Interventions for treating wrist fractures in children

Handoll, Helen; Elliott, Joanne; Iheozor‐Ejiofor, Zipporah; Hunter, J. B.; Karantana, Alexia

doi:10.1002/14651858.cd012470.pub2

Cited by 38 publications

(40 citation statements)

References 107 publications

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“…[8][9][10][11][12][13][14] Buckle fractures can be conservatively managed akin to soft tissue injuries. 5 If they can be reliably distinguished from other fractures using POCUS, x-rays can potentially be avoided, 15 which supports the 'as low as reasonably achievable' principle. 16,17 Furthermore, POCUS performed at the bedside at the time of clinical review may expedite the discharge of patients without a fracture or with a buckle fracture, which could lead to reduced healthcare costs.…”

Section: Introductionmentioning

confidence: 87%

“…The majority of the false negatives in this trial were not deemed clinically significant as per paediatric orthopaedic surgeon review and could be managed conservatively, including a radius bowing fracture, a radial head Salter-Harris 2 fracture, non-displaced ulnar styloid fractures, and non-displaced distal radius greenstick fractures. 5 However, there were 3 missed fractures that may have been clinically relevant including a greenstick fracture of the distal radius with mild dorsal angulation (not requiring manipulation), a Salter-Harris 2 fracture of the distal radius with mild dorsal angulation (not requiring manipulation), and a proximal third radius complete fracture with mild angulation (receiving manipulation), which was not detected during clinical examination for study eligibility. 23 All the other 12 angulated fractures that required manipulation were identified on POCUS.…”

Section: O N F I D E N T I a L : F O R R E V I E W O N L Ymentioning

confidence: 99%

“…[3][4] Buckle fractures of the distal forearm can be discharged with a wrist splint or soft bandage with no requirement for further imaging or follow-up. [4][5] The current reference standard to diagnose a distal forearm fracture is 2-view x-ray, 6 which conveys a small dose of ionising radiation. 7 Point-of-care ultrasound (POCUS), a portable form of non-ionising imaging conducted at the patient bedside, has been proposed as a potential alternative.…”

Section: Introductionmentioning

confidence: 99%

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Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Snelling¹,

Jones

Keijzers³

et al. 2020

Emerg Med J

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BackgroundPaediatric distal forearm fractures are a common ED presentation. They can be diagnosed with point-of-care ultrasound (POCUS) as an alternative to X-rays. Given that ED nurse practitioners (NPs) are relied on for the diagnosis of paediatric fractures, it is important to describe the diagnostic accuracy of NP-conducted POCUS versus X-ray.MethodsThis prospective diagnostic study was conducted in a tertiary paediatric hospital in Queensland, Australia, between February 2018 and April 2019. Participants were children aged 4–16 years with a clinically non-angulated, suspected distal forearm fracture. Diagnosis from 6-view NP-administered POCUS of the distal radius and ulna was compared against the reference standard of 2-view X-ray. Each patient received both imaging modalities. Overall forearm diagnosis was classified as ‘no’, ‘buckle’ or ‘other’ fracture for both modalities. The primary outcome was diagnostic accuracy for ‘any’ fracture (‘buckle’ and ‘other’ fractures combined). Secondary outcomes included diagnostic accuracy for ‘other’ fractures versus ‘buckle’ and ‘no’ fractures combined, and pain, imaging duration and preference for modality.ResultsOf 204 recruited patients, 129 had X-ray-diagnosed forearm fractures. The sensitivity and specificity for NP-administered POCUS were 94.6% (95% CI 89.2% to 97.3%) and 85.3% (95% CI 75.6% to 91.6%), respectively. ‘Other’ fractures (mostly cortical breach fractures), when compared with ‘buckle’/ ‘no’ fractures, had sensitivity 81.0% (95% CI 69.1% to 89.1%) and specificity 95.9% (95% CI 91.3% to 98.1%). Pain and imaging duration were clinically similar between modalities. There was a preference for POCUS by patients, parents and NPs.ConclusionsNP-administered POCUS had clinically acceptable diagnostic accuracy for paediatric patients presenting with non-angulated distal forearm injuries. This included good sensitivity for diagnosis of ‘any’ fracture and good specificity for diagnosis of cortical breach fractures alone. Given the preference for POCUS, and the lack of difference in pain and duration between modalities, future research should consider functional outcomes comparing POCUS with X-ray in this population in a randomised controlled trial.

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Section: Introductionmentioning

confidence: 87%

Section: O N F I D E N T I a L : F O R R E V I E W O N L Ymentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Snelling¹,

Jones

Keijzers³

et al. 2020

Emerg Med J

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“…Distal radius fracture is a common injury in children and adolescents [1]. The nonoperative method of treatment remains the primary choice for the pediatric population, especially in younger children [2,3]. Adolescents with similar injury patterns of the distal radius as in adults display a unique fracture, and the vulnerable zone is usually the metaphyseal diaphyseal junction (MDJ) [4].…”

Section: Introductionmentioning

confidence: 99%

Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator

Rai

Tang

et al. 2020

BMC Musculoskelet Disord

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Background: Conservative treatment remains the preferred choice for distal radius fracture in children. However, loss of reduction is problematic, especially in an older child. Crossed Kirschner-wires is widely used to treat distal radius fracture in adolescents. This study aimed to compare the application of crossed Kirschner-wiring (KW) and non-bridging external fixator (EF) for the treatment of delayed distal radial fracture involving metaphyseal diaphyseal junction (MDJ) in adolescents. Methods: Between January 2012 to January 2017, 146 (male = 101, female = 45) patients in EF group and 117 (male = 76, female = 41) in KW group, were reviewed retrospectively. Preoperative data were collected from the hospital database, and postoperative clinical outcomes data were collected during the follow-up visits. We used SPSS for data analysis. Results: There existed no significant difference between EF and KW regarding sex, body weight, fracture side, duration from injury to surgery. The duration of surgery was significantly shorter in EF (30.5 ± 6.1 min) than the KW group (44.6 ± 9.4 min), P < 0.001. The number of intraoperative X-ray images was significantly lower in EF (6.5 ± 1.1) than KW (11.8 ± 2.3), P < 0.001. The incidence of tendon irritation is significantly higher in the KW (19.7%) than the EF group (0%), P < 0.001. The residual angulation on the AP view was higher in KW (3.8 ± 2.3, degrees) than the EF group (2.5 ± 1.6, degrees), P < 0.001. The volar tilting is better in EF (6.6 ± 1.1, degrees) than the KW group (1.0 ± 1.5, degrees), P < 0.001. However, the functional outcomes of the wrist showed no significant difference between EF and KW group, P = 0.086. Conclusion: The EF was superior to KW in the treatment of radial MDJ fractures in adolescents. The EF displayed shorter duration of surgery, less tendon irritation, and better radiographic outcomes than the KW. However, the cost-effect analysis remains to be investigated, because the EF is more expensive than KW.

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“…Full function was evident by 6 months. A recent Cochrane analysis (Handoll et al 2018) outlines the need for high-quality studies on whether cast immobilization has better results with no formal reduction or with closed reduction and percutaneous pin fixation of distal displaced forearm fractures in children. AO Surgery Reference Guidelines for treatment of displaced distal metaphyseal forearm fractures do not give an upper limit for angulation or shortening in children aged under 10 years.…”

Section: Resultsmentioning

confidence: 99%

Most surgeons still prefer to reduce overriding distal radius fractures in children

Laaksonen¹,

Puhakka

Kosola

et al. 2020

Acta Orthopaedica

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Background and purpose — Traditionally, overriding distal radius fractures in children have been reduced and immobilized with a cast or treated with percutaneous pin fixation. There is recent evidence that these fractures heal well if immobilized in the bayonet position without reduction. We evaluated the present treatment of these fractures. Methods — A questionnaire including AP and lateral radiographs of overriding distal radius fractures in 3 pre-pubertal children was answered by 213 surgeons from 28 countries. The surgeons were asked to choose their preferred method of treatment (no reduction, reduction, reduction and osteosynthesis), type and length of cast immobilization, and the number of clinical and radiographic follow-ups. Results — Of the 213 participating surgeons, 176 (83%) would have reduced all 3 presented fractures, whereas 4 (2%) would have treated all 3 children with cast immobilization without reduction. Most reductions (77%) would have been done under general anesthesia. Over half (54%) of the surgeons who preferred anesthesia would have fixed (pins 99%, plate 1%) the fractures. An above-elbow splint or circular cast was chosen in 84% of responses, and the most popular (44%) length of immobilization was 4 weeks. Surgeons from the Nordic countries were more eager to fix the fractures (54% vs. 31%, p < 0.001) and preferred shorter immobilization and follow-up times and less frequent clinical and radiological follow-ups compared with their colleagues from the USA. Interpretation — Most of the participating surgeons prefer to reduce overriding distal radius fractures in children under anesthesia. There is substantial lack of agreement on the indications for osteosynthesis, type of cast, length of immobilization, and follow-up protocol.

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Interventions for treating wrist fractures in children

Cited by 38 publications

References 107 publications

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Nurse practitioner administered point-of-care ultrasound compared with X-ray for children with clinically non-angulated distal forearm fractures in the ED: a diagnostic study

Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator

Most surgeons still prefer to reduce overriding distal radius fractures in children

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