Pediatric Forearm Fractures Research Articles

Deformed pediatric forearm fractures: Predictors of successful reduction by emergency providers

Forearm fractures are common pediatric injuries. Most displaced or angulated fractures can be managed via closed reduction in the operating room or in the Emergency Department (ED). Previous research has shown that emergency physicians can successfully perform closed reduction within ED; however, the fracture morphology amendable to ED physician reduction is unclear. The aim of this study is to detail the fracture characteristics associated with successful reduction by ED physicians. We conducted a retrospective study of children (aged <18 years) presenting to the ED of a tertiary care children's hospital (annual census 90,000) between January 2018 and December 2018 with closed distal and midshaft forearm fractures requiring reduction. Data collected included patient demographics, fracture morphology, management, and complications. Successful ED physician reduction was based on predefined criteria. Orthopedic referrals included those patients sent directly to the operating room, closed reductions performed by orthopedic trainees within the ED, and patients requiring orthopedic consultation after failed ED reduction. A total of 340 patients with forearm fractures were included in the study. ED clinicians attempted to reduce 274 (80.6%) of these fractures and were successful in 256/274 (93.4%) cases. Of the 84 orthopedic referrals, 18 were after failed ED clinician attempt, and 66 were ab initio managed by orthopedics (37 in the operating room and 29 in ED). Compared to the fractures with successful ED reduction (n = 256), factors associated with orthopedic referral (n = 84) included: increasing age, midshaft location, higher degree of angulation, and completely displaced fractures. Angulated distal greenstick fractures were most likely to be successfully reduced by ED clinicians. There were no difference in complication rates between the two groups. In this series, fractures most amenable to reduction by ED clinicians include distal greenstick fractures, whereas midshaft and completely displaced fractures are more likely to need treatment by orthopedics.

Operative Fixation of Pediatric Forearm Fractures: Does the Fracture Location Matter?

Background Flexible intramedullary nails (FNs) are successfully used to treat pediatric forearm fractures, especially midshaft fractures. Distal forearm fractures have been described as “difficult to manage” with FN insertion. The purpose of this study was to report the clinical and radiographic outcomes of using flexible nails in pediatric forearm fractures and the impact of fracture location on the outcome of the procedure. Methods This is a retrospective review of pediatric patients who presented with forearm fractures that were surgically treated with flexible nails between 2009 and 2018. Patient demographics, fracture location, and classification were reported. Intraoperative and postoperative complications were reported. The primary outcomes were fracture radiographic union, intraop and postop complications, and the need for additional surgical procedures. Results Fifty-nine patients were included, with a mean age of 11 years. All fractures healed with patients regaining full range of motion. The authors were able to use flexible nails successfully in 48/59 (81%) patients. In eleven cases (19%), FN fixation was not able to provide adequate fixation to maintain reduction. The method of fixation was changed from FN insertion to another method in nine cases. In two cases, FN fixation was augmented with another fixation method. Fractures within 3 inches of the distal articular surface were at a higher risk of intraoperative change/augmentation of the fixation method (29%) compared with fractures that occurred more than 3 inches from the distal articular surface (11%). Conclusion The majority of pediatric forearm fractures can be treated successfully with flexible nails. Surgeons involved in treating these fractures should pay attention to distal third fractures. Stabilizing the distally located fractures using FN fixation can be challenging. Surgeons should be prepared to use an alternative fixation method when needed.

STUDY OF TENS NAIL IN PAEDIATRIC RADIUS AND ULNA FRACTURE

Introduction: Forearm is considered as a functional joint, therefore near anatomical reduction is essential to regain normal supination and pronation. In older children many forearm fractures can be treated conservatively, but failures continue to occur despite good orthopaedic intentions. The fracture which are irreducible or unstable fracture which tends to re-displace needs surgical interventions. Among various surgical treatment one is internal xation using TENS. Various studies in the recent shows excellent to good clinical outcomes using TENS. Aims: Our study is intended to evaluate the clinical and radiological outcomes in paediatric both bone forearm fracture using TENS. Materials and methods: A total of 30 patients are included in our study. All are investigated, undergone preanesthetic check-up and taken for TENS application under image intensier. Nail diameter taken as 33-40% of narrowest diameter of diaphysys were introduced proximally in ulna and distally in radius under image intensier in closed manner. Postoperatively, patients encouraged for active shoulder, elbow and nger movements and suture removal done after 2 weeks. All patients are followed up to 24 week, when implant removal was done. Results: In our study 90% patients show excellent functional results. Conclusion: We conclude that TENS in both bone forearm fractures in adolescent age group in terms of union and range of motion is a minimally invasive and effective method of xation

Clinical Outcomes of Management of Pediatric Diaphyseal Forearm Fractures Using Flexible Elastic Nailing

Clinical Outcomes of Management of Pediatric Diaphyseal Forearm Fractures Using Flexible Elastic Nailing

The effects of maximal radial bowing on forearm rotation in pediatric diaphyseal forearm fractures.

To evaluate the effects of radial bowing on forearm rotation in forearm fractures compared with healthy children. A retrospective study was conducted on children aged 1-16years old. Group 1 was children with history of diaphyseal forearm fractures, and group 2 was healthy children. Children in group 1 with ≤ 70° forearm pronation and/or ≤ 80° supination on affected side are defined as "case." In group 2, children with forearm pronation > 70° and/or supination > 80° are defined as "control." Radial bowing was measured on AP radiograph of the forearm; maximal radial bowing (MRB) and location of the maximal radial bowing (LMRB) were recorded. Total of 112 children were included (group 1 = 70, group 2 = 42). In group 1, there were 28 children with ≤ 70° forearm pronation and/or ≤ 80° forearm supination (case group). In group 2, there were 33 children with > 70° forearm pronation and > 80° forearm supination (control group). Mean age of case and control group was 11.08 ± 3.02 and 7.85 ± 3.93years, respectively. Average MRB was 6.15 ± 1.93% and LMRB was 61.94 ± 9.41% in case group. In control group, average MRB was 7.23 ± 1.03% and LMRB was 62.08 ± 4.24%. There was statistically significant correlation between children with ≤ 70° forearm pronation and MRB (P = 0.034) compared with control group. Also, there was statistically significant correlation between children with ≤ 80° forearm supination and MRB (P = 0.023) compared with control group. For ROC curve analysis, MRB ≤ 6.84% showed the association with ≤ 70° forearm pronation (72.2% sensitivity and 73.8% specificity) and MRB ≤ 5.75% associated with ≤ 80° forearm supination (54.6% sensitivity and 84.9% specificity). Children with MRB ≤ 6.84% can result in ≤ 70° forearm pronation, and MRB ≤ 5.75% can be presented with ≤ 80° forearm supination.

Do We Need to Stabilize All Reduced Metaphyseal Both-bone Forearm Fractures in Children with K-wires?

Short-term follow-up studies have shown that reduced metaphyseal both-bone forearm fractures in children should be treated with K-wires to prevent redisplacement and inferior functional results. Minimum 5-year follow-up studies are limited. Range of motion, patient-reported outcome measures, and radiographic parameters at minimum 5-year follow-up should be evaluated because they could change insights into how to treat pediatric metaphyseal forearm fractures. (1) Does K-wire stabilization of reduced metaphyseal both-bone forearm fractures in children provide better forearm rotation at minimum 5-year follow-up? (2) Do malunions (untreated redisplaced fractures) of reduced metaphyseal both-bone forearm fractures in children induce worse functional results? (3) Which factors lead to limited forearm rotation at minimum 5-year follow-up? We analyzed the extended minimum 5-year follow-up of a randomized controlled trial in which children with a reduced metaphyseal both-bone forearm fracture were randomized to either an above-elbow cast (casting group) or fixation with K-wires and an above-elbow cast (K-wire group). Between January 2006 and December 2010, 128 patients were included in the original randomized controlled trial: 67 in the casting group and 61 in the K-wire group. For the current study, based on an a priori calculation, it was determined that, with an anticipated mean limitation in prosupination (forearm rotation) of 7° ± 7° in the casting group and 3° ± 5° in the K-wire group, a power of 80% and a significance of 0.05, the two groups should consist of 50 patients each. Between January 2014 and May 2016, 82% (105 of 128) of patients were included, with a mean follow-up of 6.8 ± 1.4 years: 54 in the casting group and 51 in the K-wire group. At trauma, patients had a mean age of 9 ± 3 years and had mean angulations of the radius and ulna of 25° ± 14° and 23° ± 18°, respectively. The primary result was limitation in forearm rotation. Secondary outcome measures were radiologic assessment, patient-reported outcome measures (QuickDASH and ABILHAND-kids), handgrip strength, and VAS score for cosmetic appearance. Assessments were performed by the first author (unblinded). Multivariable logistic regression analysis was performed to analyze which factors led to a clinically relevant limitation in forearm rotation. There was a mean limitation in forearm rotation of 5° ± 11° in the casting group and 5° ± 8° in the K-wire group, with a mean difference of 0.3° (95% CI -3° to 4°; p = 0.86). Malunions occurred more often in the casting group than in the K-wire group: 19% (13 of 67) versus 7% (4 of 61) with an odds ratio of 0.22 for K-wiring (95% CI 0.06 to 0.80; p = 0.02). In patients in whom a malunion occurred (malunion group), there was a mean limitation in forearm rotation of 6° ± 16° versus 5° ± 9° in patients who did not have a malunion (acceptable alignment group), with a mean difference 0.8° (95% CI -5° to 7°; p = 0.87). Factors associated with a limited forearm rotation ≥ 20° were a malunion after above-elbow casting (OR 5.2 [95% CI 1.0 to 27]; p = 0.045) and a refracture (OR 7.1 [95% CI 1.4 to 37]; p = 0.02). At a minimum of 5 years after injury, in children with a reduced metaphyseal both-bone forearm fracture, there were no differences in forearm rotation, patient-reported outcome measures, or radiographic parameters between patients treated with only an above-elbow cast compared with those treated with additional K-wire fixation. Redisplacements occurred more often if treated by an above-elbow cast alone. If fracture redisplacement is not treated promptly, this leads to a malunion, which is a risk factor for a clinically relevant (≥ 20°) limitation in forearm rotation at minimum 5-year follow-up. Children with metaphyseal both-bone forearm fractures can be treated with closed reduction and casting without additional K-wire fixation. Nevertheless, a clinician should inform parents and patient about the high risk of fracture redisplacement (and therefore malunion), with risk for limited forearm rotation if left untreated. Weekly radiographic monitoring is essential. If redisplacement occurs, remanipulation and fixation with K-wires should be considered based on gender, age, and direction of angulation. Future research is required to establish the influence of (skeletal) age, gender, and the direction of malunion angulation on clinical outcome. Level I, therapeutic study.

Titanium Elastic Nailing System, An Effective Way Of Pediatric Forearm Fracture Management

Introduction- Pediatric both bone forearm fracture commonly encountered in orthopedic emergency, their treatment varies widely from simple sling and cast to operative fixation with nailing and plating with no definitive consensus on one treatment modality. Although most of cases are satisfactorily managed with conservative measure, current innovation in elastic nailing, instrumentation and poor compliance to cast and frequent revisits to check the adequacy of reduction makes treatment with elastic titanium nailing an excellent means of intervention in unstable both bones fractures in children.Materials methods- The study was conducted at Dept of orthopedics, SHKM Govt medical college Nuh , India, which included 30 patients, 18 male, 12 female with age from 6 to 15years, with mean age of 10 years. Twenty patients had middle third fractures, 6 proximal 1/3rd and 3 distal 1/3rd fractures. Closed reduction was done in 24 (80%) patients and 6(20%) patients needed open reduction at # site.The transverse fractures were seen in 17 patients, oblique fractures in 6 patients, communicated in 4patients and spiral fractures in 3 patients. Results- The functional Outcome as per Price et al Criteria (7) was Excellent in 28 patients, good in 2 patients. None of the patients showed poor function at the final follow up at 1 year. Discussion and conclusion- Tens allows micro motion at fracture site due to elasticity of nails elastic deformation within the medullary canal creates a bending moment within the long bone that is not rigid, but that is stable enough to reduce and fix the fracture, and favors callous formation and bone healing. The treatment of pediatric both bones fractures with TENS continue to be the unparallel success and reliable treatment method with predictable outcome and minimal complication. We certainly recommend this type of treatment in angulated and unstable forearm fractures in children.

Comparison of Three Different Surgical Fixation Techniques in Pediatric Forearm Double Fractures.

IntroductionAlthough forearm fractures are one of the most common fractures in children, controversy remains about the optimal fixation technique in the surgical treatment of these fractures. The aim of this study was to compare the results of pediatric patients with a forearm double fracture who underwent open reduction and internal fixation (plate-screw group), elastic intramedullary nailing to both bones (ESIN), and hybrid fixation (the radius or ulna is fixed with the help of ESIN and the other forearm bone is fixed using plate-screw).MethodsA retrospective scan was made of the records of 51 patients with forearm double diaphyseal fractures (19 plate-screw, 18 ESIN, and 14 hybrid fixation). Comparisons were made in respect of the duration of surgery, length of the incision, duration of follow-up, time to union, functional results, and complication rates.ResultsThe study results showed that the surgical incision length and operating time in the hybrid group were statistically significantly shorter than in the plate-screw group (p<0.05). No statistically significant difference was determined between the three groups in respect of the functional results (p>0.05).ConclusionWhen the hybrid fixation technique was compared with other methods, the results were equal or better in terms of surgery time, incision length, time to union, and complications. Therefore, this technique can be used as an effective and reliable method in appropriate pediatric forearm diaphyseal double fractures.

Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old Children.

New surgical techniques have challenged traditional guidelines for nonsurgical treatment in pediatric and adolescent distal forearm fractures. This study was performed to compare outcomes and costs between closed reduction with percutaneous pinning (CRPP) and closed reduction with casting in the treatment of complete distal forearm fractures in children 8 to 14 years old. A retrospective cohort study was performed of 175 displaced distal forearm fractures treated with 2 different methods in the emergency department of a children's trauma center. One hundred and fourteen children were managed using CRPP. The remaining 61 were treated with closed reduction and casting. All patients had initial follow-up radiographs. The quality of reduction and the residual angulation in both the coronal and sagittal planes were recorded. Outcomes included the angulation after reduction, residual angulation at final follow-up, radiation exposure, total immobilization time, days absent from school, total costs, and postoperative complications. The postreduction sagittal plane angulation was significantly lower in the CRPP group (P=0.037). While residual deformity between the groups at the 6-month final follow-up was not significantly different in either the sagittal or coronal planes (P=0.486, 0.726), patients in the nonoperative group received greater radiation than those in the operative group (P<0.001). Patients in the nonoperative group missed fewer classes and sustained lower costs (P<0.001, <0.001). The mean immobilization time in each group was not significantly different (31.4±4.4 vs. 32.8±5.9 d; P=0.227). Although the postreduction quality was a little better and radiation exposure was less in the CRPP group, there was no difference between the 2 groups in angulation, total immobilization time, or complication rates after 6 months. The cost and time absent from school of patients in the nonoperative group was significantly lower than in the operative group. There is no clear advantage to CRPP treatment on outcomes. Therefore, closed reduction and casting is recommended in complete distal forearm fractures of children 8 to 14 years old. Level III-therapeutic study.

Outcomes of 3-D corrective osteotomies for paediatric malunited both-bone forearm fractures.

Closed treatment of paediatric diaphyseal forearm fractures carries the risk of re-displacement, which can lead to symptomatic malunions. This is because growth will not correct angulation deformity as it does in metaphyseal fractures. The purpose of this prospective cohort study was to evaluate the outcomes after 3-D-planned corrective osteotomy with patient-specific surgical guides for paediatric malunited forearm fractures causing impaired pro-supination. Our primary outcome measure was the gain in pro-supination at 12 months follow-up. Fifteen patients with a mean age at trauma of 9.6 years and time until osteotomy of 5.9 years were included. Preoperatively, patients displayed a mean pro-supination of 67° corresponding to 44% of the contralateral forearm. At final follow-up, this improved to 128°, achieving 85% of the contralateral side. Multivariate linear regression analysis revealed that predictors of greater functional gain after 3-D corrective osteotomy are severe preoperative impairment in pro-supination, shorter interval until 3-D corrective osteotomy and greater angulation of the radius.Level of evidence: III

CHARACTERISTICS OF FOREARM RE-FRACTURE IN YOUTH ATHLETES

Background:The forearm is the most common site of fracture, and perhaps re-fracture, in the pediatric population. Although both bone forearm (BBFA) fractures represent approximately 30% of pediatric upper extremity fractures, little is known about BBFA re-fractures, particularly among youth athletes.Purpose:To evaluate characteristics of BBFA re-fracture and recurrent fractures.Methods:An IRB-approved retrospective chart review based on CPT and ICD-9/10 codes of forearm fractures (ages 10-18 years) treated by a single academic pediatric orthopedic group from June 2009 to May 2020 was conducted. All BBFA, radial, or ulnar fractures with ipsilateral same-site, or non-identical ipsilateral or contralateral forearm fracture were included. Demographics, injury characteristics, length of immobilization, timing of return to activity, and radiographic data (angulation, distance between radius fracture and ulna fracture [in mm], position of fracture within bone, and radiographic healing). An analysis was performed to evaluate associations of ipsilateral same-site re-fracture versus ipsilateral or contra-lateral non-identical site fractures.Results:Twenty-nine of 686 BBFA and distal radius fractures were identified to have recurrent fracture (4.23%), with an average age of 11.5 years and male-to-female ratio of 6.25:1. 67% of ipsilateral same-site re-fractures occurred within one year. The most common mechanisms of primary fracture were contact sports (40%) and tumbling (30%), and re-fracture occurred 182 days after original fracture.52% percent of recurrent fractures were ipsilateral same-site re-fractures, while 48% occurred in a non-identical site, either ipsilaterally or contralaterally. The most common mechanisms of recurrent fracture were contact sports (38%), falls (38%), and tumbling (14%). Ipsilateral same-site re-fractures compared to other recurrent fractures, were significantly associated with a mid-shaft location (p=0.0029), increased radius to ulna fracture distance (21.14 mm versus 11.3 mm, p=0.0277) [Figure 1], and earlier occurrence following index fracture (re-fracture= 397.33 days versus non-identical recurrent fracture= 884.07 days, p=0.0056). Degree of angulation was not significantly associated with re-fracture.Conclusion:Recurrent fracture may occur at different times and locations following primary injury treatment. Ipsilateral same-site re-fractures tend to occur within the first year of treatment following mid-shaft fractures incurred during contact sports and tumbling, with widely spaced radial and ulnar fracture sites. Further research may be warranted to evaluate biologic, bone health, or personality traits that may lead to recurrent and re-fractures in pediatric forearm fractures.Figure 1.Anteroposterior images of a left forearm demonstrating a primary fracture (A) and a same-site ipsilateral re-fracture (B). Distance between fractures on the radius and ulna are noted.

Single-bone versus both-bone plating of unstable paediatric both-bone forearm fractures. A randomized controlled clinical trial

PurposeThis clinical trial compares the functional and radiological outcomes of single-bone fixation to both-bone fixation of unstable paediatric both-bone forearm fractures.MethodsThis individually randomized two-group parallel clinical trial was performed following the Consolidated Standards of Reporting Trials (CONSORT) statement at a single academic tertiary medical centre with an established paediatric orthopaedics unit. All children aged between nine and 15 years who presented to the emergency department at Assiut university with unstable diaphyseal, both-bone forearm fractures requiring surgical intervention between November 1, 2018, and February 28, 2020, were screened for eligibility against the inclusion and exclusion criteria. Inclusion criteria were diaphyseal unstable fractures defined as shaft fractures between the distal and proximal metaphyses with an angulation of > 10°, and/or malrotation of > 30°, and/or displacement > 10 mm after attempted closed reduction. Exclusion criteria included open fractures, Galeazzi fractures, Monteggia fractures, radial head fractures, and associated neurovascular injuries. Patients who met the inclusion criteria were randomized to either the single-bone fixation group (intervention) or the both-bone fixation group (control). Primary outcomes were forearm range of motion and fracture union, while secondary outcomes were forearm function (price criteria), radius re-angulation, wrist and elbow range of motion, and surgical timeResultsA total of 50 children were included. Out of these 50 children, 25 were randomized to either arm of the study. All children in either group received the treatment assigned by randomization. Fifty (100%) children were available for final follow-up at six months post-operatively. The mean age of single-bone and both-bone fixation groups was 11.48 ± 1.93 and 13 ± 1.75 years, respectively, with a statistically significant difference (p = 0.006). There were no statistically significant differences in gender, laterality, affection of the dominant hand, or mode of trauma between single-bone and both-bone fixation groups. All patients in both groups achieved fracture union. There mean radius re-angulation of the single-bone fixation groups was 5.36 ± 4.39 (0–20) degrees, while there was no radius re-angulation in the both-bone fixation group, with a statistically significant difference (p < 0.001). The time to union in the single-bone group was 6.28 ± 1.51 weeks, while the time to union in the both-bone fixation group was 6.64 ± 1.75 weeks, with no statistically significant difference (p = 0.44). There were no infections or refractures in either group. In the single-bone fixation group, 24 (96%) patients have regained their full forearm ROM (loss of ROM < 15°), while only one (4%) patient lost between 15 and 30° of ROM. In the both-bone fixation group, 23 (92%) patients have regained their full forearm ROM (loss of ROM < 15°), while only two (8%) patients lost between 15 and 30° of ROM. There was no statistically significant difference between groups in loss of forearm ROM (p = 0.55). All patients in both groups regained full ROM of their elbow and wrist joints. On price grading, 24 (96%) and 23 (92%) patients who underwent single bone fixation and both-bone fixation scored excellent, respectively. Only one (4%) patient in the single-bone fixation group and two (8%) patients in the both-bone fixation group scored good, with no statistically significant difference in price score between groups (p = 0.49). The majority of the patients from both groups had no pain on the numerical pain scale; 22 (88%) patients in the single-bone fixation group and 21 (84%) patients in the both-bone fixation groups, with no statistically significant difference between groups (p = 0.38). The single-bone fixation group had a significantly shorter mean operative time in comparison to both-bones plating (43.60 ± 6.21 vs. 88.60 ± 10.56 (min); p < 0.001).ConclusionSingle-bone ulna open reduction and plate fixation and casting are safe and had a significantly shorter operative time than both-bone fixation. However, single-bone ORIF had a higher risk radius re-angulation, alas clinically acceptable. Both groups had equally excellent functional outcomes, forearm ROM, and union rates with no complications or refractures. Long-term studies are required.

Trends in Operative Treatment of Pediatric and Adolescent Forearm Fractures Among American Board of Orthopaedic Surgery Part II Candidates.

Pediatric and adolescent forearm fractures are among the most common injuries treated by orthopaedic surgeons. Recent literature shows that there has been an increased interest in operative management for these injuries. The purpose of the current study was to examine the trends in case volume, patient age, surgeon fellowship training, and postoperative complications of surgically treated pediatric forearm fractures over >15-year period of American Board of Orthopaedic Surgery (ABOS) Part II Oral Examination candidates. ABOS Part II candidates' Oral Examination Case List data from 2003 to 2019 was queried for all pediatric and adolescent (19 y of age and below) forearm fractures treated operatively. Patient demographics, fracture type, complications, and candidate fellowship type were identified for each case. Linear regression was used to delineate annual trends in patient age, complication rates, and case volume by fellowship type. Analysis of variance was performed to evaluate complication rates by fellowship type. Statistical significance for all comparative analyses was set at P-value <0.05. A total of 4178 pediatric and adolescent forearm fractures (mean age: 12.6 y; SD: 3.7 y) were treated surgically among ABOS Part II Oral Examination candidates during their 6-month collection periods from 2003 to 2019. The mean patient age decreased significantly (P<0.001) over the study timeframe, while complication rates increased (P<0.001). Pediatric fellowship-trained orthopaedic surgeons performed significantly more cases than general orthopaedic surgeons over recent years (P<0.001). No significant trends were identified between fellowship type and complication rates. The overall surgical complication rate was 17%. The complication rate of open fractures was 24%, which was significantly >15% complication rate of closed fractures (P<0.001). Fellowship-trained pediatric orthopaedic surgeons are performing an increasing number of pediatric and adolescent forearm fracture fixation when compared with other orthopaedic surgeons. The mean age of surgically managed pediatric forearm fracture patients has decreased from 2003 to 2019. There has been an increase in the rate of overall reported complications following pediatric forearm fracture surgery over recent years, without any significant association to any particular subspecialty. Future studies should evaluate the comparative effectiveness of surgical treatment of pediatric forearm fractures compared with closed management.

The use of real-time sonography-assisted fracture reduction in children with displaced forearm fractures.

Pediatric forearm and wrist fractures are common; furthermore, some are displaced and require manipulation and reduction. The procedure is commonly performed without real-time image guidance and evaluated radiographically after reduction and casting, leading to multiple reduction attempts and malalignment. Although fluoroscopy can provide real-time assessment of fracture alignment during the procedure, it is not readily available in many emergency departments (EDs) and involves radiation exposure. Ultrasonography is an alternative real-time imaging modality that is inexpensive and readily available. The purpose of this study was to determine whether the use of real-time bedside sonography during closed reduction of distal and middle third forearm fractures can decrease the number of reduction attempts and reduce the number of patients requiring surgery. We compared the results of a conventional blind manipulation, fracture reduction, and casting to fracture reduction under real-time ultrasonographic guidance, in patients treated in our ED between 2014 and 2016. Overall, 458 patients with distal or middle third fractures were included. Of these reductions, 289 were performed without real-time imaging (group 1) and 169 under real-time ultrasound guidance (group 2). In group 1, 10% of patients required re-reduction, and 5% of patients needed surgery. In group 2, only one patient (0.6%) required re-reduction and 1% of patients required surgery due to fracture instability. In conclusion, the current study shows that real-time ultrasound-guided forearm fracture reduction is an effective and inexpensive method for correction of displaced forearm and wrist fractures in children, which does not involve any radiation exposure.

Successful results obtained in the treatment of adolescent forearm fractures with locked intramedullary nailing

PurposeIn the surgical treatment of paediatric forearm fractures, plate-screw and titanium elastic nails are used. During the transformation of ligamento-osseous structures from adolescence form into adult form, more stable fixation is required. The aim of this study was to evaluate the results of locked intramedullary nail fixation in adolescent forearm fractures. MethodsA retrospective examination was made on 36 adolescent patients who underwent surgery with locked intramedullary nail fixation due to a forearm fracture. The included patients were in the adolescent age group (12–17 years), did not meet conservative follow-up criteria and had unstable fractures (>10° angulation and <50% cortex continuity after plaster casting). Patients were excluded from the study if they were aged >18 years or <12 years, had Gustilo-Anderson type 2/3 open fractures, multi-trauma, history of physeal injuries or could not be contacted during follow-up. Patients’ age, gender, body mass index, affected side, and the pronation and supination values during follow-up were noted. Functional evaluation of the patients was performed with disabilities of the arm, shoulder and hand score and the surgical outcomes were evaluated according to the Price criteria. The time to union, infection during follow-up, re-fracture and vascular nerve damage were also examined. Data were analyzed using SPSS 22 Windows package program software. ResultsThe patients comprised 30 males and 6 females (ratio, 5:1) with a mean age of (14.7 ± 2.1) years (range, 12–18 years). According to the Price criteria, the results of 33 patients were excellent, 3 were good and there were no moderate or poor cases. The mean disabilities of the arm, shoulder and hand score was 11.2 ± 6.1 (range, 4–28). The mean time to union was (8.7 ± 2.2) weeks (range, 6–14 weeks), while patients aged >15 years had prolonged time to union ([11.1 ± 1.8] weeks). There were no non-unions, re-fractures or infections. No complications were observed during implant removal. None of the patients had sensorial radial nerve injury or tendon damage. ConclusionThe locked intramedullary nailing technique, which is minimally invasive and provides biological fixation, was found to be successful and safe in the treatment of adolescent forearm fractures.

Accuracy of point-of-care ultrasound for determining the adequacy of pediatric forearm fracture reductions

The objective of the present study was to the determine the accuracy of point-of-care ultrasound (POCUS) in assessing closed reduction (CR) of pediatric forearm fractures in a pediatric emergency setting. After determination of the need for CR using X-ray images by an orthopedic consultant, POCUS examinations were performed just before and after the reduction attempt. The transducer was positioned longitudinally over the dorsal, volar, and lateral surfaces of the radius and ulna to view the fracture site. The presence of angulation, displacement, or bayonetting of the fracture fragments was recorded. The adequacy of realignment according to the POCUS and the orthopedic consultant's final determination were recorded. Sixty-two patients were enrolled in the study and 96 bones were evaluated. The sensitivity and specificity of POCUS for adequacy of CR were 95.8% [95% confidence interval (CI): 88.3-99.1)] and 95.8% (95% CI: 78.8-99.8), the positive predictive value was 98.5% (95% CI: 91.0-99.7), and the negative predictive value was 88.4% (95% CI: 71.6-95.8). The corresponding positive and negative likelihood ratios were 23 (3.37-156.77) and 0.04 (0.01-0.12). There was high agreement between POCUS and X-ray images for predicting adequacy of CR [κ: 0.892 (±0.053)]. There was also a significant correlation between POCUS and X-ray measurements of angulation and displacement performed before and after CR, respectively (p < 0.001). Our study has reported the successful use of POCUS for the management of pediatric forearm fractures in a pediatric emergency department. Point-of-care ultrasound can minimize radiation exposure and appears to be an alternative and accurate tool for reduction attempts.

741 Manipulation and Reduction of Paediatric Forearm Fractures in The Emergency Department Using Intranasal Diamorphine and Entonox

Abstract Background Paediatric forearm fractures are commonly encountered in Trauma and Orthopaedics. Currently most forearm fractures are manipulated in theatre the following day, increasing resource burden and delays in management. The aim of this project was to introduce guidelines to reduce fractures in the Emergency Department (ED) using intranasal Diamorphine and Entonox. Method 197 cases were identified over a 6-month period in 2018 and 2019. 74 distal radial fractures and 123 mid shaft forearm fractures were analysed. Fractures with an intact periosteal hinge or a Salter Harris type 2 were reduced in ED. The pre manipulation and post manipulation radiographs were compared with particular attention to the post reduction angles. Results 67% of fractures were reduced in the correct setting. A number of fractures reduced in ED required re-manipulation or internal fixation. Overall, there was a 56% reduction in patients undergoing general anaesthetic. There was a reduction in the mean length of stay from 36 hours to 3.5 hours. Conclusions Intranasal Diamorphine and Entonox offer a safe method for managing paediatric forearm fractures in ED. Implementation of this method facilitates early access to treatment and early patient discharge. Manipulation in ED offers significant financial savings and reduces demands on the Trauma Theatres.

English

BACKGROUND Diaphyseal fractures of the forearm are one of the common fractures in the paediatric population. Closed reduction and cast immobilisation remain the standard treatment for paediatric diaphyseal forearm fractures owing to their unique remodelling potential. The main concern of conservative management is re-displacement of fracture in cast resulting in the unacceptable angular deformity in the forearm. Intramedullary fixation with titanium elastic nails for paediatric diaphyseal forearm fractures is becoming the trending surgical technique in those cases that warrant surgical intervention. The purpose of this study was to evaluate the functional outcome of the management of fracture of both bones forearm in the older children with titanium elastic nailing system. METHODS This was a prospective study done among thirty patients aged 5 to 16 years admitted to the Department of Orthopaedics at GEMS &amp; Hospital, Ragolu, Srikakulam with diaphyseal fractures of both bones forearm from September 2017 to September 2019. We treated the patients by closed / open reduction and internal fixation with elastic stable intramedullary nailing. The patients were followed-up for six months. RESULTS We evaluated the patients clinically and radiologically after surgery. We assessed the outcome using modified Anderson’s AO criteria for forearm fractures extracted from the international journal of current pharmaceutical and clinical research functions. All fractures united at an average of 9.1 weeks without any delayed or non-union. The results were excellent in 86.6 % of patients and good in 13.3 % of patients without significant complications. There were minor complications in 6 patients (20 %). CONCLUSIONS Titanium elastic intramedullary nailing is a safe, effective and minimally invasive surgical method for treatment of displaced both bones forearm diaphyseal fractures in older children. This technique gives relative stability with a three-point fixation principle resulting in secondary bone healing by promoting early callus, ideal for early mobilisation. The technique offers several advantages, including minimal incision, preservation of fracture haematoma, dynamic axial stabilisation, and shorter hospitalisation. KEYWORDS Both Bone Fracture Forearm, Titanium Elastic Nailing System, Early Mobilisation

Paediatric diaphyseal forearm fractures: Is titanium elastic nailing a safe option?

Paediatric forearm fractures are common injuries accounting for 40% of all the fractures in children. They are traditionally treated conservatively with casting. However there has been short and long term complications associated with such treatment and in recent times, closed reduction and flexible nailing has shown favourable clinical outcomes. In this prospective study, we evaluated functional outcome in closed forearm diaphyseal fractures of children and adolescents treated with titanium elastic intramedullary nails. All cases achieved bony union at an average of eight weeks and excellent functional outcome without significant complications. Nails were removed under anaesthesia after radiological union. Intramedullary nailing with elastic nails is an effective method of treatment for these unstable diaphyseal fractures of forearm in children and adolescents.

Management of Pediatric both-bone Forearm Fractures by Titanium Elastic Nailing System: A Prospective Study of 60 Cases

Intramedullary nailing procedure is highly appreciated by many phsyicians for treating pediatrics forearm fractures. Minimum operating time, fewer chances of incisions, faster bone healing, and accuracy in bone alignment less rigid fixation made this technique more popular and preferable. This study was specially designed to observed the management of pediatric both forearm fracture by using the titanium elastic nail technique.&#x0D; Methodology: Our prospective descriptive study was conducted in King Abdul Aziz Hospital Makkah Saudi Arabia from march 2018 to march 2021. Total 60 patients were enrolled which were treated with titanium elastic nail system (TENS). In this study patients with close displaced and open type 1 fractures with age range of 4 to 14 years were included.&#x0D; Results: Total 42.5% of participants were under the age of 10, and 57.5% of patients were above 10 years or equal to 10 years age. We reported 58.9% prevelance of injury among male patients. Along with these, we reported 53.4% cases with left side fractures and 60.3% had middle bone fractures. In our study, we reported that the overall average union time was 9.10±1.8.&#x0D; Conclusion: Titanium elastic nailing is the most effective technique for managing unstable fractures among pediatrics. The male population was more prone to forearm fracture, especially at the middle third shaft. Overall meantime 9 weeks were reported for bone unification. Titanium elastic nailing is more effective technique for patients less than 10 years old. Mean unification time of bone was less among them with little compliactions.