Roth Kasper C, Denk Katharina, Colaris Joost W, Jaarsma Ruurd L
Erasmus University (Faculty of Medicine and Health Sciences) and Erasmus Medical Centre, Rotterdam, The Netherlands.
Arch Orthop Trauma Surg. 2014 Dec;134(12):1699-707. doi: 10.1007/s00402-014-2091-8. Epub 2014 Oct 7.
Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided.
Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1-8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire.
Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups.
Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9-<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.
小儿桡骨远端骨折移位的治疗并非总能成功。角度畸形复发是常见的并发症。对于何时进行二次手法复位尚无共识。本研究的目的是分析小儿前臂骨折再成角的长期预后，以确定是否可以避免再次手法复位。
本回顾性队列研究纳入了因桡骨远端骨折接受闭合复位且随访时出现再成角的儿童。我们将接受再次手法复位的儿童与保守治疗的儿童进行了比较。再成角定义为前后位或侧位片上成角≥15°。受伤后1 - 8年对儿童进行复查。观察指标包括X线片上的残余成角、主动活动范围、握力、视觉模拟评分（满意度、外观和疼痛）以及儿童ABILHANDS问卷。
纳入66名儿童（平均年龄9.6岁）。24例骨折接受了再次手法复位，42例骨折任其在成角位置愈合。再成角时，保守治疗组中年龄<12岁的儿童与接受再次手法复位的儿童成角情况相似。再次手法复位组中年龄≥12岁的儿童成角明显大于保守治疗组的儿童。在平均4.0年的最终随访时，所有患者X线片显示接近解剖复位。功能预后主要为优。治疗组之间在功能、主观或影像学预后方面无显著差异。
12岁以下儿童桡骨远端骨折再次手法复位并未改善预后，认为再次手法复位不必要。保守治疗组中年龄≥12岁的儿童尽管成角超过现行指南，但仍取得了满意的预后。基于观察到的重塑情况，我们现在接受再成角时9岁以下儿童成角可达30°；9 - <12岁儿童成角25°；≥12岁儿童成角20°。我们得出结论，临床医生应更慎重地进行再次手法复位。
