Displaced Forearm Fractures Research Articles

125 Reducing Displaced Forearm Fractures in Children: Are we following the guidelines?

Abstract Primary Subject area Emergency Medicine - Paediatric Background Forearm fractures account for 45% of pediatric fractures, mainly involving the distal third of the forearm. Some will be displaced, requiring a closed reduction and plaster cast immobilization. Re-displacement during follow-up is reported in 7 to 35% of the cases. Objectives To identity discrepancies between hospital guidelines and patient management for forearm fracture reduction in children aged 1 to 17. Design/Methods This retrospective case series was conducted by a medical audit committee of CHU Sainte-Justine for the purpose of improving quality of care. This project aimed to evaluate the clinical course following closed reduction of forearm fractures in patients presenting to the emergency department (ED) or to the orthopedic clinic in a pediatric tertiary care centre. Children aged 1 to 17 years old presenting between January 1 and December 31 2019 were considered for this study. We selected a convenience sample of 50 consecutive cases and reviewed their medical and radiological data from first consultation through follow-ups. The management of these cases was evaluated against established hospital guidelines for primary or secondary fracture reduction (primary outcome). The angulation and displacement of fractures were measured using original imaging taken prior to reduction, and at follow-up. At their last appointment, all patients’ range of motion and angulation were assessed. Complications of sedation and immobilization were also reviewed. Descriptive statistics were performed for all variables. Results From the 106 radiologic files retrieved of closed forearm fracture reduction using fluoroscopy, a convenient sample of 50 cases was reviewed. The mean age was 7 years and 60% of them were boys. Forty-eight (96%) had an initial fracture reduction consistent with the local practice guideline for need of reduction. Sedation adverse events were noted in 10 patients (20%), most often nausea, but no severe adverse event was identified. According to the local practice guideline, 13 (26%) patients suffered re-displacement at follow-up. Of these, 3 underwent a second closed reduction, 4 had a gypsotomy, and 6 had no attempt at a second reduction. Five patients (10%) had a second reduction during follow-up, despite the displacement not meeting the local guideline criteria for reduction. Cast-related issues were reported in 14 patients (28%), with the molding technique accounting for most of the problems observed. At their final follow-up, 40 patients (80%) had an excellent or good functional outcome. In the remaining 10 (20%), the range of motion was more limited, but measurements were done for many of them following immediate cast removal. Forty patients (80%) had either a normal or near normal alignment at their final follow-up. In the remaining 10 (20%), none of these patients had an angulation greater than 20 degrees. Conclusion From this audit of patients presenting with displaced forearm fractures in a pediatric tertiary care centre, the initial management of patients was in accordance with the established guidelines of practice in 96% of cases. Re-displacements at follow-up were identified in a quarter of patients. Nonetheless, angulation and the final range of motion of the wrist were favorable shortly after cast removal. Further improvement in the management could be achieved by improving the technique of cast immobilization.

Outcomes of Displaced Forearm Fractures in Children Treated With Closed Reduction and Casting and a Loop and Sling Attached to the Cast Proximal to the Fracture Site

Outcomes of Displaced Forearm Fractures in Children Treated With Closed Reduction and Casting and a Loop and Sling Attached to the Cast Proximal to the Fracture Site

Predictors for losing reduction after reposition in conservatively treated both-bone forearm fractures in 38 children

BackgroundsAlignment loss after reduction and cast immobilisation of angulated and/or complete displaced forearm fractures is challenging. Many authors have tried to describe risk factors and create indices (initial angulation, initial complete displacement, lack of anatomic reduction, cast and padding index) in order to identify those fractures that are prone to losing their alignment during treatment. MethodsThis retrospective case-control study included children sustaining both-bone forearm fractures treated by closed reduction and cast immobilisation. Basic characteristics were recorded and radiographs evaluated to measure displacement and angulation before and after reduction, cast index and padding index. The primary outcome was loss of reduction during the immobilisation period. ResultsGroup A consisted of 22 patients in whom >5° reduction loss was seen during cast immobilisation. Group B consisted of 16 patients with <5° reduction loss. After multivariate analyses we found group A included more broken cortices, with a statistically significant higher number of initial displaced fractures (p < 0.001 and p = 0.010) and residual displacement (p = 0.022). The cast and padding index did not differ significantly between groups (p = 0.77 and 0.15 respectively). ConclusionsCast and padding index did not correlate well as predictor of alignment loss, although in this study cortical stability seemed more important towards predicting alignment loss.

Forearm Fixation is Not Necessary in the Treatment of Pediatric Floating Elbow.

Ipsilateral supracondylar humerus and forearm fractures in the pediatric population are an uncommon injury associated with high-energy trauma. Current literature suggests a high rate of compartmental syndrome with this fracture pattern and recommends surgical stabilization of both injuries. We investigate whether surgical treatment of the supracondylar fracture with closed reduction of the forearm fracture and placement into a noncircumferential cast may be an appropriate treatment. Retrospective clinical and radiographic review of 47 patients (22 male, 25 female; mean age 6 y) with modified Gartland type 2 or type 3 supracondylar humerus fracture requiring surgical stabilization and an ipsilateral forearm fracture from a single institution over 78 months. Forty-seven pediatric "floating elbow" cases that had operative management of the supracondylar fracture were identified. A total of 21/47 (45%) had displaced forearm fractures that required closed manipulation. Of these, 17/21 (81%) underwent closed reduction of the displaced forearm fracture(s) and were placed into a noncircumferential cast or splint. No patients lost reduction or required remanipulation of either fracture. No patients developed signs of elevated compartment pressures. All patients went on to radiographic union without secondary procedures. We demonstrate that a supracondylar humerus fracture with an ipsilateral forearm fracture can be safely managed with operative stabilization of the supracondylar humerus fracture alone. Simultaneous closed reduction of the ipsilateral displaced forearm fracture and use of noncircumferential immobilization postoperatively is safe and was not associated with the development of elevated compartment pressures or need for remanipulation. Previous studies that relate a high rate of compartment syndrome with this injury pattern may be misguided, as method of postoperative immobilization may be a more significant factor in the development of elevated compartment pressures than the injury pattern. Level IV.

Bivalved Versus Circumferential Cast Immobilization for Displaced Forearm Fractures: A Randomized Clinical Trial to Assess Efficacy and Safety.

The purpose of this study was to determine the effects of bivalved versus circumferential cast immobilization on maintenance of reduction and associated complications after closed reduction (CR) of radius and/or ulna fractures in children. Two hundred two children with displaced radius and/or ulna fractures were randomized to either circumferential (n=101) or bivalved (n=101) long-arm casts after CR. The mean age was 10±3 years. There were no significant differences between groups in terms of age, sex, or initial fracture displacement or angulation. Clinical and radiographic evaluations were performed at 1, 2, 4, and 6 weeks postreduction. Radiographic loss of reduction (LOR), need for remanipulation or surgery, and associated complications of compartment syndrome, cast saw injury, and neurovascular compromise were recorded. Overall, the median angulation of the radius and ulna fractures improved from 20 and 18 degrees to 3 and 2 degrees after CR, respectively. The median cast index after reduction was 0.78 in the bivalved group and 0.80 in the circumferential group. The median angulation of the radius and ulna was 8 and 1 degrees at 4 weeks, with no significant difference between groups. By the fourth week of follow-up, 70 patients (34%)-35 bivalved and 35 circumferential-had radiographic LOR. Forty-seven patients (23%)-23 bivalved and 24 circumferential-underwent remanipulation or surgical reduction and fixation. There were no significant differences between groups with respect to LOR rate or need for surgical treatment. One bivalved patient sustained a cast saw injury, and 3 bivalved patients had transient neurological abnormalities. No patients developed compartment syndrome. Cast immobilization is effective in the majority of patients after CR of displaced forearm fractures. There were no significant differences in maintenance of reduction, need for surgery, or complications between bivalved or circumferential long-arm casts. Level I-therapeutic.

Uso de Clavos Endomedulares Flexibles de Titanio en el Tratamiento de Fracturas Diafisarias de Antebrazo en Pacientes Pediátricos

&lt;div class="page" title="Page 1"&gt;&lt;div class="layoutArea"&gt;&lt;div class="column"&gt;&lt;p&gt;&lt;strong&gt;Objetivo: &lt;/strong&gt;&lt;span&gt;Evaluar el resultado del tratamiento de niños con fractura desplazada de antebrazo mediante la estabilización con clavos endomedulares flexibles de titanio. &lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Materiales­y­Métodos: &lt;/strong&gt;&lt;span&gt;Se evaluaron, en forma retrospectiva, 13 pacientes (edad promedio 11 años; rango 6-15). Se realizó una evaluación comparativa entre el antebrazo operado y el antebrazo sano contralateral. La evaluación radiológica comparó la longitud del radio, y la ubicación y magnitud del lugar de máxima curvatura del radio entre ambos antebrazos. La evaluación funcional comparó el rango de pronosupinación del antebrazo. El seguimiento promedio fue de 37 meses (rango 12-68).&lt;br /&gt; &lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Resultados: &lt;/strong&gt;&lt;span&gt;La longitud del radio operado fue de 18,1 cm y la del radio contralateral sano, de 18,1 cm (p = 1). La localización del lugar de máxima curvatura del radio se ubicó a nivel del 66,8% de la longitud en el radio operado y a nivel del 61,5% de la longitud en el radio contralateral no operado (p &amp;lt;0,01). La magnitud de la máxima curvatura del radio fue del 6,2% y del 6,7% de la longitud total del radio, en el antebrazo operado y en el no operado, respectivamente (p = 0,26). La pronación del antebrazo operado fue de 87,7 grados y la del contralateral sano, de 88,3 grados (p = 0,26). La supinación fue de 89,9 grados y de 90,9 grados en el antebrazo operado y en el no operado, respectivamente (p = 0,49).&lt;br /&gt; &lt;/span&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusiones: &lt;/strong&gt;&lt;span&gt;El tratamiento de niños con fracturas desplazadas de antebrazo mediante la estabilización con clavos endomedulares flexibles produce resultados radiológicos y funcionales similares a los del antebrazo contralateral sano.&lt;/span&gt;&lt;/p&gt;&lt;p&gt; &lt;/p&gt;&lt;/div&gt;&lt;/div&gt;&lt;/div&gt;

Circumferential vs Bivalved Cast Immobilization for Displaced Forearm Fractures: A Randomized Clinical Trial to Assess Safety and Efficacy: Level 1 Evidence

Circumferential vs Bivalved Cast Immobilization for Displaced Forearm Fractures: A Randomized Clinical Trial to Assess Safety and Efficacy: Level 1 Evidence

Reply to “Displaced distal forearm fractures in children with an indication for reduction under general anesthesia should be percutaneously fixated” by van Egmond PW, Schipper IB, van Luijt PA in Eur J Orthop Surg Traumatol. 2012 Apr;22(3):201–207

With great interest we read the article ‘‘Displaced distal forearm fractures in children with an indication for reduction under general anesthesia should be percutaneously fixated’’ by van Egmond et al. [1]. We agree with the authors that displaced forearm fractures are commonly encountered injuries in childhood. In our own publication, we have shown that distal forearm fractures account for almost a tenth of all pediatric fractures [2]. The authors show that 43.7 % of the children treated with unfixed reduction of a displaced forearm fracture needed a secondary procedure under general anesthesia. Comparable high rates of re-displacement have been described previously [3]. These high rates of re-dislocations motivated us to perform a retrospective analysis of our own patients. Between 2007 and 2011, we treated 109 children (mean age 8.9, range 2–15 years) with 111 displaced distal forearm fractures with closed reduction and cast immobilization under general anesthesia. Five of these fractures (4.5 %) were complicated by re-displacement necessitating secondary intervention consisting of closed reduction and cast immobilization in two patients, closed reduction and internal plate fixation in one patient (15 a) and open reduction and internal K-wire fixation in one other child (12 a). In addition to anatomical reduction and meticulous follow-up, a good cast is the key to prevent re-displacement of conservatively treated fractures. The pivotal role of cast quality has already been addressed by other authors [4]. Can methodical differences in applying the plaster cast, therefore, explain the abovementioned differences in the percentage of re-dislocations? In our department, the main goal—when applying the cast—is avoiding excessive padding and poor molding. Additionally, our patients were followed on a weekly basis for a mean of 4.6 weeks (range 3–8 weeks) until radiographic union was achieved and the cast could be removed. These facts may explain the low percentage of re-displacements necessitating secondary intervention in our series of patients. In conclusion, we cannot agree with the authors’ recommendation to primary perform invasive fixation of dislocated distal forearm fractures in children.

Ultrasound imaging of undisplaced partial forearm fractures in children

Objective: To check the value of ultrasonography in the diagnosis of undisplaced partial forearm fractures in children. Methods: A case series study was conducted in AL-Khansa'a and Al-Zahrawy teaching hospitals in Mosul over a period between November 2005 to October 2006. One hundred patients (54 male and 46 female) between the age of 2-15 years suffering from high clinical suspicion of non displaced forearm fractures were first examined by ultrasound (Sonoline SL 100, Siemens Nurnberg Germany) with 7.5MHZ linear array transducer by a radiologist who gave an immediate report. Standard two views radiography of the forearm then obtained. The radiographs were reported by another senior radiologist. Ultrasonographic and radiographic reports were then compared.Results: One hundred patients were examined, 54 male and 46 female with male/female ratio 1:1.7. The type of fractures found were 46 torus type, 48 greenstick and 6 were plastic deformity. Subperiosteal haematoma was encountered in 100% of the fractures, bending sign was 100% and finally reverberation echoes was shown in all the fracture types too.Conclusion: Ultrasound is a useful method in the diagnosis of undisplaced forearm fractures in children. It is an easy, safe , fast and in-expensive procedure. More studies are indicated to confirm its reliability in different pediatric fractures.

Management of Markedly Displaced Forearm Fractures in Children

Management of Markedly Displaced Forearm Fractures in Children