Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old Children

Abstract

Supplemental Digital Content is available in the text.

Letter to the Editor Regarding: “Treatment Choice of Complete Distal Forearm Fractures in 8 to 14 Years Old Children”

“…We read with interest the recent publication by Liu et al1 Liu et al1 recorded in their abstract and first paragraph of their results section that 114 patients were managed operatively and 61 nonoperatively, which is not consistent with the first table and first figure where the group numbers are reversed?…”

“…The US Department of Energy issued that the radiation exposure to minors should be limited to 100 mrem per year unless there is a medical necessity (https://www.energy.gov/sites/prod/files/2016/09/f33/Radiation_in_Perspective.pdf). The latter concern about radiation exposure to minors is not reflected in Liu et al’s1 statement that the radiation exposure was “quite low and controllable,” which does not have any specific meaning to us, does not explain if the 32% higher radiation dose for nonoperative management is clinically relevant and does not stimulate any reflection on how to reduce radiation for minors and staff, for example, not to take immediate postreduction radiographs in addition to fluoroscopy images, not to take further radiographs at week 2 and 3 and fluoroscopy specific radiation reductions: use of laser pointer and pulsed fluoroscopy, not to use magnification, to position the X-ray tube under the patient, to use image hold, to remove the antiscatter grid and not to use a mini-C-arm (53% to 70% increased radiation exposure compared with regular C-arms) 4…”

“…Liu et al1 reported in their abstract that all 175 fractures were treated in the emergency department (A&E), which indicates that the closed reduction and percutaneous pinning (CRPP) group had a failed reduction attempt in A&E before CRPP. Data for translational and rotational displacement and the number of fractures which were off-ended were not provided, which raises the possibility that surgeons might have based their decision to perform CRPP on the amount of translational displacement and failure to achieve adequate stable fracture reduction in A&E, rather than CRPP having been an arbitrary unnecessary management decision as it was implied by Liu et al1…”

“…Considering Liu et al’s1 conclusions, we would like to ask the authors if they have changed their practice, so that all distal third forearm fractures matching their study inclusion criteria are now being manipulated in A&E only, without pinning in theatre and why they want to exclude children from nonoperative management who have <2 years of growth potential left, despite the reported postreduction angles being in our opinion acceptable for any age2?…”

“…Maempel et al3 reported a 2.6 times higher median intraoperative radiation exposure for CRPP compared with closed reduction and casting, which would reduce the radiation dose difference between the groups. We would like to ask Liu et al1 to explain the inconsistency between their radiation dose estimates and our calculations, which is based on the information provided in their method section and how they establish reliably in A&E if 2 years of growth potential is remaining, with their chosen upper age range of 14 years not being applicable to females?…”