Management of Distal Radius Fractures in Adolescent Patients.

BACKGROUND: While management recommendations for distal radius fractures in both young and skeletally mature patients have been generally well-established, controversy still exists regarding optimal management in adolescent patients approaching skeletal maturity. Thus, the goal of this review is to analyze relevant literature and provide expert recommendations regarding the management of distal radius fractures in this patient population. METHODS: A PubMed search was performed to identify literature pertaining to distal radius fractures in adolescent patients, defined as 11 to 14 years in girls and 13 to 15 years in boys. Relevant articles were selected and summarized. RESULTS: Distal radius fractures demonstrate significant potential for remodeling of angular deformity and bayonet apposition, even in patients older than 12 years of age. Rotational forearm range of motion and functional outcomes are acceptable with up to 15 degrees of residual angulation. Closed reduction and percutaneous pinning reduces fracture redisplacement but has a high associated complication rate. There is no literature comparing plate versus pin fixation of distal radius fractures in the pediatric population, but in adults plate fixation is associated with higher cost with no improvement in long-term functional outcomes. CONCLUSIONS: Remodeling can still be expected to occur in adolescent patients, and even with residual deformity functional outcomes after distal radius fractures are excellent. Up to 15 degrees of residual angulation can be accepted before considering operative management. Smooth pins should be considered over plates as first-line operative management for unstable fractures that fail nonoperative treatment.

Radius Shaft Fractures-What Alignment is Acceptable at What Age? Plates or Flexible Nails?

INTRODUCTION: The transition from pediatric to adolescent fractures can lead to uncertainty on what level of surgical correction is warranted as remodeling is limited in these older patients. DISCUSSION: Adolescent diaphyseal radial shaft fractures present several unique challenges; the radial bow must be restored to preserve forearm rotation and there are several clinical scenarios where plating, even in the skeletally immature child, is strongly recommended and will have more reliable results over flexible intramedullary nails. In addition, judging how much angulation, rotation, and displacement will remodel in the older child can be a challenging decision, even for experienced pediatric orthopaedists. CONCLUSION: This overview discusses parameters for acceptable alignment in these fractures, when surgical fixation should be considered, and circumstances where plating should be considered over flexible nails.

Four-Year Follow-Up of the World's First Pediatric Bilateral Hand-Forearm Transplants: Do They Grow as Expected?

BACKGROUND: In 2015, the first bilateral pediatric hand-forearm transplant was performed in an 8-year-old boy. The growth rate of the transplanted upper extremities was unknown at the time. METHODS: Forearm and hand radiographs were obtained annually. Radius and ulna measurements were performed by multiple coauthors and mathematically normalized using a standardized methodology. The Greulich and Pyle atlas was used to estimate hand bone age. RESULTS: From July of 2015 to July of 2019, unadjusted bone length (metaphysis to metaphysis) increased 38.8 and 39.6 mm for the left radius and ulna, and 39.5 and 35.8 mm for the right radius and ulna, respectively. Distal physes of the donor limbs increasingly contributed to overall bone length relative to proximal physes. Normalized growth between the two limbs was statistically similar. At each annual follow-up, the bone age increased by 1 year. CONCLUSIONS: Successful pediatric hand-forearm transplantation offers the advantage of growth similar to that of nontransplanted pediatric patients. The transplanted distal physes contributes more to the overall growth, paralleling normal pediatric growth patterns. Chronologic age parallels the increase in bone age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Intergenerational changes in limb circumferences in children and adolescents aged 3-18 from Kraków (Poland) from 1983 to 2010.

OBJECTIVES: Measurements of body circumferences are often used in anthropology. The research on this topic, however, rarely concerns limb girths or secular trends. The main aim of this study was to investigate the occurrence of secular trends in selected limb circumferences among children and adolescents. METHODS: The research was based on measurements from two cross-sectional studies carried out in 1983 and 2010 with children and adolescents aged 3-18 from Krakow, Poland. The circumferences of the arm, forearm, thigh and calf, as well as the sum of circumferences and selected indicators, were analyzed. The series were compared using the two-way anova test. RESULTS: In most age groups of both sexes, a positive secular trend was observed for the majority of studied traits. The exception was the thigh circumference, for which, among girls, measurements in both series were similar, and negative intergenerational changes were recorded in the youngest age groups of both sexes as well as among the oldest girls. Most observed discrepancies were statistically significant in pre-school children and adolescents. CONCLUSIONS: The presence of positive secular trends shows that limb circumferences were increasing in subsequent generations, especially in boys. Contemporary girls, particularly in the older age groups, were more determined to have a slim figure and practiced conscious weight control. Summarizing, observed tendencies resulted from the improvement of socio-economic conditions, but were also related to the low level of physical activity.

Sexual dimorphism in growth in the relative length of the forearm and relative knee height during adolescence.

There are numerous studies concerning sexual dimorphism in body proportions, but only a few have investigated growth in the relative length of particular segments of the upper and lower limbs during adolescence. The aim of the study is an assessment of sex differences of longitudinal growth in the relative length of the forearm and knee height among adolescents. Sample involved 121 boys and 111 girls, participants of the Wroclaw Growth Study, examined annually between 8 and 18 years of age. Sexual dimorphism in six ratios: forearm length and knee height relatively to: trunk, height, and limb length were analyzed using a two-way analysis of variance with repeated measurements. The sex and age relative to an estimate of maturity timing (3 years before, and after age class at peak height velocity [PHV]) were independent variables. All of the ratios showed significant sex differences in interaction with age relative to age at PHV. The relative length of the forearm, in boys, did not change significantly with the years relative to age at PHV, whereas in girls, was the lowest in the two first age classes and afterward significantly increased just 1 year before and during the adolescent growth spurt, remaining unchanged in further age classes. For relative knee height no clear pattern for sex differences was noticed. It is proposed that relatively longer forearms, particularly in relation to the trunk in girls, could have evolved as an adaptation to more efficient infant carrying and protection during breastfeeding.

Developmental Changes in Skin Barrier and Structure during the First 5 Years of Life.

The structure of the stratum corneum (SC) and the corresponding skin barrier develops from before birth up to about 4 years of age. Large subject-to-subject variability within an age group requires a large population to observe trends in skin barrier properties over time. Barrier function, quantified by transepidermal water loss (TEWL) and SC thickness, was measured on the upper inner arm and dorsal forearm in subjects aged 3 months to 4 years (n = 171) and a subset of mothers (n = 44). The rate of skin surface area expansion as a function of age peaked before birth (∼90 cm2/week) and declined to a steady plateau (∼10 cm2/week) by 1 year of age. SC thickness increased and TEWL decreased, but did not reach adult values until 3-4 years of age. A better understanding of how skin hydration changes after birth suggests that barrier function may be related mechanistically to skin surface area expansion.

Within arm's reach: Measuring forearm length to assess growth patterns in captive bonobos and chimpanzees.

OBJECTIVES: Bonobos and chimpanzees are known to differ in various morphological traits, a dichotomy that is sometimes used as an analogy for evolutionary splits during human evolution. The aim of our study was to measure the forearm length of immature and adult bonobos and adult chimpanzees to assess the extent of age-related changes of forearm length in bonobos and sex-dimorphism in bonobos and chimpanzees. MATERIALS AND METHODS: As a proxy of somatic growth we measured forearm length of captive bonobos and chimpanzees ranging in age from 1 to 55 years. Measures were taken from subjects inserting their arms into a transparent Plexiglas® tube, a novel technique facilitating repeated measures of nonanesthetized apes in captivity. RESULTS: Measures from adult females (>12 years) showed that bonobos exceed chimpanzees in terms of forearm length and that sexual dimorphism in forearm length is pronounced in chimpanzees, but not in bonobos. Forearm length increased significantly with chronological age in bonobos. Validation tests revealed that the device generates useful data on morphometric dimensions. DISCUSSION: In most primates, sexual dimorphism in body size is male-biased and the differences in forearm length in chimpanzees follow this trend. Given that males of the two species did not differ in forearm length, the absence/presence of sexual dimorphism of this trait must be due to differences in somatic growth in females. Our novel method offers an alternative to obtain morphometric measures and facilitates longitudinal studies on somatic growth. Am J Phys Anthropol 161:37-43, 2016. © 2016 Wiley Periodicals, Inc.

Early initiation of smoking and alcohol drinking as a predictor of lower forearm bone mineral density in late adolescence: a cohort study in girls.

BACKGROUND: Adolescence is a critical stage for bone accrual. It is also decisive for the establishment of behaviors such as smoking and alcohol drinking. OBJECTIVE: To quantify the short- and long-term associations between smoking and drinking initiation and bone mineral density in adolescent girls. METHODS: We used prospective data from 731 girls identified in public and private schools in Porto, Portugal. Evaluations were conducted when participants were 13 and 17 years old. Bone mineral density (BMD) was measured at the forearm by dual-energy X-ray absorptiometry and weight, height and fat-free mass were measured. Pubertal development status was estimated using menarche age. Self-administered questionnaires were used to collect data on smoking and alcohol drinking, physical exercise and calcium and vitamin D intakes. BMD in early and late adolescence was analyzed as a continuous or dichotomous (Z-score cutoff: -1.0) variable. Associations were calculated using linear or logistic regression. RESULTS: Over one quarter of these girls had tried smoking by 13, while 59% had drunk alcoholic beverages and 20% had experienced both behaviors by that age. Lower mean BMD at 17 years of age was observed in girls who had ever smoked by 13, as well as in those who reported drinking at that age. There were no significant cross-sectional associations between experience and frequency of smoking or drinking and BMD at 13 years of age. However, we observed significant associations between BMD z-score<-1 in late adolescence and having ever smoked by 13, after adjustment for menarche age and sports practice, (OR = 1.92; 95% CI: 1.21, 3.05) and with ever smoking and drinking in the same period (OR = 2.33; 95% CI: 1.36, 4.00). CONCLUSION: Our study adds prospective evidence to the role of early initiation of smoking and alcohol drinking as relevant markers of lower bone mineral density in late adolescence.

Radiographic early to midterm results of distraction osteogenesis in radial longitudinal deficiency.

PURPOSE: To analyze early to midterm radiographic results after forearm lengthening in children with radial longitudinal deficiency. METHODS: We conducted a retrospective chart review of patients with radial longitudinal deficiency undergoing distraction osteogenesis with an Ilizarov device. We retrospectively reviewed 8 lengthening procedures in 6 children with respect to distraction details and assessed anteroposterior and lateral radiographs of the hand and forearm of the preoperative and postoperative follow-up investigations. RESULTS: The mean age at time of ulna lengthening was 9.9 years (range, 6.3-14.0 y). The mean follow-up period was 4.7 years (range, 1.0-8.5 y). Mean lengthening of the ulna was 7.0 cm (range, 3.5-8.7 cm), and the mean length gain of the ulna compared with its preoperative length was 75% (range, 42% to 103%). The mean ulna bowing was 25° preoperatively (range, 7° to 42°), 6° after forearm distraction (range, 0° to 14°), and 17° at latest follow-up (range, 0° to 45°). The mean hand-forearm angle was 25° of radial deviation preoperatively (range, 15° ulnar to 60° radial deviation), 11° of radial deviation after distraction (range, 0° to 41°), and 23° at latest follow-up (range, 0° to 45°). We encountered 2 major complications: 1 ulna fracture after removal of the Ilizarov device and 1 insufficient bone regenerate during lengthening. CONCLUSIONS: We achieved both deformity correction and improvement of limb length after distraction osteogenesis with an Ilizarov device. However, some of the deformity-in particular, ulnar bowing and radial deviation of the hand-recurred at midterm follow-up.

Growth from birth to adulthood and peak bone mass and density data from the New Delhi Birth Cohort.

UNLABELLED: Growth in early life may predict adult bone health. Our data showed that greater height and body mass index (BMI) gain in utero and infancy are associated with higher peak bone mass, and greater BMI gain in childhood/adolescence with higher peak bone density. These associations are mediated by attained adult height and BMI. INTRODUCTION: To study the relationship of height and BMI during childhood with adult bone mineral content (BMC), areal density (aBMD) and apparent density (BMAD, estimated volumetric density). METHODS: Participants comprised 565 men and women aged 33-39 years from the New Delhi Birth Cohort, India, whose weight and height were recorded at birth and annually during infancy (0-2 years), childhood (2-11 years) and adolescence (11 years-adult). Lumbar spine, femoral neck and forearm BMC and aBMD were measured using dual X-ray absorptiometry; lumbar spine and femoral neck BMAD were calculated. RESULTS: Birth length, and height and height gain during infancy, childhood and adolescence were positively correlated with adult BMC (p≤0.01 all sites except birth length with femoral neck). Correlations increased with height from birth to 6 years, then remained constant for later height measurements. There were no associations with BMAD. BMI at birth, and during childhood and adolescence was also positively correlated with BMC (p < 0.01 all sites). BMI at 11 years, and BMI gain in childhood and adolescence, were correlated with aBMD and BMAD (p < 0.001 for all); these correlations strengthened with increasing age of BMI measurement. The associations with height and BMI in early life became non-significant after adjustment for adult height and BMI. CONCLUSIONS: Greater skeletal growth and BMI gain in utero and during infancy are associated with higher peak BMC, and greater BMI gain in childhood and adolescence is associated with higher peak aBMD and BMAD. These associations are mediated by the attainment of adult height and BMI, respectively.

Growth of segment parameters and a morphological classification for children between 15 and 36 months.

This study is part of a research program that aims at a better understanding of the influence of individual morphological differences and physical growth on development of independent walking in toddlers. As morphometric and segment inertial parameters for toddlers aged between 15 and 36 months are indispensable for the mechanical analyses inherent to this purpose, parameter data were collected. The provided dataset of morphological and segment inertial parameters is a valuable tool for locomotor biomechanical modelling. Analysis of the parameter data showed that there are substantial changes of most segment inertial parameters across body length and body mass. In addition, a classification system was developed to categorize toddlers on the basis of morphometry, reflecting the segment inertial constitution of the child. A principal components analysis (PCA) was applied to define the variance in physique between the children. PCA resulted in three newly composed variables: the 'Axis of chubbiness', the 'Axis of allometric growth' and the 'Axis of relative limb length'. The three axes are plotted against each other, resulting in eight morphological classes. With this classification the morphotype of toddlers between 15 and 36 months can be specified and used for further research on their walking patterns.

Correction of severe wrist deformity following physeal arrest of the distal radius with the aid of a three-dimensional computer simulation.

Growth arrest following physeal injury may result in severe limb deformity. We report a case of complex wrist deformity caused by injury to the distal radial physis resulting in radial shortening and abnormal inclination of the radial articular surface, which was successfully treated by gradual correction after computer simulation. The simulation enabled us to develop an appropriate operative plan by accurately calculating the axis of the three-dimensional (3D) deformity using computer bone models. In the simulative surgery with a full-size stereolithography bone model, an Ilizarov external fixator was applied to the radius such that its two hinges were located on the virtual axis of the deformity, which was reproduced in the actual surgery. This technique of 3D computer simulation is a useful alternative to plan accurate correction of complex limb deformities following growth arrest.

The 'functional muscle-cartilage unit': a reasonable approach to describe a putative relationship between muscle force and longitudinal growth at the forearm in children and adolescents?

BACKGROUND: Several reports give evidence that the perichondral ossificiation of bone tubes (modeling) strongly depends on muscular forces in children and adolescents. The present analyses intend to investigate the hypothesis that muscular forces also partly determine enchondral ossification and, therefore, longitudinal growth of bone tubes. SUBJECTS AND METHODS: Analyses were based on a single cross-sectional investigation with peripheral quantitative computed tomography in 296 individuals (age 5-19 years) participating in the Dortmund Nutritional and Anthropometric Longitudinally Designed (DONALD) study. RESULTS: Forearm length (FL) was correlated with body height in gender-related subgroups of prepubertal and pubertal individuals (rs between 0.76 and 0.86). Cross-sectional muscle area (MA) increased faster than FL and faster than cross-sectional bone area (BA) close to the distal growth plate in puberty. Close to the growth plate, longitudinal growth was faster than perichondral ossification in females. The ratio MA/BA (surrogate of pressure on the distal growth plate) was correlated with FL in prepubertal boys (r = -0.249, p = 0.043) and pubertal individuals (r = 0.153, p = 0.051). CONCLUSIONS: Results support the hypothesis that longitudinal growth precedes modeling at the distal forearm. Confounding variables such as puberty may modify the relationship between muscle forces and longitudinal growth at the forearm in boys.

Local body composition is associated with gender differences of bone development at the forearm in puberty.

BACKGROUND/AIMS: The present analyses intend to clarify if gender and puberty modify the relationship between bone development (modeling and remodeling) and fat mass at the forearm. METHODS: Data were collected from participants (139 males, 157 females, age = 5-19 years) of the Dortmund Nutritional and Anthropometric Longitudinally Designed study in a cross-sectional investigation. The main outcome measures were total and trabecular bone mineral density (BMDtot and BMDtrab), strength strain index (SSI) and parameters associated with modeling (cortical area, CA; periosteal circumference, CP) and remodeling (cortical bone mineral density, BMDcort, endosteal circumference, CE) were analyzed in their relationship to cross-sectional fat (FA) and muscle area (MA) at the forearm. RESULTS: BMDtot was correlated with FA in pubertal males (r = -0.25). BMDtrab was contrarily predicted by FA in pubertal males and females (r = -0.28 vs. 0.31). FA was correlated with BMDcort (r = -0.32) and CE (r = 0.26) in pubertal females. MA was positively correlated with CA, CP and SSI. CONCLUSIONS: Modeling and bone strength were primarily predicted by MA. Markers of remodeling were positively correlated with FA in pubertal females, but not in prepubertal individuals and pubertal males. Therefore, gender and puberty modify the relationship between FA and bone development.

Radiological aspects of the Poland syndrome and implications for treatment: a case study and review.

UNLABELLED: Poland syndrome (PS) (OMIM 173800) is a rare congenital anomaly classically consisting of the combination of unilateral aplasia of the sternocostal head of the major pectoral muscle and an ipsilateral hypoplastic hand with simple syndactyly and short fingers. The aetiology is most probably a vascular disruption sequence of the subclavian arteries. In most cases, PS is sporadic. Familial occurrence suggests that genes exist which are involved in the pathogenesis as paradominant traits. The syndrome may include mammary hypoplasia and further muscle abnormalities which can be accurately defined by sonography and MRI. The evaluation of the vascular status can be performed using colour coded duplex sonography for peripheral arteries and contrast-enhanced MR-angiography for supra-aortic arteries. CONCLUSION: We report a 7-year-old girl with unilateral right sided Poland syndrome with particular emphasis on the radiological investigations of vascular abnormalities. A review of the literature concerning the origin, outcome, and implications for treatment is given.

[Osteogenesis in healthy children and in children with growth retardation depending on body constitution]. / Konstitutsional'naia obuslovlennost' tempov osteogeneza u zdorovukh detei i ego osobennosti u detei s zaderzhkoi rosta.

Somatometric and radiographic study of bones of the hand and of the distal forearm was performed in 258 healthy children and adolescents (148 boys and 110 girls) aged 11-17 years and in 115 children (84 boys and 31 girl) aged 13-16 years which were under the observation due to growth retardation. It was shown that within the groups of the same age children with various somatometric characteristics possessed different levels of skeletal (and therefore, biological) maturity. In the group of healthy children, different variants of skeletal maturation were established, which corresponded to the constitutionally stipulated rates of somatic development including accelerated, average and retarded. In children with growth retardation, the third (retarded) variant of somatic development rate was prevalent, which was also found in the group of healthy children and was accompanied with its peculiar osteogenesis characteristics. In the other cases, when such abnormalities of skeletal maturation as asymmetry in the appearance of ossification centers and synostoses as well as the presence of pseudoepiphyses, were observed, growth retardation could be caused by some endocrine pathology. Thus, the radiographic study enables the differentiated approach to the evaluation of the morphological status of children and adolescents and permits to avoid the unjustified administration of hormonal treatment.

[Ulnar lengthening in osteochondroma (multiple cartilagenous exostoses) of the forearm]. / Die Ulnaverlängerung beim Osteochondrom (multiple kartilaginäre Exostosen) am Unterarm.

The osteochondroma is the most frequent bone tumor to occur during the period of growth. The multiple hereditary form often involves the forearms. Depending on localisation and size of the tumor, shortening of the bones in the forearm, angular malalignments and functional impairment of the wrist and elbow joints may result. Early diagnosis and surgery in the growing child can prevent these complications. 13 children were operated on altogether 15 forearms. In nine cases lengthening of the ulna was necessary to correct ulnar instability of the wrist as well as improving the support of the carpus and preventing dislocation of the radial head.

Daily physical activity program increases bone mineralization and growth in preterm very low birth weight infants.

OBJECTIVE: A study of daily physical activity was performed with 32 preterm infants to evaluate changes in body weight and bone mineralization. STUDY DESIGN: Subjects were matched by birth weight and gestational age and randomly assigned to the physical activity (PA; n = 16) or to the control (C; n = 16) program. PA consisted of range of motion against passive resistance to all extremities for 5 to 10 minutes daily. Peripheral dual-energy x-ray of the right forearm (ulna and radius); biomarkers of bone formation (serum type I collagen C-terminal propeptide [PICP]) and resorption (urine pyridinoline cross-links of collagen [Pyd]); serum calcium, phosphate, alkaline phosphatase, parathyroid hormone (PTH), and 1, 25-(OH)(2) vitamin D; and urine levels of calcium, phosphate, and creatinine were obtained. All measurements were made at study entry and at 2.0 kg of body weight. RESULTS: Despite a similar nutrient intake at advised levels for preterm infants, gains in body weight (g) and forearm bone length (cm), bone area (BA; cm(2)), bone mineral content (BMC; mg), and fat-free mass (g) were greater in PA infants. Forearm bone mineral density and fat mass gains did not differ between groups. Serum PICP levels remained constant in PA infants but decreased in C infants suggesting a slower rate of bone formation. Urine Pyd or bone resorption activity was similar between groups. A higher level of serum PTH was observed in PA infants at 2. 0 kg of body weight; however, the change from study entry to completion did not differ between groups. All other serum and urine values were similar and within normal limits. CONCLUSION: A daily PA program promotes greater gains in body weight, forearm length, BA, BMC, and fat-free mass in premature infants.

Reference data of forearm bone mineral density in healthy Japanese male and female subjects in the second decade based on calendar age and puberty onset: Japanese Population Based Osteoporosis (JPOS) study.

Osteoporosis is a major public health problem in Japan. The second decade is an important period in which to attain a high peak bone mass. However, normal values of forearm bone mineral density (BMD) are not well known in children and adolescents. BMD at one-third of forearm length proximal to the ulnar end plate (BMD1/3) and the ultradistal forearm (BMDud) was measured using dual-energy X-ray absorptiometry (DXA) in 1207 (631 males, 576 females) Japanese subjects aged 9-18 years. Puberty onset was assessed by questionnaire, by obtaining the time that pubic hair appeared in males and the time that menstruation started in females. BMD1/3 and BMDud increased steadily with age in males. In relation to puberty development, these parameters also increased after puberty onset although the increase in BMD1/3 was not statistically significant after the fifth year from puberty onset and that of BMDud was not significant after the sixth year from puberty onset. BMD1/3 and BMDud increased with age and then plateaued in females. The increase in BMD1/3 was not statistically significant after 15-16 years of age and that of BMDud was not significant after 13-14 years of age. In relation to puberty development, the increase in BMD1/3 leveled out after the fourth year from puberty onset and that of BMDud also plateaued after the third year from puberty onset. We provide reference values of forearm BMD in Japanese children and adolescents by DXA according to calendar age and puberty development. Peak bone mass of the forearm may be in the late second decade in Japanese females.