Immobilisation of forearm fractures in children: extended versus flexed elbow

Redisplacement of unstable forearm fractures in plaster is common and may be the result of a number of factors. Little attention has been paid to the influence of immobilisation with the elbow extended versus flexed. We prospectively treated 111 consecutive children from two centres with closed forearm fractures by closed reduction and casting with the elbow either extended (60) in China or flexed (51) in Israel. We compared the outcome of the two groups. There was no statistically significant difference in the distribution of the age of the patients, the site of fracture or the amount of angulation and displacement between the groups. During the first two weeks after reduction, redisplacement occurred in no child immobilised with the elbow extended and nine of 51 children (17.6%) immobilised with the elbow flexed. Immobilisation of unstable forearm fractures with the elbow extended appears to be a safe and effective method of maintaining reduction.     

Forearm fractures in children. Cast treatment with the elbow extended

Fractures of the proximal forearm in young children may be unstable with the elbow flexed but stable with it in extension. Fifteen such fractures were managed by immobilisation in long-arm casts with the elbow extended. Only one patient had more than 15 degrees angulation at the time of bony union. All obtained normal elbow movement at two weeks and full forearm rotation at follow-up. No casts fell off. The extended elbow cast is awkward but it provides an alternative to internal fixation for some unstable fractures.     

Le fratture di avambraccio

Fractures of the forearm in the growing skeleton in a common event, accounting for 10% of the overall fracture and at the third place for long bone fractures. Most of these fractures present a simple line. There are several classification but the most widely use is the anatomo-radiological one. The majority of the fracture require closed reduction and immobilization in a long arm cast, with the elbow flexed at 90°, since residual defect that can occur are well tolerate. Under the age of nine angulation deformities lesser than 15° have the possibility to remodell completely. Over the age of nine the toleration is lower than 10°. The time of immobilization has to be at least of 8 weeks, in order to reduce the high risk of refracture. The surgical management of these fracture must to be reserved in case of unstable fractures or impossibility to gain good reduction by closed means. The best surgical solution nowadays is stabilization with elastic stable intramedullary nail. Open reduction and plate osteosynthesis must to be reserved for late adolescent, very near to skeletal maturity. External fixation has limited indication, expecially in politrauma and very high grade of open fractures.

     

Combination of ipsilateral supracondylar humeral- and forearm fractures in children

In an 11-year period, from 01. 08. 1987 to 31. 08. 1998, a total of 72 children (mean age 7.6 years, range 2-12 years) with dislocated supracondylar humeral fractures were treated surgically in the Department for Traumatology, University Hospital, Essen. The combination of supracondylar humeral fracture and ipsilateral forearm fracture occurred in 8 children (11.1 %). 4 revealed a complete forearm fracture in the distal third, 4 children a fracture of the distal physis (Salter-Harris type II). The supracondylar humeral fractures were reduced openly via a single lateral approach and stabilized by crossed K-wire fixation. The distal forearm fractures were treated by closed reduction and percutaneous pinning. Fractures of the distal physis were treated by closed reduction and application of an above elbow cast. Excellent results were achieved in all children with ipsilateral supracondylar and forearm fractures.     

Elbow dislocation with ipsilateral diaphyseal forearm bone fracture: A rare injury report with literature review

Dislocation of the elbow along with shaft fractures of both bones of the ipsilateral forearm is a rare injury though elbow dislocation or fracture of the forearm bones may occur separately. Such injuries need a concentric reduction of the dislocation and an anatomical fixation of forearm bones for optimal functional outcomes. We report a case of elbow dislocation with fracture of the lateral condyle of the humerus along with fractures of shafts of the radius and ulna in a 44-year-old female. Closed reduction of the elbow and operative stabilization of all fractures were done with good clinical, radiological and functional outcomes in 2 years follow-up period. A significant degree of force is needed to produce a combined dislocation of a joint and fracture of bones around that joint and these complex injuries may be missed if the clinician is not aware of the possibility of such injuries. The fact that the previously reported cases had a posterolateral dislocation while our case had a posteromedial dislocation and a fracture of the lateral humeral condyle as well makes it unique in its presentation and worth reporting. We have also included an up to date literature review on this topic.     

Factors affecting forearm compartment pressures in children with supracondylar fractures of the humerus

This study evaluated forearm compartment pressures in 29 children with supracondylar humerus fractures. Pressures were measured before and after reduction in the dorsal, superficial volar, and deep volar compartments at the proximal 1/6th and proximal 1/3rd forearm. Pressures in the deep volar compartment were significantly elevated compared with pressures in other compartments. There were also significantly higher pressures closer to the elbow within each compartment. Fracture reduction did not have a consistent immediate effect on pressures. The effect of elbow flexion on post-reduction pressures was also evaluated; flexion beyond 90 degrees produced significant pressure elevation. We conclude that forearm pressures after supracondylar fracture are greatest in the deep volar compartment and closer to the fracture site. Pressures greater than 30 mm Hg may exist without clinical evidence of compartment syndrome. To avoid unnecessary elevation of pressures, elbows should not be immobilized in >90 degrees of flexion after these injuries.     

儿童肱骨髁上骨折术后关节功能恢复临床评估

[目的]回顾性分析儿童肱骨髁上骨折术后关节活动度(range of motion,ROM)的恢复过程及相关影响因素.[方法] 2007年11月～2010年3月间收集71例儿童肱骨髁上骨折的手术病例,同时收集67例儿童前臂远端骨折采用闭合复位、长臂石膏外固定的患者作为对照组,均在1个月后拆除固定装置并进行患肢功能锻炼,系列观察随访至活动度恢复到健侧的90％为止.对儿童肱骨髁上骨折术后及前臂远端骨折外固定后肘关节活动度的恢复情况对比分析.[结果]术前评价两组患者一般资料差异无统计学意义,具有可比性.肱骨髁上骨折组分别需14.05,16.23,3.05,2.11周可恢复肘关节伸、屈及前臂旋前、旋后四个方向的90％活动度.前臂远端骨折组中,肘关节伸、屈及前臂旋前、旋后活动度要恢复到预期目标分别需2周和4～5周.两组患者在肘关节伸屈、前臂旋转功能恢复方面差异有统计学意义.[结论]伸直型儿童肱骨髁上骨折术后固定1个月,肘关节伸屈功能恢复至正常需3～4个月,前臂旋转功能恢复需2～3周,旋后较旋前功能更易于恢复,肘关节屈曲功能恢复最慢.长臂石膏外固定一个月对儿童肘关节功能恢复影响较小.     

手法整复硬纸夹板外固定治疗前臂双骨折

目的：探讨骨科手法外固定治疗前臂双骨折疗效及并发症。方法：2005年11月至2010年12月,采用骨科手法硬纸夹板外固定治疗前臂双骨折38例,其中男26例,女12例;年龄18～66岁,平均28岁。损伤至手法整复硬纸夹板外固定时间20min～2d,平均8h。施术前患肢肿胀、疼痛、畸形、异常活动,肘、腕屈伸功能及前臂旋转功能障碍,X线片显示均为前臂尺桡双骨折。术后通过对骨折的愈合情况、肘腕的屈伸功能及前臂的旋转功能进行疗效评定。结果：所有患者获得随访,时间3～8个月,平均5.7个月。根据Anderson前臂骨折治疗效果评价分级,优33例,骨折愈合,肘或腕关节的屈伸活动范围丢失〈10%以及前臂旋转丢失〈25%;良5例,骨折愈合,肘或腕关节的屈伸活动范围丢失〈20%以及前臂旋转丢失〈50%。结论：采用骨科手法外固定治疗前臂双骨折固定牢固且不会出现组织压疮及坏死,安全有效,值得临床推广。     

The supracondylar fracture of the humerus in children (author's transl)

To find out the cause of posttraumatic varus and valgus deformity of the elbow a long-term follow-up examination of 183 dislocated and 20 undislocated supracondylar extension-fractures of the humerus was done. There were different methods of treatment: In most of the cases closed reduction was performed and fixation in acute angle-plaster or by percutaneous radial or radial and ulnar wires. 75% showed radiologically and 55% clinically an alteration of the carrying angle. The clear reason for this deformity was a rotation displacement, which leads in oblique fractures directly, in transverse fractures--caused by an instability--indirectly seldom to a valgus, in most of the cases to a varus deformity of the elbow. A special quotient to judge the rotation displacement is presented: the rotation failure quotient (rfq). There is no influence of lateral compression to the carrying angle. Lateral tilting is in any case a result of rotation displacement. Growth disturbance after supracondylar fractures is possible without lesion of the epiphysial plate: but as growth disturbances are seldom and their extent small, they are of no significant clinical importance. Extension displacement of the distal fragment will be spontaneously corrected in ca. 80% of all cases during the further growth. The clinical importance of posttraumatic deformities and the primary management to avoid them is discussed. The crossed percutaneous rotation-stable wire osteosynthesis is recommended as the best way of treatment. For all kinds of treatment the challenge is asked to avoid the ventral spur as a sign of rotation till consolidation of the fracture. By correct reposition in all other planes complicated measurements and reflections, as for instance the alpha-angle by Baumann, oblique or transverse fracture, pro- or supination of the forearm during fixation a.o. are unnecessary.     

Pediatric forearm fractures: Indications, technique, and limits of conservative management

Summary Although several “minimal invasive” techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4–112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 ° (15 °–50 °). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.      

Pediatric forearm fractures: Indications, technique, and limits of conservative management Indikationen, Technik und Grenzen der konservativen Behandlung

Although several “minimal invasive” techniques for the operative management of pediatric forearm fractures have been developed recently, conservative treatment still remains the option with the lowest risk for small patients. We present the results of our clinical and radiological follow-up after an average of 52.4 months (4–112) in 102 pediatric patients. All fractures were treated conservatively. There were 68 fractures (66.7 %) of the distal third of the forearm, 30 fractures (29.4 %) of the midshaft area, and four fractures (3.9 %) in the proximal third of the shaft. Greenstick fractures were seen in 58 cases (56.8 %), complete fractures with displacement of both corticalices in 26 patients (25.5 %), and folding fractures in 18 cases (17.7 %). With the exception of one fracture with the necessity of remanipulation after redisplacement in the cast, all fractures healed uneventfully without any further intervention. Functional results were excellent with a free range of motion of the wrist and elbow and without any signs of muscular atrophy in 96 children (94.1 %) at the time of follow-up. Six patients, however, showed a significant loss of forearm rotation of an average of 25 ° (15 °–50 °). In four of these six patients, the fracture had been situated in the proximal and midshaft area. Thus, two out of four fractures of the proximal forearm (50.0 %) showed a poor functional outcome. On the basis of our data we recommend conservative management for (closed) pediatric fractures of the distal and midshaft area. Operative treatment is indicated in forearm fractures close to the elbow.     

Pediatric fractures of the forearm

Forearm fractures are common injuries in childhood. There are a number of important principles that should be followed to achieve the ideal goal of fracture healing without deformity or dysfunction. I will review the general principles, classifications, diagnosis, treatment, and complications of pediatric forearm fractures, including some specific injuries such as Monteggia fractures, Galeazzi injuries, and open fractures. The basic principle is to accurately align the fracture fragments and to maintain this position until the fracture is united. Forearm fractures in children can be treated differently from adult fractures because of continuing growth in both bones (radius and ulna) after the fracture has healed. As long as the physes are open, remodeling can occur. However, generally it is thought that rotational deformity does not remodel. Undisplaced fractures may be treated in a cast until the fracture site is no longer painful. Most displaced fractures of the forearm are best maintained in a long arm cast. However, redisplacement occurs in 7 to 13% of cases, usually within 2 weeks of injury. Unstable metaphyseal fractures should be percutaneously pinned. Unstable diaphyseal fractures can be stabilized by intramedullary fixation of the radius and ulna. If none of these techniques is helpful, plate and screw fixation is the best choice.     

The sequelae of a missed Essex-Lopresti lesion

Radial head fractures are the most common type of elbow fracture in adults. Unrecognised disruption of the intraosseous membrane at the time of injury can lead to severe wrist pain from proximal radial migration especially if the radial head is excised. In this case, despite anatomical reduction and internal fixation of the radial head fracture, longitudinal forearm instability developed after delayed radial head resection was performed 7 months post-injury. A Suave-Kapandji procedure was performed due to ongoing wrist pain. Because of the previous radial head resection, this led to a floating forearm that could only be solved by creating a one-bone forearm, sacrificing all forearm rotation to achieve a stable lever arm between the elbow and wrist joint.     

Cast index in predicting outcome of proximal pediatric forearm fractures

Background:Many pediatric forearm fractures can be treated in plaster following closed reduction. The cast index (CI, a ratio of anteroposterior to lateral internal diameters of the cast at the fracture site) is a simple, reliable marker of quality of molding and a CI of >0.8 correlates with increased risk of redisplacement. Previously, CI has been applied to all forearm fractures. We hypothesize that an acceptable CI is more difficult to achieve and does not predict outcome in fractures of the proximal forearm.Results:The mean CI was 0.77. Remanipulation was required in five cases (6%), all distal half fractures – mean CI 0.79. CI was higher in proximal half forearm fractures (0.83 vs. 0.76, P = 0.006), nonetheless these fractures did not re-displace more than distal fractures.Conclusion:Cast index is useful in predicting redisplacement of manipulated distal forearm fractures. We found that in proximal half forearm fractures it is difficult to achieve a CI of <0.8, but increased CI does not predict loss of position in these fractures. We therefore discourage the use of CI in proximal half forearm fractures.     

Variation in risk factors for fractures at different sites

Fractures in older people are important medical problems. Knowledge of risk factors is essential for successful preventive measures, but when fracture sites of diverse etiology are combined, risk factors for any one site are difficult to identify and may be missed entirely. Among older people, incidence rates of hip, proximal humerus, and vertebral fractures increase with age, but not rates of distal forearm and foot fractures. Low bone mineral density is strongly associated with hip, distal forearm, vertebral, and proximal humerus fractures, but not foot fracture. Most fractures of the hip, distal forearm, and proximal humerus result from a fall, whereas smaller proportions of fractures of the foot and vertebrae follow a fall. Frail people are likely to fracture their hip or proximal humerus, while healthy, active people tend to fracture their distal forearm. We strongly recommend that studies identify risk factors on a site-specific basis.     

Closed cast treatment of scaphoid fractures.

Cast immobilization of the wrist remains the treatment of choice for stable fractures of the waist and distal pole of the scaphoid. Criteria for diagnosis of stability should be stringent; plain radiographs may be misleading. CT may provide more accurate information on displacement. Immobilization of the thumb confers no advantage and restricts function unnecessarily. Evidence to support immobilization of the elbow is weak, but it may be useful for selected fractures. A cast does not protect the carpus from the effects of axial loading, which can produce large angulatory forces at the fracture. A gap or fracture offset of 1 mm or more are indicators of instability with potential for nonunion or malunion; internal fixation should be considered for these fractures. Internal fixation may also be considered routinely for proximal pole fractures, regardless of the degree of displacement, in view of their long healing time and high risk of nonunion after cast treatment.     

桡骨远端骨折合并同侧肘关节损伤的手术治疗体会

目的探讨桡骨远端骨折合并同侧肘关节周围骨折或脱位的治疗方法,提高临床治疗效果。 方法回顾性分析本院自2012年1月至2016年10月收治的桡骨远端骨折合并同侧肘关节脱位或骨折病例22例。22例桡骨远端骨折中13例伴尺骨茎突骨折,3例伴尺骨远端骨折,2例伴舟状骨骨折。22例肘关节周围损伤中5例为尺桡骨近端骨折,3例为肱骨远端骨折,14例发生肘关节后脱位。 结果所有患者均获得随访,术后平均随访时间为13.6个月（11~26个月）,所有骨折均愈合,未发生感染。Cooney腕关节评分平均为92.5分（55~100分）,其中优13例、良7例、中1例、差1例。Mayo肘关节功能评分平均为87.5分（50~100分）,其中优10例、良8例、中3例,差1例。其中1例就诊时已出现骨筋膜室综合征,尺神经、正中神经、桡神经均损伤,肌肉部分坏死切除,功能恢复较差。 结论桡骨远端骨折合并同侧肘关节损伤多为高能量损伤,早期积极而恰当的处理能为患者二次手术提供良好的条件,结合积极的康复锻炼,能取得良好的治疗效果。     

Ellengelenknahe Unterarmfrakturen

Fractures of the forearm close to the elbow are relatively rare, accounting for approximately 7% of all fractures. Of those sited in the proximal forearm, about 38% involve the olecranon and 20–30%, the radial head. The AO classification of forearm fractures in close proximity to the elbow has not attained general acceptance. Classifications with implications for the treatment are most commonly used. For fractures of the olecranon, we prefer the classification devised by Schatzker, since it takes account of the course of the fracture and the number of bone fracture fragments and therefore dictates what type of osteosynthesis is needed. The Mason classification has become widely accepted for fractures of the radial head. Depending on the type of fracture, conservative treatment, an operative procedure or a resection is recommended. Fractures of the coronoid process are classified with reference to Regan and Morrey’s system. The size of the fracture fragment is used as an indirectly indicator of the stability of the joint and thus of what operative intervention is needed. In addition to Monteggia’s fracture, Essex-Lopresti fracture and the terrible triad of the elbow are also discussed in detail.     

Combined Monteggia and Galeazzi fractures in a child: a case report and review of the literature

We present an unusual case in which a combination of Monteggia and Galeazzi fractures occurred in the same forearm. The patient was a 10-year-old male who climbed up the pole of a basketball net, caught hold of the net, then lost his grip, and fell onto his right hand. On physical examination, a complete paralysis of the radial ulnar and median nerves was recognized. X-rays showed an olecranon fracture and lateral dislocation of the radial head in the elbow joint, a dorsal dislocation of the distal bone fragments due to a fracture of the distal third of the radius, and a palmar dislocation of the distal end of the ulna at the wrist joint. The injuries were diagnosed as a combination of a Bado type III Monteggia fracture and a palmar-type Galeazzi fracture of the same arm. Manual reduction and immobilization in a plaster cast were performed. Three years after the injury, both the distal and proximal radioulnar joints were maintained in the reduction position. Range of motion was reduced minimally in extension at the patient's elbow, and there was complete recovery of all three nerves. A combination of Monteggia and Galeazzi fractures in the same arm has been reported in only two pediatric patients worldwide and in eight cases total when adult patients are included, indicating that this is an extremely rare trauma.     

Forearm fractures in the head-injured adult

Forty-seven of 661 head-injured adults sustained 50 forearm fractures. Eight extremities exhibited elbow flexion contractures greater than 55 degrees. Traumatic heterotopic ossification at the elbow developed in ten (20%) extremities: four with Monteggia fractures, two with olecranon fractures, and four with no known trauma. Only two of 18 (11%) extremities treated by plaster immobilization achieved good or excellent results, while 17 of 32 (53%) extremities treated by open reduction and internal fixation achieved good or excellent results. Union of fractures of one or both bones occurred at the same rate as for the normal population. There were no nonunions or deep infections, and there was only one delayed union. Calcification occurred in the interosseous membrane in 12 extremities (24%). In nine forearms (18%) a complete synostosis developed. One isolated radial fracture treated by open reduction and internal fixation and one isolated ulnar fracture treated by plaster incurred a synostosis. Seven of 21 (33%) fractures of both bones developed synostosis. Five of 16 (31%) fractures of both bones treated by open reduction and internal fixation developed a synostosis. These observations corroborate reports demonstrating that head injury predisposes to heterotopic ossification in forearm fractures.