Single-bone versus both-bone plating of unstable paediatric both-bone forearm fractures. A randomized controlled clinical trial

Abstract

Purpose This clinical trial compares the functional and radiological outcomes of single-bone fixation to both-bone fixation of unstable paediatric both-bone forearm fractures. Methods This individually randomized two-group parallel clinical trial was performed following the Consolidated Standards of Reporting Trials (CONSORT) statement at a single academic tertiary medical centre with an established paediatric orthopaedics unit. All children aged between nine and 15 years who presented to the emergency department at Assiut university with unstable diaphyseal, both-bone forearm fractures requiring surgical intervention between November 1, 2018, and February 28, 2020, were screened for eligibility against the inclusion and exclusion criteria. Inclusion criteria were diaphyseal unstable fractures defined as shaft fractures between the distal and proximal metaphyses with an angulation of > 10°, and/or malrotation of > 30°, and/or displacement > 10 mm after attempted closed reduction. Exclusion criteria included open fractures, Galeazzi fractures, Monteggia fractures, radial head fractures, and associated neurovascular injuries. Patients who met the inclusion criteria were randomized to either the single-bone fixation group (intervention) or the both-bone fixation group (control). Primary outcomes were forearm range of motion and fracture union, while secondary outcomes were forearm function (price criteria), radius re-angulation, wrist and elbow range of motion, and surgical time Results A total of 50 children were included. Out of these 50 children, 25 were randomized to either arm of the study. All children in either group received the treatment assigned by randomization. Fifty (100%) children were available for final follow-up at six months post-operatively. The mean age of single-bone and both-bone fixation groups was 11.48 ± 1.93 and 13 ± 1.75 years, respectively, with a statistically significant difference (p = 0.006). There were no statistically significant differences in gender, laterality, affection of the dominant hand, or mode of trauma between single-bone and both-bone fixation groups. All patients in both groups achieved fracture union. There mean radius re-angulation of the single-bone fixation groups was 5.36 ± 4.39 (0–20) degrees, while there was no radius re-angulation in the both-bone fixation group, with a statistically significant difference (p < 0.001). The time to union in the single-bone group was 6.28 ± 1.51 weeks, while the time to union in the both-bone fixation group was 6.64 ± 1.75 weeks, with no statistically significant difference (p = 0.44). There were no infections or refractures in either group. In the single-bone fixation group, 24 (96%) patients have regained their full forearm ROM (loss of ROM < 15°), while only one (4%) patient lost between 15 and 30° of ROM. In the both-bone fixation group, 23 (92%) patients have regained their full forearm ROM (loss of ROM < 15°), while only two (8%) patients lost between 15 and 30° of ROM. There was no statistically significant difference between groups in loss of forearm ROM (p = 0.55). All patients in both groups regained full ROM of their elbow and wrist joints. On price grading, 24 (96%) and 23 (92%) patients who underwent single bone fixation and both-bone fixation scored excellent, respectively. Only one (4%) patient in the single-bone fixation group and two (8%) patients in the both-bone fixation group scored good, with no statistically significant difference in price score between groups (p = 0.49). The majority of the patients from both groups had no pain on the numerical pain scale; 22 (88%) patients in the single-bone fixation group and 21 (84%) patients in the both-bone fixation groups, with no statistically significant difference between groups (p = 0.38). The single-bone fixation group had a significantly shorter mean operative time in comparison to both-bones plating (43.60 ± 6.21 vs. 88.60 ± 10.56 (min); p < 0.001). Conclusion Single-bone ulna open reduction and plate fixation and casting are safe and had a significantly shorter operative time than both-bone fixation. However, single-bone ORIF had a higher risk radius re-angulation, alas clinically acceptable. Both groups had equally excellent functional outcomes, forearm ROM, and union rates with no complications or refractures. Long-term studies are required.

Risk Analysis of Re-displacement After Conservative Treatment of Pediatric Unstable Fractures of Middle and Distal Forearm

“…The definition of unstable fractures in the distal forearm is unknown. Mohamed Khaled et al defined unstable diaphyseal fractures as diaphyseal fractures between the distal and proximal metaphysis, with an angle > 10°, and/or malrotation > 30°, and/or a displacement > 10 mm after an attempted closed reduction (15). Kay et al defined that the closed reduction of fractures of the middle ulna and radius over 10 years with an angle of more than 10°is unstable (16).…”

“…A, white box illustrating metaphysis; from radial tuberosity to metaphysis, backbone regarded as backbone; backbone divided into three equal parts, followed by proximal, middle, and distal segments; B, in lateral radiograph, CD considered perpendicular to the epiphyseal plate of distal radius; angle between AB and CD considered the angle of radius fracture; angle between EF and GH considered the angle of ulna fracture; in the orthographic film, KL considered perpendicular to the epiphyseal plate of the distal radius, and angle between IJ and KL considered -3.7°(i.e., the angle of radius fracture). (15,(22)(23)(24), and consider that the failure rate of closed reduction in children over 10 years is high and the acceptable angle range is small. Finally, this study limited the age of children to 6 -9 years, thereby reducing the effect of age on fracture shaping.…”

What’s New in Pediatric Orthopaedics

“…Khaled et al enrolled 50 children between 9 and 15 years of age in a randomized controlled trial comparing the management of both-bone forearm fractures by plating only the ulna (single-bone technique) and the traditional method of plating both the ulna and the radius. They found that the single-bone technique yielded more reangulation but still achieved healing in an acceptable alignment with shorter operative times and equivalent functional outcomes 8 .…”

Seven-year Outcomes of Adolescent Forearm Fractures Treated With Plate Fixation

“…P ediatric forearm fractures are common injuries, comprising nearly 40% of childhood fractures. [1][2][3][4][5][6][7][8][9][10][11][12] The most prevalent mechanisms of injury include fall on an outstretched hand and trauma. 4,13 After the fracture, these injuries have a wide range of treatments with indications depending on specific patient and fracture characteristics.…”

“…12 Common treatment includes operative intervention, with plate or nail fixation, or nonoperative treatments such as casting. [2][3][4]7,9,[11][12][13] The general treatment consensus is to first attempt management with closed reduction and immobilization. 2 Surgery may be indicated in polytraumatic or open fracture settings, when the patient is nearing skeletal maturity, or when closed reduction is unsuccessful.…”