fracture distal radius in children factors responsible for redisplacement after closed reduction dr....

Fracture Distal Radius in Children

Factors Responsible for Redisplacement after Closed Reduction

Dr. Mohammed M. Zamzam, MDAssociate Professor & Consultant

Pediatric Orthopedic SurgeonKKUH, Riyadh, Saudi Arabia

Distal Radius Fractures in Children

• Epidemiology– The commonest fracture in

children – Up to 23% of all pediatric skeletal

injuries– Boys > girls

Distal Radius Fractures in Children

• Etiology– Resultant deformities

are usually a product of indirect trauma involving angular loading combined with rotational displacement

Distal Radius Fractures in Children

• Outcome– Greenstick or

complete fracture– Partial or complete

displacement– Complications

• Compartment syndrome

• Malunion

Distal Radius Fractures in Children

• Good outcome– Restoration of wrist and

forearm motion– Acceptable cosmetics– These goals are usually met

with conservative treatment by reduction and immobilization

Distal Radius Fractures in Children

• Management– Anesthesia– Manipulation– Immobilization– Primary int.

fixation?

Distal Radius Fractures in Children

• Management– Anesthesia– Manipulation– Immobilization– Primary int.

fixation?

Distal Radius Fractures in Children

• Management– Anesthesia– Manipulation– Immobilization– Primary int.

fixation?

Distal Radius Fractures in Children

• Reduction– Perfect– Acceptable

• 50% contact• Up to 20° AP

angulation

Distal Radius Fractures in Children

• Reduction– Stable– Unstable

Distal Radius Fractures in Children

• Follow up

Redisplacement

Aim of the study

• To identify the possible factors responsible for redisplacement after acceptable closed reduction of fracture distal radius in children

• To delineate a clear and simple guidance while treating fracture distal radius in children

Methodology

• Criteria of patient selection– Age– Diagnosis– Treatment– Duration

Methodology

• Exclusion– Open fractures– Unacceptable initial reduction– Primary int. fixation– Inappropriate cast condition

Methodology

• Data collection– Age– Gender– Treating physician– Type of anesthesia– Redisplacement– Follow up and outcome

Methodology

• Radiographic analysis– Initial displacement– Ulnar fracture– Initial closed reduction– Redisplacement– Final outcome

Methodology

• Statistical study– Univariant analysis– Multivariate Logistic Regression Analysis

Results

• 183 children with displaced distal radial fractures

• 144 boys (79%) and 39 girls (21%)

• The mean age was 8 years (range 3-16)

• Associated distal ulnar fractures in 50 cases (27%)

Results

• 183 children with displaced distal radial fractures

• 144 boys (79%) and 39 girls (21%)

• The mean age was 8 years (range 3-16)

• Associated distal ulnar fractures in 50 cases (27%)

Results

• 183 children with displaced distal radial fractures

• 144 boys (79%) and 39 girls (21%)

• The mean age was 8 years (range 3-16)

• Associated distal ulnar fractures in 50 cases (27%)

Results

• 183 children with displaced distal radial fractures

• 144 boys (79%) and 39 girls (21%)

• The mean age was 8 years (range 3-16)

• Associated distal ulnar fractures in 50 cases (27%)

Results

Radiological assessment at the time of injury

- initial complete displacement in 75 patients (41%)

- incomplete displacement in 108 patients (59%)

Results

The type of anesthesia was chosen according to the age of the child, his/her cooperation and sometimes according to the surgeon’s preference

• Sedation and/or local haematoma block in 101 (55%)

• General anesthesia in 82 patients (45%)

Results

Radiological assessment after reduction

– Perfect reduction in 142 fractures (78%)

Results

• Redisplacement in 46 patients (25%) • 37 boys and 9 girls• 35 patients (76%) had associated distal ulnar

fractures• Diagnosed within 2 weeks of the initial CR

Type of Initial DisplacementNumberRedisplacement

Initial Complete Displacement75/183 (41%)37/75 (49%)

- Perfect initial reduction52/75 (69%)25/52 (48%)

- Imperfect initial reduction23/75 (31%)12/23 (52%)

Initial Incomplete Displacement108/183 (59%)9/108 (8%)

- Perfect initial reduction90/108 (83%)7/90 (8%)

- Imperfect initial reduction18/108 (17%)2/18 (11%)

Incidence of Redisplacement in relation to

Initial Displacement and Post Reduction Position

Relation of Redisplacement to Initial Displacement

According to the Type of Anesthesia

Type of Initial Displacement

Deep Sedation and/orLocal Haematoma Block

General Anesthesia

NumberRedisplacement

NumberRedisplacement

Initial Complete Displacement

16/101 (16%)

14/16 (88%)

59/82(72%)

23/59 (39%)

Initial Incomplete Displacement

85/101 (84%)

9/85 (11%)

23/82(28%)

0/23 (0%)

Total101 23/101(23%)

8223/82(28%)

Results

Remanipulation

- More than 20° angulation or- less than 50% contact between radial

fragments

- Under GA + k-wire fixation

Follow up

• Average 13 weeks (range, 11-18) • 3 cases with superficial wound infection• Healing

Risk Factors for Redisplacement

Significant

• Older children 10-16 years (P<0.003)

• Associated distal ulnar fractures (P<0.001 )

• Reducing fractures under deep sedation and/or local haematoma block ( P<0.002)

• Initial complete displacement (P<0.00001)

Not Significant

• Gender (P>0.8)

• Imperfect reduction (P>0.19)

Results of multivariate logistic regression analysis

S.E.Sig.Odds ratio95.0% C.I. for odds ratio

LowerUpper

Gender.653.173.411.1141.477

Age.518.193.509.1851.406

Initial Displacement

.762.00024.7375.557110.123

Associated Fracture Ulna

.566.00022.5077.42368.244

Type of Anesthesia

.791.0068.9671.90342.241

Result of Manipulation

.622.6931.279.3784.328

2.894.000.000

Literatures’ Review

• Redisplacement is linked to the position of forearm in the cast or loss of cast fixation (Voto et al 1990, Gupta et al 1990)

• Redisplacement is less likely when an experienced surgeon performs the initial reduction (Haddad et al 1995)

Literatures’ Review

• K-wire fixation had a better result than cast immobilization alone in treating displaced distal radial fractures in children (McLauchlan et al,2002)

Causes of Redisplacement

• Two factors increase the chance of redisplacement– the presence of initial complete displacement – the failure to achieve a perfect reduction(Proctor et al 1993)

• They stressed only on imperfect reduction to perform percutaneous K-wire fixation

• The most important favorable prognostic factor was a perfect anatomical reduction (Haddad et al 1995)

Study Findings

• Perfect reduction did not reduce the incidence of redisplacement of initially completely displaced fractures

• The most important factor that can affect the outcome significantly is the initial displacement of the fracture

Study Findings

• Explanations – Completely displaced distal radial fractures are

usually associated with severe injury to the periosteum and the surrounding soft tissues

– Lack of periosteal hinge may affect the stability and increases the incidence of redisplacement

– Severe soft tissue injury causes more initial swelling which usually subsides in a week resulting in loose cast that in turn increases the chance of redisplacement

Risk Factors

• Presence of associated distal ulnar fracture

• The use of deep sedation or local haematoma block to reduce completely displaced fractures

Conclusion

• Children who had completely displaced distal radial fractures particularly those associated with fracture of the ulna should be manipulated under G.A.

• It is recommended to perform percutaneous K-wire fixation to ensure stabilization and avoid redisplacement, even if perfect reduction could be achieved

Thank you