Premature closure of the distal radial physis

Stable elastic nail application with poller K-wire for Irreducible distal radius metaphyseal-diaphyseal Junction fractures in preadolescents: a new operative technique

BACKGROUND

Surgical treatment of irreducible distal radius diaphyseal- metaphyseal junction fractures involves difficulties as the fracture remains too proximal for K-wire fixation and too distal for the elastic stable intramedullary nail. Our study aims to present the clinical results of applying an elastic stable intramedullary nail with a poller K-wire to achieve both reduction and stable fixation.

PATIENTS AND METHODS

A retrospective analysis was performed on 26 patients who underwent ESIN with a poller K-wire for distal radius diaphyseal-metaphyseal region fracture. Reduction parameters such as residual angulation and alignment were evaluated on postoperative follow-up radiographs. Changes in angular and alignment parameters on follow-up radiographs were recorded. Wrist and forearm functions were evaluated at the last follow-up.

RESULT

There were 17 male and nine female patients with an average age of 10.9. The residual angulation in coronal and sagittal planes on immediate postoperative radiographs was 4.0 ± 1.62° and 3.0 ± 1.26°, respectively. The mean translation rate on immediate postoperative radiographs was 6.0 ± 1.98% and 5.0 ± 2.02% in the coronal and sagittal planes, respectively. No change was observed in translation rates in the last follow-ups. The mean angulation in the coronal and sagittal planes measured on 6th-week radiographs was 4.0 ± 1.72°and 3.0 ± 1.16°, respectively. No significant difference was observed in angular changes in the sagittal and coronal planes at the last follow-up (p > 0.05). No tendon injury or neurovascular injury was observed in any of the patients.

CONCLUSION

In the surgical treatment of pediatric DRDMJ fractures, applying ESIN with poller K-wire is an effective, safe, and novel method for achieving reduction and stable fixation.

Long-term in vivo degradation of Mg-Zn-Ca elastic stable intramedullary nails and their influence on the physis of juvenile sheep

The use of bioresorbable magnesium (Mg)-based elastic stable intramedullary nails (ESIN) is highly promising for the treatment of pediatric long-bone fractures. Being fully resorbable, a removal surgery is not required, preventing repeated physical and psychological stress for the child. Further, the osteoconductive properties of the material support fracture healing. Nowadays, ESIN are exclusively implanted in a non-transphyseal manner to prevent growth discrepancies, although transphyseal implantation would often be required to guarantee optimized fracture stabilization. Here, we investigated the influence of trans-epiphyseally implanted Mg-Zinc (Zn)-Calcium (Ca) ESIN on the proximal tibial physis of juvenile sheep over a period of three years, until skeletal maturity was reached. We used the two alloying systems ZX10 (Mg-1Zn-0.3Ca, in wt%) and ZX00 (Mg-0.3Zn-0.4Ca, in wt%) for this study. To elaborate potential growth disturbances such as leg-length differences and axis deviations we used a combination of in vivo clinical computed tomography (cCT) and ex vivo micro CT (μCT), and also performed histology studies on the extracted bones to obtain information on the related tissue. Because there is a lack of long-term data regarding the degradation performance of magnesium-based implants, we used cCT and μCT data to evaluate the implant volume, gas volume and degradation rate of both alloying systems over a period of 148 weeks. We show that transepiphyseal implantation of Mg-Zn-Ca ESIN has no negative influence on the longitudinal bone growth in juvenile sheep, and that there is no axis deviation observed in all cases. We also illustrate that 95 % of the ESIN degraded over nearly three years, converging the time point of full resorption. We thus conclude that both, ZX10 and ZX00, constitute promising implant materials for the ESIN technique.

Distal Radius Physeal Bar and Ulnar Overgrowth: Indications for Treatment

BACKGROUND

Distal radius physeal bar with associated growth arrest can occur because of fractures, ischemia, infection, radiation, tumor, blood dyscrasias, and repetitive stress injuries. The age of the patient as well as the size, shape, and location of the bony bridge determines the deformity and associated pathology that will develop.

METHODS

A search of the English literature was performed using PubMed and multiple search terms to identify manuscripts dealing with the evaluation and treatment of distal radius physeal bars and ulnar overgrowth. Single case reports and level V studies were excluded.

RESULTS

Manuscripts evaluating distal radial physeal bars and their management were identified. A growth discrepancy between the radius and ulna can lead to distal radioulnar joint instability, ulnar impaction, and degenerative changes in the carpus and triangular fibrocartilage complex. Advanced imaging aids in the evaluation and mapping of a physeal bar. Treatment options for distal radius physeal bars include observation, bar resection±interposition, epiphysiodeses of the ulna±completion epiphysiodesis of the radius, ulnar shortening osteotomy±diagnostic arthroscopy to manage associated triangular fibrocartilage complex pathology, radius osteotomy, and distraction osteogenesis.

CONCLUSIONS

Decision-making when presented with a distal radius physeal bar is multifactorial and should incorporate the age and remaining growth potential of the patient, the size and location of the bar, and patient and family expectations.

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

PURPOSE

Displaced distal radius fractures in children are common and often reduced if necessary and immobilized in cast. Still, fracture redisplacement frequently occurs. This can be prevented by fixation of fracture fragments with K-wires, but until now, there are no clear guidelines for treatment with primary K-wire fixation. This meta-analysis aimed to identify risk factors for redisplacement after reduction and cast immobilization of displaced distal radius fractures in children, and thereby determine which children will benefit most of primary additional K-wire fixation.

METHODS

Eight databases were searched to identify studies and extract data on the incidence of and risk factors for redisplacement of distal radius fractures after initial reduction and cast immobilization in children.

RESULTS

Twelve studies, including 1256 patients, showed that initial complete displacement (odds ratio [OR] 4.69, 95% confidence interval [CI] 2.98-7.39) and presence of a both-bone fracture (OR 1.95, 95% CI 1.34-2.85) were independent risk factors for redisplacement. Anatomical reduction reduced the redisplacement risk (OR 0.14, 95% CI 0.05-0.40). No significant influence on redisplacement risk could be established for female sex, experience level of the attending surgeon, Cast Index < 0.8, Three-Point Index < 0.8 and patient's age.

CONCLUSIONS

For children with a displaced distal radius fracture, the presence of a both-bone fracture, complete displacement of the distal radius and non-anatomical reduction are risk factors for redisplacement after reduction of their initially displaced distal radius fracture. Children with one or more of these risk factors probably benefit most of reduction combined with primary K-wire fixation.

Displaced distal radius fractures in children, cast alone vs additional K-wire fixation: a meta-analysis

Purpose

Displaced distal radius fractures in children are common and often treated by reduction and cast immobilization. Redisplacement occurs frequently and may be prevented by additional treatment with K-wire fixation after initial reduction. This meta-analysis aims to summarize available literature on this topic and determine if primary K-wire fixation is the preferred treatment for displaced distal radius fractures in children.

Methods

A search in eight databases identified studies that compared cast immobilization alone to additional K-wire fixation as treatment for displaced paediatric distal radius fractures. The primary outcome was the redisplacement rate. Secondary outcomes were secondary reduction rate, range of motion and complications. This meta-analysis was performed according to the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement.

Results

Three RCTs and 3 cohort studies, analysing 197 patients treated with cast immobilization alone and 185 with additional K-wire fixation, were included in this meta-analysis. Redisplacement occurred less frequently after additional K-wire fixation than after cast alone (3.8 versus 45.7%; OR 0.07, 95% CI 0.03–0.15). Secondary reduction was performed in 59.8% of the redisplaced fractures. Complications, other than redisplacement, occurred more often after additional K-wire fixation than after cast alone (15.7 versus 3.6%). Range of motion did not differ after both treatments.

Conclusions

Additional K-wire fixation is a suitable treatment to prevent redisplacement and secondary operations after initial reduction of displaced distal radius fractures in children, but is associated with post-procedural complications. Additional K-wire fixation does not result in a better range of motion than cast immobilization alone. More research is needed to identify those patients who will benefit the most from K-wire fixation as a treatment for displaced distal radius fractures in children.

Electronic supplementary material

The online version of this article (10.1007/s00068-018-1011-y) contains supplementary material, which is available to authorized users.

Intrafocal pinning for distal radius metaphyseal fractures in children

The purpose of this retrospective case control study was to evaluate the results of intrafocal pinning for distal radius metaphyseal fractures in children and to compare these results with conventional pinning. Data were collected from medical records and radiographs from patients who underwent closed reduction and percutaneous pinning for distal radius fracture in a Level I trauma center at the authors' institution between 2008 and 2010. Inclusion criteria included a dorsally angulated metaphyseal fracture without physeal involvement, an open distal radius physis, and a follow-up to radiographic union. A total of 10 patients with intrafocal pinning were compared to 26 patients with conventional pinning. Preoperatively, angulation was greater in patients who received intrafocal pinning than conventional pinning based on anteroposterior radiographs. Postoperatively, the 2 groups did not differ in angulation on either anteroposterior or lateral radiographs. One malunion and 2 pin-related complications occurred in the conventional pinning group, and 1 pin-related complication occurred in the intrafocal pinning group. The 2 groups did not differ by age, sex, side of injury, days to surgery, or initial shortening. This study affirms that the intrafocal pinning technique is an alternative to the conventional pinning technique for the stabilization of displaced metaphyseal distal radius fractures in children. Intrafocal pinning can also be used as a reduction tool for fractures that cannot be reduced by closed manipulation. The complications are comparable between the 2 techniques.

Distraction osteogenesis for correction of distal radius deformity after physeal arrest

PURPOSE

To present intermediate-term follow-up for pediatric patients following correction of forearm deformity with the use of distraction osteogenesis after distal radius physeal arrest in the setting of trauma.

METHODS

Retrospective review of a single surgeon's experience using a circular external fixator to correct forearm deformity in four patients whose average age at time of application was 13.8 years. All patients were evaluated clinically with radiographs, physical examination, and functional outcome assessments including the Short-Form 12, Disabilities of the Arm, Shoulder and Hand, and Mayo Wrist score.

RESULTS

At the time of intermediate-term follow-up, at a mean of 112 months, all patients were nearly pain free (average visual analog scale of 1). All were willing to undergo the same treatment again. Wrist flexion increased 11 degrees , extension decreased 2 degrees , radial deviation decreased 14 degrees , ulnar deviation increased 7 degrees , and pronation and supination both decreased 5 degrees on average. The radius was lengthened an average of 7 mm, with an average preoperative ulnar variance of +7 mm and an average postoperative ulnar variance of +1 mm. Mean outcome scores were as follows: Short-Form 12 was 82, Disabilities of the Arm, Shoulder and Hand was 11, and Mayo Wrist was 76. Three of four patients experienced treatment-related complications, whereas two of four required unplanned returns to the operating room.

CONCLUSIONS

The use of distraction osteogenesis is a reasonable alternative to osteotomy, bone grafting, and internal fixation in pediatric patients with severe forearm deformity and dysfunction after physeal arrest in the setting of trauma. This procedure is burdened with complications and requires a committed patient and surgeon. It provides good correction of deformity and relief of pain, and maintains functional range of motion while avoiding the use of permanent orthopedic implants.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Pediatric distal radius fractures and triangular fibrocartilage complex injuries

Management of distal radius fractures is guided by the pattern and location of injury, degree of deformity, and expectations of bony remodeling based on the amount of remaining skeletal growth.Indications for surgical treatment include unstable or irreducible fractures, open fractures, floating elbow injuries, and neurovascular or soft-tissue compromise precluding cast immobilization. Patients and families should be counseled regarding the potential for post-traumatic distal radial growth arrest following physeal fractures. In these cases, epiphysiodeses, ulnar shortening osteotomies, or corrective radial osteotomies may be performed, depending on the pattern of arrest,degree of deformity, and remaining skeletal growth.TFCC tears may be the source of ulnar-sided wrist pain in children and adolescents, though symptoms and physical examination findings maybe subtle. Patients who have persistent pain and functional limitations despite activity modification and therapy are candidates for surgical treatment. Appropriate repair of peripheral TFCC tears with correction of concomitant wrist pathology restores normal wrist anatomy, alleviates pain, and allows for return to functional activities.

Cast immobilization versus percutaneous pin fixation of displaced distal radius fractures in children: a prospective, randomized study

Thirty-four patients were enrolled in a prospective randomized study comparing cast immobilization alone versus percutaneous pin fixation following closed reduction of distal radial metaphyseal fractures. Patients older than 10 years of age with greater than 30 degrees of dorsal angulation or with complete fracture displacement were eligible for enrollment. Average follow-up was 10.5 weeks. All fractures healed uneventfully without deformity, growth arrest, or functional limitations. Overall complication rates were similar between groups. Thirty-nine percent of patients treated with casting had subsequent loss of reduction requiring remanipulation; there were no cases of loss of reduction in patients treated with pin fixation. Thirty-eight percent of patients treated with pin fixation had pin-related complications; all resolved following pin removal without long-term sequelae. Cost analysis showed no significant difference in treatment charges between groups. Treating surgeons should be aware of the potential short-term complications of each treatment method and adjust their postoperative care appropriately.