Management of Diaphyseal Forearm Fractures in Paediatric Patients: Lesson Learnt During COVID-19 Pandemic

Abstract

Objectives: Our objectives were to study the epidemiology, management and change in trends in management of paediatric diaphyseal forearm fractures during the COVID-19 pandemic. Methods: It was a prospective study which included all fresh (≤ 3 weeks), traumatic, forearm diaphyseal fractures in paediatric patients ≤ 16 years. Closed & compound grade I fractures were included. Pathological fractures, compound grade II/III fractures and fractures ≥ 3 weeks old were excluded. All patients underwent closed reduction and above elbow cast application. Acceptability of reduction was graded as per the criteria described by Noonan KJ, et al. At 2 weeks follow-up, repeat check radiograph was done for assessing acceptable reduction. Patients with acceptable reduction were continued with nonsurgical treatment and patients with loss of reduction were offered operative intervention. But due to refusal of operative intervention by the parents, patients were continued with the nonsurgical treatment. Results: Eighty patients were available for follow-up. Mean age was 7.78 years. Left to right side involvement was 58% & 42% respectively. Out of 80 patients, 20 patients were operated due to failed closed reduction, while 60 patients were managed nonsurgically. Out of 60 patients, 18 (30%) presented with loss of reduction and were offered surgery. Refusal to surgery pushed us to continue with nonsurgical treatment and evaluation as a separate group in the study as nonsurgically treated, not meeting the acceptability criteria. In nutshell out of 80 patients, 20 were managed operatively, while 60 were managed nonsurgically, 42 (70%) patients meeting the acceptable reduction criteria while 18 patients (30%) were not meeting the acceptable reduction criteria. Restriction of forearm rotations was found to be statistically insignificant in all nonsurgically treated patients irrespective of the reduction criteria met or not. Furthermore, on sub-grouping the patients with loss of reduction, on the basis of age and angulation it was observed that there was no significant change in the final functional outcome in the patients with angulation of 15-18 degrees in ≤ 10 years of age and 10-13 degrees in > 10 years of age weather treated conservatively or operatively (p value = 0.522). However, when angulation was > 18 degrees in ≤ 10 years of age and > 13 degrees in > 10 years of age, it was observed that operated patients had statistically significant better functional outcome when compared to conservatively treated patients (p value < 0.05). Conclusion: Our study attempts to highlight the management of paediatric forearm diaphyseal fractures with emphasis on nonsurgical management of these injuries to deal with the scarcity of follow-up care during the global health crisis. The encouraging results of our conservatively treated patients, even when angulation is few degrees more than the acceptable limit, allows us to widen the acceptable limit of reduction in paediatric population, especially when the health care system is challenged by the global pandemic and its restrictions. However more studies are required to confirm our findings before making them generalizable.