Pediatric Forearm Fractures with Unacceptable Angulation: Is Remodeling Effective?

Öz

The aim of this study is to examine the remaining deformity after remodeling and its relationship with pronation/supination limitation in patients with unacceptable angulation according to the literature. 45 patients who had forearm fractures treated with closed reduction and plaster cast between 2014 and 2019 were included in the study. The maximum angulation amount was determined on anteroposterior or lateral radiographs by measuring the angulation of the radius and ulna on the radiographs taken during plaster removal (T1) and on the radiographs after remodeling (T2) at the last follow-up. The average follow-up period was 61.6 months (36-90 months). The patients were divided into 2 groups according to the angulation in the radiographs taken on the day the cast was removed (T1): Group 1 (acceptable angulation), and Group 2 (unacceptable angulation). While the average of maximum angulation values at T1 in Group 1 was 8.2 (±2.6) it was 15.4 (±4.1) in Group 2 (p = 0.002). While the mean residual angulation value at T2 was 3.5 (±1.8) in Group 1, it was 6.8 (±3.1) in Group 2 (p = 0.002). It was determined that 7 of 19 patients in Group 1 and 13 of 26 patients in Group 2 had a limitation of more than 10° (p = 0.382). Conservatively treated pediatric forearm fractures have the potential to heal to normal degrees at a high rate after remodeling, even if they have unacceptable angulation degrees, and the pronation/supination limitation in these patients is not directly related to the residual angulation degrees.

Anahtar Kelimeler

• Radius and ulna fracture
• Closed fracture reduction
• Malunion
• Bone remodeling.

Kabul Edilemez Angulasyonu Olan Çocuk Önkol Kırıkları: Remodelizasyon Etkili mi?

Öz

Bu çalışmanın amacı literatüre göre aslında kabul edilemez angulasyona sahip olan hastalarda, remodelizasyon sonrası kalan deformiteyi ve bunun pronasyon/supinasyon kısıtlılığı ile ilişkisini incelemektir. 2014-2019 yılları arasında kapalı redüksiyon ve alçı ile tedavi edilmiş 45 hasta çalışmaya dahil edildi. Alçı çıkarılması sırasında çekilen radyografiler (T1) ve son kontroldeki remodelizasyon sonraki grafiler (T2) üzerinden radius ve ulnanın angulasyonları ölçülerek ön-arka veya yan grafilerde maksimum angulasyon miktarı belirlendi. Ortalama takip süresi 61.6 aydı (36-90 ay). Hastalar alçının çıkarıldığı gün (T1) çekilen radyografilerdeki angulasyona göre 2 gruba ayrıldı (Grup 1: kabul edilebilir angulasyon; Grup 2: kabul edilemez angulasyon). Grup 1'de T1'de maksimum angulasyon değerlerinin ortalaması 8.2 (±2.6) iken, Grup 2'de 15.4 (±4.1) idi (p=0.002). T2'de ortalama rezidü angülasyon değeri Grup 1'de 3.5 (±1.8) iken, Grup 2'de 6.8 (±3.1) idi (p=0.002). Grup 1'de 19 hastanın 7'sinde, Grup 2'de ise 26 hastanın 13'ünde pronasyon veya supinasyonda 10'den fazla kısıtlılık olduğu saptandı (p=0.382). Konservatif tedavi edilen çocuk önkol kırıkları kabul edilemez angulasyon derecelerinde olsa bile yüksek oranda normal derecelere iyileşme potansiyeline sahip olup, hastalarda oluşan pronasyon/supinasyon kısıtlılığı rezidü angulasyon dereceleri ile direkt ilişkili değildir.

Anahtar Kelimeler

• Radius ve ulna kırığı
• Kırığın kapalı redüksiyonu
• Anormal kaynama
• Kemik remodelizasyonu.

Kaynakça

1. 1. Rennie, L., C.M. Court-Brown, J.Y. Mok, and T.F. Beattie, The epidemiology of fractures in children. Injury, 2007. 38(8): p. 913-22.
2. 2. Schulte, L.M., C.G. Meals, and R.J. Neviaser, Management of adult diaphyseal both-bone forearm fractures. J Am Acad Orthop Surg, 2014. 22(7): p. 437-46.
3. 3. Noonan, K.J. and C.T. Price, Forearm and distal radius fractures in children. J Am Acad Orthop Surg, 1998. 6(3): p. 146-56.
4. 4. Matthews, L.S., H. Kaufer, D.F. Garver, and D.A. Sonstegard, The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am, 1982. 64(1): p. 14-7.
5. 5. Price, C.T., D.S. Scott, M.E. Kurzner, and J.C. Flynn, Malunited forearm fractures in children. J Pediatr Orthop, 1990. 10(6): p. 705-12.
6. 6. Hansen, B.A., J. Greiff, and F. Bergmann, Fractures of the tibia in children. Acta Orthop Scand, 1976. 47(4): p. 448-53.
7. 7. Tarr, R.R., A.I. Garfinkel, and A. Sarmiento, The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg Am, 1984. 66(1): p. 65-70.
8. 8. Li, T.P., A. Wollstein, S. Sabharwal, S.K. Nayar, and S. Sabharwal, Malunion of Pediatric Forearm Shaft Fractures: Management Principles and Techniques. Curr Rev Musculoskelet Med, 2022. 15(6): p. 427-437.

9. 9. Colaris, J., M. Reijman, J.H. Allema, M. de Vries, U. Biter, R. Bloem, C. van de Ven, and J. Verhaar, Angular malalignment as cause of limitation of forearm rotation: an analysis of prospectively collected data of both-bone forearm fractures in children. Injury, 2014. 45(6): p. 955-9.
10. 10. Price, C.T. and D.R. Knapp, Osteotomy for malunited forearm shaft fractures in children. J Pediatr Orthop, 2006. 26(2): p. 193-6.
11. 11. Wilkins, K.E., Principles of fracture remodeling in children. Injury, 2005. 36 Suppl 1: p. A3-11.
12. 12. Vittas, D., E. Larsen, and S. Torp-Pedersen, Angular remodeling of midshaft forearm fractures in children. Clin Orthop Relat Res, 1991(265): p. 261-4.
13. 13. Johari, A.N. and M. Sinha, Remodeling of forearm fractures in children. J Pediatr Orthop B, 1999. 8(2): p. 84-7.
14. 14. Nagy, L., L. Jankauskas, and C.E. Dumont, Correction of forearm malunion guided by the preoperative complaint. Clin Orthop Relat Res, 2008. 466(6): p. 1419-28.
15. 15. Soubeyrand, M., B. Assabah, M. Begin, E. Laemmel, A. Dos Santos, and M. Creze, Pronation and supination of the hand: Anatomy and biomechanics. Hand Surg Rehabil, 2017. 36(1): p. 2-11.