Forearm Fractures In Children Research Articles

Which factors affect limitation of pronation/supination after forearm fractures in children? A prospective multicentre study

IntroductionBoth-bone forearm fractures in children frequently result in a limitation of pronation/supination, which hinders daily activities. The purpose of this prospective multicentre study was to investigate which clinical factors are related to the limitation of pronation/supination in children with a both-bone forearm fracture. MethodsIn four Dutch hospitals, consecutive children (<16 years) who sustained a both-bone forearm fracture were included. Children were followed up for 6–9 months and data from questionnaires, physical examination and X-rays were collected. Univariate and multivariate logistic regression analyses were used to assess the relationship between limitation of pronation/supination (≥20°) and several clinical factors. ResultsA group of 410 children with both-bone forearm fractures were included, of which 10 children missed the final examination (follow-up rate of 97.6%). We found that a re-fracture (odds ratio (OR) 11.7, 95% confidence interval (CI) 1.2; 118.5), a fracture in the diaphysis (OR 3.3, 95% CI 1.4; 7.9) and less physiotherapy during follow-up (OR 0.90, 95% CI 0.82; 0.98) were independently associated with a limitation of pronation/supination of 20° or more. ConclusionsThese findings imply that a re-fracture and a diaphyseal located fracture were associated independently of each other with a limitation of pronation/supination in children with a both-bone forearm fracture. Furthermore, in children with severe limitation extensive physiotherapy is associated with better functional outcome.

Conversion to below-elbow cast after 3 weeks is safe for diaphyseal both-bone forearm fractures in children

Background It is unclear whether it is safe to convert above-elbow cast (AEC) to below-elbow cast (BEC) in a child who has sustained a displaced diaphyseal both-bone forearm fracture that is stable after reduction. In this multicenter study, we wanted to answer the question: does early conversion to BEC cause similar forearm rotation to that after treatment with AEC alone?Children and methods Children were randomly allocated to 6 weeks of AEC, or 3 weeks of AEC followed by 3 weeks of BEC. The primary outcome was limitation of pronation/supination after 6 months. The secondary outcomes were re-displacement of the fracture, limitation of flexion/extension of the wrist and elbow, complication rate, cast comfort, complaints in daily life, and cosmetics of the fractured arm.Results 62 children were treated with 6 weeks of AEC, and 65 children were treated with 3 weeks of AEC plus 3 weeks of BEC. The follow-up rate was 60/62 and 64/65, respectively with a mean time of 6.9 (4.7–13) months. The limitation of pronation/supination was similar in both groups (18 degrees for the AEC group and 11 degrees for the AEC/BEC group). The secondary outcomes were similar in both groups, with the exception of cast comfort, which was in favor of the AEC/BEC group.Interpretation Early conversion to BEC cast is safe and results in greater cast comfort.

A new mini-invasive technique in treating pediatric diaphyseal forearm fractures by bioabsorbable elastic stable intramedullary nailing: a preliminary technical report

Operative treatment is often indicated in unstable pediatric diaphyseal forearm fractures. Recently minimally invasive reduction and elastic stable intramedullary nailing have been of increasing interest, instead of open reduction and internal fixation with plates. There are several disadvantages of metallic intramedullary implants, such as soft-tissue irritation and a risk of disturbing later imaging. Thus, they are generally removed in later operations. We aimed to develop a new technique to stabilize pediatric forearm fractures by the bioabsorbable intramedullary nailing. We developed a new, two-stage mini-invasive surgical technique to stabilize the unstable diaphyseal fractures in children. The procedure is bioabsorbable elastic stable intramedullary nailing. Ultra-high-strength bioabsorbable intramedullary nails of poly(lactide-co-glycolide) were manufactured for our purpose. The material has been widely proven to be biocompatible and stable enough for fracture treatment as screws and pins. We have used the new technique in the unstable both-bone diaphyseal forearm fractures in children between the ages of 5 and 15 years. We report the technique and our clinical experience in the series of those three cases that have been followed up for at least 12 months. The present series has been randomized for the procedure instead for titanium elastic stable intramedullary nailing, and the series represents a part of ongoing randomized trial. The reported cases operated by the new technique referred good union in the fractured bones and acceptable alignment in the follow-up. Removal of the implants was not required. No troubles with the procedure or implant per se were noticed, indicating good feasibility. One high-energy refracture occurred half year after the primary trauma. Traditional titanium implants were used to control the refracture. We report our preliminary experience of a new surgical mini-invasive procedure to stabilize the unstable pediatric forearm shaft fractures by bioabsorbable elastic stable intramedullary nailing. Our clinical experience suggests that the procedure combined with long-arm casting is feasible in treating the pediatric forearm fractures. The technique may bring benefits to handling these challenging fractures. The disadvantages of metallic implants may be avoided. In addition, removal of the implant will not be required. There was one refracture in the series, but it was due to new high-energy trauma. According to our understanding, it was not related to the type of former osteosynthesis. However, ignoring the good preliminary experience, still we do not have results of the superiority of the procedure over traditional elastic stable intramedullary nailing. Our ongoing randomized multicenter study is aimed to determine its long-term outcome against the present golden standard. Nevertheless, due to encouraging preliminary results, we see it necessary to report the technique.

Nonunion of the Radius After Elastic Stable Intramedullary Nailing of a Midshaft Forearm Fracture in a Seven-Year-Old Child: A Case Report.

Although closed reduction and immobilization remains the gold standard for treating the vast majority of forearm fractures in children, there has been an increased trend toward surgical fixation with elastic stable intramedullary nailing (ESIN) of unstable fractures1. This method allows for early mobilization, and the technique is fairly easy to master. Although complications are rare, pseudarthrosis of the ulna has been reported2,3. To the best of our knowledge, nonunion of the radius has not previously been described after ESIN of forearm fractures in children. This report describes a nonunion of the radius after ESIN of a midshaft forearm fracture in a young child. The patient and his parents were informed that data concerning the case would be submitted for publication, and they provided consent. The patient, a previously healthy seven-year-old boy, sustained a closed displaced midshaft fracture of the right forearm (Fig. 1) while playing on a trampoline. He was seen at the regional emergency center; closed reduction was initially attempted, but the fracture of the radius could not be reduced. The patient was then referred to our hospital. Under general anesthesia, an osteosynthesis of both the radius and ulna with ESIN by an experienced surgeon was performed, taking care to avoid the radial sensory nerve and extensor tendons. Closed reduction of the radial fracture was unsuccessful, and an open reduction had to be performed by a small dorsal incision. A Hohmann retractor was inserted; the interposing soft tissue was removed and the fracture was reduced. Postoperative radiographs showed good alignment and no diastases of the fracture sites (Fig. 2). The patient was provided with a long arm cast for two weeks. He was discharged to his parents’ care two days after surgery. Fig. 1 Anteroposterior (left) and lateral (right) primary radiographs of the fracture. Fig. 2 Anteroposterior …

Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial

This multicentre randomised controlled trial was designed to explore whether 6weeks above-elbow cast (AEC) or 3weeks AEC followed by 3weeks below-elbow cast (BEC) cause similar limitation of pronation and supination in non-reduced diaphyseal both-bone forearm fractures in children. Children were randomly allocated to 6weeks AEC or to 3weeks AEC followed by 3weeks BEC. The primary outcome was limitation of pronation and supination after 6months. The secondary outcomes were re-displacement of the fracture, complication rate, limitation of flexion and extension of wrist and elbow, cast comfort, cosmetics, complaints in daily life and assessment of radiographs. A group of 23 children was treated with 6weeks AEC and 24 children with 3weeks AEC and 3weeks BEC. The follow-up rate was 98% with a mean follow-up of 7.0months. The mean limitation of pronation and supination was 23.3±22.0 for children treated with AEC and 18.0±16.9 for children treated with AEC and BEC. The other study outcomes were similar in both groups. Early conversion to BEC is safe in the treatment of non-reduced diaphyseal both-bone forearm fractures in children. Multicentre randomised controlled trial, Level II.

Unterarmpseudarthrosen im Kindes- und Jugendalter

Due to the changing attitude of treating paediatric forearm fractures increasingly towards the surgical stabilisation rather than conservatively by the method of elastic stable intramedullary nailing (ESIN), we are confronted with complications which have not been described in childhood previously. Pseudarthrosis following surgically treated forearm fractures in children is only found in single reports with none in the German-speaking area. The goal of this study is to define predisposing factors which may lead to pseudarthrosis after surgery for forearm fractures. From 1990 to 2011 all children having sustained a pseudarthrosis following forearm fractures treated in our institution were included. All children who did not demonstrate a complete consolidation of the forearm fractures after 6 months from injury were considered for the study. Those pseudarthroses which were caused through systemic diseases were excluded. During the time period of 21 years, fourteen children were treated who fulfilled the criteria of having a pseudarthrosis. Nine of the fourteen children had primarily been treated in an outside hospital, five in our institution. The average age was 10.8 years (7-15 years). There were thirteen ulnar shaft and one radius shaft pseudarthroses. In 11 children the pseudarthrosis was located in the middle third and there was one child each with a pseudarthrosis in the proximal and distal third of the ulna. There were 13 ulnar shaft fractures and one monteggia lesion. Twelve of the fractures were primarily closed and there were two open cases. In nine cases an open reduction of the ulna was necessary, the radius was openly reduced in four patients. In five children technical mistakes of the osteosynthesis were identified to contribute to the formation of the pseudarthrosis. Five of the 14 children had experienced a re-fracture. Nine children had revision surgery. These children were treated by plate osteosynthesis or ESIN. In five patients the pseudarthrosis healed spontaneously without interference. There were 13 hypertrophic and one hypotrophic pseudarthroses. Pseudarthrosis of the forearm following surgical treatment of forearm fractures in children and adolescents mainly occurred in the middle third of the ulna. In primarily open fractures or in cases which needed to be openly reduced the risk of pseudarthrosis formation was higher. Inadequate osteosynthetic stabilisation is another factor to contribute to difficulties in fracture healing. Despite of the possibility of pseudarthrosis, the indication to ESIN treatment in paediatric forearm fractures is not doubted. It is important to keep the surgical trauma as small as possible if open reduction is required in order to not disturb the perfusion of the bone.

Single-bone intramedullary fixation of unstable both-bone diaphyseal forearm fractures in children leads to increased re-displacement: a multicentre randomised controlled trial

Both-bone diaphyseal forearm fractures in children can be stabilised without cast by a flexible intramedullary nail in both the radius and the ulna. Adequate results with single-bone fixation combined with a complementary cast are also reported. However, because those results are based on a selection of children, this trial investigates whether single-bone intramedullary fixation, compared with both-bone intramedullary fixation, results in similar pronation and supination in children with an unstable diaphyseal both-bone forearm fracture. In four Dutch hospitals, 24 consecutive children aged <16 years with a displaced unstable both-bone diaphyseal forearm fracture were randomly allocated to single-bone or both-bone intramedullary fixation. Primary outcome was limitation of pronation and supination 9 months after initial trauma. Secondary outcomes were limitation of flexion/extension of wrist/elbow, complication rate, operation time, cosmetics of the fractured arm, complaints in daily life, and assessment of radiographs. Between January 2006 and August 2010, 11 children were randomised to single-bone fixation and 13 to both-bone fixation. In the both-bone fixation group, two fractures were stabilized by only one nail. In both groups, median limitation of pronation/supination at 9-month follow-up was 5°-10°. In both groups operation time was similar but in the single-bone fixation group cast immobilisation was longer (median of 37 vs. 28 days). In four children, re-displacement of the fracture occurred in those fractures without an intramedullary nail. These results caution against the use of single-bone fixation in all both-bone forearm fractures. This method may lead to increased re-displacement and reduced clinical results.

Conservative interventions for treating diaphyseal fractures of the forearm bones in children.

Diaphyseal forearm fractures in children are common injuries, the vast majority of which are treated conservatively. There is a need to assess the role of modifiable factors such as techniques of reduction and casting in order to optimise functional recovery. To assess the effects of different conservative interventions for diaphyseal forearm fractures in children, including adolescents. We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (to November 2012), the Cochrane Central Register of Controlled Trials (The Cochrane Library, 2012 Issue 11), MEDLINE (1950 to November 2012), EMBASE (1980 to November 2012), CINAHL (1982 to November 2012), trial registries (to November 2012), conference proceedings and reference lists of articles. Randomised or quasi-randomised trials comparing conservative interventions for diaphyseal forearm fractures in children were eligible for inclusion. Two review authors independently examined search results to identify eligible trials. After screening 493 citations, 17 potentially eligible studies were identified. Of these 13 studies were excluded, two studies, both reported incompletely in conference abstracts only, await assessment and two are ongoing trials whose recruitment status is unknown. This review found no usable evidence from randomised trials to make recommendations concerning different conservative interventions for the treatment of diaphyseal fractures of the forearm bones in children. Publication in full of trials that have already been performed on this topic would be a useful start to changing this unsatisfactory situation.

Application of elastic stable intramedullary nailing for treating forearm fractures in children

Objective To summarize the application of elastic stable intramedullary nailing for treating forea-rm fractures in children and to evaluate its therapeutic effect. Methods A total of 98 cases of forearm fractures in children treated by elastic stable intramedullary nailing were analyzed, retrospectively.Eighty-seven cases were postoperatively followed up, but 11 cases were lost.Fifty-nine cases were male, 39 cases were female, ageing from 3 to 16 year-old, and the mean age was 6.5 year-old.Sixty-seven cases were ulnar shaft fracture, 23 cases were radial neck fractures and 8 cases were Monteggia fracture. Results Patients were followed up 4 to 36 months.Eighty-seven cases successfully achieved complete healing.Patients recovered with no pain, no deformity and obtained excellent functional recovery.One case achieved delayed healing, and skin irritation was found in 8 cases. Conclusions Elastic stable intramedullary nailing is a minimally invasive, approch easy to deal with soft tissue injury, quick in recovery, and has a good curative effect and fewer complications.Rationally using elastic stable intramedullary nailing for treating forearm fractures in children can achieve satisfactory postoperative outcomes. Key words: Elastic stable intramedullary nailing; Forearm fracture; Minimally invasive; Child

Forearm Fractures in Children: Split Opinions about Splitting the Cast

Fractures of the forearm are the most common fractures in children. Various methods of cast immobilization have been recommended. Currently, there is still controversy regarding the optimal method of treatment, especially regarding the need for cast splitting. We conducted a single-center randomized and controlled trial between June 2008 and September 2009. Children younger than 16 years presenting to the emergency department with a closed fracture of the forearm needing reduction were eligible for random assignment to immobilization in a closed or split circumferential semirigid cast. The primary outcome was the incidence of cast-related soft-tissue problems such as compartment syndrome, neurovascular compromise, saw burns, or skin breakdown. The secondary outcome was fracture stability. During this period, 100 patients were randomly assigned to one of the two procedures and analyzed. Follow-up was completed in 99 patients. No compartment syndrome was observed in either group. Moderate skin breakdown (< 2 cm(2)) occurred in two patients, one in the closed cast and one in the split cast group. Secondary splitting was necessary in one patient because of a reversible lymphedema. Significant secondary displacement of the fracture was slightly more common in the split group (5 of 50 patients [10%] vs. 4 of 49 patients [8%] in the closed cast group) without reaching statistical significance. No significant difference in the incidence of cast-related problems was observed between the groups. Fracture stability was comparable in both groups. We suggest that closed circumferential semirigid casts are a safe and effective immobilization technique for fractures of the forearm in children and splitting can be omitted.

Ulnar nerve palsy associated with forearm fracture in children: A case report

Ulnar nerve palsy associated with forearm fracture in children: A case report

Risk factors for the displacement of fractures of both bones of the forearm in children

Forearm fractures in children have a tendency to displace in a cast leading to malunion with reduced functional and cosmetic results. In order to identify risk factors for displacement, a total of 247 conservatively treated fractures of the forearm in 246 children with a mean age of 7.3 years (sd 3.2; 0.9 to 14.9) were included in a prospective multicentre study. Multivariate logistic regression analyses were performed to assess risk factors for displacement of reduced or non-reduced fractures in the cast. Displacement occurred in 73 patients (29.6%), of which 65 (89.0%) were in above-elbow casts. The mean time between the injury and displacement was 22.7 days (0 to 59). The independent factors found to significantly increase the risk of displacement were a fracture of the non-dominant arm (p = 0.024), a complete fracture (p = 0.040), a fracture with translation of the ulna on lateral radiographs (p = 0.014) and shortening of the fracture (p = 0.019). Fractures of both forearm bones in children have a strong tendency to displace even in an above-elbow cast. Severe fractures of the non-dominant arm are at highest risk for displacement. Radiographs at set times during treatment might identify early displacement, which should be treated before malunion occurs, especially in older children with less potential for remodelling.

The Results of Surgical Management of Unstable Both-Bone Forearm Fractures in Children

The Results of Surgical Management of Unstable Both-Bone Forearm Fractures in Children

Re-displacement of stable distal both-bone forearm fractures in children: A randomised controlled multicentre trial

IntroductionDisplaced metaphyseal both-bone fractures of the distal forearm are generally reduced and stabilised by an above-elbow cast (AEC) with or without additional pinning. The purpose of this study was to find out if re-displacement of a reduced stable metaphyseal both-bone fracture of the distal forearm in a child could be prevented by stabilisation with Kirschner wires. MethodsConsecutive children aged <16 years with a displaced metaphyseal both-bone fracture of the distal forearm (n=128) that was stable after reduction were randomised to AEC with or without percutaneous fixation with Kirschner wires. The primary outcome was re-displacement of the fracture. ResultsA total of 67 children were allocated to fracture reduction and AEC and 61 to reduction of the fracture, fixation with Kirschner wires and AEC. The follow-up rate was 96% with a mean follow-up of 7.1 months. Fractures treated with additional pinning showed less re-displacement (8% vs. 45%), less limitation of pronation and supination (mean limitation 6.9 (±9.4)° vs. 14.3 (±13.6)°) but more complications (14 vs. 1). ConclusionsPinning of apparent stable both-bone fractures of the distal forearm in children might reduce fracture re-displacement. The frequently seen complications of pinning might be reduced by a proper surgical technique.

A 5-year Overview of Forearm Fracture Etiology and Treatment Options in 7-15 Years Old Children

SummaryIntroduction.Forearm fractures make up a significant part of overall fracture rate in pediatric population, especially in 7-15 years old children. Different methods of treatment have been used, depending on the age of children and type and localization of fracture. Most controversies can be seen among conservative and surgical methods of treatment.Aim of the Study.The aim of our study is to identify common localizations and types of forearm bone fractures in pediatric population, as well as analyze patient data and treatment process depending on selected method of treatment for out-patients and in-patients.Materials and Methods.Retrospective analysis of out-patient and in-patient records, treated in University Children’s hospital from 2007 to 2011 was made, including first time patients with fractures of one or both forearm bones, according to ICD-10 codes S52.0- S52.9. Demographical data, trauma mechanisms, localization and type of fracture, as well as applied treatment and stay length at hospital were analyzed. 1742 out-patients and 1029 in-patients, 7-15 years old at the moment of trauma, were included in this research.Results.2771 forearm fractures were registered, 62.9% patients were treated on out-patient basis, 37.1 % patients required treatment in hospital. Forearm bone fractures were gender specific - 2235 boys and 536 girls had to be treated (Male:Female ratio was 4.2 : 1). The peak incidence was seen in 13 years old boys and girls. Boys suffered from forearm fractures more often in any age group. Most common mechanisms of injuries causing forearm fractures in children were related with sports trainings - 22.1%, skiing - 15.0% and traffic injuries - 10.0%. Most common activities at the moment of trauma differ by season - during winter months they include skiing, skating and sledging while in summer falls from height, bicycles and swings are dominant. Several trauma mechanisms, like sport trainings, are not season-dependent. Some injury mechanisms differ significantly by gender. Boys were more often as girls injured during sports trainings and skiing, while girls experience forearm fractures due to bicycling and skating. Occurrence of forearm fractures in children has seasonal differences with two peaks: from June to August and from December to February. Distal forearm fractures are the most often seen localization of overall forearm fractures (42 % in boys and 36 % in girls). In out-patients group conservative treatment was performed - plaster immobilization in 1339 cases and closed reduction, followed by plaster immobilization in 403 cases. In-patients were treated both - conservatively with immobilization in 21 cases and closed reduction in 188 cases, and surgically with K-wire osteosynthesis in 137 cases or elastic stable intramedullary nailing (ESIN) in 683 cases. The type and localization of each fracture, along with the age of patient, are the key factors for choosing the right treatment method. K-wire osteosynthesis was performed in all age groups for unstable fractures in distal or proximal third of forearm. ESIN was a method of choice for unstable or comminuted midshaft fractures of one or both bones, metadiaphyseal fractures and some specific conditions (radial neck fractures, Monteggia fractures-dislocations), especially in older patients. Stay length at hospital was ranging from 1 to 2 hospital days in case of immobilization (mean = 1,05 days), from 1 to 4 days in closed reduction group (mean = 1,32 days), but 1 to 12 days in hospital spent children after K-wire osteosynthesis (mean = 1,99 days) or ESIN (mean = 2,38 days).Conclusions.1. Forearm fractures in children have a significant gender diversity (M : F ratio is 4,2 : 1).2. Peak incidence group is 13 years old adolescents of both genders.3. Seasonality and season-specific injury patterns are typical for pediatric forearm fractures.4. The most common anatomic localization is the distal segment of forearm bones.5. Younger children (7-9 years) are mainly treated by conservative methods, while methods of choice for treatment of forearm fractures in adolescents (13-15 years) are operative.6. Surgical treatment of fractures do not significantly increase stay length at hospital.

Sonographic Diagnosis of Metaphyseal Forearm Fractures in Children

Metaphyseal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to x-ray diagnosis. We investigated 76 patients aged between 1 and 14 years. After clinical assessment, patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard 2-view radiographs of the wrist. Ultrasound and radiographic findings were then compared, and sensitivity and specificity for ultrasound were calculated. Of 76 patients, we found 42 patients with 52 metaphyseal forearm fractures by x-rays. By ultrasound, we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to x-ray, we calculated for ultrasound a sensitivity of 96.1% and a specificity of 97%. Comparing axis deviation of displaced fractures, we found a mean difference of 2.1 degrees between sonographic and x-ray values. We confirm that ultrasound is an applicable and safe alternative tool to x-rays in nondisplaced or excluded metaphyseal forearm fractures in children.

Late Presentation of Isolated Digital Contracture following Forearm Fracture

The inflammatory response associated with fracture healing induces varying levels of local scarring and adhesions. Associated morbidity from local adhesions is rare in forearm fractures, but entrapment of flexor tendons has been reported in the literature following both-bone forearm fractures in children and adolescents [1–9]. In 14 of the 15 cases of flexor tendon entrapment following both-bone forearm fractures, the flexor digitorum profundus (FDP) tendon was involved. Akita and Kawai [1] reported on a flexor digitorum superficialis tendon entrapment 4 weeks following injury. It is thought that the more superficial location of the flexor digitorum superficialis (FDS) tendon affords some protection from adhesion to the fracture site. We present a delayed presentation of contracture of the index finger in a 15-year-old patient 5 years following a forearm fracture.

Above- or below-elbow casts for distal third forearm fractures in children? An updated meta-analysis of the literature

Introduction Fractures of the distal third forearm are common fractures in childhood. Most of these fractures can be treated non-operatively by means of closed reduction and immobilization. The purpose of this meta-analysis is to investigate whether above- or below-elbow cast should be considered the first-choice for conservative treatment.

Die Sonografie als sichere Alternative zur konventionellen Röntgendiagnostik bei distalen Unterarmfrakturen im Kindesalter

Distal forearm fractures are very common in childhood. Radiography of the wrist is the standard diagnostic procedure. But because of higher sensitivity of growing bones to ionising radiation the diagnostic use of X-rays should be minimised as much as possible. Recent studies have shown that distal forearm fractures in children can be safely and reliably diagnosed using only ultrasound. The aim of our study was to evaluate and confirm the safety and applicability of the ultrasound diagnostic procedure in comparison to X-ray diagnosis under routine conditions of our paediatric emergency department. We investigated 115 patients aged 2-14 years. After clinical assessment patients with suspected forearm fractures first underwent ultrasound examination of the metaphyseal forearm followed by standard two view radiographs of the wrist. Ultrasound and radiographic findings were then compared and sensitivity and specificity for ultrasound were calculated. In 9 patients with suspected displacements, sonographic and radiographic axis measurement were done and also compared. Radiologically we found 62 patients with 78 distal forearm fractures. By ultrasound we also diagnosed 52 fractures. All patients with no fractures were correctly diagnosed as well. Referring to X-rays we calculated for ultrasound a sensitivity of 94.9 %, a specificity of 98 %, a negative predictive value of 97.4 % and a positive predictive value of 96.1 %. The mean difference of the deformities of the radius in the sagittal section measured sonographically and radiologically were 1.7° (SD 1.6°). We confirm ultrasound is an applicable, rapid and safe alternative to X-rays in diagnosing metaphyseal forearm fractures in children. Even sonographic axis measurement seems to be a viable method. Thereby ultrasound potentially reduces the X-ray burden in children and additionally accelerates the diagnostic procedure.

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.