Department of Orthopaedics and Sports Medicine, Erasmus University Medical Centre, Rotterdam, the Netherlands.
Department of Orthopedics, Elkerliek Hospital, Helmond, the Netherlands.
Clin Orthop Relat Res. 2024 Oct 1;482(10):1873-1881. doi: 10.1097/CORR.0000000000003100. Epub 2024 May 7.
For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.
QUESTIONS/PURPOSES: In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?
In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.
At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).
In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.
Level I, therapeutic study.
对于儿童的远端前臂骨折，已经证明使用肘下石膏固定是一种有效的治疗方法，可以克服肘上石膏固定带来的不适和不必要的肘部固定。对于缩短的尺桡骨干双骨折，我们之前的随机对照试验（RCT）——比较了肘上石膏固定和早期转换为肘下石膏固定——在短期随访时发现，再移位风险或功能结果没有差异。尽管在儿童尺桡骨干双骨折后进行更长时间随访的研究很少，但这些研究是必不可少的，因为生长可能会影响结果。
问题/目的：在这项早期 RCT 的二次分析中，我们提出了以下问题：（1）对于稳定的缩短尺桡骨干双骨折儿童，早期从肘上转换为肘下石膏固定是否会导致更差的临床和影像学结果？（2）在 7.5 年的随访中，发生愈合不良是否会导致临床结果较差？
在这项研究中，我们评估了至少随访 5 年的儿童患者，这些患者都参与了之前的 RCT。中位（范围）随访时间为 7.5 年（5.2 至 9.9 年）。这项 RCT 的患者来自四家不同的城市医院的急诊科。2006 年 1 月至 2010 年 8 月，我们治疗了 128 例尺桡骨干双骨折的儿童患者。所有 128 名患者均符合纳入标准；24%（31 名）因在最低研究随访前丢失或数据集不完整而被排除，97%（97 名）的患者可进行二次分析。随访组的失访率与纳入人群相当。符合条件的患者被邀请进行二次功能和影像学评估。主要结局是与未受伤的对侧手臂相比，前臂旋转的差异。次要结局包括 ABILHAND-kids 和 QuickDASH 问卷、与对侧前臂相比，肘部和腕部的屈伸丢失、JAMAR 握力比和残余畸形的影像学评估。研究对儿童、家长和临床医生没有进行盲法。
在 7.5 年的随访中，ABILHAND-kids 问卷评分（肘上石膏固定：41±2.4；肘上/下石膏固定：41.7±0.7，平均差异-0.7[95%置信区间（CI）-1.4 至 0.04]；p=0.06）、QuickDASH（肘上石膏固定：5.8±9.6；肘上/下石膏固定：2.9±6.0，平均差异 2.9[95%CI-0.5 至 6.2]；p=0.92）和握力（肘上石膏固定：0.9±0.2；肘上/下石膏固定：1±0.2，平均差异-0.04[95%CI-1 至 0.03]；p=0.24）均无差异。功能结果无差异（前臂旋转丢失：肘上石膏固定：7.9±17.7；肘上/下石膏固定：4.1±6.9，平均差异 3.8[95%CI-1.7 至 9.4]；p=0.47；运动弧：肘上石膏固定：152°±21°；肘上/下石膏固定：155°±11°，平均差异-2.5[95%CI-9.3 至-4.4]；p=0.17；腕部屈伸丢失：肘上石膏固定组：1.0°±5.0°；肘上/下石膏固定组：0.6°±4.2°，平均差异 0.4°[95%CI-1.5°至 2.2°]；p=0.69）。两组在 7 个月时与 7 个月时相比，前臂旋转均有改善。对于影像学分析，唯一的差异是尺骨正位（肘上石膏固定：6°±3°；肘上/下石膏固定：5°±2°，平均差异 1.8°[0.7°至 3°]；p=0.003），尽管这可能没有临床意义。其他参数没有差异。在 7 个月随访时有持续愈合不良的 13 例患者，在 7.5 年随访时与无愈合不良的儿童患者相比，功能结果无明显差异。在愈合不良组，前臂旋转丢失为 5.5°±9.1°，在无愈合不良组为 6.0°±13.9°，平均差异为 0.4°（95%置信区间为-7.5 至 8.4；p=0.92）。
鉴于这些结果，我们建议对儿童缩短的尺桡骨干双骨折进行早期转换为肘下石膏固定。这项研究表明，即使在发生二次骨折移位的患者中，也会发生重塑。即使存在愈合不良，这些患者大多仍表现出良好至优秀的最终结果。未来的研究，如荟萃分析或大型前瞻性观察研究，将有助于确定骨骼年龄、性别以及桡骨和尺骨的畸形角度和方向对临床结果的影响。此外，类似的系统评价可能有助于阐明儿童下肢骨折可接受的畸形角度。
I 级，治疗性研究。
