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.     

Carpal fractures in children

This study addresses the likelihood of false negative urine pregnancy test results, due to physiological urine dilution as described in some anecdotal reports. In this prospective study 320 pregnancy tests were performed on urine samples of varying concentrations obtained from 40 women, with suspected complications of early pregnancy, who had presented for ultrasound scans. Four different pregnancy tests were used and serum betahCG levels were measured quantitatively. Despite a mean fivefold increase in urine dilution, the pregnancy tests with low betahCG detection limits maintained maximal sensitivity. The detection of betahCG in dilute urine was adversely affected by using pregnancy tests with higher betahCG detection limits and these tests should be used with caution when assessing gynaecological emergencies.     

Isolated fractures of the lesser trochanter in children

In a retrospective study of 1126 children with fractures of the proximal third of the femur, three children were found to have isolated fractures of the lesser trochanter. This fracture occurred from a fall in one child and following sporting activities, without a history of injury, in the others. In the latter children, the clinical presentations were similar to those of children with transient synovitis of the hip or Perthes disease. In each child, plain radiographs showed an avulsion fracture of the bony portion of the lesser trochanter. Early and complete recovery followed symptomatic treatment even when there was marked proximal displacement of the avulsed segment of the lesser trochanter.     

Supracondylar humerus fractures in children

Supracondylar fractures of the humerus are the most common fractures in children that require surgery. A significant advancement in the field of pediatric orthopedics has been closed reduction and percutaneous pinning of these fractures. This technique, using high quality fluoroscopic imaging, allows for a near anatomical reduction of fractures without the need for an open surgical procedure or prolonged traction. Supracondylar fractures in children are often associated with neurologic and vascular damage that must be recognized before fracture reduction. Nursing staff members' skill with pediatric patients can greatly aid the surgeon in the timely and safe treatment of these fractures.     

Problem elbow fractures in children

In this article guidelines are given for the treatment of pediatric elbow fractures, including supracondylar, medial epicondylar, lateral condylar, proximal radial, and olecranon fractures. Treatment techniques are described in detail and suggestions are provided to minimize complications.     

406 femoral fractures in children

406 fractures of the femur in persons younger than 17 years of age were treated at Haukeland University Hospital, Bergen, from January 1980 to December 1993. The incidence was 35/100,000 per year; 57/100,000 for boys, and 24/100,000 for girls. No significant changes in the incidence occurred during the study period. 70% of the fractures occurred in boys. 78% had an isolated fracture, while 7% had other fractures, 7% head injuries and 8% injuries of multiple organs as well. Traffic accidents accounted for 35% of the fractures. 65% of the femur fractures were treated by skeletal traction (mean hospitalisation 30 days), 21% were operated on initially (hospitalisation 12 days), and 14% were given early spica cast (hospitalisation three days). The results of the treatment were generally satisfactory. Neither anisomelia (8.5% more than 10 mm) nor malrotation (12% more than 10 degrees) of the femur was a serious problem, but the length of time the patients were hospitalized was rather long.     

Treatment of closed fractures in children

The principles of treatment of bone fractures in children differ from those in adults and are determined by the morphofunctional features of the growing and developing child organism: the anatomo-physiological peculiarities of the structure and blood supply of the bone of a child, the high regenerative possibilities, the capability for self-correction of some types of residual displacement during growth. Peculiar types of bone injuries occur in childhood which are not encountered in adults. These are subperiosteal linear and folded fractures, fractures of the green stick type, damage to the growth zones (epiphyseolysis and osteo-epiphyseolysis), etc. The localization of the fracture and the size (degree) of displacement of the fragments are very important in the choice of the therapeutic tactics. Predominantly qualitative appraisal of the displacement suffices in metaphyseal and diaphyseal fracture and in injury to the growth zones (extra-articular fracture). Quantitative appraisal of the size of the displacement is advisable in intra-articular fractures, for which the techniques are suggested. Four degrees of fragment displacement are distinguished. Depending on the localization and character of the fracture and the size of the displacement of the fragments, conservative, active surgical, and operative therapeutic tactics may be chosen according to strictly differentiated indications. Each of them includes various methods of fracture management.     

Classification of ankle fractures in children

The roentgenograms of 310 children treated for ankle fractures were evaluated for grouping according to the classifications of Ashhurst-Bromer-Weber, Lauge-Hansen, and Salter-Harris. The mean age of the children at the time of injury was 11.1 years (range 2-14 years). Two hundred twenty-one (71.3%) children had malleolar fractures, 71 (22.9%) had tibial epiphyseal fractures, and 18 (5.8%) had syndesmotic lesions. The age distribution of fractures was typical: malleolar fractures predominated among the younger children, epiphyseal fractures among the older. Only the oldest children had avulsion fractures of the syndesmosis. Grouping of the fractures according to Lauge-Hansen and Ashhurst-Bromer-Weber, classifications suited to adults was largely unsuccessful. Epiphyseal fractures, moreover, were easily classified according to Salter-Harris. In spite of their complexity, ankle fractures in children can be roughly divided into avulsional and epiphyseal fractures. Adequately reduced avulsional fractures can be expected to heal well; epiphyseal fractures, however, may five rise to late complications. We propose, therefore, that ankle fractures in children be classified on the basis of roentgenological findings with respect primarily to epiphyseal lesions as well as on an additional simple grouping as to risk for clinical purposes: Group I, low risk, avulsional fractures and epiphyseal separations; Group II, high risk, fractures through the epiphyseal plate.     

Remanipulation of forearm fractures in children

AIMS: To determine whether operator experience or time of operation affects the outcome of fractures of the forearm in the paediatric age group as measured by the need for remanipulation. METHODS: A retrospective analysis of 1155 children with forearm fractures requiring manipulation was undertaken. RESULTS: The remanipulation rate for these 1155 children was 136 or 11.7%. There was a significant difference in those fractures requiring remanipulation dependent upon the experience of the operator and the time of day the procedure was performed. The lowest rate of remanipulation was obtained by senior registrars operating between the hours of 0800-1700 (6/113 or 5.3%). The highest rate was found to be junior registrars between the hours of 1700-2200 (39/167 or 23.3%). It is especially interesting to note the relatively low rate (31/437 or 7.1%) obtained by junior registrars during the night shift (2200-0800 hours). CONCLUSIONS: The current overall remanipulation rate is acceptable. The low rate between 2200-0800 hours means rescheduling of these patients is unnecessary. The rate for junior registrars between 1700-2200 hours needs to be improved.     

Controversies regarding radial neck fractures in children

Fractures of the radial neck in children are not uncommon, yet several aspects of their management remain controversial. Until a consensus is reached regarding the determination of displacement, acceptability of initial angulation, treatment, and outcome, the complication rate of these fractures will remain high. The authors recommend measuring the displacement as the angle between a line perpendicular to the articular surface of the radial head with a line down the shaft of the proximal radius. Fractures that are angulated less than 30 degrees require immobilization alone. Fractures angulated more than 30 degrees should be treated with an attempt at closed reduction. If closed reduction fails, a percutaneous reduction should be attempted before open reduction. Internal fixation should be performed using an oblique extraarticular Kirshner wire for all unstable fractures. Grading outcome based on range of motion and the presence or absence of pain is recommended. It is hoped that once the controversies surrounding these fractures are resolved, the long term results of these troublesome injuries will improve.     

Forearm fractures in children: avoiding redisplacement

We reviewed eighty-six children with closed extra-articular distal forearm fractures to determine the factors responsible for early redisplacement. The most important favourable prognostic factor was a perfect anatomical reduction on the immediate post-reduction radiograph. This was far more likely when the manipulation was performed by an experienced surgeon.     

Characteristics of fractures of the distal part of the clavicle in children

Fractures of the clavicle are frequent in children and mostly affect the middle third. On the other hand, traumatic fractures of both medial and lateral thirds of the clavicle are rare. The lesions have special characteristics: difficulty in diagnosis for the medial third; risk of callus formation in the absence of surgical reduction of the lateral third. The authors report two observations of fractures of the medial and lateral thirds of the clavicle; they insist on the value of investigation by CT scan.     

Forearm fractures in children: pitfalls and complications

Five hundred fourty-seven consecutive forearm fractures in children were studied, with special emphasis on complications encountered. The most important apparent conclusion reached from this study is that greenstick and complete fractures are different, and that some of the pitfalls and complications seen following these injuries can be avoided if different methods of reduction are used for each. Greenstick fractures should be reduced by manipulating them into the correct proper plane of rotation; i.e., maximum pronation for distal third fractures, neutral for middle third fractures, and supination for proximal third fractures. Application of this familiar "rule of thirds" to complete fractures, however, may result in ratational deformity at the fracture site. Completer fractures should be reduced by finger trap traction, allowing the fracture to seek its own level of rotation. Several other observations were also noted. Angulation into radial deviation was found to remodel and equally as well as volar angulation, and remodeling may contine for as long as two years after injury. Growth disturbance following fractures through the distal radial epiphyseal plate is uncommon, but premature closure of the epiphysis did occur in one patient with a typical Type II fracture. Six concomitant nerve injuries were seen; all recovered spontaneously within 3 weeks.     

Intramedullary fixation of unstable both-bone forearm fractures in children

Mesaconitine, one of the main alkaloids contained in Aconiti tubers, is a centrally acting analgesic without affinity to opioid receptors. It has been reported that the antinociception is due to an interaction with the noradrenergic system. In the present study, the effect of mesaconitine on the uptake of noradrenaline and on neuronal activity was examined in rat hippocampus. Experiments were performed as a study of [3H]noradrenaline uptake into rat hippocampal synaptosomes. Mesoconitine inhibited [3H]noradrenaline uptake in a concentration-dependent manner with a Ki of 111.95+/-18 nM. In a further series of experiments, the effects of mesaconitine on the extracellularly recorded population spike were investigated in rat hippocampal slices. At a concentration of 10 nM, mesaconitine increased the amplitude of the postsynaptic population spike by 31.10%+/-6.7% of control and elicited one or two additional spikes. The presynaptic fiber spike and the field excitatory postsynaptic potential were not affected by this alkaloid. The enhancement of neuronal activity was abolished by 1 microM propranolol as well as by 1 microM timolol. It is concluded that mesoconitine increased the excitability in rat hippocampal pyramidal cells by an involvement of the noradrenergic system, with at least one mechanism being inhibition of noradrenaline uptake leading to an enhanced extraneuronal noradrenaline level.