Redisplacement Rates after Reduction and Cast Immobilization of Isolated Distal Radial Fractures

Background The maintenance of satisfactory alignment in distal radial fractures following closed reduction and casting of the forearm is challenging. Redisplacement rates of between 2 and 91% have been described, mostly for Western populations and for fractures involving both the forearm bones. The local scenario is unexplored. Objective This study sought to determine the rate of redisplacement in isolated closed distal radial fractures in children aged 6-15 years and the factors contributing to the redisplacement. Setting The Kenyatta National Hospital, a teaching and referral hospital in Kenya. Patients and Methods This was a prospective study carried out between June 2005 and February2006. Patients were recruited from casualty, where the fracture was reduced and casted. Immediate check x-rays were taken to ascertain satisfactory alignment. At follow up the fractures were evaluated for redisplacement in the fracture clinic in the second and fourth weeks with further check x-rays. Redisplacement was regarded as the presence of dorsal or volar- angulation of greater than 200. The data was collected and entered into statistical package for social sciences (SPSS) 12.0 version. Comparison of the binomial outcomes of the factors determining the redisplacement of the distal radial fractures was carried out using Fischer’s exact test. P valu

Factors affecting early re-displacement of paediatric diaphyseal forearm fractures at Korle Bu Teaching Hospital

Background: Complete fractures of the forearm have the potential to displace and angulate with overriding fracture fragments. Maintaining acceptable reduction is not always possible, and re- displacement or re-angulation is the most commonly reported complication. Factors responsible for the re-displacement after an initial acceptable reduction have not been clearly defined. The study aimed to determine the factors that influence early re-displacement of paediatric diaphyseal forearm fractures in Korle-Bu Teaching Hospital.Methods: A prospective study in a cohort of 72 children below the age of 12 years with diaphyseal forearm fracture attending the Orthopaedic clinic were followed with close reduction casting from April 2017-December, 2017. Factors analysed included demographics, initial fracture features and the radiographic indices of the cast quality.Results: 93.1% (67) of the fractures were because of the children falling on an outstretched arm. Majority of the children had a fracture of the distal 1/3 of the radius (n=38, 52.6%). The overall C.I was 0.8 (SD 0.1). The only significant predictor for predicting re-displacement was children falling on an outstretched hand (p-value=0.0).Conclusion: This study has shown that the degree of initial displacement and the ability to achieve good reduction with a well moulded cast, constitute the major factors for early re-displacement of paediatric forearm fracturesKeywords: cast index, intermedullary nailing, elastic stable intramedullary nail, open reduction, internal fixationFunding: Personal fundin

Displaced distal forearm fractures in children with an indication for reduction under general anesthesia should be percutaneously fixated

Surger

The CAST study protocol:A cluster randomized trial assessing the effect of circumferential casting versus plaster splinting on fracture redisplacement in reduced distal radius fractures in adults

Background There is no consensus concerning the optimal casting technique for displaced distal radius fractures (DRFs) following closed reduction. This study evaluates whether a splint or a circumferential cast is most optimal to prevent fracture redisplacement in adult patients with a reduced DRF. Additionally, the cost-effectiveness of both cast types will be calculated. Methods/design This multicenter cluster randomized controlled trial will compare initial immobilization with a circumferential below-elbow cast versus a below-elbow plaster splint in reduced DRFs. Randomization will take place on hospital-level (cluster, n = 10) with a cross-over point halfway the inclusion of the needed number of patients per hospital. Inclusion criteria comprise adult patients (≥ 18 years) with a primary displaced DRF which is treated conservatively after closed reduction. Multiple trauma patients (Injury Severity Score ≥ 16), concomitant ulnar fractures (except styloid process fractures) and patients with concomitant injury on the ipsilateral arm or inability to complete study forms will be excluded. Primary study outcome is fracture redisplacement of the initial reduced DRF. Secondary outcomes are patient-reported outcomes assessed with the Disability Arm Shoulder Hand score (DASH) and Patient-Rated Wrist Evaluation score (PRWE), comfort of the cast, quality of life assessed with the EQ-5D-5L questionnaire, analgesics use, cost-effectiveness and (serious) adverse events occurence. In total, 560 patients will be included and followed for 1 year. The estimated time required for inclusion will be 18 months. Discussion The CAST study will provide evidence whether the type of cast immobilization is of influence on fracture redisplacement in distal radius fractures. Extensive follow-up during one year concerning radiographic, functional and patient reported outcomes will give a broad view on DRF recovery. Trial registration Registered in the Dutch Trial Registry on January 14th 2020. Registration number: NL8311

Treating Displaced Distal Forearm Fractures in Children

Purpose:: Distal forearm fractures are among the most common fractures in children. In the past few years the option of percutaneous pinning has gained more attention in the treatment of unstable fractures. However, it remains unclear in which cases a fracture or its reduction should be considered unstable. Study Design:: In order to evaluate which type of fractures profit most from additional pinning after closed reduction, we performed a retrospective analysis of 225 consecutive cases using the recently published AO pediatric classification of long bone fractures. Results:: After closed reduction, position in the cast was lost in 23% of the cases. The proportion of unstable reductions was much higher in completely displaced fractures. The amount of dislocation was more important than the type of fracture according to the AO classification proposal. Conclusions:: Fully displaced fractures should always be reduced in a setting with pins immediately available. If anatomical reduction cannot be achieved, pinning is advocated. The AO proposal for pediatric long bone fracture classification could be a useful tool to render the diverse studies more comparable. However, the important feature of complete versus subtotal displacement is lackin

Importance of calculating various casting indices in predicting radiological outcomes of paediatric forearm fractures

Background: The present study is aimed at determining the importance of various casting indices in predicting the outcome of paediatric forearm fractures treated with closed reduction and plaster application in our department.Methods: Thirty children, aged 5 to 15 years, with closed forearm fractures not requiring surgical fixation were included to assess their casting indices and radiological outcomes using X-rays. After satisfactory casting, patients were followed up weekly till 6 weeks with anteroposterior (AP) and lateral X-ray.Results: Acceptable reduction was achieved in 26 cases, while re-manipulation was done in 4 cases. Cast Index ranged from 0.80±0.09 at first week to 0.78±0.09 at 6 weeks, Padding Index was 0.30±0.04 at first week and increased to 0.31±0.03 at 6 weeks, Canterbury Index was 1.07±0.24 at first week and 1.07±0.78 at 6 weeks, Gap Index 0.15±0.02 remained the same throughout, and Three Point Index changed from 0.81±0.08 at first week to 0.77±0.18 six weeks. Radial bow of children showed no significant change at various time points of assessment. Rotational mal-alignment was observed in 5 patients, one had a 0.5 cm radial overlap, while none had an ulnar overlap. Radial angulation was observed in five and six children on AP and lateral X-ray respectively. Ulnar angulation was seen in two and one child on AP and lateral X-ray respectively.Conclusions: Continued use of these casting indices to assess paediatric forearm cast adequacy is supported by this study

Treatment of displaced proximal humeral fractures in elderly patients

The optimal treatment for patients with displaced fractures of the proximal humerus, especially elderly patients with osteoporosis, is still controversial. For the 2- and 3-part fractures according to the Neer classification, there is a trend towards more frequent surgical interventions with modern locking plates. For the more comminuted 4-part fracture with a higher risk for avascular necrosis, a primary hemiarthroplasty (HA) has been the accepted treatment. The alternative treatment for these fractures is non-operative with a short immobilization period and early physiotherapy. The latest Cochrane review regarding this topic concludes that there is insufficient evidence from randomized controlled trials (RCTs) to determine which interventions are the most appropriate for the management of different types of fractures. It is also stated that future trials should use validated outcome measures, including patient-assessed functional outcomes such as health-related quality of life (HRQoL). However, due to their design, quality-of-life instruments may be less sensitive for detecting small but yet important changes, i.e. they may have a limited responsiveness. In a prospective cohort study with a 2-year follow-up, 50 elderly patients with a displaced 2-part fracture of the proximal humerus were treated with open reduction and internal fixation with a locking plate. The result showed that locking plates appear to be a good treatment alternative with an acceptable complication rate and an acceptable functional outcome. In an RCT with a 2-year follow-up, 60 elderly patients with a displaced 3-part fracture of the proximal humerus were allocated to treatment with open reduction and internal fixation with a locking plate or non-operative treatment. The results of the study indicated an advantage in functional outcome and HRQoL in favor of the locking plate as compared to non-operative treatment, but at a cost of additional surgery in 30% of the patients. The main advantage of the locking plate appeared to be an improved range of motion (ROM). In an RCT with a 2-year follow-up, 55 patients with a displaced 4-part fracture of the proximal humerus were allocated to treatment with a primary HA or non-operative treatment. The results of the study demonstrated a significant advantage in quality of life in favor of HA as compared to non-operative treatment. The main advantage of HA appeared to be less pain, while there were no differences in ROM. 145 patients with a displaced proximal humeral fracture were included in a study with the aim to evaluate the responsiveness of the EQ-5D instrument. The EQ-5D displayed good internal and external responsiveness and can be recommended for use as a quality-of-life measure in patients with this particular injury. An additional conclusion of the studies was that, regardless of primary treatment, a displaced fracture of the proximal humerus results in a substantial negative effect upon the patients‟ HRQoL

Interventions for treating wrist fractures in children:Review

© 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. Background: Wrist fractures, involving the distal radius, are the most common fractures in children. Most are buckle fractures, which are stable fractures, unlike greenstick and other usually displaced fractures. There is considerable variation in practice, such as the extent of immobilisation for buckle fractures and use of surgery for seriously displaced fractures. Objectives: To assess the effects (benefits and harms) of interventions for common distal radius fractures in children, including skeletally immature adolescents. Search methods: We searched the Cochrane Bone, Joint and Muscle Trauma Group's Specialised Register, the Cochrane Central Register of Controlled Trials, MEDLINE, Embase, trial registries and reference lists to May 2018. Selection criteria: We included randomised controlled trials (RCTs) and quasi-RCTs comparing interventions for treating distal radius fractures in children. We sought data on physical function, treatment failure, adverse events, time to return to normal activities (recovery time), wrist pain, and child (and parent) satisfaction. Data collection and analysis: At least two review authors independently performed study screening and selection, 'Risk of bias' assessment and data extraction. We pooled data where appropriate and used GRADE for assessing the quality of evidence for each outcome. Main results: Of the 30 included studies, 21 were RCTs, seven were quasi-RCTs and two did not describe their randomisation method. Overall, 2930 children were recruited. Typically, trials included more male children and reported mean ages between 8 and 10 years. Eight studies recruited buckle fractures, five recruited buckle and other stable fractures, three recruited minimally displaced fractures and 14 recruited displaced fractures, typically requiring closed reduction, typically requiring closed reduction. All studies were at high risk of bias, mainly reflecting lack of blinding. The studies made 14 comparisons. Below we consider five prespecified comparisons: Removable splint versus below-elbow cast for predominantly buckle fractures (6 studies, 695 children)One study (66 children) reported similar Modified Activities Scale for Kids - Performance scores (0 to 100; no disability) at four weeks (median scores: splint 99.04; cast 99.11); low-quality evidence. Thirteen children needed a change or reapplication of device (splint 5/225; cast 8/219; 4 studies); very low-quality evidence. One study (87 children) reported no refractures at six months. One study (50 children) found no between-group difference in pain during treatment; very low-quality evidence. Evidence was absent (recovery time), insufficient (children with minor complications) or contradictory (child or parent satisfaction). Two studies estimated lower healthcare costs for removable splints. Soft or elasticated bandage versus below-elbow cast for buckle or similar fractures (4 studies, 273 children)One study (53 children) reported more children had no or only limited disability at four weeks in the bandage group; very low-quality evidence. Eight children changed device or extended immobilisation for delayed union (bandage 5/90; cast 3/91; 3 studies); very low-quality evidence. Two studies (139 children) reported no serious adverse events at four weeks. Evidence was absent, insufficient or contradictory for recovery time, wrist pain, children with minor complications, and child and parent satisfaction. More bandage-group participants found their treatment convenient (39 children). Removal of casts at home by parents versus at the hospital fracture clinic by clinicians (2 studies, 404 children, mainly buckle fractures) One study (233 children) found full restoration of physical function at four weeks; low-quality evidence. There were five treatment changes (home 4/197; hospital 1/200; 2 studies; very low-quality evidence). One study found no serious adverse effects at six months (288 children). Recovery time and number of children with minor complications were not reported. There was no evidence of a difference in pain at four weeks (233 children); low-quality evidence. One study (80 children) found greater parental satisfaction in the home group; low-quality evidence. One UK study found lower healthcare costs for home removal. Below-elbow versus above-elbow casts for displaced or unstable both-bone fractures (4 studies, 399 children) Short-term physical function data were unavailable but very low-quality evidence indicated less dependency when using below-elbow casts. One study (66 children with minimally displaced both-bone fractures) found little difference in ABILHAND-Kids scores (0 to 42; no problems) (mean scores: below-elbow 40.7; above-elbow 41.8); very low-quality evidence. Overall treatment failure data are unavailable, but nine of the 11 remanipulations or secondary reductions (366 children, 4 studies) were in the above-elbow group; very low-quality evidence. There was no refracture or compartment syndrome at six months (215 children; 2 studies). Recovery time and overall numbers of children with minor complications were not reported. There was little difference in requiring physiotherapy for stiffness (179 children, 2 studies); very low-quality evidence. One study (85 children) found less pain at one week for below-elbow casts; low-quality evidence. One study found treatment with an above-elbow cast cost three times more in Nepal. Surgical fixation with percutaneous wiring and cast immobilisation versus cast immobilisation alone after closed reduction of displaced fractures (5 studies, 323 children) Where reported, above-elbow casts were used. Short-term functional outcome data were unavailable. One study (123 children) reported similar ABILHAND-Kids scores indicating normal physical function at six months (mean scores: surgery 41.9; cast only 41.4); low-quality evidence. There were fewer treatment failures, defined as early or problematic removal of wires or remanipulation for early loss in position, after surgery (surgery 20/124; cast only 41/129; 4 studies; very low-quality evidence). Similarly, there were fewer serious advents after surgery (surgery 28/124; cast only 43/129; 4 studies; very low-quality evidence). Recovery time, wrist pain, and satisfaction were not reported. There was lower referral for physiotherapy for stiffness after surgery (1 study); very low-quality evidence. One USA study found similar treatment costs in both groups. Authors' conclusions: Where available, the quality of the RCT-based evidence on interventions for treating wrist fractures in children is low or very low. However, there is reassuring evidence of a full return to previous function with no serious adverse events, including refracture, for correctly-diagnosed buckle fractures, whatever the treatment used. The review findings are consistent with the move away from cast immobilisation for these injuries. High-quality evidence is needed to address key treatment uncertainties; notably, some priority topics are already being tested in ongoing multicentre trials, such as FORCE

The evolution of hand function during remodelling in nonreduced angulated paediatric forearm fractures:a prospective cohort study

Forearm fractures are very common orthopaedic injuries in children. Most of these fractures are forgiving due to the unique and excellent remodelling capacity of the juvenile skeleton. However, significant evidence stating the limits of acceptable angulations and taking functional outcome into consideration is scarce. The aim of this study is, therefore, to get a first impression of the remodelling capacity in nonreduced paediatric forearm fractures based on radiological and functional outcome. Children aged 0-14 years with a traumatic angular deformation of the radius or both the radius and ulna, treated conservatively without reduction, were included in this prospective cohort study. Radiographs were taken and functional outcome was assessed at five fixed follow-up appointments throughout a period of one year. Outcome measurements comprised radiographic angular alignment, grip strength and wrist mobility. A total of 26 children (aged 3-13 years) with a traumatic angulation of the forearm were included. Mean dorsal angulation at the time of presentation amounted to 12° (5-18) and diminished after one year to a mean angulation of 4° (0-13). Grip strength, pronation and supination were significantly diminished compared to the unaffected hand up to 6 months after injury. After one year, no significant differences in function between the affected and the unaffected arm were found. Nonreduced angulated paediatric forearm fractures have the potential to remodel in time and have good radiographic and functional outcome one year after trauma, where pronation and grip strength take the longest to recover