Factors Responsible for Redisplacement of Pediatric Forearm Fractures Treated by Closed Reduction and Cast

Abstract

Background:Pediatric forearm fractures are still considered an enigma in view of their propensity to redisplace in cast. The redisplacement may be a potential cause for malalignment. We prospectively analyzed the role of risk factors and above casting indices in predicting significant redisplacement of pediatric forearm fractures treated by closed reduction and cast.Materials and Methods:113 patients of age range 2–13 years with displaced forearm fractures, treated by closed reduction and cast were included in this prospective study. Prereduction and postreduction angulation, translation, and shortening were noted. In addition, for distal metaphyseal fractures, obliquity angle was noted. In postreduction X-ray, apart from fracture variables, casting indices were also noted (cast index [CI] for all patients with three-point index [TPI] and second metacarpal radius angle in addition for distal metaphyseal fractures). In 2nd week, X-rays were again obtained to check for significant redisplacement. These patients were managed with remanipulation and casting or were operated if remanipulation failed. Comparison of various risk factors was made between patients with significant redisplacement and those which were acceptably reduced. A subgroup analysis of patients with distal metaphyseal fractures was done.Results:Thirteen (11.5%) patients had significant redisplacement; all of them required remanipulation. No association with respect to age, sex, level of fracture, side of injury, surgeon's experience, number of bones fractured, and injury to definitive cast interval was seen. The presence of complete displacement in any of the plane in either of the bones was seen to be highly significant predictor of redisplacement (P < 0.001). Postreduction angulation more than 10° in any plane in either of the bone and fracture obliquity angle in distal metaphyseal fracture also had a highly significant association with redisplacement. There was a significant difference in the mean values of all three casting indices assessed. TPI was the most sensitive casting index (87.5%).Conclusions:Conservative management with aim of anatomical reduction, especially in patients with complete displacement, should be the approach of choice in closed pediatric forearm fractures. Casting indices are good markers of quality of cast.

Risk factors for fracture redisplacement after reduction and cast immobilization of displaced distal radius fractures in children: a meta-analysis

“…After reduction and application of the cast, measurements on plain radiographs can be made and if needed, and the cast can be adjusted to reduce the risk of redisplacement. Even though the Cast Index is easier to measure, the Three-Point Index was found to be superior in predicting redisplacement when compared to the Cast Index (sensitivity 94.7%, specificity 95.2%, NPV 98.4%, PPV 85.7% for Three-Point Index and sensitivity 63.2%, specificity 52.4%, NPV 82.5%, PPV 28.6% for Cast Index) with high inter-and intra-observer reliability (intra class correlation coefficient 0.99) [18,19]. The studies included in the present meta-analysis reported redisplacement rates between 9.7% and 35% after reduction and cast immobilization of displaced distal radius fractures in children.…”

“…Twelve articles that met the inclusion criteria and reported on similar age groups and definitions for redisplacement were included in this meta-analysis ( Fig. 2) [5,7,18,19,[25][26][27][28][29][30][31][32]. Table 1 shows the characteristics of the twelve included studies.…”

“…The risk of bias of the included studies was low for almost all six domains (Table 2). Arora et al, Haddad et al and Ghimire et al scored moderate on the risk of bias in the domain of prognostic factor measurement, because it was not reported who performed the measurements of the potential risk factors for redisplacement [19,30,31]. Many of the included studies also scored moderate on biases in the domain of study confounding.…”

Comparison of complications of the treatment of diaphyseal forearm fractures in children with respect to the treatment method

“…These are: translation of bone fragments more than 50% in each plane, the patient's age above 9 y.o., complete radial fracture, and angulation of the radius > 15° on lateral radiographs and of the ulna >10° on AP radiographs [13]. A similar analysis was carried out by Arora et al who evaluated 113 patients [8]. In their study, they did not link late complications with any characteristics of the population under study.…”

Outcome of Surgically Managed Diaphyseal Fractures in Children- A Prospective Study

“…Kemal K et al 11 in their study comprising of children between 6-15 years, found the mean age to be 8.6 years. Flynn JM et al 7 had a mean age of 9.5 years while Arora R et al 12 had a mean age of 8.62 years in their respective studies. In the present study, there were 17 boys (60.71%) and 11 girls (39.29%).…”