Reduction Of Forearm Fractures Research Articles

Tenodesis Effect Mimicked by Flexor Tendon Entrapment in a Paediatric Midshaft Forearm Fracture: a Case Report and Review of the Literature

Entrapment of the flexor digitorum profundus (FDP) tendon following radius and ulna midshaft paediatric forearm fractures has been reported rarely in the literature. To date, 19 cases have been described. A characteristic fracture pattern, persistent cortical defect at the fracture site and flexion contracture not responsive to hand therapy are all hallmarks of the condition. We present a case along with a review of the literature. A 12-year-old boy underwent exploration of a primary right open radius and ulna fracture site 22 months following initial open reduction and titanium elastic nail system (TENS) fixation. The little finger FDP tendon was found interposed between the ulna bone with a significant defect in the cortical surface of the ulna, correlating with a lucency identified on plain radiograph preoperatively. Removal of all interposed tissue, debridement of the bone edges and Pulvertaft tendon weave of the FDP of the little finger to the ring finger were performed. The patient recovered full upper limb function. Clinicians should be vigilant to identify this complication when managing patients with forearm fractures. A thorough clinical examination pre– and post–open or closed forearm fracture reduction should be performed to ensure early recognition of this rare complication. If the tenodesis effect and post-operative adhesions cannot be adequately released by therapy, interposition of the tendon at the fracture site should be considered as a differential diagnosis. If the complication is suspected, early operative intervention should be performed to ensure optimal fracture healing and restoration of function.

Complications and Risk Factors Influencing Hardware Removal after Open Reduction and Internal Fixation of the Radius or Ulna: A Nationwide Study.

Indications for open reduction and internal fixation (ORIF) of forearm fractures vary, and some patients require removal of hardware (ROH) for various complications. Currently, limited data exist to evaluate the epidemiology of and risk factors for ROH of the radius/ulna. We examine associations between radius/ulna fractures and (1) characteristics of fractures requiring ORIF, (2) indications for ROH, (3) demographic risk factors for ROH, (4) length of stay, and (5) total hospital charges. We use the Nationwide Inpatient Sample (NIS) to identify patients admitted for radius/ulna ORIF and ROH between 1998 and 2010 in the United States. To identify fracture locations, comorbidities, and indications for ROH, the International Classification of Diseases (ICD)-9 codes were accessed. We identify 423,727 ORIF patients and 12,868 patients (3.0% of ORIF admissions) who underwent ROH. Logistic regression analyses and independent sample t-tests are used to assess risk factors and differences. Among fractures requiring ORIF, the most common is for distal, closed fractures of radius and ulna. The most common indications for ROH are implant infection and mechanical complication. Risk factors for ROH include male gender, Caucasian ethnic group, and Deyo comorbidity scores of 1 or greater. Length of hospital stay and total charges are significantly higher for ROH patients compared to those with ORIF only. ROH following ORIF for radius/ulnar fractures is an infrequent but serious complication that increases patient morbidity and burdens patients and providers. Patient demographics of male gender, Caucasian ethnic group, payer status, and comorbid conditions were identified as independent risk factors for ROH.

Diaphyseal fractures of the forearm in adults, comparative study of dynamic compression plate versus intramedullary nail

<p class="abstract"><strong>Background:</strong> Forearm fractures are common nowadays because of road traffic accident. It is important to achieve anatomical reduction of both bone forearm fractures to regain function of upper limb. This study is undertaken to observe functional and radiological outcome using two different surgical modalities like dynamic compression plating (DCP), and intramedullary nailing in both bone forearm fractures and also to indivualize the optimal treatment method for different fracture pattern.</p><p class="abstract"><strong>Methods:</strong> Our study included 60 patients with diaphyseal forearm fractures in adults presenting to orthopaedic outpatient department. Among 60 patients, 30 patients underwent open reduction and internal fixation by dynamic compression plate and other 30 patients underwent closed reduction/open reduction by square nail after detailed pre-operative evaluation.<strong></strong></p><p class="abstract"><strong>Results:</strong> In our study average union time in DCP group is 23.39 weeks and square nail group is 28.89 weeks. Union in DCP group was 27 (90%) and square nail group 22 (73.33%). Delayed union in DCP group was 03 (10%) and in Square nail group was 6 (20%), non-union in DCP group was 0 (nil) and in square nail group was 2 (06%).</p><p class="abstract"><strong>Conclusions:</strong> Open reduction and internal fixation with DCP plates for both bone diaphyseal forearm fractures gives good results with early union rates. We also found that in open fractures and complex fracture like segmental fractures square nailing was better option compared to dynamic compression plate to reduce infection rates, retain periosteal blood supply from soft tissue. Thus we conclude that both implants are equally important and we should prioritize based on preoperative planning.</p>

Does Mentoring by Orthopedic Surgeons Improve Forearm Fracture Reduction Outcomes by Pediatric Emergency Physicians? Evaluation of a Process Improvement Intervention Program.

Forearm fractures are among the most frequently encountered orthopedic injuries in children. The maintenance of satisfactory alignment can be problematic and postreduction displacement with resultant malunion can occur. The objective of the study was to evaluate pediatric emergency medicine (PEM) physicians' performance on forearm fracture reduction to determine the impact of a Process Improvement Intervention Program (PIIP) on postreduction displacement rates after initial reduction. The PIIP was designed to improve our PEM physicians' skills and knowledge in how to properly apply and mold casts to better maintain the alignment of reduced forearm fractures. A PIIP was implemented during 2015-2016 when orthopedic surgeons mentored postfellowship-trained PEM physicians. Patient cohorts from pre- and post-PIIP implementation were investigated and compared to evaluate the impact of the PIIP on PEM physicians' initial fracture reduction success rates and postreduction displacement rates. Descriptive and analytical statistics including univariate and multivariate models were tested to understand changes in physicians' performance. Pre- and postcohorts had similar demographic and clinical characteristics and similarly high initial reduction success rates. When distal and midshaft fracture types were combined, there was no significant difference in postreduction displacement rates between the 2 cohorts, but when stratified based on fracture type, the distal radius postcohort showed a statistically significant improvement in postreduction maintenance. A PIIP by pediatric orthopedic surgeons did not change the PEM physicians' initial fracture reduction success rate, but it did result in a statistically significant improvement in maintenance of reduction rates.

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.

Success Rates for Reduction of Pediatric Distal Radius and Ulna Fractures by Emergency Physicians.

Emergency physicians are trained in urgent fracture reduction. Many hospitals lack readily available in-house orthopedic coverage. The aim of this study was to determine success rates for reduction of pediatric distal radius or ulna fractures by emergency department (ED) physicians. We conducted a retrospective study of children younger than 18 years presenting to a large, urban, freestanding children's hospital from January 1, 2009, to December 31, 2010, with forearm fracture. Exclusions included open fracture, those requiring immediate surgical intervention, or additional fractures. The primary end point was the proportion of successful closed forearm fracture reductions in the ED, as defined by orthopedic follow-up. All reductions were performed by a board-certified/eligible pediatric emergency medicine (PEM) physician or PEM fellow. Two hundred ninety-five fractures were reduced in the ED during the study period. Mean age was 8.27 years (median, 8 years; range, 1-16 years), and males comprised 69.2% (n = 204). A total of 222 fractures (76%) were of the distal forearm, and 70 involved the midshaft (24%). Orthopedic follow-up was completed in 77.3%. A total of 33 patients (11%) required remanipulation; 24 in the distal forearm fracture group (22 closed reductions, 2 open reductions with internal fixation) versus 9 in the midshaft group (7 closed reductions, 2 open reductions with internal fixation) (P = 0.948). The literature reveals 7% to 39% of children with fracture reductions performed in the ED by orthopedic surgeons/residents require remanipulation. Our rate of 11% is consistent within that range. With training, PEM physicians have similar success rates as orthopedists in forearm fracture reductions.

The Pediatric Floating Elbow

The pediatric floating elbow involves fractures of the humerus and forearm. Majority of these injuries include supracondylar humerus fractures with ipsilateral forearm fractures. These fractures should be managed with great caution as they often result from higher energy injuries and have increased risks of nerve palsies, open fractures, loss of forearm fracture reduction, and compartment syndrome. Previous literature has advocated for operative fixation of ipsilateral forearm fractures in addition to stabilization of the supracondylar humerus fracture, to allow for noncircumferential immobilization to decrease the risk of compartment syndrome. However, recent studies have questioned the universal need for forearm fixation in patients with these injuries. This paper will discuss the pediatric floating elbow, review the available literature, and describe our technique for managing these injuries.

The Cost and Utility of Postreduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures.

Formal radiographs are frequently obtained after reduction of closed pediatric wrist and forearm fracture performed under mini C-arm fluoroscopy. However, their utility has not been clearly demonstrated to justify the increased time, cost, and radiation exposure. We hypothesized that formal postreduction radiographs do not affect the rereduction rate of pediatric wrist and forearm fractures. We further sought to determine the time, monetary, and opportunity costs associated with obtaining these radiographs. A total of 119 patients presented to our urban, level I pediatric trauma center from April 2015 to September 2015 with isolated, closed wrist and forearm fractures who underwent sedation and reduction using mini C-arm fluoroscopy. Demographic and injury variables were collected, along with incidence of rereduction and need for future surgery. Time intervals for sedation, awaiting x-ray, and total encounter periods were noted, and total direct and variable indirect costs for each encounter were obtained from our institution's cost accounting and billing databases. Marginal time and monetary costs were noted and further calculated as a percentage of the total encounter. Opportunity costs were calculated for the time spent obtaining the postreduction radiographs. Of 119 patients with isolated, closed wrist or forearm fractures, none required rereduction after initial reduction using sedation and mini C-arm fluoroscopy. Postreduction radiographs required an average of 26.2 minutes beyond the end of sedation, or 7.3% of the encounter time and cost. The direct cost of the x-ray was 2.6% of the encounter cost. With our institution's annual volume, this time could have been used to see an additional 656 patients per year. Postreduction formal radiographs did not result in changes in management. There are significant direct and opportunity costs for each patient who undergoes additional formal radiographs. Pediatric patients with isolated, closed wrist or forearm fractures do not routinely need formal radiographs after reduction under mini C-arm fluoroscopy. Level IV-Therapeutic.

Hematoma block for fracture reduction

Introduction: Distal radius fractures are one of the commonest fractures and more commonly involve children and elderly. Analgesia during reduction are determined by safety, simplicity, effectiveness and costs. The objective of this study is to evaluate the effectiveness of the Hematoma Block (HB) for reduction in distal forearm fractures in a developing country like Nepal.&#x0D; Methods: The study design was double blind randomized control trial performed at tertiary care hospital from July 2016 to August 2017. The patients having radiologically confirmed distal forearm fractures less than 96 hours old in 46 males and 54 females included after obtaining informed consent. 50 patients receiving Brachial Plexus Block (BPB group), and 50 patients receiving HB group during reduction of distal forearm fractures were initially allotted in two arms of randomized group. Pain measured by Visual Analogue Scale (VAS) was recorded before, during, and after reduction.&#x0D; Results: The study showed that HB with (mean ± SD) a VAS score of 2.08 ± 0.85 was as effective as BPB with a VAS of 1.7 ± 0.64 in terms of producing analgesia ( p=0.013), with the advantage of no motor paralysis and a significantly higher reduction rate, odds 3.45, 95% CI 1.52 – 7.85, p = 0.0013. 1/50 patients in brachial plexus block had bronchospasm needing intubation and ICU care where as 1/50 patient with hematoma block and infection which needed incision drainage and external fixation for complete healing.&#x0D; Conclusions: “The Hematoma Block” is to be encouraged in our set up for the reduction of the distal forearm fractures. The technique may be used in those fractures like isolated ulna fractures, minially displaced tibial fractures, fracture fibula where local anesthesia can be easily infiltrated percutaneously The study may be beneficial in managing such fractures and hence, it will help change in therapeutic policies comparing other modalities.

A Novel Smartphone App to Support Learning and Maintaining Competency With Bier Blocks for Pediatric Forearm Fracture Reductions: Protocol for a Mixed-Methods Study.

BackgroundDistal forearm fractures are among the most common injuries presenting to the pediatric emergency department (PED). Bier block (BB), or intravenous regional anesthesia, is a safe and effective alternative to procedural sedation for closed reduction of forearm fractures; it is associated with fewer adverse events, a shorter length of stay, and reduced costs. BB has long remained relatively underutilized; however, with an increasing emphasis on efficient resource use and patient-centered care, there is renewed interest in this technique.ObjectiveOur tertiary PED recently became the first in Canada to successfully implement an active BB program. Subsequently, we developed a mobile BB smartphone app designed to support the sustained departmental use of BB. The app can be used for training and maintenance of competency and incorporates instructional material, as well as our institutional BB protocol, printable medication order sheets, and monitoring forms. The present report describes the development and functionality of the BB smartphone app.MethodsWe have described app development and content. App dissemination metrics will be tracked, and user feedback will be analyzed using a self-administered electronic survey. Additionally, app utilization in our PED will be compared with real-world clinical use of BB for fracture reductions.ResultsThe first iteration of the BB app was launched in 2015, with the most recent update in September 2018. App metric tracking is planned for January 2020 until December 2021.ConclusionsWe have highlighted how the BB app serves as a paradigm of an educational tool designed not only for individual users but also for supporting the department-wide implementation and dissemination of a new technique. App dissemination and use metrics will be tracked and correlated with clinical use of BB in the PED.International Registered Report Identifier (IRRID)PRR1-10.2196/10363

Pediatric Forearm Fractures Are Effectively Immobilized With a Sugar-Tong Splint Following Closed Reduction.

Following closed reduction and initial casting of pediatric forearm fractures, loss of reduction (LOR) occurs in ∼5% to 75% of fractures. Sugar-tong splinting has been shown to maintain acceptable reduction in pediatric distal radius fractures while potentially avoiding issues associated with circumferential casting. We hypothesized that the sugar-tong splint would be an acceptable method for initial immobilization to prevent LOR in distal, mid-shaft, and proximal pediatric forearm fractures. This is an IRB-approved, retrospective study. Inclusion criteria included pediatric patients age 4 to 16 years old, open growth plates, with a displaced forearm fracture (radius, ulna, or both bone) that underwent closed reduction. The clinical protocol involved closed reduction and application of a sugar-tong splint by an orthopaedic resident under conscious sedation in the emergency room. Clinical follow-up occurred at 1, 2, 4, and 6-week intervals with a long-arm cast overwrap applied at the initial clinic visit. Primary outcome was radiographic LOR which was defined as a change of >10 degrees of angulation on anterior posterior/lateral projections from initial postreduction radiograph or previous follow-up radiograph. The secondary outcome was the need for further intervention. Sixty-four (38%) patients demonstrated radiographic LOR with 90% of LORs occurring in the first 2 weeks. LOR was significantly more common in distal radius fractures [48/110 (44%)] than with either proximal [2/14 (14%), P=0.04] or mid-shaft radius fractures [7/41 (17%), P=0.004]. There was no difference in LOR by location for ulna fractures [proximal=2/13 (15%), middle=4/38 (11%), distal=20/77 (26%), P>0.08]. There was no difference in radial LOR in patients with isolated radius fractures compared with both bone forearm fracture (17/40 vs. 40/125, P=0.22), or ulnar LOR between isolated ulna and both bone forearm fracture (0/3 vs. 26/125, P>0.99). The sugar-tong splint is effective at maintaining reduction of pediatric forearm fractures similar to published rates for casting. While effective at all levels of the forearm, the sugar-tong splint performed best in proximal and mid-shaft forearm fractures. Level IV.

Ulnar Nerve Injury in Pediatric Midshaft Forearm Fractures: A Case Series.

To describe a midshaft forearm fracture pattern that places the ulnar nerve at risk in the pediatric population and provide 7 clinical case examples describing the injury pattern and treatment methods. Retrospective observational case series, review of literature, cadaver dissection, and treatment recommendations. Multi-institutional, Southeast United States. Seven pediatric patients (5 male and 2 female) with mean age of 8.7 years (range, 3-14) who sustained a significantly displaced closed, or grade I open, middle to distal one-third both-bone forearm fracture with subsequent ulnar nerve dysfunction. Manual reduction and casting of both-bone forearm shaft fractures, operative debridement, fracture fixation, nerve exploration, neurolysis, nerve repair, and nerve grafting. Radiographic fracture union, clinical ulnar nerve motor and sensory function testing, along with selective electric nerve testing and advanced imaging were monitored throughout follow-up postinjury. Five of 7 patients underwent surgical treatment and 2 others were treated with conservative measures. The ulnar nerve was entrapped within the fracture site of one patient with an open fracture along with partial nerve transection, and 4 patients were found to have the nerve encased in hypertrophic scar tissue or bony callus upon surgical exploration at 3-12 months postinjury. The ulnar nerve lies in a precarious position in the middle to distal one-third forearm and is bound by anatomic constraints that place the nerve at risk of injury. This article offers a treatment algorithm that includes conservative treatment, acute exploration, early exploration (≤3 months), and late exploration (>3 months). Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors that predict instability in pediatric diaphyseal both-bone forearm fractures.

The aim of this study was to determine the factors that may predict failure of closed reduction and casting of diaphyseal forearm fractures in children. Demographic and radiographic data of children with closed reduction and casting of these fractures in the emergency department were evaluated. Of 174 patients with adequate follow-up to union, 19 (11%) required a repeat procedure. Risk factors for repeat reduction included translation of 50% or more in any plane, age more than 9 years, complete fracture of the radius, and follow-up angulation of the radius more than 15° on lateral radiographs or of the ulna more than 10° on anteroposterior radiographs.

Outcome of Pediatric Forearm Fracture Reductions Performed by Pediatric Emergency Medicine Providers Compared With Reductions Performed by Orthopedic Surgeons: A Retrospective Cohort Study.

The aim of this study was to describe the outcome differences between board-certified orthopedists and pediatric emergency medicine (PEM) physicians conducting forearm fracture reductions. We performed an analysis of patients between 1 and 14 years of age who presented to the emergency department (ED) with a forearm fracture requiring reduction. Data collected included reducing provider (PEM or orthopedist) and prereduction, postreduction, and follow-up fracture angles and displacements of both radius and ulna. We collected costs of care, both in the ED and at follow-up, as well as length-of-stay data. χ Tests and Fisher exact test compared associations between categorical variables; 2-sample t tests compared the PEM and orthopedic groups. Regression models were used to control for injury severity confounders. Of the 222 fractures, orthopedists reduced 135, and PEM doctors reduced 87. Based on fracture angle and displacement, the orthopedic group tended to have slightly more complicated cases. After adjusting for age and time to follow-up, fractures reduced by orthopedists were less likely to require remanipulation (adjusted odds ratio, 0.30; P = 0.020). The PEM group had a significantly lower length of stay (59.4 minutes shorter; P < 0.001) and a small overall saving in charges ($273.90; P = 0.47). Orthopedists performed better in maintaining fracture reductions compared with PEM physicians but lengthened the ED stay for our patients. There was no significant difference in cost.

Short and long arm cast and pain after discharge in children who underwent reduction of distal forearm fracture in the Emergency Department: A study protocol for a randomized comparative effectiveness study.

Distal forearm fracture is the most common fracture in childhood. Patients with this type of injury suffer from meaningful pain after Emergency Department (ED) discharge. Previous studies demonstrated that short arm (below-the-elbow) casts perform as well as long arm (above-the-elbow) casts for maintaining the reduction of distal forearm fractures, with a similar rate of complications. Consequently, short casts are the commonly used method of immobilization after closed reduction of a distal forearm fractures in children older than 4 years. However, short casts carry a potential disadvantage; since they cannot prevent supination in a wrist that is held in pronation, and vice versa, their use might be associated with pain.We initiated this study to examine the effect of the type of casting on post discharge pain. We will conduct an open-label randomized, controlled trial comparing short cast immobilization with long cast immobilization in children who had a reduction of distal forearm fracture in the ED. Our hypothesis is that children with distal forearm fractures who are treated with a long cast, experience less pain during the first 48 h after ED discharge than children who are treated with a short cast.

The Cost and Utility of Post-Reduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures

HYPOTHESIS Pediatric wrist and forearm fractures account for 25-50% of pediatric fractures, many of which are managed with sedation and reduction using mini C-arm fluoroscopy. At our institution, the standard of care has been to obtain formal x-rays after fluoroscopic guided reduction, which results in additional radiation exposure, time, and cost. We seek to determine the rate of re-reduction following these radiographs, as well with their associated time and cost. METHODS …

The Cost and Utility of Post-Reduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures

The Cost and Utility of Post-Reduction Radiographs After Closed Reduction of Pediatric Wrist and Forearm Fractures

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.

Ultrasound- and Fluoroscopy-guided Reduction of Pediatric Forearm Fractures: A Prospective Observational Study

Ultrasound- and Fluoroscopy-guided Reduction of Pediatric Forearm Fractures: A Prospective Observational Study

Clinico: Radiological outcome of diaphyseal fractures of both bone forearm in adults treated with dynamic compression plates: A prospective study

The diaphyseal fractures of radius and ulna in adults can result in significant loss of function if inadequately treated. Hence, they are usually managed by internal fixation and dynamic compression plates are the most commonly used implant for this purpose. We report the clinico-radiological outcome of both bone forearm fractures treated with Dynamic Compression Plate, through a prospective study done at Government Medical College, Thrissur from December 2014 to November 2015. The final outcome evaluated by Anderson criteria showed 62.5% excellent, 33.33% good results and only one poor outcome. Our series had 95.83% union rates with mean union duration of 13.8 weeks. We concluded that open reduction and internal fixation of adult forearm shaft fractures can be appropriately treated with Dynamic Compression Plating, which will give an excellent to good results and the results are worthy of comparison with those of the expensive newer implants.