Shaw K Aaron, Jamnik Adam, Shiver Luke, Kronenberger Keegan, Harris Hilary, Burks Robert, Fletcher Nicholas D
Department of Pediatric Orthopaedics, Children's Mercy Hospital, Kansas City, MO, USA.
Department of Pediatric Orthopaedic Surgery, Scottish Rite for Children Hospital, Dallas, TX, USA.
J Pediatr Soc North Am. 2024 Feb 28;6:100013. doi: 10.1016/j.jposna.2024.100013. eCollection 2024 Feb.
The well accepted standard for the management of pediatric both bone forearm fractures (BBFFs) is closed reduction and cast management. The acceptable angulation guidelines, dictated by patient age and fracture location, help determine when nonsurgical management should be abandoned. Despite their widespread acceptance, angulation guidelines are not evidence-based and have not been critically investigated within the reported literature.
A systematic review and metanalysis was performed after isolating published articles from 1967 to 2021 from a review of MEDLINE, Embase, EBSCO, and Cochrane databases. Articles which reported on closed management of midshaft, pediatric (<16 years old), BBFF, and reported on long term outcomes regarding range of motion restriction or the need for surgical treatment of symptomatic malunion, were included in the systematic review. Pertinent patient data for meta-analysis was extracted from individual studies when feasible. Univariate and multivariate analyses were performed examining the effect of fracture angulation parameters on malunion risk.
A total of 11 articles were included which reported on the management of 372 patients with midshaft BBFF. Overall, there was a 15.0% rate of symptomatic malunion ( = 47/313). The pooled analysis using individual data from 81 patients reported in 6 studies demonstrated an 18.8% ( = 16) rate of symptomatic malunion with only final radius angulation on lateral radiographs ≥15° as an independent risk factor for symptomatic malunion development.
Although this study would appear to support current acceptable angulation parameters for pediatric midshaft BBFF and the risk for symptomatic malunion development, there was a paucity of available data that precluded a rigorous analysis. Further high-quality research is needed to ascertain if our currently accepted guidelines are indeed best practice guidelines or the representation of confirmation bias in practice.
(1)Although pediatric midshaft bone forearm fracture remain an important component of pediatric orthopedic practice, there is a lack of rigorous data available to guide treatment decisions.(2)In this study only 5 of 84 potential studies met inclusion criteria to accessing the rate of symptomatic malunion, resulting in a pooled malunion rate of 18.8%.(3)Of the potential variables, only final sagittal radius alignment >15° was significantly associated with the development of a symptomatic malunion.
II.
小儿双骨干前臂骨折（BBFFs）公认的治疗标准是闭合复位和石膏固定。根据患者年龄和骨折部位制定的可接受成角指南有助于确定何时应放弃非手术治疗。尽管这些成角指南被广泛接受，但它们并非基于证据，且尚未在已发表的文献中得到严格研究。
通过检索MEDLINE、Embase、EBSCO和Cochrane数据库，对1967年至2021年发表的文章进行系统回顾和荟萃分析。系统回顾纳入了报道小儿（<16岁）中轴型BBFF闭合治疗以及关于活动范围受限的长期结局或有症状骨不连手术治疗必要性的文章。可行时，从个体研究中提取用于荟萃分析的相关患者数据。进行单因素和多因素分析，以检验骨折成角参数对骨不连风险的影响。
共纳入11篇报道372例中轴型BBFF患者治疗情况的文章。总体而言，有症状骨不连发生率为15.0%（47/313）。对6项研究中报道的81例患者的个体数据进行汇总分析，结果显示，仅以侧位X线片上最终桡骨成角≥15°作为有症状骨不连发生的独立危险因素时，有症状骨不连发生率为18.8%（16/85）。
尽管本研究似乎支持目前小儿中轴型BBFF可接受的成角参数以及有症状骨不连发生的风险，但可用数据匮乏，无法进行严格分析。需要进一步开展高质量研究，以确定我们目前接受的指南是否确实是最佳实践指南，还是实践中确认偏倚的体现。
（1）尽管小儿中轴型前臂骨折仍是小儿骨科实践的重要组成部分，但缺乏严格数据来指导治疗决策。（2）在本研究中，84项潜在研究中只有5项符合纳入标准，以评估有症状骨不连的发生率，汇总骨不连发生率为18.8%。（3）在潜在变量中，只有最终矢状面桡骨对线>15°与有症状骨不连的发生显著相关。
II级。
