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
