View
243
Download
0
Category
Tags:
Preview:
Citation preview
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
Recommended