1. Fracture Distal Radius in Children Factors Responsible for Redisplacement after Closed Reduction Dr. Mohammed M. Zamzam, MD Associate Professor & Consultant Pediatric Orthopedic Surgeon KKUH, Riyadh, Saudi Arabia

3. Distal Radius Fractures in Children Epidemiology –The commonest fracture in children –Up to 23% of all pediatric skeletal injuries –Boys > girls

4. Distal Radius Fractures in Children Etiology –Resultant deformities are usually a product of indirect trauma involving angular loading combined with rotational displacement

5. Distal Radius Fractures in Children Outcome –Greenstick or complete fracture –Partial or complete displacement –Complications Compartment syndrome Malunion

6. Distal Radius Fractures in Children Good outcome –Restoration of wrist and forearm motion –Acceptable cosmetics –These goals are usually met with conservative treatment by reduction and immobilization

7. Distal Radius Fractures in Children Management –Anesthesia –Manipulation –Immobilization –Primary int. fixation?

8. Distal Radius Fractures in Children Management –Anesthesia –Manipulation –Immobilization –Primary int. fixation?

9. Distal Radius Fractures in Children Management –Anesthesia –Manipulation –Immobilization –Primary int. fixation?

10. Distal Radius Fractures in Children Reduction –Perfect –Acceptable 50% contact Up to 20° AP angulation

11. Distal Radius Fractures in Children Reduction –Stable –Unstable

12. Distal Radius Fractures in Children Follow up Redisplacement

13. Aim of the study To identify the possible factors responsible for redisplacement after acceptable closed reduction of fracture distal radius in children To delineate a clear and simple guidance while treating fracture distal radius in children

14. Methodology Criteria of patient selection –Age –Diagnosis –Treatment –Duration

15. Methodology Exclusion –Open fractures –Unacceptable initial reduction –Primary int. fixation –Inappropriate cast condition

16. Methodology Data collection –Age –Gender –Treating physician –Type of anesthesia –Redisplacement –Follow up and outcome

17. Methodology Radiographic analysis –Initial displacement –Ulnar fracture –Initial closed reduction –Redisplacement –Final outcome

18. Methodology Statistical study –Univariant analysis –Multivariate Logistic Regression Analysis

19. Results 183 children with displaced distal radial fractures 144 boys (79%) and 39 girls (21%) The mean age was 8 years (range 3-16) Associated distal ulnar fractures in 50 cases (27%)

20. Results 183 children with displaced distal radial fractures 144 boys (79%) and 39 girls (21%) The mean age was 8 years (range 3-16) Associated distal ulnar fractures in 50 cases (27%)

21. Results 183 children with displaced distal radial fractures 144 boys (79%) and 39 girls (21%) The mean age was 8 years (range 3-16) Associated distal ulnar fractures in 50 cases (27%)

22. Results 183 children with displaced distal radial fractures 144 boys (79%) and 39 girls (21%) The mean age was 8 years (range 3-16) Associated distal ulnar fractures in 50 cases (27%)

23. Results Radiological assessment at the time of injury -initial complete displacement in 75 patients (41%) -incomplete displacement in 108 patients (59%)

24. Results  The type of anesthesia was chosen according to the age of the child, his/her cooperation and sometimes according to the surgeon’s preference Sedation and/or local haematoma block in 101 (55%) General anesthesia in 82 patients (45%)

25. Results Radiological assessment after reduction –Perfect reduction in 142 fractures (78%)

26. Results Redisplacement in 46 patients (25%) 37 boys and 9 girls 35 patients (76%) had associated distal ulnar fractures Diagnosed within 2 weeks of the initial CR

27. RedisplacementNumberType of Initial Displacement 37/75 (49%)75/183 (41%)  Initial Complete Displacement 25/52 (48%)52/75 (69%) - Perfect initial reduction 12/23 (52%)23/75 (31%) - Imperfect initial reduction 9/108 (8%)108/183 (59%)  Initial Incomplete Displacement 7/90 (8%)90/108 (83%) - Perfect initial reduction 2/18 (11%)18/108 (17%) - Imperfect initial reduction Incidence of Redisplacement in relation to Initial Displacement and Post Reduction Position

28. Relation of Redisplacement to Initial Displacement According to the Type of Anesthesia General AnesthesiaDeep Sedation and/or Local Haematoma Block Type of Initial Displacement RedisplacementNumberRedisplacementNumber 23/59 (39%) 59/82 (72%) 14/16 (88%) 16/101 (16%) Initial Complete Displacement 0/23 (0%) 23/82 (28%) 9/85 (11%) 85/101 (84%) Initial Incomplete Displacement 23/82 (28%) 8223/101 (23%) 101Total

29. Results Remanipulation -More than 20° angulation or -less than 50% contact between radial fragments -Under GA + k-wire fixation

30. Follow up Average 13 weeks (range, 11-18) 3 cases with superficial wound infection Healing

31. Risk Factors for Redisplacement Significant Older children 10-16 years (P<0.003) Associated distal ulnar fractures (P<0.001 ) Reducing fractures under deep sedation and/or local haematoma block ( P<0.002) Initial complete displacement (P<0.00001) Not Significant Gender (P>0.8) Imperfect reduction (P>0.19)

32. Results of multivariate logistic regression analysis 95.0% C.I. for odds ratio Odds ratioSig.S.E. UpperLower 1.477.114.411.173.653 Gender 1.406.185.509.193.518 Age 110.1235.55724.737.000.762 Initial Displacement 68.2447.42322.507.000.566 Associated Fracture Ulna 42.2411.9038.967.006.791 Type of Anesthesia 4.328.3781.279.693.622 Result of Manipulation.000 2.894

33. Literatures’ Review Redisplacement is linked to the position of forearm in the cast or loss of cast fixation (Voto et al 1990, Gupta et al 1990) Redisplacement is less likely when an experienced surgeon performs the initial reduction (Haddad et al 1995)

34. Literatures’ Review K-wire fixation had a better result than cast immobilization alone in treating displaced distal radial fractures in children (McLauchlan et al,2002)

35. Causes of Redisplacement Two factors increase the chance of redisplacement –the presence of initial complete displacement –the failure to achieve a perfect reduction (Proctor et al 1993) They stressed only on imperfect reduction to perform percutaneous K-wire fixation The most important favorable prognostic factor was a perfect anatomical reduction (Haddad et al 1995)

36. Study Findings Perfect reduction did not reduce the incidence of redisplacement of initially completely displaced fractures The most important factor that can affect the outcome significantly is the initial displacement of the fracture

37. Study Findings Explanations –Completely displaced distal radial fractures are usually associated with severe injury to the periosteum and the surrounding soft tissues –Lack of periosteal hinge may affect the stability and increases the incidence of redisplacement –Severe soft tissue injury causes more initial swelling which usually subsides in a week resulting in loose cast that in turn increases the chance of redisplacement

38. Risk Factors Presence of associated distal ulnar fracture The use of deep sedation or local haematoma block to reduce completely displaced fractures

39. Conclusion Children who had completely displaced distal radial fractures particularly those associated with fracture of the ulna should be manipulated under G.A. It is recommended to perform percutaneous K-wire fixation to ensure stabilization and avoid redisplacement, even if perfect reduction could be achieved

40. Thank you