Overriding distal metaphyseal radial fractures in children – Epidemiology, treatment, and outcome

Distal radial metaphysis is the most common fracture location in children. Fracture morphology varies from stable incomplete torus fractures to complete fractures with different degrees of angulation and shortening. Completely displaced fractures in an overriding position represent the end of the spectrum and reduction of these fractures have been traditionally recommended. Pin fixation has been advocated, because retaining satisfactory fracture alignment with a cast has been proven difficult. On the other hand, it has been suggested that distal metaphyseal radial fractures in an overriding position (DMRFOP) in children under 10 years of age could be treated without reduction. The first aim was to calculate the incidence of DMRFOP in children under 16 years of age in Helsinki, and to assess retrospectively the overall management and quality of treatment of DMRFOP in New Children’s Hospital. The second aim was to outline the current treatment praxis of DMRFOP in patients under 10 years of age. The third aim was to find out retrospectively whether treatment of DMRFOP in a cast without reduction had obtained results similar to the reduction and pin fixation in prepubertal children and the fourth aim was to design a randomized controlled trial (RCT) comparing casting and percutaneous pin fixation of DMRFOP in children under 11 years of age. A total of 113 DMRFOPs in patients during 2014–19 were gathered from Kids’ Fracture Tool, Helsinki. Of these 113 children, 81 were residents of Helsinki. Prescribed treatment, outcome, and adverse events were recorded from the patients’ files. Fracture morphology of both radius and ulna were registered. Guardians of 100/112 patients replied to a telephone survey to assess their satisfaction to the prescribed treatment. The SurveyMonkey™ website was used as a platform for the survey for surgeons treating fractures in the children. The questionnaire included radiographs of three different DMRFOPs in children under the age of 10. Through multiple-choice questions, respondents (213) were asked to choose their preferred treatment and follow-up protocol. The outcomes of 12/13 children, whose DMRFOPs were treated at our institution during 2015–17 by cast immobilization, leaving the fractures in bayonet position, were assessed at 2–4 years from the fracture. Twelve age-matched children, whose DMRFOPs were reduced, and pin fixed, were chosen as controls. A noninferiority RCT comparing casting in finger-trap traction without reduction in the emergency department (ED) with the reduction and pin fixation under anesthesia in the treatment of DMRFOP, in children under 11 years of age, was designed. The mean annual incidence of DMRFOP in the pediatric census population in Helsinki was 1.42/10.000 in 2014–19. Most (73%) DMRFOPs were sustained by children under the age of 11. Reduction in the ED failed in nearly half (46%) of the cases and the rate of secondary intervention was high (56%). Impaired function at follow-up was reported by 6% of the guardians, and forearm asymmetry by 11%. Overall satisfaction to the given treatment was 6.2 on a scale from 1 to 7. The vast majority (176/213, 83%) of respondents to the web-based survey chose reduction for treatment, whereas 2% chose casting in overriding position in all three presented cases. Pin fixation would have been performed by half (49%) of the surgeons who preferred reduction. There was no consensus regarding treatment and follow-up. None of the 24 patients in the case control study had visible deformity at follow-up. Forearm and wrist range of motion (ROM) showed no differences between the method of treatment in both injured and uninjured sides, with mean ratios varying between 0.98 and 1.02. All 24 patients had returned to their preinjury activities. Of the 12 surgically treated children, one developed a superficial pin-track infection, and another had a corrective osteotomy. DMRFOPs are rare, and most of them are sustained by children under 11 years of age. Reduction in the ED is difficult, but functional and cosmetic outcome is generally satisfactory regardless of the treatment method. Treatment of DMRFOP in prepubertal children with reduction and pin fixation does not appear superior to cast immobilization without reduction, although most surgeons still prefer to reduce DMRFOP. A randomized controlled trial, between reduction and pin fixation and the casting treatment, is warranted to verify the results of these studies.Kasvuikäisten murtuma sijaitsee tavallisimmin värttinäluun alaosassa. Murtumatyyppi vaihtelee tukevista ryppymurtumista täysin paikaltaan siirtyneisiin poikkimurtumiin. Murtuman asennon korjausta on pidetty hyvän hoitotuloksen edellytyksenä. Täysin paikaltaan siirtyneiden murtumien piikkikiinnitystä on suositeltu, koska paikalleenkin kipsatun murtuman asento muuttuu usein ennen murtuman luutumista. Toisaalta on esitetty, että alle 10-vuotiaiden värttinäluun alaosan täysin paikaltaan siirtyneet murtumat voitaisiin hoitaa ilman asennon korjausta tukemalla murtuma kipsillä ns. bajonettiasentoon. Väitöskirjatyössä keskityttiin tutkimaan värttinäluun alaosan kasvulinjan ja varren välisen alueen (metafyysin) bajonettimurtumia. Selvitimme näiden murtumien esiintyvyyden alle 16-vuotiailla helsinkiläisillä, arvioimme hoidon laatua Uudessa lastensairaalassa sekä kartoitimme nykyhoitokäytäntöjä kansainvälisesti internetkyselyllä. Lisäksi vertasimme kipsillä hoidettujen potilaiden hoitotuloksia piikkikiinnityksellä hoidettujen tuloksiin. Alle 16 -vuotiaiden helsinkiläisten värttinäluun alemman metafyysin bajonettiasentoisten murtumien vuosittainen esiintyvyys oli keskimäärin 1.42/10.000 vuosina 2014-19. Suurin osa (73%) näistä murtumista todettiin alle 11-vuotiailla lapsilla. Murtuman asennon korjaus päivystyksessä epäonnistui lähes puolessa (46%) tapauksista ja uusintahoitotoimenpide tarvittiin yli puolelle (56%) näistä potilaista. Potilaiden huoltajat olivat tästä huolimatta pääsääntöisesti tyytyväisiä annettuun hoitoon (keskiarvo 6,2 asteikolla 1–7). Internetkyselyyn vastanneista kirurgeista 83% suositteli kaikissa kolmessa esitetyssä potilastapauksessa hoitomenetelmäksi murtuman paikalleen asetusta, kun taas 2 % suositteli kaikkien kolmen murtuman tukemista kipsillä bajonettiasentoon. Puolet (49 %) vastaajista, jotka olisivat asettaneet murtumat paikalleen, olisivat myös kiinnittäneet ne sileillä piikeillä. Uudessa lastensairaalassa hoidetuilla värttinäluun alaosan metafyysin bajonettimurtuman saaneille lapsille ei jäänyt näkyvää kyynärvarren virheasentoa. Hoitotavasta riippumatta ranteen ja kyynärvarren liikelaajuudet palautuivat hyvin ja kaikki potilaat ilmoittivat palanneensa entisiin harrastuksiinsa. Leikkaushoidosta ei näytä tutkimustemme perusteella olevan hyötyä ainakaan niillä lapsilla, jotka eivät ole vielä nopean kasvun vaiheessa murtuman sattuessa. Osana väitöskirjaa, suunnittelimme etenevän satunnaistetun kontrolloidun hoitotutkimuksen, jonka tavoitteena on selvittää, onko värttinäluun alaosan metafyysin bajonettimurtumien piikkikiinnitys aiheellista alle 11-vuotiailla lapsilla

Lasten murtumat ja niiden hoito

Vertaisarvioitu. English summary.• Vähintään joka kolmas lapsi saa kasvunsa aikana jonkin murtuman. • Diagnoosi perustuu kliiniseen tutkimukseen. • Röntgenkuvista selviävät murtuman tyyppi ja asento, jotka vaikuttavat hoitopäätöksiin kuten potilaan ikä ja mahdolliset liitännäisvammatkin. Murtumat voidaan jakaa neljään hoitoluokkaan. • Kasvulinjaan ulottuvissa murtumissa lopullinen hoito tulee toteuttaa ensimmäisten päivien aikana vammasta, koska tällaiset murtumat voivat johtaa luun kasvuhäiriöön ja raajan virheasentoon. • Asianmukaisella hoidolla kasvuikäisen potilaan toimintakyky voidaan tavallisesti palauttaa täysin.Peer reviewe

Lonkkakipuinen leikki-ikäinen - tapauksen ratkaisu

Ontuva 4-vuotias tuotiin toistuvasti lääkärin arvioon. Traumasta ei ollut tietoa ja tulehduskipulääke helpotti lonkassa tuntuvaa kipua, mutta ontuminen jatkui

Kampurajalka

English summar

Epidemiology and management of proximal tibia frac-tures in children and adolescents : a population-based study based on the Kids? Fracture Tool

Background and purpose - Proximal tibial fractures are infrequent injuries in children, and the literature on epi-demiology, associated injuries, and management is limited. We calculated a population-based incidence and described the characteristics of proximal tibial fractures in children in terms of complications and management.Patients and methods - This is a retrospective study over a 6-year-period during including 241 children with proximal tibial fractures who presented to our university hospital. Demographic and fracture-related data was col-lected from the Kids' Fracture Tool. The number of children during the study period was collected from statistical year-books of the City of Helsinki to estimate annual incidence.Results - Extra-articular fractures (129/241) peaked at the age of 3 and tibial tubercle (42/241) and intra-articular fractures (70/241) peaked at the age of 15. Annual incidences were estimated to be 3.4/100,000 children and 22/100,000 children in the age group of 13-16 years for ACL avulsions, and 3.8/100,000 children and 21/100,000 children in the age group of 13-16 years for tibial tubercle fractures. The inci-dence of vascular compromise (0%) and compartment syn-drome was low (0.4 %, 1/241).Conclusion - Proximal tibial fractures present with a bimodal distribution, with extra-articular fractures peaking at the age of 3 years and fractures of the tibial tuberosity and intra-articular fractures peaking at the age of 15 years. Additionally, associated compartment syndrome and vascu-lar compromise was not as common as previously reported.Peer reviewe

Most surgeons still prefer to reduce overriding distal radius fractures in children

Background and purpose - Traditionally, overriding distal radius fractures in children have been reduced and immobilized with a cast or treated with percutaneous pin fixation. There is recent evidence that these fractures heal well if immobilized in the bayonet position without reduction. We evaluated the present treatment of these fractures. Methods - A questionnaire including AP and lateral radiographs of overriding distal radius fractures in 3 pre-pubertal children was answered by 213 surgeons from 28 countries. The surgeons were asked to choose their preferred method of treatment (no reduction, reduction, reduction and osteosynthesis), type and length of cast immobilization, and the number of clinical and radiographic follow-ups. Results - Of the 213 participating surgeons, 176 (83%) would have reduced all 3 presented fractures, whereas 4 (2%) would have treated all 3 children with cast immobilization without reduction. Most reductions (77%) would have been done under general anesthesia. Over half (54%) of the surgeons who preferred anesthesia would have fixed (pins 99%, plate 1%) the fractures. An above-elbow splint or circular cast was chosen in 84% of responses, and the most popular (44%) length of immobilization was 4 weeks. Surgeons from the Nordic countries were more eager to fix the fractures (54% vs. 31%, p <0.001) and preferred shorter immobilization and follow-up times and less frequent clinical and radiological follow-ups compared with their colleagues from the USA. Interpretation - Most of the participating surgeons prefer to reduce overriding distal radius fractures in children under anesthesia. There is substantial lack of agreement on the indications for osteosynthesis, type of cast, length of immobilization, and follow-up protocol.Peer reviewe

Cast immobilization in bayonet position versus reduction and pin fixation of overriding distal metaphyseal radius fractures in children under ten years of age : a case control study

Purpose Completely displaced distal radius fractures in children have been traditionally reduced and immobilized with a cast or pin fixed. Cast immobilization leaving the fracture displaced in the bayonet position has been recently suggested as a non-invasive and effective treatment alternative. This is a pilot comparative study between reduction and no reduction. Methods We assessed subjective, functional and radiographic outcome after a minimum 2.5-year follow-up in 12 children under ten years of age who had sustained a completely displaced metaphyseal radius fracture, which had been immobilized leaving the fracture in an overriding position (shortening 3 mm to 9 mm). A total of 12 age-matched patients, whose similar fractures were reduced and pin fixed, were chosen for controls. Results At follow-up none of the 24 patients had visible forearm deformity and the maximal angulation in radiographs was 5 degrees Forearm and wrist movement was restored (<10 degrees of discrepancy) in all 24 patients. Grip strength ratio was normal in all but three surgically treated patients. All patients had returned to their previous activities. One operatively treated boy who was re-operated on reported of pain (visual analogue scale 2). Conclusion The results of this study do not demonstrate the superiority of reduction and pin fixation over cast immobilization in the bayonet position of closed overriding distal metaphyseal radius fractures in children under ten years with normal neurovascular findings.Peer reviewe

Casting in finger trap traction without reduction versus closed reduction and percutaneous pin fixation of dorsally displaced, over-riding distal metaphyseal radius fractures in children under 11 years old : A study protocol of a randomised controlled trial

Publisher Copyright: ©Introduction Distal radius is the most common site of fracture in children, comprising 23%-31% of all paediatric fractures. Approximately one-fifth of these fractures are displaced. Completely displaced distal metaphyseal radius fractures in children have traditionally been treated with closed reduction. Recent evidence suggests that correcting the shortening in over-riding distal metaphyseal radius fractures is not necessary in prepubertal children. To date, no published randomised controlled trial (RCT) has compared treatment of these fractures in children by casting the fracture in bayonet position to reduction and pin fixation. Methods and analysis We will conduct an RCT to compare the outcomes of casting the fracture in bayonet position in children under 11 years of age to reduction and percutaneous pin fixation. 60 patients will be randomly assigned to casting or surgery groups. We have two primary outcomes. The first is ratio (injured side/non-injured side) in the total active forearm rotation and the second is ratio (injured side/non-injured side) in total active range of motion of the wrist in the flexion-extension plane at 6 months. The secondary outcomes will include axial radiographic alignment, passive extension of the wrists, grip strength and length of forearms and hands, patient-reported outcome QuickDASH and pain questionnaire PedsQL. Patients not willing to participate in the RCT will be asked to participate in a prospective cohort. Patients not eligible for randomisation will be asked to participate in a non-eligible cohort. These cohorts are included to enhance the external validity of the results of the RCT. Our null hypothesis is that the results of the primary outcome measures in the casting group are non-inferior to surgery group. Ethics and dissemination The institutional review board of the Helsinki and Uusimaa Hospital District has approved the protocol. We will disseminate the findings through peer-reviewed publications. Trial registration number NCT04323410. Protocol V.1.1, 29 September 2020.Peer reviewe

Synnynnäinen lonkkaluksaatio

Vertaisarvioitu.Lonkan epätukevuus on tavallisin vastasyntyneen tukirankapoikkeavuus. Suurin osa vastasyntyneiden epätukevista lonkista tukevoituu itsestään. Kuuden viikon pituinen lastahoito aloitetaan, ellei lonkka ole tukevoitunut kahden viikon ikään mennessä. Lastahoidolla lonkasta tulee yleensä normaali. Lonkkaluksaatio voi kehittyä syntymän jälkeen tai diagnoosi voi viivästyä, mikä vaikeuttaa ja pitkittää hoitoa. Vastasyntyneellä todetun lonkkaluksaation hoitotulokset ovat hyviä, myöhään todettu lonkkaluksaatio taas johtaa lähes puolella potilaista tekonivelleikkaukseen aikuisiässä

Alaraajojen pituuseron ja asentovirheiden korjaaminen moottoroidulla ydinnaulalla : Kokemukset kolmestatoista ensimmäisestä potilaasta

English summaryPeer reviewe