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).

Traumatic Rupture of the Flexor Carpi Ulnaris Muscle Belly in a Circus Rigger.

Closed traumatic rupture of forearm flexor muscles has been reported rarely. Previous reports have included ruptures of the flexor digitorum profundus, flexor digitorum superficialis, flexor pollicis longus, flexor carpi radialis, pronator quadratus and the palmaris longus. We report a patient with a closed traumatic rupture through the muscle belly of the flexor carpi ulnaris and summarise the published literature on ruptures involving the forearm flexor muscles. Overall, conservative treatment can result in excellent outcomes. Early surgical intervention is recommended in patients with nerve involvement and compartment syndrome and delayed reconstruction may be considered for patients with functional deficits.

Treatment of nonunion after forearm fractures in children: a conservative approach.

PURPOSE: Nonunions are a very rare complication after surgical treatment of displaced forearm fractures in children, but can occur in both the radius or ulna. The aim of this study is to evaluate predisposing factors for non-unions and to discuss treatment options. METHODS: We conducted a retrospective analysis of all patients who were treated primarily or secondary at our institution for nonunion after forearm fractures and operative treatment. Therefore, we retrospectively reviewed the medical charts and radiographs of affected patients from 1990 to 2020. We analysed demographic and fracture-related data as well as treatment options. RESULTS: Twenty-seven cases were identified. Median age was 12 years (7-16 years). The ulna was affected in 20 cases and the radius in 7. The most common location for ulna nonunion was the middle third of the shaft, and for the radius the mid and distal shaft. In 21 cases an open reduction was required. In 9 cases technical problems were identified. In most cases (26/27) a hypertrophic nonunion occurred. 10 of 27 (37%) nonunions healed without any surgical management after 9 (7-15) months. The median age of the conservatively managed group was 10 (6-13) years, younger than in the group with managed with reoperation [median 13 (7-16) years]. Indications for surgical intervention were increasing deformity, pain and limitation of movement. CONCLUSION: Open reduction and technical problems seem to be influencing factors. A conservative approach can be adopted in asymptomatic patients, otherwise an operative management, constituting plate osteosynthesis with or without bone grafting, should be performed.

A Single Sugar-Tong Splint Can Maintain Pediatric Forearm Fractures.

Displaced pediatric forearm fractures often are treated with closed reduction and immobilization. Recent literature demonstrates no difference in maintaining alignment or needing repeat intervention in patients immobilized with either a single sugar-tong splint or a long-arm cast, but most series include patients with distal fractures. This study included patients 3 to 15 years old who underwent closed reduction and immobilization for displaced midshaft or proximal forearm fractures. Radiographs from the time of injury, after reduction, and at 4-week follow-up were reviewed for coronal and sagittal plane angular alignment. Secondary interventions also were recorded. A total of 121 patients (70 long-arm cast, 51 simple sugar-tong splint) met inclusion criteria. Groups were matched in terms of age (P=.95), sex (P=.41), body mass index (P=.12), and angular deformity prior to reduction in the sagittal (P=.78) and coronal (P=.83) planes. Following closed reduction, sagittal (P=.003) and coronal (P=.002) alignment improved significantly in all patients. At 4-week follow-up, there were no significant differences in sagittal (P=.15) or coronal (P=.68) alignment between the 2 groups. Nine patients underwent a secondary intervention after the index reduction (long-arm cast, n=7; simple sugar-tong splint, n=2), with no statistically significant difference between groups (P=.30). There were no statistically significant differences between patients managed with long-arm cast or simple sugar-tong splint regarding residual sagittal or coronal plane deformity at 4-week follow-up or incidence of secondary intervention. These findings indicate simple sugar-tong splint and long-arm cast appear to be acceptable and equivalent methods of immobilization for these injuries. [Orthopedics. 2021;44(2):e178-e182.].

Comparison of operating time, fluoroscopy exposure time, and functional and radiological results of two surgical methods for distal forearm fractures of both-bones in pediatric patients: Is it necessary to fix both bones?

OBJECTIVE: The aim of this study was to compare the functional results of internal fixation of both forearm bones versus fixation of the radius alone in the treatment of distal both-bone forearm fractures in children. METHODS: This study included a total of 34 children who were treated for distal forearm both-bone fracture. Patients were divided into two groups according to the technique used, which depended on the date of their surgery. Group 1 consisted of 18 children (14 males and four females; mean age: 10.3 years; age range: 7-16 years) who underwent both-bone fracture fixation using closed reduction and percutaneous pinning; Group 2 consisted of 16 children (12 males and four females; mean age: 10.1 years; age range: 6-15 years) who underwent only radius fracture fixation. The average follow-up was 65.6 months in Group 1 and 38.9 months in Group 2. Operating time, fluoroscopy exposure time, functional results (Mayo Wrist Score, visual analogue scale score, and range of motion), radiological results (time to union and malunion), and complications were recorded as outcome parameters. RESULTS: The mean operating time was 35 min (range: 30-45 min) in Group 1 and 19 min (range: 10-25 min) in Group 2 (p<0.001). The mean fluoroscopy exposure time was 54 sec (range: 40-70 sec) in Group 1 and 18 sec (range: 10-26 sec) in Group 2 (p<0.001). Only three patients in Group 1 and four patients in Group 2 exhibited <10° of limitation in pronation and supination. No significant differences were determined between the groups with respect to functional scores (p=1.000). Final follow-up radiographs showed no malalignment in either group. In terms of time to union, there was no significant difference between groups (p=1.000). Additionally, only three minor complications associated with the pin track (two patients in Group 1 and one patient in Group 2) were noted. CONCLUSION: In children with distal both-bone fractures, fixation of the radius fracture alone may be considered as an alternative method of treatment to fixation of both forearm bones as it results in satisfactory functional and radiographic outcomes. LEVEL OF EVIDENCE: Level III, Therapeutic study.

Post-traumatic proximal radioulnar synostosis: results of surgical treatment and review of the literature.

BACKGROUND: Post-traumatic proximal radioulnar synostosis is a very rare and disabling condition whose surgical treatment has traditionally been viewed with pessimism. The results of the few case series in the literature are conflicting. Our aims were (1) to describe the clinical results of a case series treated surgically by a single elbow surgeon and (2) to review the literature. METHODS: Twelve patients were evaluated. Preoperative radiographs and computed tomography scans were performed. According to the Viola and Hastings classification, there was 1 case of type IC synostosis; 3, type IIA; 2, type IIIA; and 8, type IIIB. Two patients had a double synostosis. The synostosis was excised in 10 cases; in addition, radial head excision, radial head arthroplasty, and proximal radial diaphyseal resection were performed in 1, 3, and 2 cases, respectively. The Mayo Elbow Performance Score, modified American Shoulder and Elbow Surgeons score, and QuickDASH (short version of Disabilities of the Arm, Shoulder and Hand questionnaire) score were used for the preoperative and postoperative evaluation. The nonparametric Wilcoxon signed rank test was used for the statistical analysis. RESULTS: The mean follow-up period was 20.5 months. The final mean extension-flexion and pronation-supination arcs were 116° and 123°, respectively. Significant improvements were found in the Mayo Elbow Performance Score (P = .005), modified American Shoulder and Elbow Surgeons score (P = .012), and QuickDASH score (P = .002), with mean values of 24, 28, and 17, respectively. One synostosis recurrence and one late disassembly of the radial head arthroplasty were observed. CONCLUSIONS: Post-traumatic proximal radioulnar synostosis surgery is effective, but careful preoperative planning based on the pathoanatomic characteristics of each type of synostosis and associated lesions is mandatory. Synostosis excision is performed in most cases, whereas additional surgical procedures should be considered in selected cases.

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.

Union Rates and Reported Range of Motion Are Acceptable After Open Forearm Fractures in Military Combatants.

BACKGROUND: High-energy open forearm fractures are unique injuries frequently complicated by neurovascular and soft tissue injuries. Few studies have evaluated the factors associated with nonunion and loss of motion after these injuries, particularly in the setting of blast injuries. QUESTIONS/PURPOSES: (1) In military service members with high-energy open forearm fractures, what proportion achieved primary or secondary union? (2) What is the pronation-supination arc of motion as stratified by the presence or absence of heterotopic ossification (HO) and synostosis? (3) What are the risks of heterotopic ossification and synostosis? (4) What factors may be associated with forearm fracture nonunion? METHODS: A retrospective study of all open forearm fractures treated at a tertiary military referral center from January 2004 to December 2014 was performed. In all, 76 patients were identified and three were excluded, leaving 73 patients for inclusion. All 73 patients had serial radiographs to assess for HO and union. Only 64 patients had rotational range of motion (ROM) data. All patients returned to the operating room at least once after initial irrigation and débridement to ensure the soft tissue envelope was stable before definitive fixation. The indication for repeat irrigation and débridement was determined by clinical appearance. Patient demographics, fracture and soft tissue injury patterns, surgical treatments, neurovascular status at the time of injury, incidence of infection, heterotopic ossification (defined as the presence of heterotopic bone visible on serial radiographs), radioulnar synostosis, bony status after initial definitive treatment (union, nonunion, or amputation), and forearm rotation at final followup were retrospectively obtained from chart review by someone other than the operating surgeon. Seventy-six open forearm fractures in 76 patients were reviewed; 73 patients were examined for osseous union as three went on to early amputation, and 64 patients had forearm ROM data available for analysis. Union was determined by earliest radiology or orthopaedic staff official dictation stating the fracture was healed. Nonunion was defined as the clinical determination by the orthopaedist for a repeat procedure to achieve bony union. Secondary union was defined as union after reoperation to achieve bony union, and final union was defined as overall percentage of patients who were healed at final followup. Of the patients analyzed for union, 20 had less than 1 year of followup, and of these, none had nonunion. Of the patients analyzed for ROM, eight patients had less than 6 months of followup (range, 84-176 days). Of these, one patient had decreased ROM, none had a synostosis, and the remaining had > 140° of motion. RESULTS: Initial treatment resulted in primary union in 62 of 73 patients (85%); secondary union was achieved in eight of 11 patients (73%); and final union was achieved in 70 of 73 patients (96%). Although pronation-supination arc in patients without HO was 140° ± 35°, a limited pronation-supination arc was primarily associated with synostosis (arc: 40° ± 40°; mean difference from patients without HO: 103° [95% confidence interval {CI}, 77°-129°], p < 0.001); patients with HO but without synostosis had fewer limitations to ROM than those with synostosis (arc: 110° ± 80°, mean difference: 77° [35°-119°], p < 0.001). Heterotopic ossification developed in 40 of 73 patients (55%), including a radioulnar synostosis in 14 patients (19%). Bone loss at the fracture site (relative risk (RR) 6.2; 95% CI, 1.8-21) and healing complicated by infection (RR, 9.9; 95% CI, 4.9-20) were associated with the development of nonunion after initial treatment. Other potential factors such as smoking status, vascular injury, both-bone involvement, need for free flap coverage and blast mechanism were not associated. CONCLUSIONS: Despite a high-energy mechanism of injury and high rate of soft tissue defects, the ultimate probability of fracture union in our series was high with a low infection risk. Nonunions were associated with bone loss and deep infection. Functional motion was achieved in most patients despite increased burden of HO and synostosis compared with civilian populations. However, if synostosis did not develop, HO itself did not appear to interfere with functional ROM. Future investigations may provide improved decision-making tools for timing of fixation and prophylactic means against HO synostosis. LEVEL OF EVIDENCE: Level III, therapeutic study.

Clinical and radiographic comparison of single-sugar-tong splint to long-arm cast immobilization for pediatric forearm fractures.

The purpose of this study was to compare the efficacy of a single-sugar-tong splint (SSTS) to a long-arm cast (LAC) in maintaining reduction of pediatric forearm fractures, while avoiding secondary intervention. One hundred patients age 3-15 with a forearm fracture requiring a reduction and immobilization were evaluated (50 LAC and 50 SSTS). Medical records and radiographs were reviewed at injury, postreduction, and at 1, 2, and 4 weeks postinjury. Sagittal and coronal angular deformities were recorded. Any secondary intervention due to loss of reduction was documented. The groups were matched by age (P = 0.19), sex (P = 0.26), mechanism of injury (P = 0.66), average injury sagittal deformity (LAC 27.4°, SSTS 25.4°; P = 0.50), and average injury coronal deformity (LAC 15.5°, SSTS 16°; P = 0.80) At 4 weeks postinjury follow-up, there were no statistically significant differences between use of an SSTS or LAC when comparing postimmobilization sagittal alignment (LAC 10.3 ± 7.2, SSTS 8.4 ± 5.1°; P = 0.46), coronal alignment (LAC 6.9 ± 4.6, SSTS 7.6 ± 9.3°; P = 0.46), or need for repeat manipulation or surgery (LAC 4/50, SSTS 3/50; P = 0.70).

Free vascularized osteoseptocutaneous fibular flap for radius shaft nonunion: The final solution when the iliac crest autograft fails. A case report.

Treatment of forearm nonunion associated with bone defects can be challenging. Restoring the correct length and rotation are two main principles for the management of these patients. Herein, we describe a patient with isolated radius nonunion already treated with an iliac crest autograft with no success. A free vascularized osteoseptocutaneous fibular autogenous graft was harvested as the final solution to managed long bone defect after previous multiple surgeries. At the 1- year follow-up, the patient gained full range of motion and was functioning well.

Utility of the Three-Point Index in the determination of reduction loss during the conservative treatment of pediatric forearm mid-third fractures.

BACKGROUND: Forearm fractures constitute approximately 40% of all pediatric fractures. Generally, in conservative treatment,a plaster cast is applied with the elbow in 90° flexion. Success of the treatment depends on theprevention of the reduction in the correct position and suitable duration of the plaster cast. Failure, or the risk of angulation within the cast, is associated with movement within the cast. The aim of this study was to evaluate the applicability of the Cast Index (CI) and Three-Point Index (TPI) measurements, which indicate the loss of reduction, in pediatric mid-third forearm fractures. The hypothesis of the study was that as edema decreases and deformity of the plaster cast occurs after fracture reduction, TPI and CI should be examined during follow-up, as they indicate shifting due to movement within the plaster cast. METHODS: This retrospective study included a total of 48 patients, who were treated with closed reduction and long-arm plaster cast for a mid-third forearm diaphyseal fracture at our Emergency Polyclinic between March and September 2014. The mean age of the patients was 8.15±3.19 years (range, 5-14 years). Patients were excluded from the study if they had isolated radial or ulnar fracture, open fractures, concomitant fracture or systemic disease (bone metabolism disease, etc), and <10° fracture angulation in the ulna and radius on the initial radiograph and if they did not followup. TPI and CI values were calculated on anterioposterior (AP) and lateral radiographs in the Picture Archiving Communication Systems. RESULTS: In the AP plane, compared with TPI values after reduction, statistically significant increases were observed in TPI values 10 days after reduction (p<0.01). However, no significant difference was observed between those with and without reduction loss in TPI values in the AP plane (p>0.05). Although there was a statistically significant increase in TPI values 15 daysafter reduction compared with the values immediately after reduction, a significant difference between those with and without reduction loss was observed only on lateral TPI. CONCLUSION: In cases of pediatric forearm diaphyseal fracture, ulnar TPI examined in the lateral plane can be used in monitoring the fracture in a plaster cast applied after the reduction.

In Vivo Three-Dimensional Analysis of Malunited Forearm Diaphyseal Fractures with Forearm Rotational Restriction.

BACKGROUND: The aim of this study was to clarify the mechanisms of rotational restriction in malunited forearm diaphyseal fractures. METHODS: We retrospectively analyzed the cases of 18 patients with malunited forearm diaphyseal fractures and rotational restriction. All patients underwent bilateral computed tomography (CT) of the forearm in maximum supination, pronation, and neutral positions. From these images, we created 3-dimensional (3-D) bone surface models. We quantified the 3-D deformities, identified instances of osseous impingement between the radius and the ulna during forearm rotation, calculated the path length of the central band (CB) of the interosseous membrane, and measured forearm range of motion. RESULTS: Sixteen patients had extension deformity of the radius (the RE group) and 2 had flexion deformity (the RF group). In the RE group, extension deformity of the radius and valgus deformity of the ulna had significant negative correlation with pronation range of motion (R = -0.50, p = 0.046) and supination range of motion (R = -0.63, p = 0.027), respectively. Osseous impingement was mainly observed during pronation (15 of 16 patients). The CB path with the largest changes in length originated from the distal CB attachment area of the radius and ran toward the proximal area of the ulna (the transverse CB). The transverse CB significantly increased in length in supination compared with that in pronation (p < 0.001). Therefore, tightness of the transverse CB appeared to cause supination restriction in the RE group. In the RF group, osseous impingement caused supination restriction. The greatest increases in the transverse CB length were observed in pronation in the RF group, which appeared to cause pronation restriction. CONCLUSIONS: In the RE group, pronation restriction was associated with osseous impingement that was due to extension deformity of the radius, and supination restriction was associated with CB tightness that was due to valgus deformity of the ulna. In the RF group, our results suggested that pronation restriction was caused by CB tightness and that supination restriction was caused by osseous impingement. CLINICAL RELEVANCE: Three-dimensional corrective osteotomy for extension deformity of the radius in malunited forearm diaphyseal fractures would improve rotational restriction by relieving osseous impingement during pronation and CB tightness during supination.

Treatment of posttraumatic bone defects of the forearm with vascularized fibular grafts. Follow up after fourteen years.

BACKGROUND: Among several techniques proposed for the reconstruction of posttraumatic bone defects of the forearm, that of free vascularised fibular graft (FVFG) is one of the most widely used. PATIENTS AND METHOD: We study the long-term outcomes of 14 patients who underwent FVFG between 1994 and 2009, with a minimum follow up of 8 years and a maximum of 23 years (mean: 13.9 years). Demographic, clinical and radiological variables were collected retrospectively. The DASH scale was used for clinical assessment. RESULTS: Fourteen patients were operated on by the same surgeon, applying FVFG for the reconstruction of posttraumatic bone defects of the forearm (three septic non-union of the ulna or radius, five radius fractures, two ulna fractures and four fractures of both bones). The maximum length of the defect was 11 cm and the minimum length was 6 cm. In four cases, reconstruction of the two bones was achieved using the double barrel technique, and in another four cases, an osteoseptocutaneous flap was used. Fixation was performed with 3.5 mm reconstruction plates in thirteen cases and with 3.5 mm screws in one case. Consolidation was obtained in 12 cases (85.7%) after an average time of 4.2 months (range: 2-6.5 months). In one case, consolidation of the proximal ulnar fracture site was not achieved, and in another, following the failure of reconstruction attempts, an arthrodesis was performed. At the end of the follow-up period, the patients had an average DASH score of 17.1 points (range 1.8-68.1). CONCLUSIONS: FVFG is a valid option for the reconstruction of posttraumatic bone defects of the forearm. Its use via the double barrel method or as an osteocutaneous composite graft enables the simultaneous reconstruction of both forearm bones and associated soft tissue injuries. Long-term follow-up of patients who have undergone this technique confirms its satisfactory functional and radiological results.

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.

Single- versus double-bundle suture button reconstruction of the forearm interosseous membrane for the chronic Essex-Lopresti lesion.

PURPOSE: Reconstruction of the ruptured interosseous membrane (IOM) is critical to restore forearm stability for the chronic Essex-Lopresti injury. Positive outcomes have been reported following IOM reconstruction with a single-bundle suture button (Mini-Tightrope) construct, although recent work suggests that double-bundle Mini-TightRope® IOM reconstruction is biomechanically superior. The purpose of this study was to determine whether double-bundle Mini-TightRope® reconstruction of the forearm IOM results in superior clinical outcomes to the single-bundle technique. METHODS: Five patients with chronic Essex-Lopresti injuries treated with double-bundle Mini-TightRope® IOM reconstruction were matched to five patients treated with single-bundle Mini-TightRope® reconstruction. Improvement in clinical examination measures and patient-reported outcomes was compared between the groups. RESULTS: Results were good to excellent in all 10 patients. At final follow-up, forearm rotation was significantly better in the single-bundle group, while maintenance of ulnar variance was better in the double-bundle group. No significant differences were noted between the two groups for any other numerical outcomes, and no complications occurred. CONCLUSION: These findings suggest that while IOM reconstruction with a double-bundle Mini-TightRope® construct results in greater resistance to proximal migration of the radius in the intermediate term, there is a modest concomitant loss of forearm rotation when compared to single-bundle reconstruction. LEVEL OF EVIDENCE: Therapeutic Level IV.

Complications and Outcomes of One-Bone Forearm Reconstruction.

Background: The objective of this study was to review the outcomes of patients who underwent one-bone forearm (OBF) reconstruction. Methods: A retrospective review of patients who underwent OBF surgery between 1994 and 2014 was undertaken. Patient demographics, etiology, associated injuries, number of surgeries prior to OBF surgery, surgical details, and postoperative information were collected. A telephone interview was conducted at final follow-up, including a Quick Disabilities of the Arm, Shoulder and Hand (QuickDASH) questionnaire, a 10-point scoring system used by Peterson et al, and a series of questions concerning pain and patient satisfaction. Results: There were 6 males and 2 females with a mean age of 44 years (range, 20-66 years). All patients had traumatic etiology, with 6 having open wounds and 2 having closed wounds. All patients had union with a mean follow-up of 83.6 months (range, 16-218 months). The mean pain score was 3 (range, 0-8), of which 3 were painless (score 0). The mean QuickDASH score was 39 (range, 7-75), and 4 patients had good or excellent results according to the 10-point score system used by Peterson et al. All patients were satisfied with the result. Five of 8 had complications related to soft tissues that were residual from their prior injuries and surgeries. One patient had post healing fracture requiring revision fixation and 1 had a postoperative infection requiring parenteral antibiotics. Conclusions: OBF surgery is an effective salvage procedure for complicated forearm instability, particularly after trauma. While union rates are high, complications are typically related to pain and soft tissue secondary to the previous injury and reconstructive procedures.

Mini C-arm: faster, cheaper, safer?

BACKGROUND: Mini C-arm image intensifiers (IIs) are promoted to permit lower radiation dose than traditional IIs with a lower purchase price and without the need for a radiographer, saving time. In real-world usage, radiation dose is not always lower. METHODS: A retrospective review of prospectively collected data for 620 children undergoing forearm fracture reduction in theatre was undertaken. Imaging was performed with the Fluoroscan mini C-arm or a comparison traditional II. Radiation dose and theatre time were recorded. RESULTS: There was no significant difference in radiation dose as measured by dose-area product (0.013 versus 0.014 Gy.cm2 , P = 0.22). We noted an inverse association between operator experience and radiation dose. The mini C-arm allowed a shorter procedure time (26 versus 30 min, P < 0.001) and theatre time (13 versus 16 min, P < 0.001). Re-displacement rates were similar (1.3 versus 2.2%). The Fluoroscan is AU$120 000 cheaper to purchase and AU$35 283 cheaper to run per year than the comparison II. Consultants had a 14% lower dose-area product (0.012 versus 0.014 Gy.cm2 , P < 0.001) and 18% shorter screening time (8 versus 9.8 s, P < 0.001) than registrars. CONCLUSION: The Fluoroscan mini C-arm II does not demonstrate a radiation saving during closed reductions of paediatric forearm fractures but allows shorter procedures and theatre time with similar re-displacement rates. The purchase price is lower than a traditional II. We noted that operator experience reduces radiation dose.

Reliability of Casting Indices Among Members of an Orthopaedic Surgery Residency.

BACKGROUND: Multiple casting indices have been described to evaluate the adequacy of cast placement in pediatric distal forearm fractures. The aim of this study was to determine the intrarater and interrater reliability of the measurements of 5 common casting indices among members of an orthopaedic surgery residency program. The cast index, 3-point index, gap index, padding index, and Canterbury index were evaluated. METHODS: This was a single-center prospective cohort reliability study that included 12 members of an orthopaedic surgery residency. Participants were placed into 1 of 4 groups by level of training: physician assistants, junior residents, senior residents, and attending orthopaedic surgeons. Twelve radiographs of casted pediatric distal forearm fractures were measured by each participant on 2 separate occasions. Statistical analysis using the intraclass correlation coefficient was used to determine the intrarater and interrater reliability. RESULTS: The cast index was the only casting index to meet our criteria for good intrarater and interrater reliability. CONCLUSION: Continued use of the cast index as a tool to assess pediatric distal forearm cast application is supported by this study. LEVEL OF EVIDENCE: Level 2.

The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF).

Background and purpose - The AO Pediatric Comprehensive Classification of Long Bone Fractures (PCCF) describes the localization and morphology of fractures, and considers severity in 2 categories: (1) simple, and (2) multifragmentary. We evaluated simple and multifragmentary fractures in a large consecutive cohort of children diagnosed with long bone fractures in Switzerland. Patients and methods - Children and adolescents treated for fractures between 2009 and 2011 at 2 tertiary pediatric surgery hospitals were retrospectively included. Fractures were classified according to the AO PCCF. Severity classes were described according to fracture location, patient age and sex, BMI, and cause of trauma. Results - Of all trauma events, 3% (84 of 2,730) were diagnosed with a multifragmentary fracture. This proportion was age-related: 2% of multifragmentary fractures occurred in school-children and 7% occurred in adolescents. In patients diagnosed with a single fracture only, the highest percentage of multifragmentation occurred in the femur (12%, 15 of 123). In fractured paired radius/ulna bones, multifragmentation occurred in 2% (11 of 687); in fractured paired tibia/fibula bones, it occurred in 21% (24 of 115), particularly in schoolchildren (5 of 18) and adolescents (16 of 40). In a multivariable regression model, age, cause of injury, and bone were found to be relevant prognostic factors of multifragmentation (odds ratio (OR) > 2). Interpretation - Overall, multifragmentation in long bone fractures in children was rare and was mostly observed in adolescents. The femur was mostly affected in single fractures and the lower leg was mostly affected in paired-bone fractures. The clinical relevance of multifragmentation regarding growth and long-term functional recovery remains to be determined.

Quantification of radiation exposure in the operating theatre during management of common fractures of the upper extremity in children.

Introduction Surgical procedures to manage trauma to the wrist, forearm and elbow in children are very common. Image intensifiers are used routinely, yet studies/guidelines that quantify expected radiation exposure in such procedures are lacking. Methods Information on demographics, injury type, surgeon grade and dose area product (DAP) of radiation exposure per procedure was collected prospectively for 248 patients undergoing manipulation/fixation of injuries to the elbow, forearm or wrist at a paediatric hospital over 1 year. Results DAP exposure (in cGycm(2)) differed significantly across different procedures (p<0.001): wrist manipulation under anaesthesia (MUA; median, 0.39), wrist k-wiring (1.01), forearm MUA (0.50), flexible nailing of the forearm (2.67), supracondylar fracture MUA and k-wiring (2.23) and open reduction and internal fixation of the lateral humeral condyle (0.96). Fixation of a Gartland grade-3 supracondylar fracture (2.94cGycm(2)) was associated with higher exposure than grade-2 fixation (1.95cGycm(2)) (p=0.048). Fractures of the wrist or forearm necessitating metalwork fixation resulted in higher exposure than those requiring manipulation only (both p<0.001). For procedures undertaken by trainees, trainee seniority (between year-5 and year-8 and clinical fellow, p≥0.24) did not affect the DAP significantly. Conclusions The spectrum of radiation exposures for common procedures utilised in the management of paediatric upper limb trauma were quantified. These findings will be useful to surgeons auditing their practice and quantifying radiation-associated risks to patients. Our data may serve as a basis for implementing protocols designed to improve patient safety.