Distal metaphyseal radius fractures in children following closed reduction and casting: can loss of reduction be predicted?

Abstract

Purpose The aim of this study was to identify factors which contribute to loss of reduction (LOR). Methods Outpatient records and initial, post-reduction (PR) and follow-up radiographs of patients with a distal radial metaphyseal fracture were reviewed to determine demographic factors; fracture characteristics (obliquity, comminution, intact ulna); three-point cast index (3PI); and initial, PR, and follow-up displacement (angulation and translation in the sagittal and coronal planes). Univariate and multivariate regression were used to identify significant risk factors for LOR. Results A total of 161 patients were included in our series (119 boys and 42 girls). Fifty-seven (35%) patients met the criteria for LOR. Multivariate logistic regression revealed that patients over 14 years old were 4.8 times more likely (p00.01) to lose reduction, and those with more than 10% PR translation in the sagittal plane were four times more likely (p00.03) to lose reduction. In younger patients, initial coronal translation and PR sagittal translation were independent risk factors. Patients with over 10% initial translation in the coronal plane were 2.4 times more likely (p00.01) to lose reduction, and those with over 10% PR translation in the sagittal plane were 2.7 times more likely (p00.03) to lose reduction. Three point cast index was not found to be a significant risk factor (1.64 vs. 1.57, p00.43).Conclusion Our study, the largest dedicated series of distal radial metaphyseal fractures, indicates that loss of reduction is common. Our analysis suggests that an anatomical reduction, which minimises residual translation, is the most important variable in preventing a loss of reduction.

Factors Responsible for Redisplacement of Pediatric Forearm Fractures Treated by Closed Reduction and Cast

“…This rate of redisplacement was comparable to previous studies on the subject; 4 15 16 17 18 19 20 21 22 23 however, these studies had different criteria to define redisplacement. 22 Hence, comparison with such studies is not of much significance. We used remanipulation as the rescue therapy for significantly redisplaced fractures which proved to be an effective measure as shown in previous studies.…”

“…Initial angulation or prereduction angulation has been reported as a risk factor by Pretell Mazzini et al . 22 However, for current series, no difference was seen between the patients with acceptably reduced fractures and significantly redisplaced fractures as also seen previously by most authors. 3 11 12 14 17 18 19 20 21 Angulation only suggests bending of bones without complete disruption of periosteum.…”

“…No significant association was seen between age, sex, or side of injury with redisplacement as has been seen in previous studies. 15 16 17 18 19 20 21 22 Iltar et al . 23 had shown that children <7 years of age have more chance of redisplacement due to their small forearm, leading to difficulty in application of a well-molded cast.…”

“…For the past two decades, multiple studies (mostly retrospective) have tried to identify the risk factors responsible for redisplacement. 4 11 12 13 14 15 16 17 18 19 20 21 22 23 They have classified them into fracture-related, surgeon/treatment-related and patient-related factors 24 [ Table 1 ]. The previous series have objectively used several radiographic indices (called as “casting indices” 24 ) to asses cast quality and fracture reduction for pediatric forearm fractures [ Table 2 ].…”

Closed reduction and immobilization of displaced distal radial fractures. Method of choice for the treatment of children?

“…Distal radial fractures are among the most common injuries in children [ 1 , 2 ], and fractures at the metaphysis are especially prevalent [ 3 , 4 ]. Closed reduction and cast immobilization play a major role in the treatment of these fractures in children [ 4 , 5 ]. However, various rates of unacceptable loss of reduction have been described in the literature [ 6 – 12 ] and therefore many studies have been undertaken to identify the factors which increase the risk of redisplacement.…”