Department of Orthopaedic Surgery, Elkerliek Hospital, Helmond, the Netherlands.
Department of Orthopaedics and Sports Medicine, Erasmus Medical Centre, Rotterdam, the Netherlands.
Clin Orthop Relat Res. 2022 Feb 1;480(2):395-404. doi: 10.1097/CORR.0000000000001980.
Short-term follow-up studies have shown that reduced metaphyseal both-bone forearm fractures in children should be treated with K-wires to prevent redisplacement and inferior functional results. Minimum 5-year follow-up studies are limited. Range of motion, patient-reported outcome measures, and radiographic parameters at minimum 5-year follow-up should be evaluated because they could change insights into how to treat pediatric metaphyseal forearm fractures.
QUESTIONS/PURPOSES: (1) Does K-wire stabilization of reduced metaphyseal both-bone forearm fractures in children provide better forearm rotation at minimum 5-year follow-up? (2) Do malunions (untreated redisplaced fractures) of reduced metaphyseal both-bone forearm fractures in children induce worse functional results? (3) Which factors lead to limited forearm rotation at minimum 5-year follow-up?
We analyzed the extended minimum 5-year follow-up of a randomized controlled trial in which children with a reduced metaphyseal both-bone forearm fracture were randomized to either an above-elbow cast (casting group) or fixation with K-wires and an above-elbow cast (K-wire group). Between January 2006 and December 2010, 128 patients were included in the original randomized controlled trial: 67 in the casting group and 61 in the K-wire group. For the current study, based on an a priori calculation, it was determined that, with an anticipated mean limitation in prosupination (forearm rotation) of 7° ± 7° in the casting group and 3° ± 5° in the K-wire group, a power of 80% and a significance of 0.05, the two groups should consist of 50 patients each. Between January 2014 and May 2016, 82% (105 of 128) of patients were included, with a mean follow-up of 6.8 ± 1.4 years: 54 in the casting group and 51 in the K-wire group. At trauma, patients had a mean age of 9 ± 3 years and had mean angulations of the radius and ulna of 25° ± 14° and 23° ± 18°, respectively. The primary result was limitation in forearm rotation. Secondary outcome measures were radiologic assessment, patient-reported outcome measures (QuickDASH and ABILHAND-kids), handgrip strength, and VAS score for cosmetic appearance. Assessments were performed by the first author (unblinded). Multivariable logistic regression analysis was performed to analyze which factors led to a clinically relevant limitation in forearm rotation.
There was a mean limitation in forearm rotation of 5° ± 11° in the casting group and 5° ± 8° in the K-wire group, with a mean difference of 0.3° (95% CI -3° to 4°; p = 0.86). Malunions occurred more often in the casting group than in the K-wire group: 19% (13 of 67) versus 7% (4 of 61) with an odds ratio of 0.22 for K-wiring (95% CI 0.06 to 0.80; p = 0.02). In patients in whom a malunion occurred (malunion group), there was a mean limitation in forearm rotation of 6° ± 16° versus 5° ± 9° in patients who did not have a malunion (acceptable alignment group), with a mean difference 0.8° (95% CI -5° to 7°; p = 0.87). Factors associated with a limited forearm rotation ≥ 20° were a malunion after above-elbow casting (OR 5.2 [95% CI 1.0 to 27]; p = 0.045) and a refracture (OR 7.1 [95% CI 1.4 to 37]; p = 0.02).
At a minimum of 5 years after injury, in children with a reduced metaphyseal both-bone forearm fracture, there were no differences in forearm rotation, patient-reported outcome measures, or radiographic parameters between patients treated with only an above-elbow cast compared with those treated with additional K-wire fixation. Redisplacements occurred more often if treated by an above-elbow cast alone. If fracture redisplacement is not treated promptly, this leads to a malunion, which is a risk factor for a clinically relevant (≥ 20°) limitation in forearm rotation at minimum 5-year follow-up. Children with metaphyseal both-bone forearm fractures can be treated with closed reduction and casting without additional K-wire fixation. Nevertheless, a clinician should inform parents and patient about the high risk of fracture redisplacement (and therefore malunion), with risk for limited forearm rotation if left untreated. Weekly radiographic monitoring is essential. If redisplacement occurs, remanipulation and fixation with K-wires should be considered based on gender, age, and direction of angulation. Future research is required to establish the influence of (skeletal) age, gender, and the direction of malunion angulation on clinical outcome.
Level I, therapeutic study.
短期随访研究表明，儿童尺桡骨干骺端双骨折应采用克氏针固定以防止再移位和功能结果不佳。最小 5 年随访研究有限。最小 5 年随访时应评估关节活动度、患者报告的结果测量和影像学参数，因为这些结果可能会改变我们对儿童尺桡骨干骺端双骨折治疗方法的认识。
问题/目的：(1) 儿童尺桡骨干骺端双骨折经克氏针稳定后，在最小 5 年随访时前臂旋转是否更好？(2) 儿童尺桡骨干骺端双骨折未治疗的骺端移位（未复位骨折）是否会导致功能结果更差？(3) 哪些因素导致最小 5 年随访时前臂旋转受限？
我们对一项随机对照试验的扩展最小 5 年随访进行了分析，该试验将儿童尺桡骨干骺端双骨折患者随机分为上肘石膏固定组（石膏组）或克氏针固定和上肘石膏固定组（克氏针组）。2006 年 1 月至 2010 年 12 月期间，纳入了 128 例符合原始随机对照试验标准的患者：石膏组 67 例，克氏针组 61 例。基于事先的计算，为了评估在旋前（前臂旋转）方面的限制，我们预计石膏组的平均限制为 7°±7°，克氏针组为 3°±5°，这需要 80%的效能和 0.05 的显著性，两组应各包括 50 例患者。2014 年 1 月至 2016 年 5 月，82%（128 例中的 105 例）患者纳入研究，平均随访 6.8±1.4 年：石膏组 54 例，克氏针组 51 例。创伤时，患者平均年龄为 9±3 岁，桡骨和尺骨的平均成角分别为 25°±14°和 23°±18°。主要结果是前臂旋转受限。次要结果包括影像学评估、患者报告的结果测量（QuickDASH 和 ABILHAND-kids）、手握力和美容外观的视觉模拟评分。评估由第一作者（未设盲）进行。多变量逻辑回归分析用于分析哪些因素导致前臂旋转受限。
石膏组和克氏针组的前臂旋转受限平均分别为 5°±11°和 5°±8°，平均差异为 0.3°（95%CI-3°至 4°；p=0.86）。石膏组的骺端移位发生率高于克氏针组：19%（13/67）比 7%（4/61），克氏针固定的优势比为 0.22（95%CI 0.06 至 0.80；p=0.02）。在发生骺端移位的患者（骺端移位组）中，平均前臂旋转受限为 6°±16°，而未发生骺端移位的患者（可接受对线组）为 5°±9°，平均差异为 0.8°（95%CI-5°至 7°；p=0.87）。与前臂旋转受限≥20°相关的因素是石膏固定后的骺端移位（OR 5.2[95%CI 1.0 至 27]；p=0.045）和再骨折（OR 7.1[95%CI 1.4 至 37]；p=0.02）。
在受伤后至少 5 年，儿童尺桡骨干骺端双骨折，与单独使用上肘石膏固定相比，使用附加克氏针固定的患者在前臂旋转、患者报告的结果测量或影像学参数方面无差异。单独使用上肘石膏固定更容易发生骺端移位。如果骨折骺端移位未及时治疗，会导致骺端愈合不良，这是最小 5 年随访时前臂旋转受限（≥20°）的一个危险因素。尺桡骨干骺端双骨折的儿童可以采用闭合复位和石膏固定，而无需附加克氏针固定。然而，临床医生应该告知家长和患者骨折骺端移位（和因此的骺端愈合不良）的高风险，如果不及时治疗，会导致前臂旋转受限。每周进行影像学监测至关重要。如果发生移位，应根据性别、年龄和成角方向考虑重新复位和克氏针固定。需要进一步的研究来确定（骨骼）年龄、性别和愈合不良的成角方向对临床结果的影响。
I 级，治疗性研究。
