Displaced fracture of the distal radius in children: FACTORS RESPONSIBLE FOR REDISPLACEMENT AFTER CLOSED REDUCTION
Zamzam, M M
We retrospectively reviewed 183 children with a simple fracture of the distal radius, with or without fracture of the ulna, treated by closed reduction and cast immobilisation. The fracture redisplaced after an initial, acceptable closed reduction in 46 (25%). Complete initial displacement was identified as the most important factor leading to redisplacement. Other contributing factors were the presence of an ipsilateral distal ulnar fracture, and the reduction of completely displaced fractures under deep sedation or local haematoma block. We recommend that completely displaced fractures of the distal radius in children should be reduced under general anaesthesia, and fixed by primary percutaneous Kirschner wires even when a satisfactory closed reduction has been achieved.
Fractures of the distal forearm are one of the most common fractures in children.1-4 They usually heal rapidly with excellent functional recovery, after closed reduction and casting.2,5,6 It is reported that up to 34% of fractures of the distal radius can redisplace early after reduction.4,6,7 The factors responsible for redisplacement after an initial acceptable closed reduction have not been clearly defined.2,4 This study was conducted to identify these factors.
Patients and Methods
A retrospective analysis was carried out of all children under the age of 16 years who presented with a displaced fracture of the distal radius. They were initially treated by closed reduction and cast immobilisation at the King Khalid University Hospital between January 1998 and December 2003. Open fractures, fractures involving the distal radial epiphysis, unacceptable initial reduction, or fractures treated primarily by internal fixation were not included in the study. Children who had an inappropriate initial cast or required splitting of the cast for any reason were also excluded.
The hospital charts were reviewed and data, age and gender of the patient, level of the treating physician, type of anaesthesia used for the initial closed reduction, time at which redisplacement (if it occurred) was diagnosed, management of the redisplacement, duration of follow-up, and final clinical outcome were recorded.
The radiographs were reviewed for initial displacement, the presence of an ipsilateral distal ulnar fracture, the acceptability of initial closed reduction, criteria for diagnosing redisplacement and final radiological outcome.
The data were analysed using the chisquared test for univariant analysis where p
Results
A total of 183 children with displaced fractures of the distal radius fulfilled the inclusion criteria and were entered in the study. There were 144 boys (79%) and 39 girls (21%), with a mean age of eight years (3 to 16). The distal ulna was fractured in 50 (27%). All were treated initially by the junior physician on call. For initial closed reduction, deep sedation and/ or local haematoma block was used in 101 (55%) patients with a mean age often years (8 to 16), while general anaesthesia was used in 82 patients (45%) with a mean age of 5.5 years (3 to 15). The type of anaesthesia chosen depended upon the age of the child, his/her cooperation and the surgeon’s preference. A satisfactory initial reduction was obtained in all patients. All were immobilised in an above-elbow cast in a position of stability which avoided extreme pronation or wrist flexion.
Redisplacement occurred in 46 patients (25%), 37 boys and nine girls. Of these, 35 (76%) had an associated fracture of the distal ulna. Redisplacement was diagnosed in the first 14 days after initial closed reduction (mean, nine days). All patients with redisplacement underwent a further manipulation under general anaesthesia and the fractures fixed using percutaneous Kirschner (K-) wires, except in two patients where open reduction was necessary. Post-operatively the limb was immobilised in an above-elbow cast. All remanipulations were performed or supervised by a senior orthopaedic surgeon. The mean follow-up was 13 weeks (11 to 18). The only complications noted during follow-up were three cases of superficial wound infection at the K-wire site. All healed satisfactorily following removal of the wires.
Radiological assessment at the time of injury showed initial complete displacement in 75 patients (41%) and incomplete displacement in 108 (59%). Perfect reduction was achieved initially in 142 fractures (78%). The degree of redisplacement which required remanipulation was based upon radiological assessment during follow-up. Remanipulation was carried out if angular displacement was more than 20° or there was less than 50% contact between the radial fragments.2,5,6 These were the agreed criteria used in the authors’ institute. Table I shows the incidence of redisplacement in relation to initial displacement and post-reduction position. Table II shows this in relation to the type of anaesthesia. Union was achieved in all patients during the follow-up period. Insignificant residual angulation was observed in 19 patients (10%), none of whom had undergone remanipulation.
Univariant statistical analysis showed no significant difference related to gender (p > 0.8). Significantly greater redisplacement occurred in children aged between ten and 16 years than those aged between three and ten years (p 0.19).
The results of multi-variate logistic regression analysis (Table III) showed that the most predictive variable for the occurrence of redisplacement was an initial complete displacement (odds ratio (OR) 24.7; 95% confidence interval (CI) 5.6 to 110) followed by the presence of an associated fracture of the ulna (OR 22.5; 95% CI 7.4 to 68). The least significant factor was manipulation under sedation and/or local anaesthesia (OR 8.9; 95% CI 1.9 to 42). These three factors together predicted 91% of the redisplacements. The gender, age and result of manipulation (perfect or imperfect) were not significant predictors of redisplacement.
Discussion
Some reports have suggested that redisplacement of distal radial fractures in children was associated with the position of forearm in the cast or loss of cast fixation.4,8 Others reported that redisplncement was less likely when an experienced surgeon performed the initial reduction.2 McLaughlan et al,5 in their excellent prospective randomised study, concluded that K-wire fixation was better than cast immobilisation alone in the treatment of displaced distal radial fractures in children. However, their study did not attempt to identify the causative factors of redisplacement in order to give clear indications for K-wire fixation.
Proctor et al identified two factors which increase the chance of redisplacement; the presence of initial complete displacement and the failure to achieve a perfect reduction. However, they only advised percutaneous K-wire fixation when reduction was imperfect. Haddad and Williams2 reported that a perfect anatomical reduction was the most important favourable prognostic factor. In this study perfect reduction did not reduce the incidence of redisplacement of initially completely displaced fractures. The initial displacement of the fracture was found to be the most significant factor affecting outcome. This may be because completely displaced fractures are usually associated with severe injury to the periosteum and the surrounding soft tissues. The lack of a periosteal hinge may affect stability and increase the incidence of redisplacement. Severe softtissue injury causes more initial swelling which usually subsides in about a week resulting in a loose cast and increasing the chance of redisplacement.
Other factors which increased the risk of redisplacement were the presence of an associated fracture of the distal ulna and the use of deep sedation or local haematoma block to reduce a completely displaced fracture. We noticed that the increased risk of redisplacement associated with these factors could be linked to the presence of an initial complete displacement of the fracture. The significant risk of redisplacement in the presence of a distal ulnar fracture in this study runs counter to the observation of Gibbons et al that an intact ulna can increase the incidence of redisplacement. In contrast, McLauchlan et al5 reported than an associated fracture of the distal ulna did not influence the outcome of a fracture of the distal radius.
In conclusion, we suggest that children who initially have a completely displaced fracture of the distal radius should be manipulated under general anaesthesia and recommend that percutaneous K-wire fixation is used to ensure stabilisation and avoid redisplacement, even when a perfect closed reduction has been achieved.
We wish to thank the other consultants in our institute for allowing us to include their patients in the study. We thank Dr. Ashry Gad (MD) and Mr. Amir Marzouk (M.Sc) for their help in the statistical analysis of the data.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
References
1. Fuller DJ, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg [Br] 1982;64-B:364-7.
2. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury 1995;26:691 -2.
3. Khosla S, Melton LJ 3rd, Dekutoski MB, et al. Incidence of childhood distal forearm fractures over 30 years: a population-based study. JAMA 2003;290:1479-85.
4. Voto SJ, Weiner DS, Leighley BL Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 1990;10:79-84.
5. McLauchlan GJ, Cowan B, Annan IH, Robb JE. Management of completely displaced metaphyseal fractures of the distal radius in children: a prospective, randomised controlled trial. J Bone Joint Surg [Br] 2002;84-B:413-17.
6. Proctor MT, Moore DJ, Paterson JMH. Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg [Br] 1993;75-B:453-4.
7. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop 1976;120:172-83.
8. Gupta RP, Danielsson LG. Dorsally angulated solitary metaphyseal greenstick fractures in the distal radius: results after immobilization in pronated, neutral and supinated position. J Pediatr Orthop 1990;10:90-2.
9. Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-10.
M. M. Zamzam, K. I. Khoshhal
From King Khalid University Hospital, Riyadh, Saudi Arabia
* M. M. Zamzam, MD, Consultant Paediatric Orthopaedic Surgeon
* K. I. Khoshhal, FRCS, Consultant Paediatric Orthopaedic Surgeon
Department of Orthopaedics
College of Medicine and King Khalid University Hospital, P O Box 7805, Riyadh 11472, Saudi Arabia.
Correspondence should be sent to Dr M. M. Zamzam; e-mail: mmzamzam@yahoo.com
©2005 British Editorial Society of Bone and Joint Surgery
doi: 10.1302/0301-620X.87B6. 15648 $2.00
J Bone Joint Surg [Br] 2005;87-B:841-3.
Received 17 May 2004; Accepted after revision October 2004
Copyright British Editorial Society of Bone & Joint Surgery Jun 2005
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