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Distal radius fractures in children: Risk factors for redisplacement following closed reduction

Background

  • 21-39% of pediatric distal radius fractures are reported to re-displace after closed reduction
  • Few prospective studies have examined risk factors for redisplacement
  • Purpose of study: Determine rate of redisplacement and identify those risk factors

Methods

  • Prospective study from 2/2011-10/2012. Inclusion criteria- CR of displaced distal radius fx under sedation. Exclusion criteria- previous fx at same site or pathologic fx. 147 fractures treated in time period and 12 excluded leaving 135 for the study
  • 36% female and 64% male, Mean age 9 (range 3-17). 56% left, 44% right, 1 bilateral. 1 open fx and 2 associated with ipsilateral SCH fx. 91% had above elbow plaster cast and 9% below elbow plaster cast
  • Risk factors evaluated: age, sex, location of DR fx, initial fracture displacement, presence of ispilateral ulna fx, quality of reduction, level of experience of physician, type of cast, quality of cast, residual post reduction displacement.
  • Radiographs taken at week 1 and 6 post-reduction
  • Descriptive and frequency statistics reported on multiple variables. Independent sample t test used to compare means of normally distributed variables, Mann-Whitney test to compare non-normally distributed means, chi squared test to find significant categorical variables. Univariate and multivariate analyses conducted to determine significant risk factors

Results

  • No difference in age, sex, fx side, or interval between injury and treatment between fx’s that maintained reduction and those that did not.
  • 28% re-displacement rate. Median interval to loss of reduction was 11 days. 7% of all fx’s required a second procedure: 1 remanipulated, 5 CRPP, 4 ORIF
  • Significant risk factors for displacement by univariate analysis: complete displacement, anatomic reduction, fracture location, residual post-reduction translation
  • Multivariate analysis revealed initial complete displacement was most predictive for loss of reduction (odds ratio 6.94). Anatomic reduction was most protective (odds ratio 0.29).

Discussion

  • Complete loss of reduction identified in many studies as a significant risk factor. Possibly due to loss of periosteal hinge for stability or greater loosening of cast once initially greater amount of swelling subsides.
  • Multiple studies also found anatomic reduction is protective. However, studies have found excellent outcomes can occur in children even without a reduction.
  • Contrary to other studies, this study found neither presence of an ipsilateral ulna fx or isolated radius fx to be a risk factor for loss of reduction
  • Strengths: prospective study, use of previously cited criteria for displacement
  • Limitations: relatively short follow-up, no functional outcome measures, radiographic measurements could be influenced by poor AP and lateral radiographs
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