Open reduction and internal fixation of forearm fractures in children

We retrospectively reviewed 16 children younger than 13 years with 17 fractures of the shafts of the radius or ulna or both who had undergone an open reduction-internal fixation (ORIF). ORIF was performed when a closed reduction was deemed unacceptable in 14 radius fractures and for three unstable open fractures of the radius. The average age was 9.4 +/- 2.3 years (range, 5.0-12.5). Of the 14 fractures with an unacceptable closed reduction, soft-tissue interposition was encountered in seven. Fixation was secured by plates and screws, percutaneous Steinmann pins, or intramedullary Steinmann pins. There were no delayed unions or nonunions, no infections, and no neurovascular injuries. The average follow-up was 12.3 months; all 17 fractures had excellent results (forearm rotation loss of < 10 degrees). Our study indicates that excellent results can be expected with no increased risk of complications if the treating physician elects to proceed with an ORIF in a pediatric forearm fracture with proper indications.     

Sensitivity of a method for the analysis of facial mobility. II. Interlandmark separation

PURPOSE OF THE STUDY: The purpose of this study was to increase the knowledge about these rare and serious injuries and to produce guidelines for a more successful ORIF. MATERIAL: 120 cases of combined fractures in adults with late results (minimum one year) stored in the AO Documentation-Center between 1979 and 1989 were analyzed. Monotrauma was dominant, additional injuries were rare. No vasculo-nervous lesions were reported. 15 fractures were open. For the ulna 4 fractures types were isolated, fractures of the coronoid process and the radial head (CR) 25 cases. Olecranon and radial head fracture (OR) 22 cases. Combination of anterior (coronoid) and posterior (olecranon) ulnar fracture with radial head fracture (COR) 41 cases. Metaphyseal ulnar and radial head fractures (MR) 32 cases. For the radial head we have distinguished partial (61) and complete (59) fractures, the latter including 14 neck fractures. RESULTS: In the CR type indirect fixation technique was never perfect. Best results were obtained after ORIF of partial radial fractures. After resection, arthrosis (8/11) and valgus (8/11) were very frequent. In the OR type the stability was restored in simple fractures by the tension band technique even when the radial head was resected. In the severe COR type good results were rare. Arthrosis was important and frequent (36/41) especially after radial head resection. In the MR type ORIF of the radial head combined with ulnar plating gave the best results. Ulnar union was delayed or missing in 13 cases especially after radial head resection. Functional results after one year were better than expected on X-rays. This was due to immediate ORIF (92/120) and early mobilization. There were only 3 infections and 2 reflex-dystrophies. DISCUSSION: The Coronoid is the key-fragment of the ulna. It is best reduced in CR-Type under vision by an anterior approach. In COR-lesions its reduction should be the first step of ulnar ORIF. Comminutions in OR, COR and MR-Types showed a high number of delayed or non union. The reason may be a biological weakness (reduced vascularization) in these areas. Therefore we advocate for bridging plates (and cancellous grafts) for the stabilization of such areas, especially for the metaphysis where a strong valgus force appears after radial resection. Radial head as the lateral pillar of the elbow should be restored by ORIF in partial fractures (excellent results) and even in complete fractures (5/10 excellent results) under favourable conditions. Prosthesis is indicated in severe radial comminution or serious ulnar instability.     

Preliminary experimental evaluation of an inverse source imaging procedure using a decoupled coil detector array in magnetic resonance imaging

Results of treatment for 104 forearm shaft fractures in 70 patients have been presented. In all cases included in this study an open reduction of the fracture was followed by AO plate stabilization. Functional and radiological assessment was carried out according to the criteria of Anderson et al. Excellent and good functional results were achieved in 48 cases, fair in 10 and poor in 12 cases. The ulna united in 75%, the radius in 78% (delayed union included). Cross- union occurred in three patients, one case of destabilization at fracture site was observed, no infection has been noted. AO plate osteosynthesis proved to be still valuable mode of treatment for forearm shaft fracture.     

Randomized study of chemotherapy and surgery versus radiotherapy for stage IIIA non-small-cell lung cancer: a National Cancer Institute of Canada Clinical Trials Group Study

We treated two children with the unusual complication of ulnar nerve palsy after closed both-bone forearm fractures. Both patients developed an ulnar claw-hand deformity within 7 weeks of injury that resolved spontaneously by 20 weeks postinjury with nonoperative treatment. No patient showed any signs or symptoms of an ischemic compartment syndrome. Both nerve injuries were identified immediately at the time of fracture by a careful neurologic examination. This avoids confusion with a postreduction nerve entrapment injury or ischemic injury after a localized compartment syndrome, which may have considerably different treatments and outcomes. We recommend that a careful neurologic examination be recorded before any manipulative reduction of forearm fractures in children. If an ulnar nerve palsy is detected, it is probably a result of nerve contusion and should resolve without the need for surgical exploration.     

Effect of antenatal betamethasone and dexamethasone administration on fetal heart rate variability in growth-retarded fetuses

The results of the operative treatment of 27 humeral shaft fractures treated at the University of Louisville during a 2-year period were reviewed. The aim of this study was to analyze 1) the indications and results of surgical treatment, 2) the indications for nailing versus plating, and 3) the failures and their treatment (especially surgical nonunions). Indications for surgery were polytrauma patients (including open fractures, associated neurovascular injuries, associated ipsilateral forearm injuries) and isolated unstable fractures in which closed reduction failed. Plate and screw osteosynthesis was used in patients with proximal and distal fractures, in the presence of neurovascular injuries, progressive radial nerve palsy and failure of closed reduction due to interposition of soft tissue. Intramedullary antegrade nailing was preferentially used in polytrauma patients. Seven patients (25%) needed further surgery because of nonunion. The frequency was higher after plating (30%) than after nailing (20%), it was more common in comminuted fractures, middle third fractures and after insufficient distal locking. Exchange nailing resulted in union in 5 of the 7 cases. Although excellent results with low complication rates are reported in the recent literature following plate and screw osteosynthesis or locked intramedullary nailing, we found that operative treatment of difficult humeral shaft fractures is still fraught with a high complication rate.     

Regional proliferative patterns in the colon of patients at risk for hereditary nonpolyposis colorectal cancer

Between 1989 and 1993, 20 intercondylar fractures of the distal humerus were treated by open reduction, internal fixation and early postoperative mobilisation. One patient died on the third postoperative day as a result of multiple injuries, leaving 19 patients for evaluation. The mean follow-up period was 4.1 years (range 2.0 to 6.7 years). According to the Muller system, there were 7 type C1 and 12 type C2 fractures. Using the Jupiter criteria, 6 elbows were rated as excellent, 9 good and 4 fair. Complications included late ulnar neuritis in one patient and wound infection in another patient.     

Incidentally detected mitral valve anomaly?

Four children, who developed ulnar nerve palsy following percutaneous fixation of supracondylar fracture of the humerus by Kirschner wires (K-wires) are reported. In one the K-wire was removed within 48 h and the neuropraxia recovered immediately. In the other three patients recovery took an average of 6 weeks after removal of the wires and only after exploration of the ulnar nerve. The nerve was found to be trapped behind the medial epicondyle of the humerus. Release and subsequent transposition of the nerve resulted in recovery. Certain measures are suggested to prevent this avoidable complication in the treatment of supracondylar fractures of the humerus in children.     

Blue light inhibits mitosis in tissue culture cells

The eponymous term "Monteggia fracture" is most precisely used to refer to dislocation of the proximal radioulnar joint in association with a forearm fracture. It is the character of the ulnar fracture, rather than the direction of radial head dislocation, that is useful in determining the optimal treatment of Monteggia fractures in both children and adults. Stable anatomic reduction of the ulnar fracture results in anatomic reduction of the radial head. The notoriously poor results of treatment of Monteggia fractures in adults improved dramatically after the development of modern techniques of plate-and-screw fixation, which facilitate early mobilization by ensuring anatomic reduction. The relatively good results associated with nonoperative treatment of pediatric Monteggia injuries reflect the prevalence of stable (incomplete) fractures in children. Unstable (complete) ulnar fractures are prone to residual or recurrent displacement and may require operative fixation. Late reconstruction of chronic Monteggia lesions in children can be complicated and unpredictable. The key to a good outcome after a Monteggia-type fracture-dislocation of the forearm remains early recognition of proximal radioulnar dissociation.     

Fractures in childhood in Khartoum

A prospective study of fractures in 231 children received at Khartoum North Teaching Hospital(KNTH) was carried out for a period of six months. The incidence of child fracture rated as one per day, then it increased from the age of 5 years onwards in boys and between 6 and 8 years in girls. Most injuries were sustained during the day time, especially between late afternoon and sunset. 82% of injured children presented to a medical facility, while 18% were taken to native healers first. Non-road traffic accidents accounted for 84% of the fractures mainly due to sports, domestic injuries and falls; whereas road traffic accidents were 16% and occurred mainly in pedestrians. Forty three percent of the fractures needed only first aid and splintage while 42% needed closed reduction. Thirty one percent of all patients were treated as inpatients. The long bones were affected in 91% of all fractures, the commonest site being the distal end of the forearm (26%), followed by supracondylar fracture of the humerus (15.6%). In the upper limb, left-sided fractures predominated. The epiphyseal injuries were 3.5% of all fractures, mainly at the distal radial epiphysis. Boys were commonly affected between 13-15 years of age. Open fractures constituted 9.8% of the series and were mainly due to traffic accidents in town dwellers, the most vulnerable bones were those of the leg and foot. Pathological fractures accounted for 2.2% and were due to bone cysts and osteogenesis imperfecta. The problem of child safety and the preventive measures need to be more stressed.     

Heparin, low molecular weight heparin, heparinoid, and antithrombin III therapy of disseminated intravascular coagulation

OBJECTIVE: To determine features of fractures in young children that would be helpful in distinguishing child abuse from unintentional injuries. DESIGN: Case series. SETTING: Pediatric Services of Yale-New Haven (Conn) Hospital (a tertiary care center). PATIENTS: Consecutive children who were less than 3 years of age and who were examined for a fracture from January 1979 through December 1983 were identified from the daily logs of the emergency department or the hospital's child abuse registry. OUTCOME MEASURE: Each case was rated, by means of predefined criteria and a consensus of two clinicians and two pediatric radiologists, on a seven-point scale from "definite child abuse" to "definite unintentional injury." A middle rating of "unknown" was used if there was not enough information to reach a consensus. RESULTS: Of the 253 fractures in 215 children that were identified, we categorized 24.2% as abuse, 8.4% as unknown, and 67.4% as unintentional injuries. Fractures that were considered likely due to abuse were (1) fractures in children whose caretakers reported either a change in the child's behavior, but no accidental event, or a minor fall, but the injury was more severe than expected; (2) fractures of the radius/ulna, tibia/fibula, or femur in children less than 1 year of age; or (3) midshaft or metaphyseal fractures of the humerus. Linear fractures of the parietal bone were the most common skull fractures, whether due to abuse or unintentional injuries. CONCLUSION: In young children with fractures, child abuse is common. By comparing fractures due to abuse and those due to unintentional injuries, we obtained empiric evidence to help clinicians and radiologists correctly examine children with such serious injuries.     

Pediatric forearm fractures. Diagnosis, therapy and possible complications

Nonoperative management of forearm fractures in children has a good outcome in over 90% of all cases. In our own series (n = 102) there were only six children (6.1%) with significant limitation (> 25 degrees) of forearm rotation. In these cases two out of four (50%) were located in the proximal third but only two out of 68 in the distal third. Indications for operative stabilization are the following: compound fractures, fractures associated with vessel and nerve injuries, joint fractures, dislocated fractures of the middle and proximal third, and Monteggia/Galeazzi injuries. As implants intramedullary devices are preferred. Twenty children were managed with elastic IM rods between 1994 and 1995 at our institution. At final follow-up all had a free ROM and a maximal axial malalignment of less than 5 degrees. In the region of the distal forearm K-wires are useful. Plates play a dominant role for corrections and nonunions; external skeletal stabilization is indicated for temporary fixation in compound fractures.     

Basic epidemiology of fractures of the upper and lower limb among Americans over 65 years of age

Current knowledge regarding the basic epidemiology of fractures is largely limited to a few fracture sites, notably those of the hip and distal forearm. To clarify the patterns of incidence of limb fractures in the elderly, we used data from a 5% sample of the U.S. Medicare population over age 65 years during the years 1986-1990. We identified incident fractures of the proximal humerus, other parts of the humerus, proximal radius/ ulna, shaft of the radius/ulna, distal radius/ulna, pelvis, hip, other parts of the femur, patella, ankle, and other parts of the tibia/fibula from diagnoses and procedures coded on claims for inpatient services, outpatient facility use, and physician services. We used Poisson regression to investigate the relation between demographic factors and fracture risk at these sites. Fractures at the hip were the most common, accounting for 38% of the fractures identified. The proximal humerus, distal radius/ulna, and ankle also were common fracture sites. A pattern of rapidly rising rates with age was seen for fractures of the pelvis, hip, and other parts of the femur among women. Fractures distal to the elbow or knee, however, had, at most, modest increases in incidence with age over 65 years. For each of the fractures studied, women had higher rates than men of the same race, and whites generally had higher rates than blacks of the same gender. Gender-related differences in risk were larger among whites than among blacks, and racial differences in risk were more marked among women than among men.     

Entrapment and transection of the median nerve associated with greenstick fractures of the forearm: case report and review of the literature

OBJECTIVE: To report an unusual neurologic complication associated with greenstick fractures of the forearm. METHODS: Near-complete transection of the median nerve associated with greenstick fractures of the shaft of the left radius and ulna in a 13-year-old boy is described. The results of treatment are reported in detail. CONCLUSION: Significant median nerve injury may coexist with apparently benign, closed greenstick fractures of the forearm.     

Tethered spinal cord syndrome in adults

Twenty-six of 27 patients in whom an ulnar shortening osteotomy had been performed to treat ulnar impaction following distal radius (20 patients) or forearm (6 patients) fractures were evaluated at an average follow-up of 21 months. All but 3 patients were satisfied with the end-result and according to a modified Gartland-Werley score there were 1 excellent, 10 good, 10 fair and 5 poor results. This is distinctly inferior to other reports of mainly non-traumatic indications. Degenerative changes at the distal radioulnar joint were associated with fair and poor results and careful radiological examination of this joint is mandatory before ulnar shortening is performed in posttraumatic ulnar impaction syndrome. Bony union of the osteotomy was achieved at 12 to 16 weeks postoperatively except for 2 cases and there was no difference between transverse (13 cases) and oblique osteotomies (13 cases). We therefore prefer the technically easier transverse osteotomy and recommend the use of 3.5 dynamic compression plates for stabilisation which resulted in a low complication rate in our series and enables early active wrist mobilisation.     

Single-bone fixation of both-bone forearm fractures

Seventeen children with diaphyseal both-bone forearm fractures, for which closed reduction had failed, were treated with fixation of either the radius or ulna. Sixteen were followed up to their clinical end point. Results in all children were excellent; all had a full return of motion except two who lacked 5 degrees of pronation. This retrospective series is the first reported to date looking exclusively at diaphyseal both-bone forearm fractures in children treated with fixation of a single bone. The rationale of treatment is to stabilize one bone while the other is rotated into reduction. Repeated anesthetics are avoided, and malreduction is prevented without adult-style both-bone plating. We prefer intramedullary fixation as hardware is easier and safer to place and remove.     

Monteggia fractures in adults

The records concerning ten consecutive years of experience with Monteggia fractures in adult patients at a level-one trauma center were retrospectively reviewed. Forty-eight patients who had been followed for a minimum of two years (average, 6.5 years; range, two to fourteen years) were identified. There were twenty-five women and twenty-three men, and the average age was fifty-two years (range, eighteen to eighty-eight years). According to the classification of Bado, there were seven type-I, thirty-eight type-II, one type-III, and two type-IV injuries. Twenty-six patients (68 percent) who had a Bado type-II fracture had an associated fracture of the radial head; ten of these patients also had a fracture of the coronoid process as a single large fragment. The ulna was fixed with a tension band-wire construct supplemented with screws in three patients (all of whom had a Bado type-II fracture). An ulnar diaphyseal fracture was fixed with an intramedullary Steinmann pin in one patient. The remaining patients had fixation with a plate and screws. The fracture of the radial head was treated with either complete or partial excision of the fragments in twelve patients (with replacement with a silicone prosthesis in two), open reduction and internal fixation in ten patients, and no intervention in four patients. Nine patients, all of whom had a Bado type-II fracture, needed a reoperation within three months after the initial operation; five had revision of a loose ulnar fixation device, three had resection of the radial head, and one had removal of a wire that had migrated from the radial head into the elbow articulation. Other important complications included proximal radioulnar synostosis in three patients, ulnar malunion in three, posterolateral rotatory instability of the ulnohumeral joint in one, and instability of the distal radioulnar joint in one. At the most recent follow-up examination, which was performed after all of the reoperations and reconstructive procedures had been done, the average score according to the system of Broberg and Morrey was 86 points (range, 15 to 100 points). The result was excellent for eighteen patients, good for twenty-two, fair for two, and poor for six. Six of the eight patients who had an unsatisfactory (fair or poor) result had had a Bado type-II fracture with a concomitant fracture of the radial head. These unsatisfactory results were related to a malunited fracture of the coronoid process in two patients, a proximal radioulnar synostosis in one, a malunited fracture of the coronoid process and a proximal radioulnar synostosis in one, a malunion of the ulna in one, and painfully restricted rotation of the forearm after operative fixation of a comminuted fracture of the radial head in one. The other two unsatisfactory results were in a patient who had had a Bado type-I fracture and in one who had had a Bado type-IV fracture. The results of the present series are much better than those reported in most earlier studies, suggesting that stable anatomical fixation of the ulnar fracture (including associated fracture fragments of the coronoid process) with a plate and screws inserted with use of current techniques of fixation leads to a satisfactory result in most adults who have a Monteggia fracture. The posterior (Bado type-II) fracture is the most common type of Monteggia fracture in adults. Problems with the elbow related to fractures of the coronoid process and the radial head, which are common with Bado type-II Monteggia fractures, remain the most challenging elements in the treatment of these injuries.     

Prolonged fasting in pediatric outpatients does not cause hypoglycemia

The long-term results after the manipulation and strapping in flexion of selected extension supracondylar fractures of the humerus were evaluated in 43 children. Reduced fractures that were stable when immobilized in approximately 110 degrees of flexion, without producing circulatory obstruction, were treated in this manner. After a minimum review of 4 years, 95 per cent of the children had an excellent or good range of elbow motion and 88 per cent had excellent or good elbow alignment. No child had Volkmann's ischaemic contracture. Five children had cubitus varus which was due to malunion in three, but was unrelated to the treatment of the supracondylar fracture in two children. If these two latter children were excluded then excellent or good alignment was observed in all children who had a Baumann (humerocapitellar) angle of 80 degrees or less at the time of reduction and 84 degrees or less 10 days after the fracture. We concluded that manipulation and strapping in flexion was suitable for approximately 60 per cent of children with isolated displaced supracondylar fractures of the humerus.     

Abdominal trauma and pelvic injury in the growth period

Children with pelvic fractures usually are polytraumatized. Concomitant abdominal and pelvic injuries are not uncommon. Medical records and X-rays of 54 children, in which a pelvic fracture was diagnosed at our institution from 1974-1993, were reviewed. Children ages < or = 16 years and treated as in-patients were included in this study. The fractures were classified according to the AO-Classification. 47 patients (87.0%) had concomitant injuries. The mean Polytrauma Score was 23.7 (mean Injury Severity Score 30.5). Nine Children sustained an open pelvic fracture with rectal and/or vaginal tear. 15 genitourinary lesions were found in 13 children. 18 patients underwent laparotomy. A large pelvic/retroperitoneal hematoma was found in 11 cases. There were 7 liver lacerations, 7 splenic injuries, 2 mesenteric tears, 2 kidney injuries and 1 small bowel lesion. Eight children (14.8%) died with 5 of them due to retroperitoneal or/and abdominal bleeding complications. A recent follow-up examination (81.8%) with a mean follow-up of 11.3 years showed that long-term morbidity usually was attributed to pelvic concomitant injuries.     

Prognostic value of male diagnostic profiles in intracytoplasmic sperm injection (ICSI)

This reported investigation was designed to determine the role of a new synthetic conduit-expanded polytetrafluoroethylene (ePTFE) tube--in clinical repair of median and ulnar nerves in the upper extremities. The main goals of this study were: to determine the effectiveness of the ePTFE conduit in clinical nerve reconstruction; to evaluate the potential of this technique in reconstruction of various nerve gaps (1.5 to 6 cm); and to analyze the results of repair with the ePTFE tube regarding different mechanisms of injury. Forty-three patients were evaluated. They had upper-extremity peripheral-nerve injuries (21 injuries to the median nerve, and 22 ulnar nerve injuries) located at the various levels of the upper extremities. All surgical procedures described in the study were secondary reconstructions, and the average delay from injury to repair was 4.2 months. With regard to the nerve-gap lengths, patients were categorized in two groups. Group 1 (gaps from 1.5 to 4 cm) included 28 patients (17 median nerve injuries and 11 ulnar nerve injuries), and Group 2 (gaps from 4.1 to 6 cm) comprised 15 patients (4 median nerve injuries and 11 ulnar nerve injuries). Results showed that 78.6 percent of patients from Group 1 demonstrated functional motor and sensory recovery, while reconstruction of only 13.3 percent of peripheral nerves from Group 2 resulted in useful reinnervation. According to published results, ePTFE conduit is a reliable and successful surgical procedure for nerve repair in reconstruction of nerve gaps up to 4 cm between the ends of median and ulnar nerves in various levels of the upper extremity. Because of its properties, ePTFE conduit has the advantages of promoting better nerve regeneration, compared to other synthetic tubes, especially in reconstruction of proximal nerve injuries, larger nerve gaps, and in cases with unfavorable mechanisms of nerve injury.     

Maternal vitamin A deficiency and child growth failure during human immunodeficiency virus infection

Salter-Harris type III fractures of the proximal humerus are rare injuries. We report a Salter-Harris type III anterior fracture-dislocation of the proximal humerus in a 10-year-old boy that was open reduced and internally stabilized. A bone scan performed during the initial hospitalization and at 2-year follow-up revealed devascularization and subsequent revascularization of the humeral head. At 2-year follow-up, the patient had full motion of the shoulder, no pain, and arm strength equal to that of the contralateral side. Four cases of Salter-Harris type III fractures of the proximal humerus have been previously reported; good early clinical outcomes were obtained in all. Despite devascularization of the epiphyseal fragment, excellent clinical outcomes may result.