Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?

BACKGROUND: For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome. QUESTIONS/PURPOSES: In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up? METHODS: In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians. RESULTS: At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92). CONCLUSION: In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures. LEVEL OF EVIDENCE: Level I, therapeutic study.

Improved forearm rotation even after early conversion to below-elbow cast for non-reduced diaphyseal both-bones forearm fractures in children: a secondary 7.5-year follow up of a randomized trial.

BACKGROUND AND PURPOSE: previous RCT compared short-term results of above-elbow cast (AEC) with early conversion to below-elbow cast (BEC) in children with non-reduced diaphyseal both-bone forearm fractures. After 7 months both groups had comparable function. Our primary aim was to investigate whether forearm rotation improves or worsens over time. Secondary aims were loss of flexion and extension of the elbow and wrist, patient-reported outcomes measures, grip strength ratio, and radiographic assessment. PATIENTS AND METHODS: We performed long-term follow-up (FU) of a previous RCT. All patients were invited again for the long-term FU measurements. Primary outcome was limitation of forearm rotation. Secondary outcomes were loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, the ABILHAND-Kids questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, grip strength ratio, and radiographic assessment. RESULTS: The mean FU was 7.5 (4.4-9.6) years. Of the initial 47 children, 38 (81%) participated. Rotation improved in both groups over time, with no significant difference in the final forearm rotation: 8° (SD 22) for the AEC group and 8° (SD 15) for the BEC group with a mean difference of 0° (95% confidence interval -13 to 12). Secondary outcomes showed no statistically significant differences. Finally, children < 9 years almost all have full recovery of function. CONCLUSION: Long-term follow-up showed that loss of forearm rotation after a non-reduced diaphyseal both-bone forearm fracture improved significantly compared with that at 7 months, independent of the initial treatment and children aged < 9 will have almost full recovery of function. This substantiates that the remaining growth behaves like a "friend" at long-term follow-up.

Do We Need to Stabilize All Reduced Metaphyseal Both-bone Forearm Fractures in Children with K-wires?

BACKGROUND: Short-term follow-up studies have shown that reduced metaphyseal both-bone forearm fractures in children should be treated with K-wires to prevent redisplacement and inferior functional results. Minimum 5-year follow-up studies are limited. Range of motion, patient-reported outcome measures, and radiographic parameters at minimum 5-year follow-up should be evaluated because they could change insights into how to treat pediatric metaphyseal forearm fractures. QUESTIONS/PURPOSES: (1) Does K-wire stabilization of reduced metaphyseal both-bone forearm fractures in children provide better forearm rotation at minimum 5-year follow-up? (2) Do malunions (untreated redisplaced fractures) of reduced metaphyseal both-bone forearm fractures in children induce worse functional results? (3) Which factors lead to limited forearm rotation at minimum 5-year follow-up? METHODS: We analyzed the extended minimum 5-year follow-up of a randomized controlled trial in which children with a reduced metaphyseal both-bone forearm fracture were randomized to either an above-elbow cast (casting group) or fixation with K-wires and an above-elbow cast (K-wire group). Between January 2006 and December 2010, 128 patients were included in the original randomized controlled trial: 67 in the casting group and 61 in the K-wire group. For the current study, based on an a priori calculation, it was determined that, with an anticipated mean limitation in prosupination (forearm rotation) of 7° ± 7° in the casting group and 3° ± 5° in the K-wire group, a power of 80% and a significance of 0.05, the two groups should consist of 50 patients each. Between January 2014 and May 2016, 82% (105 of 128) of patients were included, with a mean follow-up of 6.8 ± 1.4 years: 54 in the casting group and 51 in the K-wire group. At trauma, patients had a mean age of 9 ± 3 years and had mean angulations of the radius and ulna of 25° ± 14° and 23° ± 18°, respectively. The primary result was limitation in forearm rotation. Secondary outcome measures were radiologic assessment, patient-reported outcome measures (QuickDASH and ABILHAND-kids), handgrip strength, and VAS score for cosmetic appearance. Assessments were performed by the first author (unblinded). Multivariable logistic regression analysis was performed to analyze which factors led to a clinically relevant limitation in forearm rotation. RESULTS: There was a mean limitation in forearm rotation of 5° ± 11° in the casting group and 5° ± 8° in the K-wire group, with a mean difference of 0.3° (95% CI -3° to 4°; p = 0.86). Malunions occurred more often in the casting group than in the K-wire group: 19% (13 of 67) versus 7% (4 of 61) with an odds ratio of 0.22 for K-wiring (95% CI 0.06 to 0.80; p = 0.02). In patients in whom a malunion occurred (malunion group), there was a mean limitation in forearm rotation of 6° ± 16° versus 5° ± 9° in patients who did not have a malunion (acceptable alignment group), with a mean difference 0.8° (95% CI -5° to 7°; p = 0.87). Factors associated with a limited forearm rotation ≥ 20° were a malunion after above-elbow casting (OR 5.2 [95% CI 1.0 to 27]; p = 0.045) and a refracture (OR 7.1 [95% CI 1.4 to 37]; p = 0.02). CONCLUSION: At a minimum of 5 years after injury, in children with a reduced metaphyseal both-bone forearm fracture, there were no differences in forearm rotation, patient-reported outcome measures, or radiographic parameters between patients treated with only an above-elbow cast compared with those treated with additional K-wire fixation. Redisplacements occurred more often if treated by an above-elbow cast alone. If fracture redisplacement is not treated promptly, this leads to a malunion, which is a risk factor for a clinically relevant (≥ 20°) limitation in forearm rotation at minimum 5-year follow-up. Children with metaphyseal both-bone forearm fractures can be treated with closed reduction and casting without additional K-wire fixation. Nevertheless, a clinician should inform parents and patient about the high risk of fracture redisplacement (and therefore malunion), with risk for limited forearm rotation if left untreated. Weekly radiographic monitoring is essential. If redisplacement occurs, remanipulation and fixation with K-wires should be considered based on gender, age, and direction of angulation. Future research is required to establish the influence of (skeletal) age, gender, and the direction of malunion angulation on clinical outcome. LEVEL OF EVIDENCE: Level I, therapeutic study.

Below-elbow cast sufficient for treatment of minimally displaced metaphyseal both-bone fractures of the distal forearm in children: long-term results of a randomized controlled multicenter trial.

Background and purpose - We have previously shown that children with minimally displaced metaphyseal both-bone forearm fractures, who were treated with a below-elbow cast (BEC) instead of an above-elbow cast (AEC), experienced more comfort, less interference in daily activities, and similar functional outcomes at 7 months' follow-up (FU). This study evaluates outcomes at 7 years' follow-up.Patients and methods - A secondary analysis was performed of the 7 years' follow-up data from our RCT. Primary outcome was loss of forearm rotation compared with the contralateral forearm. Secondary outcomes were patient-reported outcome measures (PROMs) consisting of the ABILHAND-kids and the DASH questionnaire, grip strength, radiological assessment, and cosmetic appearance.Results - The mean length of FU was 7.3 years (5.9-8.7). Of the initial 66 children who were included in the RCT, 51 children were evaluated at long-term FU. Loss of forearm rotation and secondary outcomes were similar in the 2 treatment groups.Interpretation - We suggest that children with minimally displaced metaphyseal both-bone forearm fractures should be treated with a below-elbow cast.

Case Report: SPECT/CT as the New Diagnostic Tool for Specific Wrist Pathology.

Introduction: Single photon emission computed tomography has been introduced as a promising new diagnostic tool in orthopaedic pathology since the early 90'. Computed tomography, the combined with SPECT, gives insight in the specific sight of wrist pathology. Literature already supports introduction of SPECT/CT in wrist pathology, but clinical application is lagging. Case Report: A 40yr old patient reported first in 2004 with persisting pain after a right distal radius fracture. Several diagnostics and operative interventions were performed, all unsuccessful. Because of the persisting pain a SPECT-CT was performed which showed a cyst in the hamate bone, which was successfully enucleated. The patient was finally pain free at recent follow-up. With a QDash-score of 43 and a PRW (H) E-DLV-score of 58/150. Discussion: In this case report, SPECT/CT proved a very sensitive diagnostic tool for specific pathology of the wrist. It offered precise localisation and thereby the clinically suspected diagnosis was confirmed and the patient successfully treated.

Systematic Review on the Functional Outcome After Treatment of a Traumatic Bowing Fracture of the Lower Arm in Children.

INTRODUCTION: Traumatic bowing is a commonly missed diagnosis on which only little information is available, inadequate treatment can cause permanent function loss. METHOD: A systematic review would determine what the effect is of treatment of traumatic bowing of the lower arm in children on the functional outcome. A search on Embase, Medline, Web of Science, Scopus, Cochrane, Pubmed publisher, CINAHL and Google scholar, last accessed at the 15th of May 2016. Intervention of interest was treatment; with reduction, reduction and cast or cast only. The primary outcome measure was (I) function; pro and supination, (II) posttraumatic function, (III) posttreatment function and (IV) residual bowing. RESULTS: Five articles were included. Treatment by reduction only showed a normal function, 4 weeks to 8 weeks of cast and reduction followed by cast, both resulted in 0 degrees to 20 degrees residual of pronation loss. DISCUSSION: The treatment was overall well tolerated, had a direct effect and lead to faster restore of function. It is unclear to what amount of bowing can be accepted without any loss of function. But in view of the few complications and good results for reduction, the overall opinion is to reduce all significant bowing fractures of the lower arm in children with limited function.

Exceptional localisation of an ectopic parathyroid adenoma at the level of the hyoid bone.

Primary hyperparathyroidism is characterised by high parathyroid hormone (PTH) levels and concomitant hypercalcaemia. Ninety per cent is caused by solitary parathyroid adenomas, 10% by multiple adenomas, hyperplasia and carcinomas. Less than 0.1% of the inferior parathyroid glands are ectopically located. This case is of a 54-year-old woman with hypercalcaemia 3.05 mmol/L and high PTH 22 pmol/L. Scintigraphy and CT scan of the neck in 2009 showed no signs of ectopic tissue. After treatment with Aredia (pamidronate disodium) infusion, calcium decreased to 2.73 mmol/L. In 2010 the serum calcium levels increased again to 3 mmol/L. Repeated CT showed no ectopic tissue. However, revision of the CT by the multidisciplinary team including an experienced endocrine surgeon revealed an ectopic parathyroid gland at the level of the hyoid bone, which was surgically removed in 2011. Preoperatively the PTH level was 16.8 mmol/L, postoperatively it decreased to 2.9 mmol/L, proving a successful excision. In case of suspicion of a parathyroid adenoma a CT of the neck should be thoroughly assessed by a dedicated multidisciplinary team, including the head and neck surgeon, as clinical data and radiological findings must be combined since ectopic parathyroid adenomas are a rare entity. Thereafter the adenoma can be surgically removed and the patient cured.