骨干远段骨折是一种有效、安全且方便可行的方法 .     

Remodeling of Salter-Harris type II epiphyseal plate injury of the distal radius

The authors studied the relation between residual angulation at the time of healing and final orientation of the distal radius as well as the clinical outcome in patients after Salter-Harris type II epiphyseal plate injury of the distal radius. Eighty-five patients were reviewed with a median follow-up of 8.5 years. Anteroposterior and lateral radiographs were taken at follow-up. The mobility of both wrists and forearms was examined, together with grip strength. Pain with activities and sports was evaluated. At follow-up, 73 patients (86%) were anatomically normal on radiographs; the remaining 12 patients had an incomplete remodeling of the volar and/or radial inclination of the distal radius. Premature closure of the growth plate in the distal radius or ulna did not occur in any of these children. Complete remodeling was seen in children aged up to 10 years in all but one patient. Remodeling after Salter-Harris type II epiphyseal plate injury occurs in all age groups, but the potential is greater in children up to 10 years of age. The incomplete remodeling does not seem to have any substantial long-term negative effect on mobility of the wrist and grip strength.     

Surgical correction of malunited fractures of the forearm in children

AIM: In our goal-oriented society the demands for a forearm with full function are increasing. Functional deficits are not acceptable even if they persist only for a limited period of time. Therefore a rising number of surgical corrections of malunited forearm fractures in the pediatric patient has been performed during the last years. However literature about indication, technique and outcome in these patients is rare. For that reason we report our experience about surgical correction of malunited fractures of the forearm in 14 children. METHODS: Fourteen patients with an average age of 13 years at the time of surgical correction of a malunited fracture of the forearm were included. Seven had a deformity of the shaft, five at the distal forearm without and two with growth disturbance. Malunions without growth disturbance were corrected with an osteotomy and plate fixation. Those with growth disturbance were first treated with callus distraction. Previous to and 24 (3 to 100) months after surgical correction the patients were examined clinically and radiologically. Range of motion was noted. Additionally to the range of motion, grip strength and pain (VAS) were documented. Patients with correction of the distal forearm were asked to fill out the DASH questionnaire. RESULTS: In all groups a significant increase of the range of motion was noted in pro-/supination of 61 per cent to 85-0-80 degrees. In patients with distal correction additionally the range of motion in extension/flexion of the wrist improved 30 per cent to 70-0-65 degrees and in ulnar/radialduction 22 per cent to 30-0-35 degrees. At follow-up the grip strength following distal corrections was 98 per cent of the opposite side. The patients had no pain (VAS < 3 points). The median subjective functional result was excellent with a median DASH score of 3.5 points. CONCLUSIONS: Our results show that potent techniques for surgical correction of malunited forearm fractures in the growing skeleton are available. These techniques allow excellent functional outcome.     

Position of immobilization for pediatric forearm fractures

The purpose of this study was to evaluate the effect of forearm position on residual fracture angulation for pediatric distal-third forearm fractures at the time of union. One hundred nine pediatric distal-third forearm fractures undergoing closed reduction and casting were prospectively randomized to be immobilized in pronated, supinated, or neutral position. Initial angulation and displacements were radiographically compared with healed fracture angulation at a minimum of 6 weeks. With 99 complete patient files, 38 fractures were casted in neutral, 26 in pronated, and 35 in supinated positions. Average initial angulation was 20 degrees; postreduction angulation measured 3 degrees. Final angulation at union averaged 7 degrees for all fractures. Forearm position failed to show a significant effect on fracture angulation at union. Residual fracture angulation at the time of union for pediatric distal-third forearm fractures was not significantly affected by forearm position (pronation, supination, neutral) during cast immobilization.     

Biological internal fixation of comminuted femur shaft fractures by bridge plating in children

Fourteen children (mean age 11.3 y) with a closed comminuted femur shaft fracture were surgically treated by biologic internal fixation using a bridging plate. The fractured area was not opened. After indirect reduction, internal fixation was made by a bridging plate through two small incisions, exposing the lateral aspects of proximal and distal fragments. The mean complete radiographic healing time was 12.4 weeks. After a mean follow-up period of 4 years, all patients were satisfied with the clinical outcome. The mean radiographic torsional deformity of the injured limb with respect to the uninjured limb was 4.5 degrees. A residual radiographic frontal or sagittal plane angulation of more than 10 degrees was seen only in one patient. It was concluded that biologic internal fixation by bridge plating was an effective surgical treatment method for the closed comminuted fractures of the proximal and distal thirds of the femur shaft in children.     

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.     

Remodeling of the skeletally immature distal radius

This case report describes the clinical course of a boy 12 years and 11 months old with the skeletal maturity of an 11.5-year-old, with a distal radial fracture that completely remodeled with 36 degrees of radial and 10 degrees of dorsal angulation. As this case demonstrates, the distal forearm may correct angulation in more than one plane. The remodeling capacity depends on the skeletal maturity of the patient, the proximity of the fracture site to the growth plate, the extent of angulation, and the relationship between the plane of angulation and motion of neighboring joints.     

Transradioulnar single Kirschner-wire fixation versus conventional Kirschner-wire fixation for unstable fractures of both of the distal forearm bones in children

The purpose of this study was to introduce transradioulnar single Kirschner-wire (K-wire) fixation technique for unstable fractures of both of the distal forearm bones in children and to evaluate the differences in clinical and radiographic results of osteosynthesis between this method and conventional K-wire fixation. Forty-one patients (20 conventional K-wire fixation, 21 transradioulnar single K-wire fixation) were reviewed who underwent a closed or mini-open reduction with K-wire fixation for fractures of both of the distal forearm bones. Their mean age at operation was 10.7 years (range, 8-16 years). Surgical intervention was indicated (1) when in addition to a complete ulnar fracture, the radius showed a 50% of displacement or greater, or 20-degree angulation or greater, (2) when in addition to an incomplete ulnar fracture, the radius was completely displaced, and (3) when reangulation was 15 degrees or greater in any direction at follow-up. The minimum follow-up period was 2 years. Bony union was achieved in both groups at approximately 7 weeks after surgery, and there were no significant differences in the operative time, duration of hospitalization, and duration of external support between the 2 groups. There were no major complications such as nonunion, radioulnar synostosis, premature physeal closure, or redisplacement or reangulation. Transradioulnar single K-wire fixation technique was a relatively simple procedure with comparable outcomes compared with conventional K-wire fixation technique. In addition, physeal injuries could be avoided, and there was no need for passing across the fracture line. Thus, it is suggested that transradioulnar single K-wire fixation technique can be a good alternative method for high-risk fractures of both of the distal forearm bones in children.     

Both-bone forearm fractures in children.

Treatment of both-bone forearm fractures remains a difficult dilemma for the orthopedist. We assessed the results of 33 children treated with closed reduction and a long-arm cast using traction with finger traps in neutral rotation. Patients were grouped according to age and analyzed for residual angulation and range of motion (ROM). Despite some residual angulation and loss of rotation, all patients were fully active with no functional restriction at follow up. For patients 10 years old or younger with less than 30 degrees of post-casting angulation, full ROM and minimal residual angulation on radiograph can be expected. For patients ages 11 to 15 years (the oldest patient in this series was 15), residual angulation is likely and approximately 60% of patients will have residual loss of less than or equal to 30 degrees of rotation. In spite of this, we found no evidence of functional loss at follow up. Our series supports the continued use of closed manipulation as an effective treatment in children with both-bone forearm fractures.     

Remodeling capacity and functional outcome of palmarly versus dorsally displaced pediatric radius fractures in the distal one-third

Introduction The purpose of this retrospective study was to compare the remodeling capacity and functional outcome of palmarly and dorsally displaced pediatric radius fractures in the distal one-third.Materials and methods Fifty-three children with a residual dorsal angulation of 15° (range 10°–28°, ±SD 5.32) and 31 children with a residual palmar angulation of 15° (range 10°–30°, ±SD 4.88) at fracture healing were re-examined clinically and radiologically with a median follow-up time of 10 years (range 5–15 years).Results There was no difference in the remodeling capacity, palmar tilt, radial inclination, and ulnar variance between both groups at follow-up. Pain as well as flexion/extension of the wrist and pronation showed no difference in both groups. Palmarly displaced fractures showed a significantly higher restriction of supination (p=0.01).Conclusion We conclude that remodeling of residual palmar angulation occurs to the same extent as it does in dorsal angulation. Functional outcome differs in forearm supination.     

Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents

The management of adolescent radius and ulna diaphyseal fractures is controversial. The purpose of this study was to address the residual deformity and functional outcome following closed treatment of these fractures. Twenty-five older children and adolescents (mean age 13.3 years, range 8.8-15.5) with displaced diaphyseal both-bone forearm fractures underwent closed treatment and were followed for a mean of 49.6 weeks. All fractures united. On the final AP radiograph, the mean angulation was 9 degrees (range 0-18 degrees) for the radius and 8 degrees (0-20 degrees) for the ulna. All patients achieved full elbow and wrist range of motion. Loss of forearm supination and pronation averaged 4 degrees (range 0 to 20 degrees) and 6.8 degrees (0 to 40 degrees), respectively. Closed reduction and casting of displaced both-bone diaphyseal forearm fractures, despite the residual angulation, results in satisfactory functional outcome and should remain a viable treatment option in the management of this injury.     

Modified functional bracing in the ambulatory treatment of femoral shaft fractures in children

Thirty children aged between 2 and 10 years with fractures of the femoral shaft were involved in a prospective study of a treatment method that requires a short period of traction followed by full weightbearing with a modified hinged functional brace and return to school after an average of 32.5 days. At an average follow-up period of 2 years, no case has shown residual angulation or rotational deformities greater than 10 and 15 degrees. No shortening was demonstrated. Overgrowth of the fractured femur was common, with a maximum of 1.5 cm. No strong correlation between overgrowth and age, site, and type of fracture was found. Results were uniformly good for proximal, middle, and distal third fractures.     

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.     

Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children

BACKGROUND: Various methods of cast immobilization have been recommended for the treatment of distal forearm fractures in children. The purpose of this study was to determine if short arm casts are as effective as long arm casts in the treatment of displaced fractures of the distal third of the forearm in these patients. METHODS: In a prospective randomized trial, consecutive patients, four years of age or older, who presented to The Women's and Children's Hospital of Buffalo with a displaced fracture of the distal third of the forearm were randomized to treatment with a short or long arm plaster cast. Radiographs were analyzed for displacement, angulation, and deviation at the time of injury, after reduction, and at subsequent follow-up intervals. The cast index at the fracture level, used to assess the quality of the cast molding, was determined from the postreduction radiographs. Changes between postreduction and final values for displacement, angulation, and deviation; the ranges of motion of both wrists and elbows; the need for physical therapy; and responses to a questionnaire used to evaluate the effects of the cast on activities of daily living were compared between the groups. RESULTS: One hundred and thirteen of the 151 patients who were assessed for eligibility were analyzed. The follow-up rate was 92%, and the average duration of follow-up was eight months. Sixty long arm casts and fifty-three short arm casts were used. There were no significant differences between the two groups with regard to patient demographics, initial fracture characteristics, mechanism of injury, cast index, or the change in displacement, angulation, or deviation during treatment. The fractures that lost reduction in the cast had significantly higher cast indices, indicating poor cast-molding. A comparison of partially and completely displaced fractures revealed no difference between the groups with regard to the change between the postreduction and final amount of displacement. Patients treated with a short arm cast missed fewer school days and were less likely to require assistance with various activities of daily living. CONCLUSIONS: A well-molded short arm cast can be used as effectively as a long arm cast to treat fractures of the distal third of the forearm in children four years of age and older, and they interfere less with daily activities.