Forearm Fractures In Children Research Articles

Comparison of three surgical fixation methods for dual-bone forearm fractures in older children: A retrospective cohort study

BackgroundThe aim of this study was to compare the outcomes of dual ESIN (D-ESIN) fixation, hybrid fixation, and open reduction and dual plate (d-plate) fixation in the treatment of dual-bone forearm fractures in children aged 10–16 years. Materials and methods137 patients with dual-bone forearm fractures (48 patients in the D-ESIN group, 45 patients in the hybrid group, and 44 patients in the d-plate group) were reviewed. Duration of surgery, length of incision, intraoperative blood loss, intraoperative times of fluoroscopy, and duration of postoperative immobilisation were recorded. Radiographic outcomes, functional outcomes, and complication rate were also recorded. ResultsSurgeries and incisions were significantly shorter, and less intraoperative blood loss occurred, in the hybrid group than the d-plate group (P < 0.001). The hybrid group was also characterised by less intraoperative fluoroscopy times and shorter duration of postoperative immobilisation compared with the D-ESIN group (P < 0.001). The union rate of the ulna at 3 months postoperatively was higher in the hybrid and d-plate groups than in the D-ESIN group (P = 0.003). The union rate of the radius was similar in all three groups (P = 0.403). No significant difference in the union rate of the radius or ulna was observed among groups at 6 months postoperatively (P = 0.052). The mean union time was notably later in the D-ESIN group than in the hybrid and d-plate groups. However, no significant difference in functional outcome or complication rate was observed among the three groups (P = 0.822 and P = 0.912). ConclusionHybrid fixation was superior in terms of the duration of surgery, intraoperative use of fluoroscopy, intraoperative blood loss, duration of postoperative immobilisation, delayed union of the ulna, and bone union time. Therefore, hybrid fixation is a safe and effective treatment for dual-bone forearm fractures in children aged 10–16 years.

Intramedullary Nailing of Both Bone Forearm Fractures in Children by Rush Nails and Titanium Elastic Nails

INTRODUCTION: Forearm fractures are common upper limb injuries among children and usually treated nonoperatively. Failure of nonoperative treatment, open injuries and multiple fractures are the indications for surgery in paediatric both bone forearm fractures. Intramedullary (IM) nailing is considered as minimally invasive procedure with excellent to fair outcomes but it is not free of complications. We reviewed the results and compared the outcomes of IM fixation by Rush nails with titanium elastic nails (TENs), to understand the risks and complications associated with this procedures. MATERIAL AND METHODS: We performed a retrospective review of all paediatric patients treated for diaphyseal forearm fractures from January 2011 to December 2015. Complications were classified according to modified Clavien-Dindo complication classification system. Outcomes were graded depending upon complication grade along with range of motion of forearm. RESULTS: There was no statistically significant difference for mean time to fracture union between the Rush nailing (10.56 weeks ) group and TENs nailing group (9.85weeks) (P = 0.43). There was no statistically significant difference in outcomes between Rush nailing and TENs nailing group p=0.65. In Rush nailing group outcomes were excellent in 16 (64%), good in 7(28%), fair in 2( 8%) patients and no poor outcome were noted. In TENs nailing group outcomes were excellent in 11 (55%) , good in 6 (30%), fair in 3 (15%) patients and no poor outcomes were noted. CONCLUSION: Fixation of pediatric forearm fractures by intramedullary Rush nails and titanium elastic nails (TENs) are minimally invasive procedures and results are excellent to fair with acceptable complication rates. Since Rush nails are easily available and affordable in developing countries like ours we can prefer Rush nails for intramedullary fixation of paediatric forearm fracture when indicated. Journal of Universal College of Medical Sciences (2016) Vol.04 No.01 Issue 13, Page: 10-15

Both-Bone Forearm Fractures in Children with Minimum Four Years of Growth Remaining: Can Cast Achieve a Good Outcome at Skeletal Maturity?

Introduction: Both-bone forearm fractures in children can be treated non-operatively with a cast. Most previous studies have shown favourable outcome; however, information on the functional outcome after skeletal maturity is still scanty. Therefore, this study was conducted to determine the functional outcome after skeletal maturity in fractures with at least four years of growth remaining.Materials and Methods: This retrospective study was conducted from March 2012 until March 2013. Age at the time of fracture was taken as until 10 years for females and until 12 years old for males with at least four years of growth remaining. Fractures occurring in the diaphysis were included in the study. Functional outcomes were assessed at or after skeletal maturity.Results: Forty-four children fulfilled the criteria. The ages of the youngest and the oldest at the time of fracture was five and 12 years old respectively. Follow-up of the male and female patients were 7.4 years and 5.5 years respectively. There was a significant difference between post-reduction angulation and angulation at skeletal maturity of the radius and ulna (p<0.001). Out of 44 patients, 39 had excellent and five had good functional outcomes. No patient had fair or poor functional outcome. There was no association between the functional outcome and the angulation of forearm bones after skeletal maturity. Age at the time of fracture had a significant association with the functional outcome.Conclusion: Non-operative treatment of both-bone diaphyseal forearm fractures in a cast has good to excellent functional outcomes in children who still have four years of growth remaining.

278 Intranasal Ketamine for Procedural Sedation in Children: A Randomized Controlled Pilot Study

The pain of intravenous (IV) insertion is rated by children as second only to disease-related pain. Procedural sedation and analgesia (PSA) is a common indication for IV insertion in the emergency department (ED). Ketamine is the most frequently used agent for PSA in children. Intranasal ketamine (INK) has shown effectiveness for PSA in a limited number of painful procedures (IV insertion, gastric aspiration, and laceration repair) but no studies have explored INK for fracture reduction in children. Our objective was to evaluate the feasibility of INK for PSA in children who sustained a fracture requiring a closed reduction. This was a randomized, blinded, controlled, trial comparing the effectiveness of INK versus intravenous ketamine (IVK). We included children 4-17 years, < 40 kg with a non-shortened distal forearm fracture requiring PSA for closed reduction. Participants were randomized using a double-dummy approach to receive single dose (i) INK 8 mg/kg (maximum 320 mg) + 0.9% IV normal saline OR (ii) IVK 1 mg/kg (maximum of 40 mg) + IN 0.9% normal saline. The primary outcome was the proportion of participants with adequate sedation during closed reduction as defined by a University of Michigan Sedation Scale (UMSS) score of > 3 of 4. Secondary outcomes included need for additional IV sedation, adverse effects, time to sedation defined as a UMSS score of > 3 of 4, and length of stay. Fifteen participants were consecutively recruited from March 1, 2016 to Feb 1, 2017. Seven children (3 females) received INK and the mean (SD) age was 6.6 (3.1) years. Eight children (3 females) received IVK and the mean (SD) age was 5.9 (2) years. Adequate sedation was achieved by 4/7 (57.1%) versus 7/8 (87.5%) participants in the INK and IVK groups, respectively (p = 0.28). The median (IQR) time to sedation was 10 (11.3) versus 5 (0) minutes in the INK and IVK groups, respectively (p = 0.23). Additional IVK was required by 5/7 (71.4%) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.13). Adverse effects consisting of nausea, vomiting, or dizziness were seen in 4/7 (57.1) versus 2/8 (25%) of participants in the INK and IVK groups, respectively (p = 0.32). No participants experienced emergence agitation and there were no serious adverse events. The median (IQR) length of stay in the INK and IVK groups was 364 (153) versus 290 (113) minutes, respectively (p = 0.13). The adequacy of sedation for INK 8 mg/kg is inconsistent for closed reduction of distal forearm fractures in children. Greater sedative efficacy may be achieved with a higher INK dose (9-10 mg/kg), consistent with demonstrated effectiveness in other studies of PSA in children undergoing painful procedures.

Elastic stable intramedullary nailing in paediatric forearm fractures: the rate of open reduction and complications.

The aim of this study was to evaluate the rate of open reduction and complications of elastic stable intramedullary nailing (ESIN) in treating unstable diaphyseal forearm fractures in children. We performed a retrospective review of a consecutive series of 102 paediatric patients with a mean age of 9 years (range: 7-14 years) who underwent ESIN of unstable closed forearm fractures at three different centres. Closed reduction of one or both bones was achieved in 68 (67%) patients and open reduction was required in 34 (33%) patients. The rate of open reduction in single-bone fractures (52.2%) was significantly higher than that in both-bone fractures (27.8%) (P=0.04, Fisher's exact test). All the fractures united within 3 months. There were six refractures following nail removal. Five patients had superficial wound infections. Seven patients developed neuropraxia of the sensory branch of the radial nerve. All resolved spontaneously within 3 months of the surgery. ESIN is an effective technique in treating unstable diaphyseal forearm fractures. The need for open reduction should be decided promptly following failed attempts of closed reduction. Single-bone fractures are more likely to require open reduction than both-bone fractures. The radius should be reduced and stabilized first. If open reduction is required, this should be performed through a volar approach rather than a dorsal one.

The efficacy and safety of combination therapy of low-intensity pulsed ultrasound stimulation in the treatment of unstable both radius and ulna fractures in children.

There are few reports of Low-intensity pulsed ultrasound (LIPUS) treatment for fresh forearm fractures in children. LIPUS stimulation was applied after surgery of forearm fractures in children and the efficacy and safety of combination therapy of LIPUS treatment were evaluated. Children with both radius and ulna fracture, twenty-five diaphysis (mid-R&U) and nineteen metaphysis (dist-R&U) fractures, were treated with intramedullary nailing followed by cast and splint mobilization. Thirteen patients in the mid-R&U fracture group and eight patients in the dist-R&U fracture group were combined with LIPUS stimulation postoperatively. Periosteal callus appeared significantly earlier after surgery in the LIPUS-treated groups than in the groups without LIPUS treatment. The duration of external fixation was significantly shorter in the dist-R&U fracture group treated with LIPUS stimulation compared with that in the mid-R&U fracture group without LIPUS treatment. Furthermore, the time span needed for bone union in the groups with LIPUS stimulation was significantly shorter than in the groups without LIPUS stimulation. It is suggested that LIPUS stimulation can lead to a reduction of treatment periods of unstable forearm fractures safely after operation even in children.

Point-of-Care US and Nonangulated Forearm Fractures

Research Article| August 01 2017 Point-of-Care US and Nonangulated Forearm Fractures AAP Grand Rounds (2017) 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation Point-of-Care US and Nonangulated Forearm Fractures. AAP Grand Rounds August 2017; 38 (2): 17. https://doi.org/10.1542/gr.38-2-17 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: diagnostic radiologic examination, forearm fractures, point-of-care ultrasonography, pain Source: Poonai N, Myslik F, Joubert G, et al. Point-of-care ultrasound for nonangulated distal forearm fractures in children: test performance characteristics and patient-centered outcomes. Acad Emerg Med. 2017; 24(5): 607– 616; doi: https://doi.org/10.1111/acem.13146Google Scholar Researchers from multiple Canadian institutions conducted a cross-sectional study to determine the utility of point-of-care ultrasonography (POCUS) in children with suspected nonangulated distal forearm fractures. Children were eligible if they were 4–17 years old and presented to the study emergency department (ED) with a suspected nonangulated distal forearm fracture, defined as maximal pain and tenderness at the distal third of the forearm after an acute fall on an outstretched hand. Each participant underwent radiography and POCUS of the distal ulna and radius. POCUS was performed and interpreted by 4 POCUS-certified pediatric ED physicians with at least 2 years of POCUS experience who were not involved in the patient’s care. POCUS evaluators were blinded to the radiographs, and radiography technicians and radiologists were blinded to POCUS interpretations. Each study child was classified as having a fracture or not on the basis of a radiologist’s interpretation of the patient’s radiographs. The primary outcome was the sensitivity and specificity of the POCUS evaluation by the ED physician (fracture or no fracture) when compared to radiograph interpretation. Secondary outcomes included (a) patient self-reported pain immediately after radiography and POCUS by using Faces Pain Scale–Revised scores, (b) caregiver satisfaction with each imaging procedure by using a single-item question and a 5-point Likert scale, and (c) duration of POCUS and radiography procedures. Of 169 children enrolled, 76 had a fracture on radiographs. The most common type was a buckle fracture (80%). The sensitivity and specificity of POCUS were 94.7% (95% confidence interval [CI], 89.7%–99.8%) and 93.5% (95% CI, 88.6%–98.5%), respectively. There were 4 fractures missed with POCUS (1 distal radius buckle fracture and 3 ulnar styloid factures). There were 6 nonfractures that were interpreted as fractures at POCUS. POCUS was associated with a significantly lower median pain score when compared with radiography. There was no significant difference in median caregiver satisfaction scores with POCUS and radiographic procedures. POCUS was associated with a significantly lower median procedure duration than radiography (1.5 vs 27 minutes, respectively; P < .001). The researchers conclude that using POCUS to assess distal forearm injuries in children is accurate, timely, and associated with low levels of pain. Dr Stevenson has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. POCUS is a useful tool in the pediatric ED setting. The current study is 1 of several published in recent years to evaluate its use in forearm fractures in children. A recent meta-analysis of these studies supports the high sensitivity and specificity reported in the present study,1 which excluded children with obvious forearm deformities and thereby reduced the potential for inflated test performance. Few prior studies have been conducted to evaluate pain... You do not currently have access to this content.

Functional Outcome of Intramedullary Nailing with Rush Pin for Pediatric Both Bone Fractures of Forearm in Western Hilly Nepal

Introduction: Both bone diaphysis fracture of forearm is common in children of hilly area in Nepal because the children climbs tree and cliff for playing and cutting grass. Close reduction and casting is the preferred method of treatment these fractures but the chances of re-displacement is very high. Intramedullary nailing with titanium elastic nails or rush pins is widely accepted these days with good outcome. Titanium nails are popular in western world but is costly whereas rush pins are cheap and are preferred in developing world. The aim of this study was to evaluate the functional outcome of intramedullary rush pin for pediatric both bone fracture of forearm.&#x0D; Methods: In this retrospective, observational study done from 1st of February 2017 to 31st of March 2017, a total of sixty patients with both bone fractures of forearm were treated with intramedullary rush pin and followed up for six months for evaluation of functional outcome. T-test and Chi-square tests were done.&#x0D; Results: Closed reduction and internal fixation was done in 48 (80%) patients. Mean age of the patients was 9.23 year (SD=2.77). Fifty-six (93.3%) patients were male with a significant difference (p&lt;0.001). With price et al. grading system, 49 (81.7%) patients had excellent results, nine (15%) had good and two (3.3%) patients had fair results. There was no major complication. Mean time to implant removal was 24.16 weeks (SD=1.62) from the time of surgery with range of 20 to 28 weeks. Among transverse and oblique fractures, patients with transverse fracture were likely to have better outcome (p=0.04).&#x0D; Conclusion: Intramedullary nailing with rush pin gives excellent to good functional outcome in majority of the cases without major complications at low cost for management of both bone fractures of forearm in children.

Results of Retrograde K-Wire Fixation in Diaphyseal Fractures of Forearm in Children

Background: Diaphyseal fractures of forearm is the third most common fracture in children. Majority of these fractures can be treated with close reduction and cast immobilization due to the growth potential of the immature skeletal. But in elder age group Intramedullary K wire fixation through retrograde approach is the most invasive and less complicated procedure to ensure the prevention of deformity and restore the functions.Aim: To evaluate the effectiveness of the treatment of diaphyseal fractures of forearm in children with intramedullary K wire fixation through retrograde approach and look for short term and immediate results.Methodology: This was a prospective observational hospital based study carried out in Nepalgunj Medical College Teaching Hospital from January 2012 to December 2013, in children between 5-15 years with K wires for diaphyseal fractures of forearm through retrograde approach which was followed up for 12 months. All patients underwent close reduction and intramedullary K wire fixation retrograde. At 6, 12 and 48 weeks; range of motion and tenderness were looked for.Results: There were 32 patients in the study with average age of 10.41 years for male and 10.21 years for female. Average time for union was 7.3 weeks. There were no nonunion and malunions in follow ups. At 6 months all had full range of motion without any complications.Conclusion: Operative treatment with K wires through retrograde approach for diaphyseal fractures of forearm is an invasive procedure for less complications, patient's comfort and early range of motion.JNGMC Vol. 14 No. 1 July 2016, Page: 27-31

Point-of-care Ultrasound for Nonangulated Distal Forearm Fractures in Children: Test Performance Characteristics and Patient-centered Outcomes.

Distal forearm fractures are the most common fracture type in children. Point-of-care-ultrasound (POCUS) is increasingly being used, and preliminary studies suggest that it offers an accurate approach to diagnosis. However, outcomes such as pain, satisfaction, and procedure duration have not been explored but may be salient to the widespread acceptance of this technology by caregivers and children. Our objectives were to examine the test performance characteristics of POCUS for nonangulated distal forearm injuries in children and compare POCUS to x-ray with respect to pain, caregiver satisfaction, and procedure duration. We conducted a cross-sectional study involving children aged 4-17 years with a suspected nonangulated distal forearm fracture. Participants underwent both x-ray and POCUS assessment. The primary outcome was sensitivity between POCUS and x-ray, the reference standard. Secondary outcomes included self-reported pain using the Faces Pain Scale-Revised, caregiver satisfaction using a five-item Likert scale, and procedure duration. POCUS was performed in 169 children of whom 76 were diagnosed with a fracture including 61 buckle fractures. Sensitivity of POCUS for distal forearm fractures was 94.7% (95% confidence interval [CI] = 89.7-99.8) and specificity was 93.5% (95% CI = 88.6-98.5). POCUS was associated with a significantly lower median (interquartile range [IQR]) pain score compared to x-ray: 1 (0-2) versus 2 (1-3), respectively (median difference = 0.5; 95% CI = 0.5-1; p < 0.001) and no significant difference in median (IQR) caregiver satisfaction score: 5 (0) versus 5 (4-5), respectively (median difference = 0, 95% CI = 0, p = 1.0). POCUS was associated with a significantly lower median (IQR) procedure duration versus x-ray: 1.5 (0.8-2.2) minutes versus 27 (15-58) minutes, respectively (median difference = 34.1, 95% CI = 26.8-41.5, p < 0.001). Our findings suggest that POCUS assessment of distal forearm injuries in children is accurate, timely, and associated with low levels of pain and high caregiver satisfaction.

Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures

Elastic stable intramedullary nailing (ESIN) has been established as state of the art treatment for forearm fractures in children, if operative stabilization is required. Their use has been expanded to single bone shaft fractures, and also more complex injuries such as Monteggia fractures or Monteggia-like lesions. A wide range of complications has been reported in the literature, up to 70% in certain investigations. The purpose of this study was to assess the complication rate after ESIN treatment of forearm fractures in children and adolescents in a representative cohort of patients from a level 1 trauma center in Germany.Between 2000 and 2015, we retrospectively analyzed all patients, up to the age of 16 years, with forearm fractures, who were operatively treated using ESIN in our department of general and trauma surgery. The main outcome measurements were the rates of postoperative complications after ESIN such as re-fracture, malunion, nonunion, tendon lesion, wound infection, and limited range of motion.In all, 201 consecutive patients with 202 forearm fractures were included in this study. Age averaged 9.7 years (range 3-16 years). Fifteen (7.4%) fractures were open. Fractures were 82.2% diaphyseal both-bone forearm fractures. Follow-up averaged 10.2 months (range 0.7-176.3 months). Complications were 10 re-fractures, 2 malunions, 3 extensor pollicis longus tendon ruptures, 1 superficial wound infection, and 2 limited range of motions. Fourteen (6.9%) children required a secondary operative intervention for their complication. Time to implant removal averaged 3.8 months (range 0.4-16.3 months).Elastic stable intramedullary nailing is a minimally invasive and reliable technique with a low complication rate. Both-bone forearm fractures and single bone fractures, and also Monteggia and Monteggia-equivalent fractures can be successfully treated with this method. As a major complication, re-fractures are frequently seen, even with ESIN in situ.

ESIN and K-wire fixation has similar results in both bone pediatric forearm fractures

The purpose of this study was to compare short-term radiographic and clinical results of pediatric both-bone diaphyseal forearm fractures treated with intramedullary nail fixation using titanium nails or K-wires. This was a prospective comparative trial. In total, 43 patients with both-bone open or closed forearm fractures who underwent surgical treatment with intramedullary fixation were randomly classified into two groups. Three patients did not return for the follow-up and were excluded from the study. Twenty of the 40 patients were assigned to the elastic stable intramedullary nail group and 20 were assigned to the K-wire group. Demographic data suggested no difference between the two groups except for the side of injury. Perioperative data and radiological and clinical outcomes were evaluated. The cohort comprised 5 girls and 35 boys whose mean age was 11.60 ± 2.69 years. Except the proportion of patients who were conservatively followed up preoperatively, all perioperative data were similar between the groups. Radiographic and functional results were similar. There were two delayed unions; one pin track infection and one re-fracture. Intramedullary fixation of forearm fractures in children with titanium nail or K-wire does not affect radiological and clinical results. Both elastic stable intramedullary nail and K-wire fixation were effective in stabilizing pediatric diaphyseal forearm fractures.

Predictive factors for re-displacement in diaphyseal forearm fractures in children—role of radiographic indices

Background and purpose — Manipulation and cast immobilization is the primary management for diaphyseal forearm fractures in children, and re-displacement is the most common complication. We wanted (1) to analyze the incidence of re-displacement in a group of children treated with close reduction and casting; (2) to determine predictive factors such as demographics, mechanism of injury, affected bone, fracture pattern, degree of initial displacement and angulation, and reduction accuracy; and (3) to determine the prognostic effect of previously defined radiographic indices.Patients and methods — We prospectively studied 269 consecutive children with closed and complete middle-third diaphyseal fractures treated with close reduction and casting from October 2014 to April 2015. Factors analyzed included demographics, initial fracture features, having a non-anatomical reduction, and the radiographic indices of cast quality.Results — There were 189 fractures of both bones (70%) and 80 solitary fractures (30%). The overall re-displacement rate was 11%. According to multivariable analysis, independent predictors of re-displacement were initial angulation >10° (RR =5) and failure to achieve an anatomical reduction (RR =2). Statistically significant radiographic indices regarding increased rate of re-displacement included cast index ≥0.7 (RR =5), Canterbury index ≥1.1 (RR =3), and 3-point index ≥0.8 (RR =6).Interpretation — Our results suggested that fractures with a higher degree of initial angulation and non-anatomical reduction more often result in re-displacement. Moreover, the casting quality examined with the radiographic indices played an important role in the success of a non-operative management.

Bedside Ultrasound vs X-Ray for the Diagnosis of Forearm Fractures in Children

BackgroundPainful forearm injuries after a fall occur frequently in children. X-ray study is currently the gold standard investigation. Ultrasound (US) is a potential alternative that avoids exposure to ionizing radiation and may be less painful than x-ray study; and familiarity and skill with US is increasing among emergency physicians. ObjectivesThe primary aim of this study was to determine if a cohort of physicians with little or no previous experience with US could, after a short training program, safely exclude forearm fractures in children. Secondary aims were to compare any pain or discomfort associated with clinical examination, US, and x-ray study and to determine the acceptability of US as a diagnostic tool to parents and patients. MethodsA prospective, nonrandomized, interventional diagnostic study was performed on children between the ages of 0 and 16 years who had a suspected fracture of the forearm. US scanning was performed by a group of physicians, most with little or no previous US experience. ResultsAfter the brief training program, a group of pediatric emergency physicians could diagnose forearm fractures in children with a sensitivity of 91.5% and a specificity of 87.6%. Pain associated with US was no better or worse than pain associated with x-ray study. Patients and parents preferred US over x-ray study as an investigation modality for suspected forearm fractures. ConclusionA group of pediatric emergency physicians with limited previous experience could, after a short training program, diagnose forearm fractures in children. Pain associated with US was no better or worse than pain associated with x-ray study.

ANALYSIS OF FAILURES AND COMPLICATIONS FOLLOWING TREATMENT OF DIAPHYSEAL FOREARM FRACTURES IN CHILDREN USING FLEXIBLE INTRAMEDULLARY NAILING

Introduction. Currently flexible intramedullary nailing (FIN) is the method of choice for treatment of diaphyseal forearm fractures in children.Purpose of the study: to perform a quantitative and qualitative analysis of failures and complications encountered in treatment of children with diaphyseal forearm fractures using FIN fixation.Materials and methods. The study included 55 consecutive continuous cases of diaphyseal forearm fractures in children operated by FIN fixation from October 2011 till October 2014. Follow up period covered timeframe from admission until implant removal but no less than 6 months. The authors studied age, gender, fracture pattern, surgical technique features, length of hospital stay, frequency of outpatient examinations, healing period, x-ray data and all complications.Results. Complications during treatment were reported in 10 patients. Two patients demonstrated two complications. In two cases a surgical procedure was required to address the complications. Early postoperative complications were observed in two cases (neuropathy of superficial branch of radial nerve). In other cases patients developed complications at outpatient stage starting one to six months after the surgery which did not impact the final outcome.Conclusion. Despite various complications observed following FIN fixation of diaphyseal forearm fractures in children, their severity and frequency had no impact on the final outcome in the authors’ case series. Majority of issues were related to violations in surgical technique and adverse fracture pattern.

Pediatric forearm fractures with tens: freedom of movements

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; A prospective analysis of a case series of diaphyseal forearm fractures in children treated with titanium elastic nails is presented. &lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; Between 2012 and 2014, 30 children aged 5-15 years with displaced diaphyseal forearm fractures underwent titanium elastic nailing. Both bones were fractured in 25 patients, four fractured only the radius, and one experienced ulna fracture. Eleven candidates had unstable irreducible fractures, 13 had loss of reduction, and six had open fractures. Titanium elastic nails were used to stabilize the fractures. All fractures were immobilized postoperatively with an above-elbow plaster slab for 2 weeks till the swelling is completely resolved followed by encouraging range of motion exercises.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; Closed reduction and TENS was successful in 20 cases, including 15 double-bone fractures and five single-bone fractures. Open reduction was completed in four fractures of both bones, and in six single-bone open fractures. Bone union was achieved in all patients at an average of 7 weeks. The ROM of the forearms was evaluated using the Daruwalla grading criteria. Excellent results were reported in 96% without significant complications after a mean follow-up of 20 months.&lt;/p&gt;&lt;p class="Default"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Titanium elastic nails fixation of pediatric forearm fractures revealed several advantages, a small incision for insertion, a low rate of complications, unhindered bone healing, and good clinical and radiological results thus achieving maximum range of motion at the earliest.&lt;/p&gt;

The Utility of Point-of-Care Ultrasound in Detecting Distal Forearm Buckle Fractures in Paediatric Patients

Abstract BACKGROUND: Distal forearm fractures are common paediatric injuries. The use of plain radiographs is almost universal for diagnosis but this technology can be painful and time consuming. It is well known that children’s pain in the emergency department (ED) is both under-recognized and suboptimally managed. Point-of-care ultrasound (POCUS) has demonstrated good accuracy in detecting cortical disruption in adults but test characteristics in the most common paediatric fracture type (buckle or torus fractures) have not been explored. POCUS may also lead to quicker assessment and be associated with less pain and improved caregiver satisfaction compared to plain radiographs. Our results may provide support an alternative diagnostic strategy for centres where plain radiographs are not readily accessible and where severe pain is an issue. OBJECTIVES: The objectives of this study were to: (i) evaluate the diagnostic accuracy POCUS in detecting suspected non-angulated distal forearm fractures in children presenting to the ED compared to AP and lateral plain film x-rays of the forearm, (ii) determine the length of time required to complete a POCUS evaluation for a suspected distal forearm non-angulated fracture in children in the ED, (iii) explore the differences in caregiver satisfaction with POCUS evaluation compared to plain radiography, and (iv) explore differences in associated pain between POCUS and plain radiography. DESIGN/METHODS: This was a prospective cohort study designed to test the hypothesis that POCUS provides comparable sensitivity and specificity to plain radiography and is associated with less pain and greater caregiver satisfaction. We included children aged 4-17 years who presented to the paediatric ED with a suspected non-angulated distal forearm fracture based on a typical mechanism of injury. The patient underwent an x-ray and a POCUS evaluation of the affected region by a Canadian Emergency Ultrasound (CEUS)-trained physician who was blinded to the x-ray results. Caregivers were asked to complete a satisfaction questionnaire using a five-point Likert scale and children were asked to complete the Faces Pain Scale – Revised (FPS-R) reflecting discomfort associated with the diagnostic modality. The primary POCUS diagnosis made by the physician was compared to the x-ray diagnosis made by the staff paediatric radiologist. All POCUS images were independently interpreted by a second expert POCUS sonographer blinded to the original POCUS interpretation, x-ray, and final diagnosis. The primary outcomes were sensitivity of POCUS and pain score using the FPS-R. RESULTS: Eighty-five participants were enrolled, of whom 33 (39%) sustained a buckle fracture. The mean (SD) age of the participants was 11 (3.4) years and 52 (61%) were male. Sensitivity and sensitivity of POCUS for detecting any cortical disruption was 97% [95% CI: 84.2, 99.9] and 96% [95% CI: 86.8, 99.5], respectively. Agreement (kappa) between sonographers was 0.74 [95% CI: 0.64, 0.87] representing substantial agreement. POCUS was associated with significantly lower mean (SD) pain scores compared to plain radiography [2.3 (2.5) vs 3.6 (3.0), p &amp;lt; 0.01]. The median (IQR) time to perform POCUS was significantly lower that plain radiography [68 (42) vs 1200 (1440) seconds, p &amp;lt; 0.01]. POCUS was associated with comparable mean caregiver satisfaction compared to plain radiography [4.7 (0.7) vs 4.4 (1.0), p = 0.15]. CONCLUSION: This prospective study of POCUS for non-angulated distal forearm injuries in children suggests that POCUS is associated with excellent sensitivity and specificity for the detection of cortical disruption. Furthermore, POCUS is associated with significantly less pain and procedure time compared to plain radiography. The results suggest that POCUS could be a useful diagnostic strategy in resource-limited settings for children with suspected forearm injuries and has the added benefit of lower associated pain.

Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation.

Metaphyseal forearm fractures are a common occurrence in childhood accounting up to 20% of all pediatric fractures. The standard diagnostic procedure is an x-ray scan. Sonographic examinations could be an alternative that avoids exposition to ionizing radiation and possibly reduces pain, time, and costs. This is a systematic review of clinical studies evaluating ultrasound as a possible alternative to radiographs in diagnosing metaphyseal forearm fractures in children. A systematic literature research for diagnostic studies and reviews was conducted in EMBASE, MEDLINE, and the Cochrane Library in May 2013 and updated in May 2014. In addition, reference lists of publications included were scanned. Outcome parameters were diagnostic accuracy, costs, examination time, and the assessment of pain. The study population is defined as children, because forearm fractures are very common in this age group and the impact of radiation on younger patients is greater than that on adults. Methodological quality of the studies has been assessed with Quality Assessment of Diagnostic Accuracy Studies-2. In addition, we carried out a cost center accounting. Eight diagnostic studies and 2 reviews were included in the analysis. The risk of bias of 4 studies was low; and of the other 4 ones, it was moderate. Critical aspects were missing or inaccurate blinding and insufficient descriptions of the study protocol, especially the order of examinations.Twenty-six to 115 patients within the age of 0 to 21 years were included in the studies. Sensitivity ranged from 64% to 100% and specificity did between 73% and 100%. Sensitivity was in six studies and specificity was in seven studies higher than 90%.Chaar-Alvarez et al reported an average time reduction of 25 minutes by using sonography instead of x-ray and a reduction of pain from 1.7 to 1.2 points on a visual analog scale (0-5 points). In 2 other studies, all patients reported pain-free sonographic examinations. The results of the cost center accounting, not being representative, were costs of &OV0556;20.54 per examination with ultrasound and &OV0556;26.60 per radiography-based one, which is a potential saving of 22.79% by replacing radiographic examinations by ultrasound. Sensitivity and specificity of ultrasound examinations are high. Single study results show that sonographic examinations can be faster and less painful. In addition, the calculation model shows a tendency towards less-expensive ultrasound examinations.Further studies are needed with an adequate sample size calculation for assessing equivalence or non-inferiority of ultrasound and x-ray and to collect data on pain, examination time, and costs. The age of the older participants may be problematic because of the fact that epiphyseal plates close within the age from 15 to 22 years, which may influence the diagnostic accuracy of sonographic examinations. Therefore, future studies should contain age-stratified analyses. In addition, the calculation model for costs should be tested on a wider data base.

Ultrasound for Distal Forearm Fracture: A Systematic Review and Diagnostic Meta-Analysis.

Study ObjectiveTo determine the diagnostic accuracy of ultrasound for detecting distal forearm fractures.MethodsA systematic review and diagnostic meta-analysis was performed according to the PRISMA statement. We searched MEDLINE, Web of Science and the Cochrane Library from inception to September 2015. All prospective studies of the diagnostic accuracy of ultrasound versus radiography as the reference standard were included. We excluded studies with a retrospective design and those with evidence of verification bias. We assessed the methodological quality of the included studies with the QUADAS-2 tool. We performed a meta-analysis of studies evaluating ultrasound to calculate the pooled sensitivity and specificity with 95% confidence intervals (CI95%) using a bivariate model with random effects. Subgroup and sensitivity analysis were used to examine the effect of methodological differences and other study characteristics.ResultsOut of 867 publications we included 16 studies with 1,204 patients and 641 fractures. The pooled test characteristics for ultrasound were: sensitivity 97% (CI95% 93–99%), specificity 95% (CI95% 89–98%), positive likelihood ratio (LR) 20.0 (8.5–47.2) and negative LR 0.03 (0.01–0.08). The corresponding pooled diagnostic odds ratio (DOR) was 667 (142–3,133). Apparent differences were shown for method of viewing, with the 6-view method showing higher specificity, positive LR, and DOR, compared to the 4-view method.ConclusionThe present meta-analysis showed that ultrasound has a high accuracy for the diagnosis of distal forearm fractures in children when used by proper viewing method. Based on this, ultrasound should be considered a reliable alternative, which has the advantages of being radiation free.

Comparison of hybrid fixation versus dual intramedullary nailing fixation for forearm fractures in older children: Case-control study

ObjectiveThe aim of the present study was to compare the clinical outcomes of hybrid fixation using elastic stable intramedullary nailing (ESIN) for the radius and plate screw fixation for the ulna (Hybrid group) with dual ESIN fixation (D-ESIN group) for both-bone forearm fractures in children between 10 and 16 years of age. MethodsFifty patients with both-bone forearm fractures (28 patients in the Hybrid group and 22 patients in the D-ESIN group) were reviewed. Functional outcomes were evaluated according to the criteria of Price et al. Radiological results were assessed by fracture union at three and six months and bone union time. Postoperative complications were also recorded. ResultsThe times of fluoroscopy intraoperatively and duration of immobilization postoperatively were significantly lower in the Hybrid group (P < 0.05). The union rate of the ulna at three months postoperatively in the hybrid group was significantly higher than that in the D-ESIN group (P < 0.05). The average time of bone union was significantly shorter in the hybrid group than that in the D-ESIN group (P < 0.05). There were no differences according to the satisfactory rate and degree, the major and minor complications between the groups. ConclusionHybrid fixation is superior in terms of the times of fluoroscopy intraoperatively, duration of immobilization postoperatively, delayed union rate of the ulna and the average time of bone union. Therefore, hybrid fixation is an alternative treatment for both-bone forearm fractures in children between 10 and 16 years of age.