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ORIGINAL ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 6  |  Page : 653-657  

Is conservative treatment still gold standard for the management of both-bone forearm fracture in children?


Department of Orthopaedics, MGIMS, Sevagram, Maharashtra, India

Date of Submission15-Jun-2019
Date of Decision21-Oct-2019
Date of Acceptance20-Dec-2019
Date of Web Publication6-Nov-2020

Correspondence Address:
Ankit B Waghela
Department of Orthopaedics, MGIMS, Sevagram, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mjdrdypu.mjdrdypu_172_19

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  Abstract 


Background: Forearm diaphyseal fractures constitute around 6% of all other children's fractures. Despite conservative management is proven and gold standard but still operative management is on rise. Aims and Objective: The aim of this study was to evaluate the outcome in conservative and surgical management of both-bone forearm fractures in children. Materials and Methods: This prospective study was conducted in children aged 3–12 years. Clinical and radiological features, time for union, angular correction over a period of management, and functional outcome were assessed. Data were entered and analyzed with Epi Info software. Results: There were 48 males (72.7%) and 18 (27.3%) females, with a mean age of 85 months (±29.7). In the present study, 34 (51.2%) at middle third was the most common site of diaphyseal fracture followed by distal third 28 (42.2) and proximal one-third. Conclusion: Fractures treated conservatively had greater healing potential and faster healing, whereas functional outcome was comparable in both conservatively and surgically treated patients.

Keywords: Angulation, cast, diaphysis, titanium elastic nailing system


How to cite this article:
Patil RR, Waghela AB, Medhi MN, Badole CM. Is conservative treatment still gold standard for the management of both-bone forearm fracture in children?. Med J DY Patil Vidyapeeth 2020;13:653-7

How to cite this URL:
Patil RR, Waghela AB, Medhi MN, Badole CM. Is conservative treatment still gold standard for the management of both-bone forearm fracture in children?. Med J DY Patil Vidyapeeth [serial online] 2020 [cited 2020 Dec 2];13:653-7. Available from: https://www.mjdrdypv.org/text.asp?2020/13/6/653/300125




  Introduction Top


Forearm diaphyseal fractures constitute around 6% of all other children's fractures.[1] The standard management of these fractures remains conservative treatment with closed manipulation and immobilization with an above-elbow plaster cast for 4–6 weeks.[2] The most common remains fracture re-displacement which can lead to malunion, causing impairment of forearm rotation.[3]

Other modalities of treatment have been proposed for the treatment of both-bone forearm fractures in children and adolescents such as closed reduction and K-wire fixation, titanium elastic nailing system (TENS), and open reduction with plate fixation. Biomechanically, these implants have shown to act as internal splints.[4]

However, as per recent literature, pediatric forearm fractures, in particular, have seen an increased rate of surgical treatment despite the lack of comparative studies showing a clear benefit over nonoperative treatment.[5],[6]

Hence, the present prospective study was planned with the aim of understanding outcomes in conservative and surgical management of both-bone forearm fractures in children.


  Materials and Methods Top


The present prospective study was conducted in a rural tertiary care center of Central India. The study was conducted from July 1, 2016, to June 30, 2018. All the children who presented with both-bone forearm fracture were included in the study. The study was approved by the institutional ethical committee.

The inclusion criteria were fractures of both forearm bones,

Definition: A diaphyseal fracture which defined as a fracture occurring within the middle three-fifth of the forearm.

Inclusion criteria

  • Willing to participate in the study
  • Age <12 years of age.


Exclusion criteria

  • Metaphyseal fracture, single bone fracture, incomplete fracture, Galeazzi fracture, Monteggia fracture, previous operative intervention to the fractures, and refracture
  • Physeal injury
  • Unable to complete follow-up.


The location of the fracture, based on the radiograph, was divided into proximal third, middle third, and distal third.

The patients were assessed based on the radiological and functional outcomes. The supination and pronation of the affected forearm were measured using handheld protractor goniometer with two moveable arms of 20 cm. The unaffected forearm was used as a normal reference. Before each measurement, the patients were required to sit in an upright position. The elbow was positioned firmly against the torso to eliminate compensating forearm rotation using movements of the elbow and shoulder. The elbow was flexed to 90° with the forearm in mid-position and the wrist in neutral, whereas the hands were holding the pens in an upright position to help in better visualization of both pronation and supination of the forearm. For the measurement, one arm of the goniometer was lined up parallel to the upper arm of the patient, and the other arm of the goniometer was placed parallel to the distal third of the forearm.

The ranges of pronation and supination of the affected forearm were measured in comparison with the unaffected forearm. The differences in the range of pronation and supination between affected and unaffected forearms were taken as the measurement.

The patients were assessed regarding the functional limitation with physical activity or activity of daily living according to the Price et al.[7] functional outcome grading which was excellent, good, fair, or poor.

  • Excellent was defined as no complaint with strenuous physical activity, for example, sports activity and/or loss of 10° or less of forearm rotation
  • Good outcome was considered when mild complaint with strenuous physical activity, for example, using a screwdriver and/or loss of 11°–30° of forearm rotation
  • The fair outcome is when the patients had a mild subjective complaint during usual physical activity, for example, opening the lid of jars or door and/or loss of 31°–90° of forearm rotation
  • Poor outcome was defined as nonfulfillment of all other results.


The degree of angulation was measured by drawing a perpendicular line following two midpoints of the radius and ulna bone for each segment of the fracture. The angle that formed in between those perpendicular lines from each segment of the fractures was taken as the reading. The same procedure was performed for both anteroposterior and lateral radiographs of the radius and ulna, and the higher measurement for each bone was taken as the final degree of angulation [Figure 1]a and b].
Figure 1: (a) Calculation of angulation (radius and ulna) in anterior and posterior view, (b) calculation of angulation (radius and ulna) in lateral view

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Local clinical examination of the injured limb was performed regarding edema, tenderness, deformity with detail neurovascular status, and movements of adjacent joints. Open fractures were graded as per the Gustilo-Anderson classification, wounds were covered with sterile dressings, and above-elbow plaster slab was applied. Radiographs of the elbow with radius-ulna with wrist, anteroposterior, and lateral views were taken. All the close reductions were done under intravenous sedation or general anesthesia. The reduction was confirmed under image intensifier guidance in both AP and lateral views. While maintaining the reduction, a well-padded above-elbow cast was given in the position. While applying cast, particular care was taken to prevent crowding of the fingers, and plaster cast was trimmed if necessary to allow free movement of the thumb and fingers.

All the operative procedures were done in a supine position under anesthesia. Closed nailing was preferred over open nailing. The approximate size of nails was taken preoperatively. Closed nailing was done under the guidance of C-arm image intensifier.

During each follow-up, the patient was examined clinically for pain and tenderness at the fracture site, status of the operative scar, movements of the adjacent joints, and forearm rotation. Radiologically, the patient was assessed for bridging callus, angulation at fracture sites, rotation of the fracture fragments, and orientation of the radial epiphysis. Union was judged by the absence of pain and tenderness at the fracture site and bridging callus and/or obliteration of fracture line. Thereafter, the patient was allowed full use of the limb. Guardians were advised against massage and manipulation implant.


  Results Top


Among study participants, 66 fulfilled the criteria for this study. Individual consent was obtained from all patients and parents.

There were 48 male (72.7%) and 18 (27.3%) female patients. The youngest age at the time of fracture was 3 years old and 12 years old was the oldest, and the mean age was 85 months (±29.7). The majority of the patients (46, 69.7%) sustaining injury were in the age group of 5–10 years. Right side 57.6% (38/66) involvement was more compared to left side 42.4% (28/66).

In this study, 4 (6.1%) patients had sustained an injury at the proximal third of the forearm, 34 (51.2%) at the middle third, and 28 at the distal third (42.2%). Displacement of more than 1 cm was more in distal one-third fracture compared to proximal and middle third fractures [Table 1].
Table 1: Displacement in both-bone forearm fracture

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The mean radius angulation in anteroposterior and lateral views was 11.7° and 12.1°, which was corrected to postoperatively to 4.4° and 5.4°, and after remodeling, it was 3.6° and 5.6°. Similar observations were noted in ulnar angulation in anteroposterior and lateral views which was 12.9° and 11.1° which was corrected to 2.4° and 4.2°, respectively, whereas after remodeling angulation, it was 3.0° and 4.3° [Table 2] and [Table 3]. Most of the patients were treated with conservative management by cast application (52/66, 78.8%), and 14/66 (21.2%) patients were managed with TENS.
Table 2: Angulation correction observed in both-bone forearm fracture

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Table 3: Angulation correction observed in conservative and operative management of radius diaphyseal fracture

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We analyzed angulation correction as per conservative management by cast application and TENS nailing. The preoperative angulation both in the radius and ulna were found to be significantly corrected after remodeling (P < 0.05) [Table 4].
Table 4: Angulation correction observed in conservative and operative management of ulna diaphyseal fracture

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In the present study, we noted faster healing by cast compared to TENS. The mean duration for healing in conservatively managed patients was found to be 5.6 weeks (±3.2) compared to 8.8 weeks in patients who were treated with TENS nailing (±3.1). This difference was found to be significant [Table 5].
Table 5: Clinic radiological union observed in conservative and operative management of both-bone forearm fracture

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All the patients had an excellent outcome except one who had a fair outcome according to functional outcome grading by Price et al.[7]


  Discussion Top


Closed reduction and cast immobilization remain the standard method of treatment for diaphyseal fractures. Malunion due to malreduction leads to restriction in forearm rotation and function.[8] Opinion differs when the selection of treatment modality comes.

We followed 66 patients with diaphyseal fractures. The male-to-female ratio was 2.6:1. Similar observations were made by Vishwanath and Satheesh where 70% of the patients were male and 30% were female.[9] The mean age of the patients with diaphyseal fracture was 85 months (±29.7). Similar observations were made by Yung et al.[10] where average age was found to be 7 years, whereas higher mean age was documented by Vishwanath and Satheesh.[9]

The right side was involved more 38 (57.5%), and the distal third 34 (51.2%) was the most common site found to be fractured. Similar findings were noted by Vander Reis et al. and others[9],[11] where middle third involvement was by far most common.

The mean duration of radiological union in conservatively managed patients was found to be 5.6 weeks (±3.2) and 8.8 weeks in patients who were treated with TENS nailing (±3.1). We observed this difference to be significant. Vishwnath C et al observed 80% fractures treated surgically with TENS united in less than 12 weeks. Similar findings were observed by Van der reis et al where mean duration for union was found to be 10 weeks and 11.5 weeks respectively for the both bones forearm fracture treated with TENS and plating respectively.

We searched for angulation correction in patients. The mean radius angulation in anteroposterior and lateral views was 11.7° and 12.1° which was corrected to postoperatively to 4.4° and 5.4°, respectively, and after remodeling, it was 3.6° and 5.6°. Similar observations were noted in ulnar angulation in anteroposterior and lateral views which was 12.9° and 11.1° which was corrected to 2.4° and 4.2°, respectively, whereas after remodeling angulation, it was 3.0° and 4.3°. This difference in angulation correction was found to be statistically significant.

Tarmuzi et al.[12] showed that the final angulation in their series ranged from 0° to 16° for the radius and 0°–20° for the ulna. The age range of their study populations was within 4–12 years old[5] which was similar to the present study group. Similar observations were noted by Hadizie and Munajat[13] where angular deformity improved once the patients reached skeletal maturity and about 72%–75% of correction was observed in our study.

In our study, 14/66 (21.2%) patients were managed with titanium elastic nails which showed a significant angulation correction after remodeling, and it was found to be statistically significant. Nowadays, titanium (Ti 6A114V) is being used more often than stainless steel in most circumstances because of the elastic properties which allow for improved insertion and rotation while still providing adequate fracture stabilization though studies have documented various complications associated with TENS nailing.[14],[15]

In Kang et al.'s study,[16] the overall complication rate was 14% (13/90). Complications secondary to intramedullary fixation include infection at the site of implantation, skin irritation, refracture after removal, implant failure, nerve/tendon injury, decreased range of motion, and compartment syndrome.[17]

In the present study, 52/66 (78.8%) patients were conservatively managed with cast application. Even we observed faster radiological union in patients managed with cast application.

Studies have observed the gold standard for pediatric forearm fractures to be closed reduction and casting.[18] Owing to excellent remodeling potential with younger patients, certain studies have argued that even with 100% displacement of the radius and ulna closed reduction and casting is an excellent treatment choice for children 9 years old and younger.

Post reduction patients should be followed weekly for the first 2-3 weeks to ensure reduction is maintained. Holmes et al. found that if the loss of reduction occurs, wedging the cast may restore alignment, but re-reduction or operative intervention may be required.[19]


  Conclusion Top


Conservative management with cast application remains the first choice for both-bone forearm fracture in children. Children have excellent remodeling potential and even fracture with displacement and greater angulation heal without any deformity. Fracture treated conservatively had a greater potential of healing along with a faster healing rate. Hence, we conclude that conservative management still remains the gold standard compared to operative treatment with TENS.

Limitation

No cases treated with TENS nailing were less compared to conservative management which affects the power of the study. Hence, a larger study may be required.

Acknowledgment

We are sincerely thankful to the Department of Orthopaedics, MGIMS, Sevagram, Maharashtra, India.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B 1997;6:79-83.  Back to cited text no. 1
    
2.
Jones K, Weiner DS. The management of forearm fractures in children: A plea for conservatism. J Pediatr Orthop 1999;19:811-5.  Back to cited text no. 2
    
3.
Mehman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Beaty JH, Kasser JR, editors. Rockwood and Wilkins' Fractures in Children: Text Plus Integrated Content Website. 7th ed. Philadelphia: Lippincott Williams & Wilkins Co.; 2009. p. 347-402.  Back to cited text no. 3
    
4.
Johnson CW, Carmichael KD, Morris RP, Gilmer B. Biomechanical study of flexible intramedullary nails. J Pediatr Orthop 2009;29:44-8.  Back to cited text no. 4
    
5.
Helenius I, Lamberg TS, Kääriäinen S, Impinen A, Pakarinen MP. Operative treatment of fractures in children is increasing. A population-based study from Finland. J Bone Joint Surg Am 2009;91:2612-6.  Back to cited text no. 5
    
6.
Eismann EA, Little KJ, Kunkel ST, Cornwall R. Clinical research fails to support more aggressive management of pediatric upper extremity fractures. J Bone Joint Surg Am 2013;95:1345-50.  Back to cited text no. 6
    
7.
Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop 1990;10:705-12.  Back to cited text no. 7
    
8.
Rodríguez-Merchán EC. Pediatric fractures of the forearm. Clinical Orthopaedics and Related Research. 2005;432:65-72.  Back to cited text no. 8
    
9.
Vishwnath C, Satheesh GS. Surgical Outcome of Fracture Both Bones Forearm in children using tens. National Journal of Clinical Orthopaedics 2017;1(2): 16-23.  Back to cited text no. 9
    
10.
Yung SH, Lam CY, Choi KY, Ng KW, Maffulli N, Cheng JC. Percutaneous intramedullary Kirschner wiring for displaced diaphyseal forearm fractures in children. J Bone Joint Surg Br 1998;80:91-4.  Back to cited text no. 10
    
11.
Van der Reis WL, Otsuka NY, Moroz P, Mah J. Intramedullary nailing versus plate fixation for unstable forearm fractures in children. J Pediatr Orthop 1998;18:9–13.  Back to cited text no. 11
    
12.
Tarmuzi NA, Abdullah S, Osman Z, Das S. Paediatric forearm fractures: Functional outcome of conservative treatment. Bratisl Lek Listy 2009;110:563-8.  Back to cited text no. 12
    
13.
Hadizie D, Munajat I. Both-bone forearm fractures in children with minimum four years of growth remaining: Can cast achieve a good outcome at skeletal maturity? Malays Orthop J 2017;11:1-9.  Back to cited text no. 13
    
14.
Sahu B, Mishra A, Tudu B. Management of pediatric both-bone forearm fractures by titanium elastic nailing system: A prospective study of 40 cases. J Orthop Traumatol Rehabil 2018;10:103.  Back to cited text no. 14
  [Full text]  
15.
Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children and adolescents. J Pediatr Orthop 2006;26:827-34.  Back to cited text no. 15
    
16.
Kang SN, Mangwani J, Ramachandran M, Paterson JM, Barry M. Elastic intramedullary nailing of paediatric fractures of the forearm: A decade of experience in a teaching hospital in the United Kingdom. J Bone Joint Surg Br 2011;93:262-5.  Back to cited text no. 16
    
17.
Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop 2010;30:313-9.  Back to cited text no. 17
    
18.
Zionts LE, Zalavras CG, Gerhardt MB. Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop 2005;25:507-12.  Back to cited text no. 18
    
19.
Holmes JH 4th, Wiebe DJ, Tataria M, Mattix KD, Mooney DP, Scaife ER, et al. The failure of nonoperative management in pediatric solid organ injury: A multi-institutional experience. J Trauma 2005;59:1309-13.  Back to cited text no. 19
    


    Figures

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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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