Bohm Eric R, Bubbar Vic, Yong Hing Ken, Dzus Anne
University of Manitoba Joint Replacement Group, Concordia General Hospital, 1095 Concordia Avenue, Winnipeg, MB R2K 3S8, Canada.
J Bone Joint Surg Am. 2006 Jan;88(1):1-8. doi: 10.2106/JBJS.E.00320.
Closed fractures of the distal third of the forearm are the most common fractures of childhood, but the method of immobilization after closed reduction is controversial. This study was undertaken to determine whether below-the-elbow casts are as effective as above-the-elbow casts in immobilizing these types of fractures and to identify patient and treatment considerations that are related to loss of reduction.
We designed a blinded, randomized, controlled trial. The criteria for reduction and remanipulation were set a priori. The primary outcome measure was fracture immobilization as reflected by reangulation in the cast and by the need for remanipulation. Exploratory analysis with use of stepwise logistic regression analysis was undertaken to search for factors predictive of loss of reduction.
A total of 102 children were enrolled in the study and were allocated to two groups: the above-the-elbow cast group (fifty-six children) and the below-the-elbow cast group (forty-six children). The mean age was 8.6 years, and sixty-one patients were boys. The groups did not differ with respect to the initial fracture angulation, postreduction angulation, reangulation during cast immobilization, and angulation of the fracture at the time of cast removal. In the above-the-elbow cast group, twenty-three (42%) of fifty-five children with adequate radiographs met the criteria for remanipulation compared with fourteen (31%) of forty-five children with adequate radiographs in the below-the-elbow cast group (p = 0.27); only four of these thirty-seven children actually underwent remanipulation. Children with fractures of both the radius and ulna (p = 0.01) and those with residual angulation after reduction (p = 0.0001) were at the highest risk of meeting the criteria for remanipulation. The rates of complications related to the cast did not differ between the groups.
Below-the-elbow casts perform as well as above-the-elbow casts in maintaining reduction of fractures in the distal third of the forearm in children, and the complication rates are similar. Factors that are associated with a higher risk of loss of reduction include combined radial and ulnar fractures and residual angulation of the fracture after the initial reduction.
儿童前臂远端三分之一处的闭合性骨折是最常见的骨折类型，但闭合复位后固定的方法存在争议。本研究旨在确定肘部以下石膏固定与肘部以上石膏固定在固定这类骨折方面是否同样有效，并确定与复位丢失相关的患者和治疗因素。
我们设计了一项双盲、随机、对照试验。复位和再次手法复位的标准是预先设定的。主要结局指标是通过石膏内的再成角和再次手法复位的必要性来反映的骨折固定情况。采用逐步逻辑回归分析进行探索性分析，以寻找预测复位丢失的因素。
共有102名儿童纳入本研究并被分为两组：肘部以上石膏固定组（56名儿童）和肘部以下石膏固定组（46名儿童）。平均年龄为8.6岁，61例患者为男孩。两组在初始骨折成角、复位后成角、石膏固定期间的再成角以及拆除石膏时骨折的成角方面无差异。在肘部以上石膏固定组中，55名有足够X线片的儿童中有23名（42%）符合再次手法复位标准，而在肘部以下石膏固定组中，45名有足够X线片的儿童中有14名（31%）符合该标准（p = 0.27）；这37名儿童中只有4名实际接受了再次手法复位。桡骨和尺骨均骨折的儿童（p = 0.01）以及复位后有残余成角的儿童（p = 0.0001）达到再次手法复位标准的风险最高。两组与石膏相关的并发症发生率无差异。
在维持儿童前臂远端三分之一处骨折的复位方面，肘部以下石膏固定与肘部以上石膏固定效果相同，且并发症发生率相似。与复位丢失风险较高相关的因素包括桡骨和尺骨联合骨折以及初次复位后骨折的残余成角。
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