The midterm psychological effect of cast removal procedures in children.

OBJECTIVES: This study aimed to compare the course of anxiety change in children who used headphones during cast removal with controls in midterm follow-up. PATIENTS AND METHODS: Sixty-six patients who underwent forearm fracture treatment with closed reduction and long arm casting between June 2021 and March 2023 were retrospectively reviewed. Patients were divided into two groups based on the use of headphones (n=27; 21 males, 6 females; mean age: 8.0±1.8 years; range, 6 to 12 years) or not (n=39; 27 males, 12 females; mean age: 8.9±1.8 years; range, 6 to 12 years) during cast removal with an oscillating saw. Primary outcome measures included preprocedure, postprocedure, and six-month anxiety assessments with the State-Trait Anxiety Inventory. RESULTS: There was an acute increase in the mean state anxiety scores after the procedure, which returned to below baseline at the six-month follow-up in the headphone (31.4±8.3, 33.3±8.7, and 25.1±4.1, respectively) and control groups (34.9±11.1, 37.4±9.5, and 27.3±5.3, respectively). The mean trait anxiety scores before the procedure, after the procedure, and at six months remained similar in the headphone (33.6±3.0, 34.6±3.2, and 32.4±2.8; p>0.05) and control groups (34.1±2.7, 33.7±3.0, and 33.7±3.0, p>0.05). CONCLUSION: This study suggests that the acute anxiety during cast removal did not create anxiety sequelae in the sixth month regardless of headphone use.

Buried or exposed Kirschner wire for the management of hand and forearm fractures: A systematic review, meta-analysis, and meta-regression.

BACKGROUND: The recommendation on whether to bury or expose the Kirschner wire (K-wire) for the management of fractures has still been controversial with inconsistent results in the published studies due to the potential issue associated with exposed K-wire is the heightened risk of infection, as it comes into direct contact with the external environment and air. This study aims to summarize the specific outcomes between buried and exposed K-wire for the management of hand and forearm fractures. METHODS: We conducted relevant literature searches on Europe PMC, Medline, Scopus, and Cochrane Library databases using specific keywords. This investigation focuses on individuals of any age diagnosed with hand or forearm fractures who underwent surgery involving Kirschner wire (K-wire) fixation. It examines the comparison between buried and exposed K-wire fixation, emphasizing primary outcome pin infection, along with secondary outcomes such as early pin removal, days to pin removal, and surgical duration. The study includes observational studies (cohort/case-control) or randomized clinical trials (RCTs). The results of continuous variables were pooled into the standardized mean difference (SMD), while dichotomous variables were pooled into odds ratio (OR) along with 95% confidence intervals using random-effect models. The quality of included studies was assessed with Cochrane Collaborations, Risk of Bias version 2 (RoB v2). RESULTS: A total of 11 studies were included. Our pooled analysis revealed that buried K-wire was associated with a lower risk of pin site infection [RR 0.49 (95% CI 0.36-0.67), p < 0.00001, I2 = 0%] and 33.85 days longer duration until pin removal [MD 33.85 days (95% CI 18.68-49.02), p < 0.0001, I2 = 99%] when compared with exposed K-wire. However, the duration of surgery was 9.98 minutes significantly longer in the buried K-wire [MD 6.98 minutes (95% CI 2.19-11.76), p = 0.004, I2 = 42%] with no significant difference in the early pin removal rate [RR 0.73 (95% CI 0.36-1.45), p = 0.37, I2 = 0%]. Further regression analysis revealed that sample size, age, sex, and duration of follow-up did not affect those relationships. CONCLUSION: Buried K-wire may offer benefits in reducing the infection rate with a longer duration until pin removal. However, further RCTs with larger sample sizes are still needed to confirm the results of our study.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications.

PURPOSE: The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults. METHODS: Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time. RESULTS: A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively. CONCLUSIONS: Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

Cat bite injuries to the hand and forearm: the impact of antibiotic treatment on microbiological findings and clinical outcome.

INTRODUCTION: Patients and physicians often underestimate cat bite injuries. The deep and narrow wound seals quickly and provides an environment for the inoculated saliva and bacteria. Interestingly, the literature reports no bacterial growth in the microbiological workup of wound swaps in up to 43%. The time between bite injury and the first clinical presentation, the start of antibiotic treatment and surgical debridement might affect these findings. Therefore, the current project examines if (1) these factors impact the outcome of microbiological results following cat bite injuries and (2) the detection of bacterial growth leads to higher complication rates, longer hospital stays, longer total treatment time, or higher total treatment costs. MATERIALS AND METHODS: This single-center retrospective study analyzed data from 102 adult patients. All patients received antibiotic and surgical treatment following a cat bite injury. Microbiological samples were collected during surgery in all cases. The time from the bite incident to the first presentation, beginning of antibiotic administration, and surgical debridement was calculated. Demographic data, complication rate, length of hospital stay, total treatment time, and total treatment costs were recorded. (1) A generalized linear model was fitted using the microbiological outcome as the dependent variable. (2) Two groups (negative or positive microbiological results) were formed and statistically compared. RESULTS: The median age was 50 (SD 16), and 72% were female. (1) The time from the bite incident to the first clinical presentation, antibiotic administration, or surgical treatment was not associated with the outcome of the microbiological result. (2) No significant differences were observed between the two groups. CONCLUSIONS: Our data do not suggest that early antibiotic administration or delayed surgical treatment affects the outcome of the microbiological workup following cat bite injuries to the hand and forearm. The microbiological outcome did not affect the complication rate, treatment time, and total treatment costs.

Options for Restoring Finger Extension in Mangled Forearm Injuries.

Restoration of finger extension in mutilating hand injuries is crucial for restoring prehension and independent use of the hand. Patients often express desire to restore finger extension once finger flexion is achieved. However, the extensive forearm injury precludes use of any of conventional donors like the wrist or finger flexors for transfer to restore finger extension. Two patients with sequelae of mangled forearm injuries, underwent biceps and long head of triceps transfer to the finger extensors to improve opening up of the fingers. We discuss the treatment considerations while planning these transfers and provide the technical details, rehabilitation and outcome of these patients. Both the patients expressed dramatic improvement of their hand function and were satisfied with the outcome. Biceps and long head of triceps could serve as an effective second-line donor for restoration of finger extension when the conventional donors are not available. Level of Evidence: Level V (Therapeutic).

Evaluation of surgical or conservative treatment of forearm fracture in pediatric floating elbow injuries.

OBJECTIVE: Floating elbow, which refers to a humerus fracture in the supracondylar region and a forearm fracture, is a very unusual injury. The purpose of this study is to compare the clinical results of patients with "floating elbows" who underwent surgical therapy and who were given forearm immobilization with a splint as follow-up care. PATIENTS AND METHODS: Fifteen patients who had been diagnosed with floating elbow owing to trauma were scanned retrospectively and followed up for at least a year. Eight individuals who suffered from broken forearms underwent surgical repair. After initial treatment, a lengthy arm splint was used to immobilize seven patients' arms. The modified Flynn criteria were used to analyze the data, and comparisons were made between the groups. RESULTS: The median age and mean follow-up time for patients whose forearms were conservatively followed was 6.1 years and 13.8 months, respectively. The median age of the patients who underwent forearm surgery was 8.5 years, and the average follow-up was 14.2 months. Five of the seven patients whose forearms underwent conservative follow-up had outstanding clinical outcomes, while two had poor and moderate outcomes. Four individuals who got surgical treatment for their forearms had excellent and good clinical outcomes, while the other four had intermediate and poor outcomes. Between the two groups, there was no discernible difference (p = 0.60). CONCLUSIONS: In the pediatric population with floating elbow injuries, using a cast for forearm fractures may not necessarily result in worse outcomes compared to surgical management.

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.

Time to surgery and outcomes following open reduction and internal fixation of both-bone forearm fractures.

PURPOSE: To determine the effect of time to surgery on outcomes following open reduction and internal fixation (ORIF) of both-bone forearm fractures (BBFFs). METHODS: Ninety-nine patients who underwent ORIF of BBFFs in a single academic medical center over a 16-year time period were retrospectively reviewed. Demographic and clinical data including age, sex, current smoking status, time from injury to surgery (tsurg), presence of open injury, polytrauma status, and complications were obtained. Radiographs of the affected extremity were reviewed for fracture morphology, reduction quality, and time to union (or presence of nonunion). In addition to descriptive statistics, Chi-square and Wilcoxon-Mann-Whitney tests were used to compare categorical and interval, respectively, with a significance level of 0.05. RESULTS: A tsurg > 48 h was associated with increased rate of delayed unions (tsurg < 48 h: 25% vs tsurg > 48 h: 59%, p = 0.03), but not complications (tsurg < 48 h: 44% vs tsurg > 48 h: 47%, p = 0.79). Open BBFFs were not associated with increased rates of delayed unions (closed: 16% vs open: 19%, p = 0.77) or complications (closed: 42% vs open: 53%, p = 0.29). A trend toward increased time to union with tsurg > 48 h was also seen, but did not reach significance (tsurg < 48 h: 13.5 weeks vs tsurg > 48 h: 15.7 weeks, p = 0.11). CONCLUSION: A tsurg > 48 h is associated with an increased rate of delayed union, but not complications, after ORIF of BBFFs. LEVEL OF EVIDENCE: Therapeutic Level III (Retrospective Cohort).

An age-matched comparative study on intramedullary nailing and plate fixation of both-bone diaphyseal forearm fracture in adolescents.

OBJECTIVE: This study aimed to compare radiological and functional outcomes and complication rates between intramedullary nailing (IMN) and plate fixation for diaphyseal forearm fractures in adolescents via an age-matched analysis. METHODS: Data were collected from medical records at 11 hospitals from 2009 to 2019, and the age-matched study was conducted between IMN and plate fixation. Functional outcomes, radiographic outcomes, and postoperative complication rates were compared. RESULTS: The IMN group (Group N) and plate fixation group (Group P) each comprised 26 patients after age matching. The mean age after matching was 13.42 years old. Bone maturities at the wrist of the radius and ulna were not significantly different between the two groups (p = 0.764 and p = 1). At the last follow-up period, functional outcomes using the Price criteria were over 90% in both groups, and the rotational range of motion was comparable to that of the healthy side. Over 70% of cases in Group N were performed by closed reduction, and operation time was half that of Group P. Postoperative neurological symptoms and refractures were more common in Group P than in Group N, although not statistically significantly so. CONCLUSIONS: Treatment outcomes for age-matched adolescent diaphyseal forearm fractures were excellent with IMN, as well as with plate fixation in many cases despite fewer complications, better cosmesis, and shorter operative times with IMN. IMN for diaphyseal forearm fractures is a useful treatment option even in adolescents although the indications for the best procedure to perform should be considered depending on individual patient needs. LEVEL OF EVIDENCE IV: Multicenter retrospective study.

Refracture Following Operative Treatment of Pediatric Both Bone Forearm Fractures.

INTRODUCTION: Both bone forearm fractures are common injuries in children. Most can be treated with reduction and casting. Those that fail nonoperative management can be treated with a plate or intramedullary fixation; however, refracture remains a problem. The goal of this study is to evaluate the refracture rate in both bone forearm fractures based on the mode of fixation. METHODS: Institutional board review approval was obtained. A retrospective chart review from 2010 to 2021 at a single tertiary care institution was conducted for all operative patients <18 years who sustained a both bone forearm fracture. Groups were stratified based on initial operative fixation type: both bones fixated using nails, 1 bone fixated with a nail; both bones plated, and 1 bone plated. Further review was conducted to identify refractures following initial operative treatment. Statistical analyses were conducted using the χ 2 test of independence and Fisher's exact test. RESULTS: In all, 402 operatively treated both bone forearm fracture patients were identified. Two hundred fifty-six of these patients underwent intramedullary fixation (average age 10.3y/o), while 146 patients received plate fixation (average age 13.8y/o). Fracture location was similar across the nailing and plating cohorts, most often occurring in the mid-shaft region. Patients aged ≤10 years refractured at a significantly higher rate than patients aged >10 years across all operative fixation cohorts (12.5% vs. 2.5%, P <0.001). Among the 256 patients who underwent intramedullary fixation, 61.3% had both bones treated (n=157/256), whereas 38.7% received single bone fixation (n=99/256). Of the 146 plate fixations, 84.4% had both bones fixed (n=123/146), and only 15.8% were treated with single bone fixation (n=23/146). In the intramedullary group, 15 patients sustained refractures, 11 of whom were treated with single bone fixation (11.1%, n=11/99) versus 4 with both both fixation (2.5%, n=4/157). Among the plating group, 7 patients sustained refractures, 6 with both bone fixation (4.9%, n=6/123) and 1 in single bone fixation (4.3%, n=1/23). Refractures were found to be significantly more prevalent among patients treated with single bone compared with both bone intramedullary nail fixation (11.1% vs. 2.5%, P =0.006). By fixated bone, single bone ulna fixations had a higher refracture rate compared with both bone fixations (12.1% vs. 3.6%, P =0.003). CONCLUSION: The overall refracture rate following operative treatment of both bone fractures is 5.5% and is similar between intramedullary and plate fixations. Overall, patients ≤10 years of age had a higher rate of refracture. Among single bone fixations, higher refracture was seen with intramedullary fixations, and when the radius was treated nonoperatively. Surgeons may be able to reduce the refracture rate by performing intramedullary fixation of both bones instead of only one bone. Effective postoperative counseling among younger patients may also decrease refracture rates.

Comparison of four surgical methods for pediatric forearm double diaphyseal fractures: a retrospective analysis.

OBJECTIVE: One of the most frequent fractures in children is a double forearm fracture. They make up 26% of children's long bone fractures in the upper extremities and their incidence has increased in recent years. In this study, pediatric patients with double forearm fractures were treated using plate screw, intramedullary K-wire (I-KW), intramedullary titanium elastic nails (TENs), and hybrid fixation (HF) to compare the radiographic and functional results. PATIENTS AND METHODS: The printed and digital medical records were retrospectively examined from our hospital's archives after receiving consent from the regional ethics committee. Legal guardians of the patients, who were under the age of 18, gave their informed consent. Based on the surgical procedure used, the patients were split into 4 groups. Double plating was the D-P group, hybrid fixation method was the HF group, intramedullary elastic titanium nail was the TEN group, and intramedullary K-wire was the I-KW group. The study comprised 78 patients in total, with 19 patients in the HF group, 21 patients in the TEN group, 20 patients in the I-KW group, and 18 patients in the D-P group. RESULTS: When the mean operating times of the four approaches were compared, a substantial difference was found. The D-P group's mean operating time (65.2±4.9 minutes) was noticeably longer than those of the other groups (p<0.001). The HF group's mean operating time was 55.93.4 min longer than that of the TENs and I-KW groups, which was statistically significant (p<0.001). In comparison to the other groups, the D-P group's mean intraoperative fluoroscopy time was considerably shorter (6±3 sec) (p<0.001). When compared to the D-P group, it was considerably higher in the HF group (12±2 sec) (p<0.001). In comparison to the TENs (20±4 sec) and I-KW groups (19±5 sec), it was significantly lower in the HF group (p<0.001). In comparison to the HF group, the D-P group's tourniquet use lasted much longer (p<0.001). The TENs and I-KW groups did not use a tourniquet because a mini-incision was made. The D-P group's mean blood loss (110±10 ml) was substantially larger than that of the other groups (p<0.001) in the mean blood loss data. In comparison to the TENs (40±5 ml) and I-KW (40±5 ml) groups, the mean blood loss in the HF group (90±10 ml) was considerably larger (p<0.001). All patients received an above-elbow postoperative cast. The HF group (2 weeks) and the D-P group (2 weeks) experienced significantly less postoperative immobility than the TENs and I-KW groups (4.4 weeks, p<0.001). CONCLUSIONS: The four fixation techniques used in the current study for juvenile diaphyseal double forearm fractures produced positive clinical and functional outcomes. The hybrid fixation technique was discovered to be comparable to the other techniques and even beneficial in some ways. So, a safe and efficient treatment option for juvenile diaphyseal double forearm fractures is hybrid fixation.

Complications and Revision Surgery of Forearm Fractures.

Nonunion or malunion of forearm fractures may result in restricted range of motion or persistent pain, leading to limitations in activities of daily living. Complications may also present in the form of ectopic bone growth or persistent infections. A systematic method to evaluate complications resulting from forearm fractures is helpful to both determine the cause for the failure and plan for adequate reconstruction.

Ballistic diaphyseal forearm fractures result in high incidence of neurovascular injury and compartment syndrome but have low rates of early infection: A single level I trauma center experience.

INTRODUCTION: Ballistic injuries to the upper extremity represent a small subset of injuries, and there is little data to provide guidance on management and outcomes. The purpose of this study is to assess the incidence of neurovascular injuries, compartment syndrome, and early postoperative infection, as well as patient and injury factors predictive of neurovascular injury following ballistic fractures of the forearm. PATIENTS AND METHODS: A retrospective review of operatively treated ballistic forearm fractures at a single level I trauma center between 2010 and 2022 was performed. Thirty-three patients with 36 forearm fractures were identified. Only diaphyseal injuries in patients greater than 18 years old were included. Medical and radiographic records were reviewed to identify pre-injury patient-specific factors, including age, sex, smoking status, and history of diabetes. Injury characteristics, including the type of firearm used, forearm fracture location, and any associated neurologic or vascular injury, as well as compartment syndrome, were collected and analyzed. Short-term outcomes such as post-operative infection and recovery of neurologic function were also collected and analyzed. RESULTS: The median age was 27 years (range: 18-62), with a majority of male patients (78.8%, n = 26). 4 patients (12.1%) sustained high-energy injuries. 4 patients (12.1%) were found to have compartment syndrome pre-operatively or intra-operatively. 11 patients (33.3%) had nerve palsies postoperatively with 8 patients (24.2%) continuing to have nerve palsies at their final follow-up (mean follow-up= 149.9 +/- 187.2 days). The median length of stay was 4 days. There were no patients with infection at follow-up. CONCLUSION: Ballistic forearm fractures are complex injuries and can result in severe complications such as neurovascular injury and compartment syndrome. As such, a comprehensive evaluation and appropriate management of ballistic forearm fractures are essential to minimize the risk of severe complications and optimize patient outcomes. In our experience, when treated operatively, these injuries have a low rate of infection.

Is an Orthopaedic Surgery Resident's Previous Case Experience Associated with Success of Initial Treatment of Pediatric Forearm Fractures?

Redisplacement and subsequent intervention are common for pediatric forearm fractures. We investigated associations between the success of closed reduction and the treating provider's experience. We identified patients aged 4-16 years with forearm fractures treated by closed reduction and cast immobilization. Clinical data and radiographs of 130 patients treated by 30 residents were reviewed to determine the treating resident's pediatric forearm fracture reduction experience and the incidence of initial treatment failure (ITF). ITF was defined as subsequent intervention before union or malunion. ITF occurred in 32 of 130 patients (25%), comprising 12 of 23 patients (52%) treated by residents with no previous experience and 20 of 107 patients (19%) treated by residents who had logged ≥ 1 previous reduction (odds ratio, 4.7). ITF was more likely to occur in pediatric forearm fractures treated by residents with no previous forearm reduction experience compared with those performed by residents who had such experience. Level of Evidence: Level III, therapeutic. (Journal of Surgical Orthopaedic Advances 32(1):032-035, 2023).

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).

Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation.

BACKGROUND: Pediatric forearm fractures are common injuries and can sometimes require surgical treatment. Few studies have evaluated the long-term outcomes of pediatric forearm fracture plating. We evaluated long-term functional outcomes and satisfaction in children with forearm fractures treated with plate fixation. METHODS: We performed a single-institution case series at a pediatric level 1 trauma center. Inclusion criteria were: patients with radius and/or ulna diaphyseal fractures, index surgery at 18 years of age or younger, plate fixation, and a minimum of 2 years follow-up. We surveyed patients with the QuickDASH outcome measure and supplemented this with functional outcomes and satisfaction questions. Demographics and surgery characteristics were obtained from the electronic medical record. RESULTS: A total of 41 patients met the eligibility criteria, of whom 17 completed the survey with a mean follow-up of 7.2 ± 1.4 years. The mean age at index surgery was 13.1 ± 3.6 years (range, 4 to 17), with 65% males. All patients reported at least one symptom, with aching (41%) and pain (35%) occurring most frequently. There were 2 complications (12%), including one infection and one compartment syndrome treated with fasciotomy. Hardware removal occurred in 29% of patients. There were no refractures. The mean QuickDASH score was 7.7 ± 11.9, with an occupation module score of 1.6 ± 3.9 and a sports/performing arts module score of 12.0 ± 19.7. The mean surgery satisfaction was 92% and scar satisfaction was 75%. All patients returned to prior activities and 88% reported a return to their preoperative baseline level of function. CONCLUSIONS: Plate fixation for pediatric forearm fractures achieves osseous union but not without the potential for long-term sequelae. All patients reported residual symptoms 7 years later. Scar satisfaction and return to baseline function were imperfect. Patient education for long-term outcomes of surgery is essential, especially in the transition to adulthood. LEVEL OF EVIDENCE: Level IV, therapeutic study.

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.

Girl predominance in trampoline-related forearm shaft fractures and their increasing incidence since 2000.

BACKGROUND: There are reports of increasing incidence of forearm shaft fractures in children. Their treatment has been preferably nonoperative but surgical fixation has gained popularity due to elastic stable intramedullary nailing. We aimed to study whether the incidence of pediatric both-bone forearm shaft fractures and their operative care have changed since year 2000. Trampoline injuries, in particular, and their treatment, re-displacement and short-term outcomes were the secondary outcomes of the study. METHODS: A population-based study in the geographic catchment area of Oulu University Hospital district in 20-years of time period (2000 - 2019) was performed. Altogether 481 diaphyseal both-bone forearm fractures in children (< 16 years) were included. Age- and sex-related incidence rates were determined, by using the official numbers of the population-in-risk by Statistics Finland. Trampoline jumping and other types of injury were reviewed, as well as particulars of treatment and outcomes. RESULTS: The incidence of diaphyseal both-bone forearm fractures increased from 9.4/100 000 in 2000-2001 to 41.7/100 000 in 2018-2019 (P < 0.001). Surgical treatment increased respectively (from 8.8/100 000 in 2000-2001 to 35.3/100 000 in 2018-2019, P < 0.0001). Trampoline injuries explained one in three (29%) of all fractures; they increased from 0% in 2000-2001 to 36.6% in 2018-2019 (P < 0.001). During the last four years of the study (2016-2019), most trampoline-related injuries occurred among girls (61.2%), compared to boys (38.8%) (P = 0.031). Trampoline-related injuries comprised 46.9% of all fractures in girls, compared to 26.0% among boys (Diff. 20.8%, 4.7% to 36.1%, P = 0.009). The mean age of the patients elevated from 6.4 years (2000-2001) to 8.6 years (2018-2019) (P = 0.015). Boys predominated (69.6%) in 2000-2009 but during the last ten years, there was no statistical difference in distribution between the genders (males 54.6%, P = 0.11). CONCLUSIONS: During the twenty-year's of study period, the incidence of pediatric diaphyseal forearm fractures increased fivefold. Trampolining was the most usual single reason for the fractures. More attention should be focused to increase the safety of trampoline jumping, in particular among the girls.

Change in treatment preferences in pediatric diaphyseal forearm fractures: a Danish nationwide register study of 36,244 fractures between 1997 and 2016.

BACKGROUND AND PURPOSE: The choice between invasive and non-invasive treatment of diaphyseal forearm fractures in children can be difficult. We investigated the trends in choice of treatment of pediatric diaphyseal forearm fractures over a 20-year period.  Patients and methods: This is a population-based register study with data from 1997 to 2016 retrieved from the Danish National Patient Registry. The primary outcome was choice of primary treatment within 1 week divided into non-invasive treatment (casting only or closed reduction including casting) and invasive (Kirshner wires, intramedullary nailing [IMN], and open reduction internal fixation [ORIF]). The secondary outcomes were further sub-analyses on invasive treatment and age groups. RESULTS: 36,244 diaphyseal forearm fractures were investigated, yielding a mean incidence of 172 per 105/year. The proportion of fractures treated invasively increased from 1997 to 2016, from 4% to 23%. The use of Kirschner wires increased from 1% to 9%, IMN increased from 1% to 14%, and ORIF decreased from 2% to 1%. The changes were evident in all age groups but smaller in the 0-3-year age group. CONCLUSION: We found an increase in invasive treatment of pediatric diaphyseal forearm fractures over the investigated period. A change in invasive methods was also found, as the rate of IMN increased over the investigated period and became the predominant surgical treatment choice.