Treatment Of Pediatric Forearm Fractures Research Articles

Modifiable and non-modifiable risk factors for failure of non-operative treatment of pediatric forearm fractures: Where can we do better?

Distal third forearm fractures are common fractures in children. While outcomes are generally excellent, some patients fail initial non-operative management and require intervention. The purpose of this study is to identify independent risk factors associated with failure of closed reduction. We conducted a retrospective review of distal third forearm fractures in children treated with closed reduction and casting. Patients were divided into two cohorts-those who were successfully closed reduced and those who failed initial non-operative management. Demographic characteristics, cast type, cast index, radiographic fracture, soft tissue characteristics, and quality of reduction were analyzed between groups. A total of 207 children treated for distal third forearm fractures were included for analysis. A total of 190 (91.8%) children maintained their reduction while 17 (8.2%) failed initial non-operative management. Modifiable risk factors associated with loss of reduction on univariate analysis included the use of a long arm cast (p = 0.003), increased post-reduction displacement (p = 0.02), and increased post-reduction angular deformity (p = 0.01). Non-modifiable risk factors included increased body mass index (p = 0.02), increased presenting fracture displacement (p = 0.002), and increased width of the soft tissue envelope at the fracture site (p = 0.0001). The use of long arm casts (13% vs 2%, odds ratio = 6.44) and soft tissue width (60.6 vs 50.4 mm, odds ratio = 1.1) remained significant risk factors for loss of reduction after multivariate analysis. Both larger soft tissue envelope at the site of the fracture and long arm cast immobilization are independently associated with an increased risk of failing initial closed reduction in distal third forearm fractures in the pediatric population. level III Case Control Study.

The Risk of Nerve Injury in Pediatric Forearm Fractures.

This article was updated on July 19, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 1080, in the last sentence of the Results section of the Abstract, the text that had read "0.05% (4 of 777)" now reads "0.5% (4 of 777)." The risk of fracture-related nerve injury associated with forearm fractures in children is unknown. The purposes of the present study were to calculate the risk of fracture-related nerve injury and to report the institutional rate of complications of surgical treatment of pediatric forearm fractures. Four thousand, eight hundred and sixty-eight forearm fractures (ICD-10 codes S52.0 to S52.7) that had been treated in our tertiary level pediatric hospital between 2014 and 2021 were identified in our institutional fracture registry. Of these, 3,029 fractures occurred in boys and 53 were open fractures. Sex, age at injury, trauma mechanism and energy, fracture type, treatment method, and cause and type of nerve injury were assessed in 43 patients with 44 registered nerve injuries. Patients with nerve injuries were reevaluated to calculate the recovery time. Univariable and multivariable regression analyses were performed to determine the risk of nerve injury. The risk of a fracture-related nerve injury was 0.7% (33 of 4,868). Only 2 injuries were permanent; thus, the risk of permanent nerve injury associated with a forearm fracture was 0.04% (2 of 4,868). The ulnar nerve was affected in 19 cases; the median nerve, in 8; and the radial nerve, in 7. In cases of open fracture, the risk of nerve injury was 17% (9 of 53). Open fractures had an OR of 33.73 (95% CI, 14.97 to 70.68) on univariate analysis and an OR of 10.73 (95% CI 4.50 to 24.22) on multivariate analysis with adjustment for female sex and both-bone diaphyseal fracture. Both-bone diaphyseal fracture (ICD-10 code S52.4) had an OR of 9.01 (95% CI, 4.86 to 17.37) on univariate analysis and an OR of 9.98 (95% CI 5.32 to 19.47) on multivariate analysis with adjustment for age and female sex. Overall, 777 fractures were internally fixed. The risk of nerve injury as a complication of internal fixation was 1.3% (10 of 777). Four of these iatrogenic injuries (including 2 involving the median nerve, 1 involving the ulnar nerve, and 1 involving the radial nerve) were permanent; thus, the risk of permanent nerve injury as a complication of internal fixation was 0.5% (4 of 777). Nerve injury following a pediatric forearm fracture is rare and has an excellent potential for spontaneous recovery. In the present study, all of the permanent nerve injuries occurred in association with open fractures or as a complication of internal fixation. Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

Long-Term Results of Extensor Indicis Transposition Following Rupture of the Extensor Pollicis Longus Tendon after Paediatric Forearm Fracture

A rare but typical perioperative complication in the surgical treatment of pediatric forearm fractures is injury to the extensor pollicis longus (EPL) tendon. This article presents the long-term results after reconstruction of the EPL tendon with transposition of the extensor indicis (EI) tendon in children and adolescents after surgically treated forearm fracture. Over a period of 15 years, 22 children up to the age of 16 were treated with EI transposition analogous to adult care. In a follow-up examination, the range of motion of the finger and thumb joints, retropulsion of the thumb and index finger, abduction and opposition were examined. In addition, hand span and strength in the gross, key, and point grasp were measured. Subjective complaints were questioned and the DASH score was assessed. Rupture of the EPL tendon is a rare complication, accounting for 1% of all surgically treated paediatric forearm fractures. 15 patients with an average age of 10.9 years could be followed up for an average of 66.5 months after transposition of the EI tendon. Significant differences were found in reduced mobility of the metacarpophalangeal joint of the thumb, isolated extensor strength of the index finger, a reduced span between the thumb and index finger in palmar abduction, and reduced strength in the pointed grip. Subjectively, the differences between the sides were not noticed by the patients and their parents in everyday life. Transposition of the EI tendon for reconstruction of a ruptured EPL tendon as a rare complication after paediatric forearm fracture does lead to a measurable and significant reduction in index finger mobility on the affected side in the long term, but without subjective limitations of the children.

Variations in the Preferred Treatment of Pediatric Forearm Fractures Among Practicing Orthopaedic Surgeons

Background: Forearm fractures are common childhood injuries. Controversy remains on the optimal treatment for certain fractures. The goal of this study was to determine variation in the treatment of pediatric forearm fractures based on fracture patterns, patient demographics, and surgeon characteristics. Methods: A survey was distributed to orthopedic surgeons consisting of 48 different cases of pediatric forearm fractures with possible treatment options. Each case included patient age and radiographs at three different time intervals: initial injury, post reduction, and first office follow-up. Respondents were asked if they would recommend non-surgical management, surgery with intramedullary nailing, or surgery with plate/screw fixation. Surgeon demographic data was also collected. The primary model investigated the effect of the attributes on the surgeon’s decision to operate. Results: 48 of 55 surgeons responded. Surgery was chosen as preferred treatment in 43% of the presented scenarios. Coronal plane angulation at first follow-up was associated with the greatest increase in marginal probability of operative treatment. For each degree increase in angulation, respondents were 5.2% more likely to operate on a patient. For each additional year of patient age, operative treatment probability increased by 3.9%. Surgeons’ sex, age, years in practice, and fellowship type were not associated with variations in treatment preferences. Conclusions: Our study demonstrates significant variability in treatment recommendations amongst orthopedic surgeons with regard to pediatric forearm fractures. Patient age and coronal plane angulation at first follow-up increased the probability of choosing operative treatment among respondents. Surgeon characteristics did not predict treatment recommendations.

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.

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.

Elastic stable intramedullary nailing for treatment of pediatric forearm fractures: A 15-year single centre retrospective study of 173 cases

The aim of this study was to analyze the outcomes and complications in children treated with elastic stable intramedullary nailing (ESIN) for forearm fracture. The study included 173 patients (126 men and 47 women; median age: 11 years (range: 3-17 years) treated with ESIN for forearm fracture between May 2002 and May 2018. Immobilization was not performed after the surgery. The median follow-up was 68 months (range: 3-161 months). The etiology, healing time, and complications were recorded. All patients achieved complete radiographic healing at a median of 6.8 weeks (range: 4-11 weeks). The most common injuries were sport related (n=65) and by falling from standing height (n=57), followed by injuries from bicycle riding, motorbike accidents, road traffic accidents, and fights. Fifteen (8.76%) postoperative complications were recorded: eight entry-site skin irritations, two cases of skin infection, two refractures, and one case each of nail migration, injury of ulnar nerve, and pseudoarthrosis. All complications, except cases of refractures and pseudoarthrosis, were treated conservatively, with no long-term consequences for the patients. Patients with refractures and pseudoarthrosis were reoperated, and complete function of the extremities was fully restored. ESIN for treatment of forearm fractures in children shows good functional and cosmetic results. This is a minimally invasive, cast-free, simple, and reproducible technique, with a low complication rate. Owing to these excellent objective and subjective results, surgical stabilization of the forearm fracture using ESIN is recommended in children and adolescents. Level IV, Therapeutic study.

Factors affecting re-displacement in pediatric forearm fractures and the role of cast indices.

Objectives This study aims to investigate the factors affecting the loss of reduction in pediatric diaphyseal forearm fractures and to compare the three-point index (TPI) with the cast index, padding index, Canterbury index, and gap index.Patients and methods This retrospective study, which was conducted between January 2016 and December 2016, included 159 patients (134 males, 25 females; mean age 8.1±2.8 years; range, 3 to 13 years) with diaphyseal forearm fracture. Patients’ age, gender, and the level, displacement, and location of the fractures were recorded. The presence of anatomic reduction, a straight ulnar border, and the cast type (banana or box type) were checked after the reduction. The TPI, cast index, padding index, Canterbury index, and gap index were measured.Results Fifty-two patients (32.7%) experienced loss of reduction during the follow-up. Displaced fractures of both the radius and the ulna, cast type-banana, anatomical reduction, straight ulnar border, TPI, cast index, padding index, and Canterbury index were found to be associated with re-displacement.ConclusionAlthough cast indices can be used as a beneficial clinical tool in predicting the loss of reduction in the treatment of pediatric forearm fractures, they may not be sufficient when used alone. Obtaining a more accurate result may be possible by assessing several parameters such as the presence of an anatomic reduction, box-type casting, and TPI together.

Surgical treatment of pediatric forearm fractures with intramedullary nails: is it a disadvantage to leave the tip exposed?

Elastic intramedullary nailing is the main treatment method in the surgical treatment of pediatric forearm fractures. In this study, we compared the clinical outcomes of intramedullary nailing of forearm fractures with leaving the tips exposed and with placing the tip of the nails under the skin. We aimed to present the clinical outcomes of intramedullary nailing and determine the advantages and disadvantages of leaving the tips of the nails exposed. One hundred and ninety-two children with both-bone forearm fracture who were treated with titanium elastic nailing (TEN) in the Department of Orthopedics at Erzurum Regional Training and Research Hospital between January 2009 and December 2016 were included in the study. All cases had been followed up for at least 1 year. The tips of the TENs were left exposed in 74 and buried subcutaneously in 118 children. Union was achieved in all cases. Delayed union was observed in just one case. Skin irritation was observed in 11 (5.7%) of the exposed TEN cases. Superficial infection developed in two (1%) cases with exposed TEN tips. Migration developed during the follow-up of 11 (5.7%) cases with buried tips. The mean time to removal of TEN was 7.9 weeks in cases with exposed and 26.2 weeks in cases with buried cases. Refracture was observed in six buried (3.1%) cases and four exposed TEN (2.1%) cases in the first year after the removal of the nails. Perfect outcomes were achieved in 146 (76%) cases and good outcomes in 36 (19%) cases in our study. On comparing the rate of complications and clinicaloutcomes, leaving the TEN exposed seems to be safe.

Improving Quality in the Treatment of Pediatric Forearm Fractures: Minimizing the Need for Repeat Intervention With Long-arm Extension Casting

Repeat intervention for pediatric forearm fractures after closed manipulation is as high as 46% with flexed elbow (FE) long-arm casts. Casting with the elbow extended (EE) has been advocated as an alternative technique. We documented outcomes of patients treated with closed manipulation and casting with EE long-arm casts for displaced, diaphyseal both-bone forearm fractures. We retrospectively reviewed charts for patients who had sedated manipulations and casting for closed, diaphyseal forearm fractures. Open fractures, immediate surgical intervention, metabolic bone disease, recurrent fractures, and Monteggia injuries were excluded. Closed manipulations were performed by orthopaedic residents assisted by cast technicians, with sedation provided by emergency department physicians. Radiographic angulation and displacement of the radius and ulna on immediate postreduction radiographs and all follow-up radiographs were recorded. Patients requiring repeat intervention were compared with those who did not by using the Mann-Whitney U and Fisher exact tests. Of 86 patients (7.2±2.8 y) available for analysis, 82 (95.3%) completed treatment after a single-sedated manipulation and placement of an EE long-arm cast. There were no malunions or nonunions. The average follow-up was 50 days. Four (4.7%) patients required repeat interventions (2 had surgery, 1 had a repeat sedated manipulation, and 1 had a nonsedated manipulation). There were no statistically significant differences in age, sex, laterality, fracture position in the diaphysis, or immediate postreduction angulation of the radius or ulna. A literature review showed average repeat intervention rates of 14.9% (range, 0% to 45.9%) for FE casts and 3.3% (range, 0% to 15%) for EE casts. There was a low rate of repeat interventions (4.7%) in patients with EE casts compared with historical rates for FE casts. Improving the quality of health care involves identifying and implementing practices that provide the best outcomes at the lowest costs. The use of EE long-arm casts following closed manipulation of pediatric forearm fractures may decrease the rate of repeat manipulation or surgery compared with conventional FE casts. Level IV-case series.

Increasing rates of surgical treatment for paediatric diaphyseal forearm fractures: a National Database Study from 2000 to 2012.

ForearmPurpose fractures are one of the most commonly sustained injuries in children and are often treated non-operatively. The purpose of this study was to estimate the rate of inpatient surgical treatment of paediatric forearm fractures over time using a large, publicly available, national database.MethodsThe Healthcare Cost and Utilization Project (HCUP) Kids’ Inpatient Database (KID) was evaluated between 2000 and 2012. Forearm fractures and surgeries were identified using International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9 CM) diagnosis and procedure codes. Univariable and multivariable logistic regression were used to determine variables associated with greater proportion of surgical treatment. All statistical analyses were performed using SAS statistical software v.9.4 (SAS Institute Inc., Cary, NC, USA). Statistical significance was set at p < 0.05.ResultsThe database identified 30 936 forearm fracture admissions. Overall, 19 837 of these patients were treated surgically (64.12%). The percentage of patients treated with surgery increased from 59.3% in 2000 to 70.0% in 2012 (p < 0.001). Multivariable regression analysis found increased age (p < 0.001), more recent year (p < 0.001), male gender (p = 0.003) and admission to a children’s hospital (p < 0.001) were associated with an increased proportion of patients receiving surgical treatment. Medicaid payer status was associated with a lower proportion of surgical treatment (p < 0.001).ConclusionsThe rate of operative treatment for paediatric forearm fractures admitted to the hospital increased over time. Increased surgical rates were associated with older age, male gender, treatment at a children’s hospital and non-Medicaid insurance status.

A prospective study of management of closed diaphyseal fractures of radius and/or ulna in children with intramedullary titanium elastic nail system

Background & Aim: Intra-medullary elastic nailing system is an ideal device for the treatment of pediatric forearm fractures. It is simple, safe, minimally invasive technique and has a fewer complications. The aim of the study was to evaluate and report our experiences regarding union rates, clinical and functional outcome and complications associated with this treatment modality in BBF between age group of 5 to 15 years. Material & Methods: 40 cases of pediatric diaphyseal both bone forearm in children of age group 5 to 15 years operated at National Institute of Medical Science and hospital, Jaipur meeting the inclusion and the exclusion criteria ( as given below) managed between January 2015 to December 2015 with TENS were prospectively reviewed. The final functional and clinical outcome & complications were assessed at 6 month of follow up by Andersons et al criteria. Results: Of all 40 patients had undergone close reduction in which 2 required open reductions. All fractures united at a mean of 7.95 weeks (range 6-10 weeks) with achievement of full R.O.M at elbow and wrist in majority with reported restriction in 3 cases. There were no major complications but encountered minor complications in 18 patients such as pain (22.5%), hardware skin irritation (12.5%), and pin track infection (10%). The final functional outcome evaluated by Andersons et al criteria showed 90% excellent results and remaining showed good outcome. Conclusion: TENS is an ideal device for the treatment of pediatric forearm fractures as it is a simple, safe, minimally invasive technique and has fewer complications. It also does not interfere with growth of the forearm and provides early union due to non interference of fracture hematoma and minimal periosteal stripping. It provides shorter hospital stay, rapid return to daily activity & school, avoids long & uncomfortable immobilization & cosmetically acceptable

Radiographic Evaluation During Treatment of Pediatric Forearm Fractures: Implications on Clinical Care and Cost.

As ≥30% of displaced pediatric forearm fractures demonstrate loss of reduction (LOR) following closed reduction (CR); radiographic follow-up is advocated at 1, 2, 4, and 6 weeks for detection of redisplacement. We hypothesized that there is minimal change in fracture alignment 2 weeks after CR, and consequently, that radiographs at 4 weeks add cost but little value to clinical care. A total of 184 patients enrolled in a prospective study of pediatric forearm fractures including both distal and diaphyseal injuries were evaluated. All were treated with CR, casting, and radiographic evaluation at 1, 2, 4, and 6 weeks postinjury. Primary endpoint was radiographic LOR. Secondary endpoint was need for any intervention. A modified number-needed to treat analysis estimated the utility of the week 4 x-ray in predicting intervention. Relative value unit (RVU) costing, time-derived activity-based costing (TDABC), and billing totals were used for cost analysis. Seventy patients (38%) demonstrated radiographic LOR. Independent predictors of LOR were initial radius displacement >75% (OR=5.40; CI, 2.23-12.60), concomitant ulna fracture (OR=1.71; CI, 1.15-2.54), and dominant arm involvement (OR=2.87; CI, 1.40-5.87). Eighty percent of all LORs occurred within the first 2 weeks. There was no statistically significant change in radiographic alignment after week 2. Of 40 total interventions, all were performed within the first 2 weeks of follow-up. The 4-week x-ray did not influence decision to intervene, and at most, 1 in every 40 patients would require an intervention after week 2. Elimination of the 4-week x-ray would result in a savings of 4.8% (RVU method) to 11.9% (TDABC method) in the overall cost of nonoperative fracture care. There is minimal change in fracture alignment 2 weeks following CR of pediatric forearm fractures, and all interventions are based on early radiographic follow-up. The week 4 x-ray adds little value to clinical decision making, and its elimination would result in savings up to 11.9% of the overall cost of nonoperative fracture care. Level II-prognostic.

Treatment of diaphyseal forearm fractures in children

Both bone forearm fractures are common orthopedic injuries. Optimal treatment is dictated not only by fracture characteristics but also patient age. In the pediatric population, acceptable alignment can tolerate greater fracture displacement due to the bone’s ability to remodel with remaining growth. Generally, these fractures can be successfully managed with closed reduction and casting, however operative fixation may also be required. The optimal method of fixation has not been clearly established. Currently, the most common operative interventions are open reduction with plate fixation versus closed or open reduction with intramedullary fixation. Plating has advantages of being more familiar to many surgeons, being theoretically superior in the ability to restore radial bow, and providing the possibility of hardware retention. Recently, intramedullary nailing has been gaining popularity due to decreased soft tissue dissection; however, a second operation is needed for hardware removal generally 6 months after the index procedure. Current literature has not established the superiority of one surgical method over the other. The goal of this manuscript is to review the current literature on the treatment of pediatric forearm fractures and provide clinical recommendations for optimal treatment, focusing specifically on children ages 3-10 years old.

Predictors of conversion from conservative to operative treatment of pediatric forearm fractures

Forearm fractures occur commonly in children; however, there is still uncertainty on what leads to conversion from conservative to operative management. Patients who initially underwent closed reduction and casting for diaphyseal forearm fractures were evaluated for predictors of conversion to operative management. We found that the 20 of 124 (16%) patients in whom there was conversion to operative management were significantly older (11.1 vs. 5.7 nonoperative), had less angulation in the anterior-posterior (or coronal) plane (20.2 vs. 12.8° for the radius, 17.5 vs. 7.8° for the ulna), had a more proximal ulnar fracture location, and had more translated or shortened radius fractures.

Paediatric forearm fractures in the west of Scotland

Forearm fractures are common paediatric injuries. This study aimed to describe the epidemiology and treatment of paediatric forearm fractures in the urban population of Glasgow. We reviewed all forearm fractures treated by the orthopaedic service in Yorkhill Children's Hospital in 2008 up to the age of 13 years. Data were gathered from case-notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 439 fractures. Census data were used to derive absolute age-specific incidences. Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year and 294 fractures per 100,000 population per year for non-torus fractures. An increased number of fractures occurred between May and August. A fall from less than 1 m was the most common mechanism of injury. Sporting injuries were the second most common. This study identifies some features which are in agreement with studies from elsewhere in Britain. However, there are also interesting differences, such as the Glasgow peak incidence for forearm fractures being at age eight, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention and likelihood of successful treatment.

Acceptance of angulation in the non-operative treatment of paediatric forearm fractures

Forearm fractures are the most common injury in paediatric traumatology. The unique properties of the juvenile skeleton make it possible to cope well with traumatic deformities such as angulation, apposition and displacement. While we make use of these properties, the exact mechanism and degree of healing remains obscure. Different types of forearm fractures require specific treatment options, each with its limitations. A meta-analysis of recent literature was carried out, and together with the opinions of 18 international experts an effort was made to provide insight into the limits of acceptance of angular deformation in the non-operative treatment of paediatric forearm fractures. With this information we constructed graphs (age versus angulation) for each of the eight types of paediatric forearm fractures. In the absence of proper trials, it is our opinion that the presented Isala graphs can provide useful support in the decision-making process of acceptance of angular deformities in paediatric forearm fractures.

Which Axial Deviation Results in Limitations of Pro- and Supination Following Diaphyseal Lower Arm Fracture in Childhood?

Background: Pediatric diaphyseal forearm fractures, if considered stable, are usually treated conservatively. Recently, however, there has been a trend towards stabilizing diaphyseal forearm fractures operatively, generally by intramedullary nailing, to avoid angular deformities and functional impairment. The aim of this study was to examine patients with an unsatisfactory outcome after diaphyseal forearm fracture for a possible correlation betwwen their outcome and a remaining axial deviation or a combined angular deformity in order to better ensure that only essential operations are performed. Patients and Methods: Analysis of 581 pediatric forearm fractures showed a similar distribution concerning age, cause, and fracture site as previously reported in other studies. Results: 14.8% of our patients showed an unsatisfactory outcome. In some patients, this was due to residual ulnar and plamar angular deformities of the radial shaft. Another reason for a poor outcome was an angular deformity > 15° not depending on the plane the dislocation occurred in; the values, however, were not statistically significant. A discriminating analysis (CART®) of combined mid-diaphyseal fractures with angular deformities of up to 15° demonstrated that the relation of the bony deformities to each other had relevant consequences for the outcome. For example, radiopalmar angular deformities of the radial shaft combined with a nondeformed ulna had a high probability of an unsatisfactory outcome. If this deformity of the radius was combined with a dorsal deformity of the ulnar diaphysis, however, the probability of a satisfactory outcome was high. Conclusions: In summary, this study indicates that the prognosis of a satisfactory outcome of forearm fractures regarding function and cosmesis is complex and influenced by both the radius and ulna. Diaphyseal angular deformities > 10° should be avoided in the treatment of pediatric forearm fractures.

Closed intramedullary nail application in pediatric forearm shaft fractures of both bones

Objectives: Forearm fractures of both bones is commonly encountered in pediatric age group. In this study, we reviewed treatment results of patients who underwent closed intramedullary nail application for this type of fractures. Methods: The study included 34 patients with forearm fractures (mean age 10 years) who were treated and followed-up between January 1998 and November 1999. Initially, closed reduction and casting were attempted at least once in all patients. Intramedullary nailing was performed in all patients. The mean follow-up was 11 months (range 4-18 months). Results: Preoperative radial angulation was 12 to 36 degrees in anteroposterior and from 9 to 46 degrees in lateral plane radiograms. Postoperatively, angulations were 0 to 14 degrees and 0 to 12 degrees in anteroposterior and lateral radiograms, respectively. Three patients exhibited limitation in supination (20, 35, and 45 degrees, respectively). In the remaining patients, wrist range of motion was normal. Conclusion: Closed intramedullary nailing proved successful in the treatment of pediatric forearm fractures of both bones.

Intravenous regional anaesthesia in the treatment of paediatric forearm fractures in the emergency department

Abstract Objective: To describe our experience using local anaesthetic‐assisted manipulation and plaster with prilocaine as a method of facilitating fracture reduction in paediatric patients; in particular, issues of efficacy and safety. Methods: Retrospective explicit chart review was performed on all paediatric patients presenting with distal forearm fractures for a 6 month period between 1 January and 31 July 1996. Data collected included: (i) the success of the procedure (defined by clinical and radiological parameters); (ii) age and gender of the patient; (iii) use of adjuvant medications; and (iv) occurrence of complications. Results: In the study period, 156 paediatric patients presented with distal forearm fractures. Of these, 78 patients required manipulation. Fifty‐three patients were treated with a local anaesthetic‐assisted manipulation and plaster, while 25 patients were admitted for a reduction under general anaesthesia. Successful fracture reduction using local anaesthetic‐assisted manipulation and plaster was achieved in 96.3% of the cases in which this method was used. With respect to safety, no adverse respiratory/haemodynamic sequelae or problems with prilocaine toxicity were found. Adjuvant medication was used frequently (49%); however, the reasons for use could not be determined in this study. Conclusions: This study suggests that local anaesthetic‐assisted manipulation and plaster using prilocaine has a high success rate and a good safety record. This should be confirmed by study of a larger population. Factors to be taken into account when considering the use of this procedure are: (i) patient and parental preference; (ii) age of the patient; (iii) experience of the available staff; (iv) availability of personnel resources; (v) impact on patient flow in the emergency department; and (vi) anticipated delay in therapy if admission for treatment under general anaesthesia is chosen.