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.     

Internal fixation of proximal humeral fractures with a locking compression plateA retrospective evaluation of 72 patients followed for a minimum of 1 year

Background Proximal humeral fractures, particularly in osteoporotic patients, remain an unsolved problem as regards the durability of the osteosynthesis. The AO/ASIF group has developed a new technique which aims to preserve the biological integrity of the humeral head and secures the reduction using multiple locking screws with angular stability (Philos), thus allowing an early mobilization. Patients and outcome We retrospectively reviewed the complications and functional outcome after a minimum follow-up of 1 year in 72 patients treated with this new method. 2 fractures failed to unite, and 3 patients developed an avascular necrosis of the humeral head. In addition, 2 implant failures were observed due to a technical error. According to the Constant score, the functional outcome was acceptable even in elderly patients. Interpretation The Philos method appears to be safe and can be recommended for the treatment of proximal humeral fractures in patients with poor bone quality.     

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.     

Effects of hyaluronic acid and basic fibroblast growth factor on motility of chondrocytes and synovial cells in culture

The capacity of chondrogenic precursor cells to migrate and proliferate in an injured area is considered to be essential for cartilage repair. We examined cell motility of chondrocytes and synovial cells in monolayer culture and the chemokinetic effects of hyaluronic acid (HA) and basic fibroblast growth factors (bFGF) on these cells. The velocity of chondrocyte migration was accelerated by giving bFGF and simultaneously administering of both HA and bFGF, but it was not affected by HA alone. The velocity of synovial cell migration was increased by HA, but not by bFGF. HA had a chemokinetic effect on synovial cells and bFGF had the same effect on chondrocytes. Treatment with exogenous HA and bFGF may be of value for repairing articular cartilage injury by recruiting chondrogenic cells and promoting migration of chondrocytes in the cartilage tissue.     

Correction with Growth Following Diaphyseal Forearm Fracture

In 25 children with fracture of the shafts of the forearm an average angulation deformity of 20° was recorded when the fracture had healed. At follow-up, which took place after the cessation of growth, the 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.     

Short-term and long-term site-specific effects of tennis playing on trabecular and cortical bone at the distal radius

Mechanical loading during growth magnifies the normal increase in bone diameter occurring in long bone shafts, but the response to loading in long bone ends remains unclear. The aim of the study was to investigate the effects of tennis playing during growth at the distal radius, comparing the bone response at trabecular and cortical skeletal sites. The influence of training duration was examined by studying bone response in short-term (children) and long-term (young adults) perspectives. Bone area, bone mineral content (BMC), and bone mineral density (BMD) of the radius were measured by DXA in 28 young (11.6 ± 1.4 years old) and 47 adult tennis players (22.3 ± 2.7 years old), and 70 age-matched controls (12 children, 58 adults) at three sites: the ultradistal region (trabecular), the mid-distal region, and the third-distal region (cortical). At the ultradistal radius, young and adult tennis players displayed similar side-to-side differences, the asymmetry in BMC reaching 16.3% and 13.8%, respectively (P < 0.0001). At the mid- and third-distal radius, the asymmetry was much greater in adults than in children (P < 0.0001) for all the bone parameters (mid-distal radius, +6.6% versus +15.6%; third-distal radius, +6.9% versus +13.3%, for BMC). Epiphyseal bone enduring longitudinal growth showed a great capacity to respond to mechanical loading in children. Prolonging tennis playing into adulthood was associated with further increase in bone mineralization at diaphyseal skeletal sites. These findings illustrate the benefits of practicing impact-loading sports during growth and maintaining physical activity into adulthood to enhance bone mass accrual and prevent fractures later in life.     

双侧髂前上棘骨骺撕脱1例

1病例资料患者,男,14岁。因双髋部疼痛、活动受限5 d入院。主诉5 d前上体育课医结合七年制2000级,四川成都6100752成都中医药大学附属医院骨科,四川成都610072参加50 m短跑,跑至终点时即感双髋部疼痛,行走受限,当时未摔倒。外院就诊行骨盆正位X线片及骨盆CT检查,诊断为双侧髂前上棘骨骺撕脱,未予处理。因双髋疼痛症状未缓解而来我院就诊。查体:双侧髂前上棘处轻度肿胀,明显压痛,触诊时有骨擦感,可扪及裂缝及骨折块;无放射痛,无明显的血管、神经损伤症状,双侧阔筋膜张肌、缝匠肌肌张力降低。仰卧位时双髋关节可屈曲40°,双髋关节其余各方向…     

Growth disturbance after osteomyelitis of femoral condyles in infants

Growth disturbance after osteomyelitis in a single femoral condyle was seen in seven infants followed by the author from infancy to maturity. Age at onset of infection was between 10 days and 4 weeks. In three cases the medial condyle was affected and in four the lateral. Angular deformity of 20-50 degrees of varus or valgus was present before correction by supracondylar osteotomy. In all seven cases the radiographic appearance before the first osteotomy was similar. Partial closure of the growth plate appeared in four cases at age 6, 7, 10 and 12 years, respectively, which was decisive for loss of growth in length. These children had 3-6 osteotomies before maturity. In three cases partial closure of the plate did not occur, progression of angulation was slow and only two femoral osteotomies were carried out.

Restitution of the epiphysis and growth disturbance are unpredictable on the basis of radiographic findings during infancy. Partial closure of the growth plate may occur at the age of 4 years. Indications for correction of deformity and for epiphyseodesis in the other leg should be considered once or twice every year during the growth period.     

Bone Growth Alterations Resulting from Application of Co2 Laser Beam to the Epiphyseal Growth Plates: An Experimental Study in Rabbits

The CO₂, laser beam was used to create defects 3 mm in depth in the distal growth plate of one femur in a group of 59 rabbits. In most of the 32 rabbits in which the defect was created on the lateral aspect of the epiphyseal plate the procedure resulted in the subsequent development of valgus deformity and shortening of the femur. In most of the 27 rabbits in which defects were produced both medially and laterally to the epiphyseal plate there was a subsequent marked shortening of the bones. Histological studies revealed that the laser-induced defects of the growth cartilage led to epiphysiodesis and premature disappearance of the epiphyseal growth plates.     

Management of ��floating elbow�� in children

Background:

Supracondylar fractures associated with ipsilateral forearm fractures, aptly termed as “floating elbow” is a rare injury in children after a fall from height. The various authors have reported their results with conservative treatment of one or both injuries to aggressive emergency operative fixation of both components.

Materials and Methods:

During a period of three years, the author managed four cases of floating elbow in children. All cases were managed by closed reduction and pinning of both components of the injury.

Results:

All patients recovered full elbow range of motion at three months followup and were rated as excellent as per modified Flynn''s criteria. None of the patients developed cubitus varus deformity, complications related to the pins or delayed union.

Conclusions:

Early closed reduction and K wire fixation of both components of this injury gives better stability and prevents development of complications like compartment syndrome and elbow deformities.     

Distal forearm fractures in children: Cast index as predictor of re-manipulation

Background:

Displaced distal forearm fractures in children have been treated in above-elbow plaster casts since the last century. Cast index (CI) has been proposed as a measure to indicate how well the cast is molded to the contours of the forearm. In this study the CI in post-manipulation radiographs were analyzed to evaluate its relevance to re-angulation of distal forearm fractures in children in different age-groups.

Materials and Methods:

Out of 174 consecutive cases treated during the study period, 156 patients (114 male and 42 female) with a mean age of 9.8 years (range: 2–15 years) were included in this retrospective radiographic analysis; 18 patients were excluded for various reasons. All patients were manipulated in the operation theater under general anesthesia and a molded above-elbow cast was applied. The CI was measured on immediate post-manipulation radiographs. Children were divided into three groups according to age: group 1: <5 years, group 2: 5–10 years, and group 3: >10 years.

Results:

Angulation of the fracture within the original plaster cast occurred in 30 patients (19.2%): 22/114 males and 8/42 females. The mean CI in these 30 patients who required a second procedure was 0.92±0.08, which was significantly more than the mean CI in the other children (0.77±0.07) (P<.001). The mean CI in children who underwent re-manipulation in the group 1 was 0.96, which was significantly higher than that of the other two groups, i.e., 0.90 in group 2 and 0.88 in group 3 (P<.05). A receiver operating characteristics (ROC) curve estimated the cutoff point for intraoperative CI of 0.84 when both the sensitivity and specificity of CI was high to predict re-manipulation for re-displaced fractures of the distal forearm in children in any age-group.

Conclusion:

The CI is a valuable tool to assess the quality of molding of the cast following closed manipulation of forearm fractures in children. A high CI (≥0.84) in post-manipulation radiographs indicates increased risk of re-displacement of the fracture in children, especially in those under the age of 5 years and over the age of 10 years.     

Rates of neurovascular injury,compartment syndrome,and early infection in operatively treated civilian ballistic forearm fractures

PurposeThe purpose of this study is to evaluate the incidence of neurovascular injuries, compartment syndrome, early postoperative infection as well as the injury factors predictive of neurovascular injury following ballistic fractures of the radius and ulna.MethodsA retrospective review was performed to identify all ballistic fractures of the radius and ulna in skeletally mature patients over a 5-year period at a single level-1 trauma center. Chart and radiographic review was performed to identify patient and injury demographics, associated neurologic or vascular injuries, and fracture characteristics. Fracture location was measured on computerized imaging software and fractures were grouped into bone(s) segments involved. Proximal, mid-diaphyseal, and distal locations were used for statistical analysis.ResultsFifty-six extremities in fifty-five patients were identified (mean age 32 years; male to female ratio 9:1). Overall incidence of neurologic injury was 50%, arterial injury 32%, and compartment syndrome 7.1%. Presence of a proximal third forearm fracture was associated with an increased risk for neurologic injury (p < 0.01), with an odds ratio of 5.7 (95% confidence interval, 1.7–18.4). Furthermore, all high velocity/energy ballistic injuries had associated neurologic injuries (p = 0.02).ConclusionBallistic forearm fractures result in high rates of neurovascular injury. Fractures caused by high velocity/energy firearms have extremely high rates of neurologic injury when compared with low velocity ballistic injuries. Ballistic fractures involving the proximal third of the radius or ulna are five times more likely to be associated with neurologic injury after a ballistic injury and should be assessed carefully on initial evaluation.     

Clinical and financial impacts of flexible intramedullary nailing in pediatric diaphyseal forearm fractures: A case–control study

Purpose:Flexible intramedullary nailing is regularly applied for pediatric displaced unstable forearm fractures. When compared to closed reduction and casting (orthopedic treatment), flexible intramedullary nailing decreases malalignment, shortens immobilization time, and should decrease follow-up controls. Comparing flexible intramedullary nailing and orthopedic treatment in the clinical, radiological, and financial managements of these fractures was performed.Methods:Retrospective 5 years study of pediatric cases in two pediatric orthopedic university departments. Treatment method, post-operative course, and radiological follow-up were reviewed. Number of radiographs, follow-up controls, type and duration of immobilization, final bone angulation, and reported complications were compared. Extensive financial analysis was completed.Results:Of 73 girls and 168 boys included in the study, 150 were treated by flexible intramedullary nailing and 91 by orthopedic treatment. No difference was noted with regard to total number of radiographs (7.3 vs 7.2, respectively). Total number of follow-ups was 6.4 and 5.5, respectively. Malalignment occurred in two flexible intramedullary nailing and sixteen orthopedic treatments. The least expensive cost was ambulatory orthopedic treatment.Conclusion:Flexible intramedullary nailing treated children had similar numbers of radiographs or follow-up consultation, but less malunion when compared to orthopedic treatment. Orthopedic management was systematically cheaper than flexible intramedullary nailing. Unless post-operative management guidelines decreasing the number of radiographs and follow-ups are implemented, flexible intramedullary nailing will remain a costly procedure when compared to conventional orthopedic treatment.Level of evidence:level III case–control retrospective study.     

The Range of Motion Following Fracture of the Shaft of the Forearm in Children

Eighteen children with fracture of the shafts of the forearm were re-examined in adulthood. All fractures had primarily been displaced but reduced to a good position without residual axial or ad latem displacement. At follow-up there was no sign of deformity in the radiograms of the two bones. However, the range of motion for supination and pronation was significantly decreased. This implies that factors other than residual deformity arc responsible for this dysfunction.     

带锁髓内针治疗尺桡骨骨折

目的评价采用交锁髓内钉固定技术治疗前臂双骨折的临床疗效。方法我院自2005年1月～2006年12月,采用施乐辉Foresight带锁髓内针固定术治疗尺桡骨双骨折16例,随访12～36个月,应用Berton评定标准评价临床疗效。结果根据Berton评定标准：优10例,良4例,中1例,差1例,优良率达93％。结论正确应用交锁髓内钉治疗前臂双骨折是一种微创、操作简单的手术方法。