Commentary Overriding fractures of the distal radial metaphysis in children are common and are of interest to many orthopaedic surgeons. The large study by Laaksonen et al. is population-based and has important data regarding the epidemiology and outcomes of treatment of overriding distal radial fractures. Closed manipulation in the emergency department was associated with a 46% failure rate and a high utilization of opioid analgesics. Fractures treated with use of cast immobilization in an overriding position showed excellent functional outcomes and a low rate of secondary interventions. In the 1955 textbook “Fractures in Children,” Blount described the principles of fracture remodeling in children and advocated for nonoperative treatment of distal radial and ulnar fractures1. Since that time, techniques and technology have evolved, and the availability of fluoroscopy, percutaneous Kirschner wire fixation, and flexible intramedullary nailing have allowed the development of better techniques than were available when that book was written. These new techniques and technologies permit accurate reduction, stable fixation, and early mobilization. Blount understood the process of remodeling of pediatric fractures better than many of his contemporaries and perhaps better than many of the current generation of orthopaedic surgeons. Blount’s principles of fracture remodeling are as follows: 1. Remodeling occurs more quickly the closer the fracture is to the physis. 2. Remodeling occurs more quickly and extensively when residual displacement is in the plane of motion of the adjacent joint. 3. The speed of remodeling is related to the age at the time of the injury, with younger children experiencing faster remodeling1. These 3 principles are relevant to the treatment of distal radial fractures in growing children. Most fractures occur within 2 centimeters of the physis, as described in the study by Laaksonen et al. The most frequent direction of displacement is dorsal, and this is the primary plane of motion of the wrist joint1. Most fractures occur in active growing children1. Therefore, according to the teachings of Blount, these fractures should remodel quickly, and in younger children, they should remodel fully1. However, of the extensive references utilized by Laaksonen et al. to support their study, only Crawford et al. supported the use of immobilization in a below-the-elbow cast rather than reduction and fixation as the primary treatment2. Three randomized controlled trials examined the benefits of adding percutaneous Kirschner wire fixation after closed reduction versus cast immobilization, yet none of these studies addressed the central question of whether such fractures should be reduced3-5. Several of the referenced studies assessed the outcomes of reduction and Kirschner wire fixation compared with immobilization following loss of position of a previously reduced fracture. The evidence, although of low quality and inconclusive, suggested that most of these fractures do very well following simple alignment in a below-the-elbow cast without reduction and without fixation1,2. In the current era, when anatomic reduction and stable fixation of fractures is the prevailing philosophy for the majority of osseous injuries, it can be difficult for attending surgeons, residents, and parents to understand that nature may be capable of doing as good a job as technology. The educated parent of today, with “Dr. Google” in hand, will want to see their child’s radiographs and may be horrified by advice to accept a displaced fracture with obvious shortening1,2. A recently published book has a treasure trove of images to reassure the anxious parent and help convince doubting residents that surgery is not always better than nature6. This book is the 2021 update to the classic textbook by Blount and is an invaluable resource for counseling parents and teaching residents1,6. The current evidence for management is inconclusive, which is unsatisfactory given that this is a common fracture with substantial associated treatment costs2. The uncertainty regarding management has been acknowledged internationally in the British Society for Children’s Orthopaedic Surgery Research Priorities and in a survey of members of the Pediatric Orthopaedic Society of North America. Additionally, a multicenter randomized controlled trial, the Children’s Radius Acute Fracture Fixation Trial (CRAFFT), has been commenced in the United Kingdom to address the question of whether outcomes following closed reduction are better than those following simple immobilization. Given that there is equipoise regarding treatment and a lack of high-quality evidence, such studies are the only way to improve the evidence base. As a surgeon who has utilized Blount’s principles of remodeling for more than 40 years, I have had the opportunity to observe excellent outcomes from nonoperative treatment of this and other pediatric fractures. However, this is anecdote, not evidence. I look forward to the outcomes of the CRAFFT Trial. My hunch is that Blount was correct and that we do not need to reduce or internally fix these fractures in younger children1,2,7.
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Oct 1, 2024
Dr Mayur Gupta + 3
Open Access