Improved forearm rotation even after early conversion to below-elbow cast for non-reduced diaphyseal both-bones forearm fractures in children: a secondary 7.5-year follow up of a randomized trial
DOI:
https://doi.org/10.2340/17453674.2023.18340Keywords:
fracture, forearm, pediatric orthopaedics, trauma, long term results, casting, radius ulna shaft fracturesAbstract
Background and purpose: previous RCT compared short-term results of above-elbow cast (AEC) with early conversion to below-elbow cast (BEC) in children with non-reduced diaphyseal both-bone forearm fractures. After 7 months both groups had comparable function. Our primary aim was to investigate whether forearm rotation improves or worsens over time. Secondary aims were loss of flexion and extension of the elbow and wrist, patient-reported outcomes measures, grip strength ratio, and radiographic assessment.
Patients and methods: We performed long-term follow-up (FU) of a previous RCT. All patients were invited again for the long-term FU measurements. Primary outcome was limitation of forearm rotation. Secondary outcomes were loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, the ABILHAND-Kids questionnaire and the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire, grip strength ratio, and radiographic assessment.
Results: The mean FU was 7.5 (4.4–9.6) years. Of the initial 47 children, 38 (81%) participated. Rotation improved in both groups over time, with no significant difference in the final forearm rotation: 8° (SD 22) for the AEC group and 8° (SD 15) for the BEC group with a mean difference of 0° (95% confidence interval –13 to 12). Secondary outcomes showed no statistically significant differences. Finally, children < 9 years almost all have full recovery of function.
Conclusion: Long-term follow-up showed that loss of forearm rotation after a non-reduced diaphyseal both-bone forearm fracture improved significantly compared with that at 7 months, independent of the initial treatment and children aged < 9 will have almost full recovery of function. This substantiates that the remaining growth behaves like a “friend” at long-term follow-up.
Downloads
References
Cheng J C, Shen W Y. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma 1993; 7(1): 15-22. doi: 10.1097/00005131-199302000-0000.
Heo J, Oh C W, Park K H, Kim J W, Kim H J, Lee J C, et al. Elastic nailing of tibia shaft fractures in young children up to 10 years of age. Injury 2016; 47(4): 832-6. doi: 10.1016/j.injury.2015.10.024. DOI: https://doi.org/10.1016/j.injury.2015.10.024
Bot A G J, Doornberg J N, Lindenhovius A L C, Ring D, Goslings J C, Van Dijk C N. Long-term outcomes of fractures of both bones of the forearm. J Bone Joint Surg Am 2011; 93(6): 527-32. doi: 10.2106/JBJS.J.00581. DOI: https://doi.org/10.2106/JBJS.J.00581
Fewtrell M S, Kennedy K, Singhal A, Martin R M, Ness A, Hadders-Algra M, et al. How much loss to follow-up is acceptable in long-term randomised trials and prospective studies? Arch Dis Child 2008; 93(6): 458-61. doi: 10.1136/adc.2007.127316. DOI: https://doi.org/10.1136/adc.2007.127316
Colaris J W, Reijman M, Allema J H, Biter L U, Bloem R M, Van De Ven CP, et al. Early conversion to below-elbow cast for non-reduced diaphyseal both-bone forearm fractures in children is safe: preliminary results of a multicentre randomised controlled trial. Arch Orthop Trauma Surg 2013; 133(10): 1407-14. DOI: https://doi.org/10.1007/s00402-013-1812-8
Colaris J W, Biter L U, Allema J H, Bloem R M, Ven V De, De Vries M R, et al. Below-elbow cast for metaphyseal both-bone fractures of the distal forearm in children: a randomised multicentre study. Injury 2012; 43: 1107-11. doi: 10.1016/j.injury.2012.02.020. DOI: https://doi.org/10.1016/j.injury.2012.02.020
Daruwalla J S. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res 1979; (139): 114-20. PMID: 455827. DOI: https://doi.org/10.1097/00003086-197903000-00019
Firl M, Wunsch L. Measurement of bowing of the radius. J Bone Joint Surg 2004; 86(7): 1047-9. doi: 10.1302/0301-620X.86B7.14294. DOI: https://doi.org/10.1302/0301-620X.86B7.14294
Schemitsch E H, Richards R R. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint Surg Am 1992; 74(7): 1068-78. PMID: 1522093. DOI: https://doi.org/10.2106/00004623-199274070-00014
Weber M B, Olgun Z D, Boden KA, Weinberg D S, Bafus B T, Cooperman D R, et al. A cadaveric study of radial and ulnar bowing in the sagittal and coronal planes. J Shoulder Elb Surg 2020; 29(5): 1010-8. doi: 10.1016/j.jse.2019.10.016. DOI: https://doi.org/10.1016/j.jse.2019.10.016
Wongcharoenwatana J, Eamsobhana P, Chotigavanichaya C, Ariyawatkul T, Kaewpornsawan K. The effects of maximal radial bowing on forearm rotation in pediatric diaphyseal forearm fractures. Musculoskelet Surg 2023; 107(1): 47-53. doi: 10.1007/s12306-021-00728-5. DOI: https://doi.org/10.1007/s12306-021-00728-5
Dumont C E, Thalmann R, Macy J C. The effect of rotational malunion of the radius and the ulna on supination and pronation: an experimental investigation. J Bone Joint Surg Br 2002; 84(7): 1070-4. doi: 10.1302/0301-620X.84B7.12593. DOI: https://doi.org/10.1302/0301-620X.84B7.12593
Kasten P, Krefft M, Hesselbach J, Weinberg A M. How does torsional deformity of the radial shaft influence the rotation of forearm?: A biomechanical study. J Orthop Trauma 2003; 17(1): 57-60. doi: 10.1097/00005131-200301000-00009. DOI: https://doi.org/10.1097/00005131-200301000-00009
Matthews L S, Kaufer H, Garver DF, Sonstegard D A. The effect on supination–pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg 1982; 64(1): 14-7. PMID: 7054197. DOI: https://doi.org/10.2106/00004623-198264010-00003
Price C T, Scott D S, Kurzner M E, Flynn J C. Malunited forearm fractures in children. J Pediatric Orthop 1990; 10: 705-12. doi: 10.1097/01241398-199011000-00001. DOI: https://doi.org/10.1097/01241398-199011000-00001
Nakamura T, Yabe Y, Horiuchi Y, Seki T, Yamazaki N. Normal kinematics of the interosseous membrane during forearm pronation–supination: a three-dimensional MRI study. Hand Surg 2000; 5(1): 1-10. doi: 10.1142/S0218810400000077. DOI: https://doi.org/10.1142/S0218810400000077
Colaris J W, Allema J H, Reijman M, De Vries M R, Ulas Biter L, Bloem R M, et al. Which factors affect limitation of pronation/supination after forearm fractures in children? A prospective multicentre study. Injury 2014; 45(4): 696-700. doi: 10.1016/j.injury.2013.09.041. DOI: https://doi.org/10.1016/j.injury.2013.09.041
Moesner J, Ostergaard H. Diafysefrakturer hos børn. Den spontane korrektion af akseskaevhed. Nord Med 1966; 75(13): 355-7. [Article in Danish] PMID: 5909151.
Högström H, Nilsson B E, Willner S. Correction with growth following diaphyseal forearm fracture. Acta Orthop 1976; 47(3): 299-303. doi: 10.3109/17453677608991994. DOI: https://doi.org/10.3109/17453677608991994
Morrey B F, Askew L J, Chao E Y. A biomechanical study of normal functional elbow motion. J Bone Joint Sur 1981; 63(6): 872-7. PMID: 7240327. DOI: https://doi.org/10.2106/00004623-198163060-00002
Roberts J A. Angulation of the radius in children’s fractures. J Bone Joint Surg 1986; 68: 751-4. doi: 10.1302/0301-620X.68B5.3782237. DOI: https://doi.org/10.1302/0301-620X.68B5.3782237
Tynan M C, Fornalski S, McMahon P J, Utkan A, Green S A, Lee T Q. The effects of ulnar axial malalignment on supination and pronation. J Bone Joint Surg Am 2000; 82(12): 1726-31. doi: 10.2106/00004623-200012000-00005. DOI: https://doi.org/10.2106/00004623-200012000-00005
Barvelink B, Ploegmakers J J W, Harsevoort A G J, Stevens M, Verheyen C C, Hepping A M, et al. The evolution of hand function during remodelling in nonreduced angulated paediatric forearm fractures: a prospective cohort study. J Pediatr Orthop Part B 2020; 29(2): 172-8. doi: 10.1097/BPB.0000000000000700. DOI: https://doi.org/10.1097/BPB.0000000000000700
Kapila R, Sharma R, Chugh A, Goyal M. Evaluation of clinical outcomes of management of paediatric bone forearm fractures using titanium elastic nailing system: a prospective study of 50 cases. J Clin Diagn Res 2016; 10: RC12-5. doi: 10.7860/jcdr/2016/22040.8917. DOI: https://doi.org/10.7860/JCDR/2016/22040.8917
Kristman V, Manno M, Côté P. Loss to follow-up in cohort studies: how much is too much? Eur J Epidemiol 2016; 19(8): 751-60. doi: 10.1023/b:ejep.0000036568.02655.f8. DOI: https://doi.org/10.1023/B:EJEP.0000036568.02655.f8
Additional Files
Published
How to Cite
License
Copyright (c) 2023 Linde Musters, Leon W Diederix, Pim P Edomskis, Kasper C Roth, Joyce L Benner, Gerald A Kraan, Jan H Allema, Max Reijman, Denise Eygendaal, Joost W Colaris
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
