Therapeutic approaches of diametaphyseal radius fractures in children.

BACKGROUND: There are clear standards for when to operate on both distal epiphyseal and diaphyseal forearm fractures in children. However, paediatric surgeons are often faced with fractures in the transition zone between metaphysis and diaphysis. This aim of the study is to compare different treatment approaches for diametaphyseal forearm fractures, to classify different types of these fractures, and to define further assessment parameters and treatment recommendations. METHODS: This retrospective study included all patients with diametaphyseal radial fractures who were seen at a paediatric surgery clinic between 01.01.2010 and 31.12.2013. Patients were treated either non-surgically (C) or surgically using bicortical Kirschner wire (BC-KW), intramedullary K-wire (IM-KW), elastic stable intramedullary nailing (ESIN), or combined bicortical and intramedullary K-wire (BCIM-KW). RESULTS: During the study period, 547 patients presented with forearm fractures of which 88 patients (16%) had a fracture in the diametaphyseal region. The majority of diametaphyseal fractures were greenstick fractures (54.4%) followed by transverse fractures (44.3%). Distal fractures were predominantly treated with bicortical K-wiring (BC-KW, 40.5%) or non-surgically (C, 26.2%). Proximal fractures were treated by ESIN osteosynthesis (50%), followed by IM-KW (30%). Intermediate fractures were just as likely to be treated with one out of the 5 above-mentioned techniques. The ulna was involved in 64 of 88 cases. Depending on the type of fracture, it was treated either by ESIN osteosynthesis or non-surgically. No superior operative technique was identified. CONCLUSIONS: The description of diametaphyseal fractures as a separate entity is important, because the therapy of these fractures is heterogeneous and challenging. A classification into proximal, intermediate, and distal may be useful in clinical decision-making. Despite the retrospective nature of this study, our data suggest that the use of a K-wire or combined technique BCIM-KW-technique, whenever technically feasible, achieves better radiological results without secondary dislocation. Further prospective studies are needed to provide better guidance to trauma surgeons.

The Risk of Nerve Injury in Pediatric Forearm Fractures.

UPDATE: This article was updated on July 19, 2023, because of a previous error, which was discovered after the preliminary version of the article was posted online. On page 1080, in the last sentence of the Results section of the Abstract, the text that had read "0.05% (4 of 777)" now reads "0.5% (4 of 777)." BACKGROUND: The risk of fracture-related nerve injury associated with forearm fractures in children is unknown. The purposes of the present study were to calculate the risk of fracture-related nerve injury and to report the institutional rate of complications of surgical treatment of pediatric forearm fractures. METHODS: Four thousand, eight hundred and sixty-eight forearm fractures (ICD-10 codes S52.0 to S52.7) that had been treated in our tertiary level pediatric hospital between 2014 and 2021 were identified in our institutional fracture registry. Of these, 3,029 fractures occurred in boys and 53 were open fractures. Sex, age at injury, trauma mechanism and energy, fracture type, treatment method, and cause and type of nerve injury were assessed in 43 patients with 44 registered nerve injuries. Patients with nerve injuries were reevaluated to calculate the recovery time. Univariable and multivariable regression analyses were performed to determine the risk of nerve injury. RESULTS: The risk of a fracture-related nerve injury was 0.7% (33 of 4,868). Only 2 injuries were permanent; thus, the risk of permanent nerve injury associated with a forearm fracture was 0.04% (2 of 4,868). The ulnar nerve was affected in 19 cases; the median nerve, in 8; and the radial nerve, in 7. In cases of open fracture, the risk of nerve injury was 17% (9 of 53). Open fractures had an OR of 33.73 (95% CI, 14.97 to 70.68) on univariate analysis and an OR of 10.73 (95% CI 4.50 to 24.22) on multivariate analysis with adjustment for female sex and both-bone diaphyseal fracture. Both-bone diaphyseal fracture (ICD-10 code S52.4) had an OR of 9.01 (95% CI, 4.86 to 17.37) on univariate analysis and an OR of 9.98 (95% CI 5.32 to 19.47) on multivariate analysis with adjustment for age and female sex. Overall, 777 fractures were internally fixed. The risk of nerve injury as a complication of internal fixation was 1.3% (10 of 777). Four of these iatrogenic injuries (including 2 involving the median nerve, 1 involving the ulnar nerve, and 1 involving the radial nerve) were permanent; thus, the risk of permanent nerve injury as a complication of internal fixation was 0.5% (4 of 777). CONCLUSIONS: Nerve injury following a pediatric forearm fracture is rare and has an excellent potential for spontaneous recovery. In the present study, all of the permanent nerve injuries occurred in association with open fractures or as a complication of internal fixation. LEVEL OF EVIDENCE: Prognostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The 3D-Printed Titanium Truss Cage for the Treatment of Concurrent Complex Malunion, Synostosis and Large Bone Defect Following Forearm Injuries: A Case Report.

A 28-year-old man sustained a complex forearm injury from high-energy trauma, causing ulnar nerve injury, a bone defect, forearm malunion and synostosis. A 3D-printed titanium truss cage was used to solve these problems. This patient achieved union of the bone defect, was pain-free and had no recurrent synostosis 2 years after reconstructive surgery. The advantages of the 3D-printed titanium truss cage included anatomical fit, immediate mobilisation and low morbidity of the donor side of the bone graft. This study reported a promising result from using 3D-printed titanium truss cages to manage complex forearm bony problems. Level of Evidence: Level V (Therapeutic).

Subsequent Forearm Fractures Following Initial Surgical Fixation.

INTRODUCTION: Forearm fractures are a common pediatric injury. Currently, there is no consensus on treatment for fractures that recur following initial surgical fixation. The objective of this study was to investigate the subsequent fracture rate and patterns and describe the treatment of these forearm fractures. METHODS: We retrospectively identified patients who underwent surgical treatment for an initial forearm fracture at our institution between 2011 and 2019. Patients were included if they sustained a diaphyseal or metadiaphyseal forearm fracture that was initially treated surgically with a plate and screw construct (plate) or elastic stable intramedullary nail (ESIN), and if they subsequently sustained another fracture that was treated at our institution. RESULTS: A total of 349 forearm fractures were treated surgically with ESIN or a plate fixation. Of these, 24 sustained another fracture, yielding a subsequent fracture rate of 10.9% for the plate cohort and 5.1% for the ESIN cohort ( P =0.056). The majority of plate refractures (90%) occurred at the proximal or distal plate edge, while 79% of the fractures treated previously with ESINs occurred at the initial fracture site ( P <0.001). Ninety percent of plate refractures required revision surgery, with 50% underwent plate removal and conversion to ESIN, and 40% underwent revision plating. Within the ESIN cohort, 64% were treated nonsurgically, 21% underwent revision ESINs, and 14% underwent revision plating. Tourniquet time for revision surgeries were shorter for the ESIN cohort (46 vs. 92 min; P =0.012). In both cohorts, all revision surgeries had no complications and healed with evidence of radiographic union. However, 9 patients (37.5%) underwent implant removal (3 plates and 6 ESINs) after subsequent fracture healing. CONCLUSIONS: This is the first study to characterize subsequent forearm fractures following both ESIN and plate fixation and to describe and compare treatment options. Consistent with the literature, refractures following surgical fixation of pediatric forearm fractures may occur at a rate ranging from 5% to 11%. ESINs are both less invasive at the time of initial surgery and can often be treated nonoperatively if there is a subsequent fracture, while plate refractures are more likely to be treated with a second surgery and have a longer average surgery time. LEVEL OF EVIDENCE: Level IV-retrospective case series.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department.

OBJECTIVES: This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery. METHODS: This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt. RESULTS: Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01). CONCLUSIONS: Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Etiology of trauma-related acute compartment syndrome of the forearm: a systematic review.

OBJECTIVES: Acute compartment syndrome (ACS) can be caused by multiple causes that affect people of different ages. It is considered an orthopedic emergency condition that requires immediate diagnosis and surgical intervention to avoid devastating complications and irreversible damages. This systematic review aimed to present the etiology of trauma-related forearm ACS. METHODS: A systematic review was performed on four different databases: Embase, Medline, Cochrane Central Register of Controlled Trials (CENTRAL) and Cochrane Database of systematic review register databases via Ovid, with no restriction on dates (last date was June 30, 2021). It included all the studies containing data about the etiology of trauma-related forearm ACS. RESULTS: A total of 4893 articles were retrieved: 122 met the inclusion criteria, 39 were excluded, 25 were out of scope and 14 had insufficient details. Hence, this review constituted 83 articles and 684 patients. The etiology of ACS causing forearm ACS was classified into three groups: fracture-related, soft tissue injury-related and vascular injury-related. The fracture-related group was the most common group (65.4%), followed by soft tissue injury (30.7%), then vascular injuries (3.9%). Furthermore, supracondylar humerus fractures were the most common cause of fractures related to forearm ACS. Blunt traumas were the most common cause of soft tissue injuries-related forearm ACS, and brachial artery injuries were the most common cause of vascular-related forearm ACS. CONCLUSION: Frequent assessment of patients with the most prevalent etiologies of forearm ACS is recommended for early detection of forearm ACS and to save limbs.

Surgical Innovations to Restore Function in Pediatric Peripheral Nerve Conditions.

Peripheral nerve injuries in children can result in devastating lifelong deficits. Because of the time-sensitive nature of muscle viability and the limited speed of nerve regeneration, early recognition and treatment of nerve injuries are essential to restore function. Innovative surgical techniques have been developed to combat the regenerative length and speed; these include nerve transfers. Nerve transfers involve transferring a healthy, expendable donor nerve to an injured nerve to restore movement and sensation. Nerve transfers are frequently used to treat children affected by conditions, including UE trauma, brachial plexus birth injury, and acute flaccid myelitis. Pediatricians play an important role in the outcomes of children with these conditions through early diagnosis and timely referrals. With this review, we aim to provide awareness of state-of-the-art surgical treatment options that significantly improve the function of children with traumatic nerve injuries, brachial plexus birth injury, and acute flaccid myelitis.

Surgical outcome of upper extremity fractures in patients with Parkinson's disease.

Patients with Idiopathic Parkinson's Disease (PD) have an increased risk for fractures. Currently, many studies have reported inferior outcomes in PD patients after orthopedic procedures. However, there are very few studies assessing the outcome of upper extremity fractures (UEF) in PD patients. In this study, we reviewed 40 patients with PD that received surgical intervention for an UEF. We retrospectively reviewed patients with PD that received surgical fixation for an UEF at a tertiary trauma center. The primary objective was to determine the treatment failure rate after surgical fixation. The secondary outcomes include mode of failure, time to treatment failure, length of hospital stay, readmission rate, reoperation rate, and postoperative complications. A total of 40 patients with PD (42 fractures) underwent surgery. The most common fracture type was radius fracture (n = 19), followed by humerus fracture (n = 15), metacarpal/phalangeal fracture (n = 5), clavicle fracture (n = 2) and olecranon fracture (n = 1). The overall treatment failure rate was 40.5% (n = 17). The time to treatment failure was 1.24 ± 3.1 months and length of hospital stay was 6 ± 3.9 days, the readmission rate within 30 days was 14% (n = 6), and reoperation rate was 14% (n = 6). The complication rate was 16.6% (n = 7) and patients with humeral fractures appeared to have the longest hospital stays (6.6 days) and increased complication rates (13%, n = 2). Patients with PD have high treatment failure rates despite surgical fixation of an UEF. These patients often have a frail status with multiple comorbidities which may complicate their postoperative course.Level of evidence level 4 case series.

[Rupture of the descending thoracic aorta following sudden traumatic deceleration injury]. / Rupture de l'aorte thoracique descendante suite à une décélération brutale post traumatique.

Acute post-traumatic rupture of the thoracic aorta is the second cause of road traffic deaths; 80% of patients die at the scene of the accident. The involvement of its descending portion outside the isthmus is rare and it is estimated to be less than 3%. We report the case of a 60-year old man, victim of road traffic accidents (RTA) whose mechanism was: the motorcyclist was struck by a car; the points of impact included the right upper limb and the chest. This RTA caused a fracture in both bones of the forearm and a rupture of the descending thoracic aorta (ATD). Treatment was based in the first time on the suture of the aortic rupture complemented by synthetic circumferential prosthesis implantation with aorto-aortic anastomosis and in a second time on the application of a screwed plate in the forearm. The outcome was good and the patient was referred to the Department of vascular surgery.

Bypass surgery in a mangled forearm using an intramedullary tunnel through the radius.

Critical ischemia in the upper extremity is rare. A surgical bypass is thought to be the superior treatment option. We describe a rare case where regular tunneling options of the bypass were not available and an intramedullary tunnel was used.

Retalho interósseo posterior reverso do antebraço para o tratamento cirúrgico do trauma elétrico da mão: relato de caso / Reverse posterior interosseous flap of the forearm for the surgical treatment of electric hand trauma: Case report

Introdução: Lesões que acometem as mãos com importante perda cutânea frequentemente requerem retalhos para cobertura precoce, visto que permitem melhor reabilitação. Dentre as opções, o retalho interósseo posterior reverso do antebraço é o mais utilizado para defeitos no dorso da mão e punho, com baixas taxas de complicações. Normalmente, esse retalho não é utilizado para a reconstrução de defeitos em região palmar, já que geralmente não alcança esse local. Relato de caso: Apresentamos o caso de um paciente com queimadura elétrica de terceiro grau, em palma da mão direita, cuja reconstrução foi realizada com o uso do retalho interósseo posterior reverso do antebraço, após debridamentos conservadores, no 14o dia após a queimadura. O paciente apresentou boa evolução pós-operatória, sem complicações ou sequelas funcionais a longo prazo. Conclusão: O retalho interósseo posterior reverso do antebraço permite cobertura adequada de lesões em palma da mão, preservando sua funcionalidade.

Introduction: Lesions affecting the hands with significant skin loss often require flaps for early coverage, as these permit faster healing. Among the various options, the reverse posterior interosseous flap of the forearm is most commonly used for defects involving the back of the hand and wrist due to low complication rates. Normally, this flap is not used for the reconstruction of defects in the palmar region since its distal reach is insufficient. Case report: We present the case of a male patient with third-degree electrical burns on his right palm, whose reconstruction was performed on the 14th day postinjury using the reverse posterior interosseous flap of the forearm after conservative debridement. The patient presented good postoperative evolution, without long-term complications or functional sequelae. Conclusion: The reverse posterior interosseous flap of the forearm permits adequate coverage of palm injuries, preserving its functionality.

A foreign body in the cephalic vein: A case report.

RATIONALE: Foreign bodies in the vasculature usually cause numerous problems for clinical physicians. Physician experience with diagnosing and treating non-iatrogenic foreign body migration in the venous system is insufficient. PATIENT CONCERNS: Here, we reported a 41-year-old male who had a foreign body in his left forearm following a work-related injury. DIAGNOSES: X-ray films indicated a 3-mm high-density shadow in the superficial soft tissue of the left forearm. During the operation, the foreign body was imaged by a C-arm fluoroscope to provide a more accurate location. INTERVENTIONS: The foreign body was removed completely following a microsuture of the cephalic vein. OUTCOMES: The procedure was uneventful, and the patient remained asymptomatic after 6 months of clinical follow-up. LESSONS: This case indicated that the foreign body in the superficial tissue needed to be accurately diagnosed and located. X-ray and C-arm fluoroscope imaging should be combined with the patient's medical history to ensure sufficient preoperative preparation.

Arthroscopic resection of an osteochondral loose body in the distal radioulnar joint: A case report.

We report a 34-year-old man who presented with ulnar wrist pain, painful click, and locking during forearm rotation following a motorcycle accident. Plain radiographs showed a loose body in the distal radioulnar joint (DRUJ), deformity of the sigmoid notch and ulnar head, and ulnar minus variant. The DRUJ deformity was assumed to be associated with physeal injury of the distal ulna during childhood. Conservative treatment with a splint and oral analgesics for 3 months failed. During DRUJ arthroscopy, osteoarthritic changes were found, and the loose body was resected using DRUJ arthroscopy. Histological examination showed an osteochondral loose body. The patient remained asymptomatic without recurrence or DRUJ instability 2 years postoperatively.

Successful management of a 24-year-old pregnant woman with necrotising fasciitis of the forearm.

A 24-year-old woman who was 24 weeks pregnant presented to the emergency department with septic shock and an elbow wound that had become infected. She sustained an injury to the tip of the right elbow on a light switch 4 days prior. In the space of 1 day, she developed a necrotising soft tissue infection, which was rapidly spread to the forearm with florid sepsis. Her initial serum C reactive protein was 392 mg/L, and white cell count was 32×109/L. The patient was treated promptly with aggressive surgical debridement and broad-spectrum antibiotics. An early multidisciplinary approach including orthopaedic surgeons, anaesthetics, intensive care, obstetrics, microbiologists and paediatrics was taken. Ultimately, both mother and child had an excellent outcome, the former of whom only had minimal soft tissue resection and primary wound closure. Emphasis is made on first treating the mother as the patient and priority.

Circumferential Adipofascial Graft for Prevention of Recurrence of Posttraumatic Radioulnar Synostosis.

Radioulnar synostosis can cause substantial loss of function, and surgical treatment can be challenging. Recurrence of the contracture related to scar or reformation of the synostosis is problematic. Several techniques have been described for prevention of recurrence. We present a technique utilizing a free wrap around adipofascial graft for interposition and circumferential coverage of the ulna after resection of the heterotopic bone. We believe this technique has the advantages of technical simplicity, secure interposition, and reliable outcomes.

Post-traumatic forearm nonunion in healthy skeletally immature children: A report on 15 cases.

BACKGROUND: Nonunion is a rare but severe complication following forearm fracture in skeletally immature patients. The purpose of this study is to describe a case series of pediatric forearm nonunions treated at our Institute. MATERIALS AND METHOD: We retrospectively reviewed medical charts and radiographs of healthy children affected by post-traumatic nonunion of the forearm, from April 1992 to July 2015. An overall series of 15 cases was included in the study. Nonunion developed at ulna in 5 cases and at radius in 10 cases, at a mean time of 9 months (range 6-12) from fracture. Surgical treatment was performed in 14 cases out of 15. Stabilization of the nonunion was achieved with Kirschner wires (5 cases), plates (4 cases), rush rods (2 cases) and unilateral external fixator (3 cases). Iliac crest bone autograft was used in 11 cases, strut cortical bone allograft was used in 2 cases while in one case no bone graft was applied. In 2 cases an additional shortening osteotomy of the ulnar shaft was necessary to obtain adequate compression of the bone fragments. Cast immobilization was maintained for 6 to 8 weeks after surgery, then a brace was applied for further 8 to 12 weeks. RESULTS: The average follow-up was 54 months (range 12-129); nonunion healed in 14 cases (93%) at an average time of 4 months (range 2-8). One case of nonunion did not heal 12 months after surgery; other complications included: radio-ulnar fusion and radial nerve palsy (1 case), myositis ossificans at the ulna (1 case), olecranon bursitis with residual elbow stiffness (1 case). One case was treated conservatively and healed after 18 months with residual malalignment. CONCLUSIONS: The present study describes the largest series of pediatric forearm nonunions in the current literature. Whether the surgical management of pediatric forearm nonunion provides satisfactory results in terms of bone healing, it may be accompanied by several complications, permanent sequelae and residual functional impairment. Any effort must be undertaken to avoid this serious complication.

Focal fibrocartilaginous dysplasia in the ulna with the radial head dislocation: a case report and literature review.

Focal fibrocartilaginous dysplasia (FFCD) is a rare benign bone lesion, which mainly occurs in the proximal tibia. In the upper extremity, only 21 cases have been reported so far and 14 of these involved the ulna. We present an additional case of FFCD in the distal ulna that showed progressive bowing of the right forearm and the radial head dislocation. Resection of the abnormal tissue, osteotomy of the radius and ulna, and gradual lengthening of the ulna were performed. On the basis of the previously published data of 14 cases and our data, we have summarized the etiology, clinical features, natural history, and treatment of FFCD in the ulna.

Flexible Intramedullary Nailing of Pediatric Humeral Fractures: Indications, Techniques, and Tips.

Most proximal and diaphyseal pediatric humeral fractures can be treated successfully by closed means; however, certain patient factors or fracture characteristics may make surgical stabilization with flexible intramedullary nails (FIN) a better choice. Common indications for FIN of pediatric humeral fractures include unstable proximal-third fractures in children nearing skeletal maturity, unstable distal metaphyseal-diaphyseal junction fractures, shaft fractures in polytraumatized patients or patients with ipsilateral both-bone forearm fractures (floating elbow), and prophylactic stabilization of benign diaphyseal bone cysts or surgical stabilization of pathologic fractures. FIN can be safely inserted in an antegrade or retrograde manner depending on the fracture location and configuration. Careful dissection at the location of rod insertion can prevent iatrogenic nerve injuries. Rapid fracture union and return to full function can be expected in most cases. Implant prominence is the most common complication.