Abstract
Background
Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided.
Methods
Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1–8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire.
Results
Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups.
Conclusion
Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9–<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.
Similar content being viewed by others
References
Walters PMMA (2006) Fractures of the distal radius and ulnar. In: Beaty JH, Kasser JR (eds) Rockwood and Wilkins’ fractures in Children, 5th edn. Lippincott Williams & Wilkins, Philadelphia, pp 337–400
Alemdaroglu KB, Iltar S, Cimen O, Uysal M, Alagoz E, Atlihan D (2008) Risk factors in redisplacement of distal radial fractures in children. J Bone Joint Surg Am 90(6):1224–1230
Colaris JW, Allema JH, Biter LU et al (2013) Re-displacement of stable distal both-bone forearm fractures in children: a randomised controlled multicentre trial. Injury 44(4):498–503
McQuinn AG, Jaarsma RL (2012) Risk factors for redisplacement of pediatric distal forearm and distal radius fractures. J Pediatr Orthop 32(7):687–692
Wilkins KEOBE (1996) Fractures of the distal radius and ulna fractures in children, 4th edn. Lippincott-Raven, Philadelphia, pp 451–515
Hove LM, Brudvik C (2008) Displaced paediatric fractures of the distal radius. Arch Orthop Trauma Surg 128(1):55–60
Ploegmakers JJ, Verheyen CC (2006) Acceptance of angulation in the non-operative treatment of paediatric forearm fractures. J Pediatr Orthop B 15(6):428–432
Flynn JM, Jones KJ, Garner MR, Goebel J (2010) Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop 30(4):313–319
Zionts LE, Zalavras CG, Gerhardt MB (2005) Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop 25(4):507–512
Franklin CC, Robinson J, Noonan K, Flynn JM (2012) Evidence-based medicine: management of pediatric forearm fractures. J Pediatr Orthop 32(Suppl 2):S131–S134
Eismann EA, Little KJ, Kunkel ST, Cornwall R (2013) Clinical research fails to support more aggressive management of pediatric upper extremity fractures. J Bone Joint Surg Am 95(15):1345–1350
Proctor MT, Moore DJ, Paterson JM (1993) Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg Br 75(3):453–454
Jordan RW, Westacott DJ (2012) Displaced paediatric distal radius fractures—when should we use percutaneous wires? Injury 43(6):908–911
van Egmond PW, Schipper IB, van Luijt PA (2012) Displaced distal forearm fractures in children with an indication for reduction under general anesthesia should be percutaneously fixated. Eur J Orthop Surg Traumatol 22(3):201–207
Monga P, Raghupathy A, Courtman NH (2010) Factors affecting remanipulation in paediatric forearm fractures. J Pediatr Orthop B 19(2):181–187
Haddad FS, Williams RL (1995) Forearm fractures in children: avoiding redisplacement. Injury 26(10):691–692
Johari AN, Sinha M (1999) Remodeling of forearm fractures in children. J Pediatr Orthop B 8(2):84–87
Pretell Mazzini J, Beck N, Brewer J, Baldwin K, Sankar W, Flynn J (2012) Distal metaphyseal radius fractures in children following closed reduction and casting: can loss of reduction be predicted? Int Orthop 36(7):1435–1440
Voto SJ, Weiner DS, Leighley B (1990) Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 10(1):79–84
Zimmermann R, Gschwentner M, Kralinger F, Arora R, Gabl M, Pechlaner S (2004) Long-term results following pediatric distal forearm fractures. Arch Orthop Trauma Surg 124(3):179–186
Greenspan A (2011) Orthopedic radiology, a practical approach. Wolters Kluwer Health/Lippincott, Williams & Wilkins, Philadelphia
Ries M, O’Neill D (1987) A method to determine the true angulation of long bone deformity. Clin Orthop Relat Res 218:191–194
Bar HF, Breitfuss H (1989) Analysis of angular deformities on radiographs. J Bone Joint Surg Br 71(4):710–711
Larsen E, Vittas D, Torp-Pedersen S (1988) Remodeling of angulated distal forearm fractures in children. Clin Orthop Relat Res 237:190–195
Vittas D, Larsen E, Torp-Pedersen S (1991) Angular remodeling of midshaft forearm fractures in children. Clin Orthop Relat Res 265:261–264
Arnould C, Penta M, Renders A, Thonnard JL (2004) ABILHAND-Kids: a measure of manual ability in children with cerebral palsy. Neurology 63(6):1045–1052
Buffart LM, Roebroeck ME, Janssen WG, Hoekstra A, Hovius SE, Stam HJ (2007) Comparison of instruments to assess hand function in children with radius deficiencies. J Hand Surg Am 32(4):531–540
Price CT, Scott DS, Kurzner ME, Flynn JC (1990) Malunited forearm fractures in children. J Pediatr Orthop 10(6):705–712
Colaris JW, Allema JH, Reijman M et al (2013) Risk factors for the displacement of fractures of both bones of the forearm in children. Bone Joint J 95(5):689–693
Miller BS, Taylor B, Widmann RF, Bae DS, Snyder BD, Waters PM (2005) Cast immobilization versus percutaneous pin fixation of displaced distal radius fractures in children: a prospective, randomized study. J Pediatr Orthop 25(4):490–494
McLauchlan GJ, Cowan B, Annan IH, Robb JE (2002) Management of completely displaced metaphyseal fractures of the distal radius in children. A prospective, randomised controlled trial. J Bone Joint Surg Br 84(3):413–417
Asadollahi S, Ooi KS, Hau RC (2014) Distal radial fractures in children: risk factors for redisplacement following closed reduction. J Pediatr Orthop
Do TT, Strub WM, Foad SL, Mehlman CT, Crawford AH (2003) Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B 12(2):109–115
Crawford SN, Lee LS, Izuka BH (2012) Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am 94(3):246–252
Jones K, Weiner DS (1999) The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop 19(6):811–815
Varela CD, Lorfing KC, Schmidt TL (1995) Intravenous sedation for the closed reduction of fractures in children. J Bone Joint Surg Am 77(3):340–345
Al-Ansari K, Howard A, Seeto B, Yoo S, Zaki S, Boutis K (2007) Minimally angulated pediatric wrist fractures: is immobilization without manipulation enough? Can J Emerg Med 9(1):9–15
Hendrickx RP, Campo MM, van Lieshout AP, Struijs PA, van den Bekerom MP (2011) Above- or below-elbow casts for distal third forearm fractures in children? A meta-analysis of the literature. Arch Orthop Trauma Surg 131(12):1663–1671
van den Bekerom MP, Hendrickx RH, Struijs PA (2012) Above- or below-elbow casts for distal third forearm fractures in children? An updated meta-analysis of the literature. Arch Orthop Trauma Surg 132(12):1819–1820
Bohm ER, Bubbar V, Yong Hing K, Dzus A (2006) Above and below-the-elbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Joint Surg Am 88(1):1–8
Webb GR, Galpin RD, Armstrong DG (2006) Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Joint Surg Am 88(1):9–17
Paneru SR, Rijal R, Shrestha BP et al (2010) Randomized controlled trial comparing above- and below-elbow plaster casts for distal forearm fractures in children. J Child Orthop 4(3):233–237
Colaris JW, Biter LU, Allema JH et al (2012) Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study. Injury 43(7):1107–1111
Rahman NAW (2011) Comparison of below the elbow cast with above the elbow cast in treating distal third forearm fractures in children. J Surg Pak (Int) 16(4):140–144
Ogden JA (2000) Skeletal injury in the child, 3rd edn. Springer, New York
Conflict of interest
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Roth, K.C., Denk, K., Colaris, J.W. et al. Think twice before re-manipulating distal metaphyseal forearm fractures in children. Arch Orthop Trauma Surg 134, 1699–1707 (2014). https://doi.org/10.1007/s00402-014-2091-8
Received:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00402-014-2091-8