Karen L. LUSCOMBE, Samena CHAUDHRY, Jonathan S. M. DWYER, Chezhiyan SHANMUGAM, Nicola MAFFULLI

Çocuklarda yer değiştirmiş distal radius kırıklarının seçici olarak Kirschner teli ile tedavisi

Amaç: Çocuklarda görülen yer değiştirmiş distal radius kırıklarının tedavisinde kliniğimizde kullanılan yöntem olan alçı ile sabitleme ve seçici olarak Kirschner (K) teli uygulama yöntemi değerlendirildi. Çalışma planı: İki yıllık süre içinde klinik deformite ile getirilen ardışık 112 yer değiştirmiş distal radius kırığı (108 çocuk; 77 erkek, 31 kız; ort. yaş 10.5±2.6; dağılım 5-16) geriye dönük olarak değerlendirildi. Kırıkların 97’si kısmi (%86.6), 15’i (%13.4) tamamen yer değiştirmişti. Tüm kırıklar genel anestezi altında manipülasyon ve alçı tespiti ile tedavi edildi. Ayrıca, tamamen yer değiştirmiş yedi kırıkta (%46.7) manipülasyondan sonra seçici K-teli tespiti uygulandı. Ortalama takip süresi 1.1 yıl (dağılım 10 hafta-2 yıl) idi. Sonuçlar: Manipülasyon öncesinde kırıkların ortalama açılanması 21.5±10.1° idi, manipülasyondan sonra açılanma ortalama 2.4±4.8 dereceye düştü. Klinik ve radyografik incelemelerde yer değiştirmenin tekrarladığı görülen 11 kırıkta (%9.8) tekrar manipülasyon gerekti. Bunların sekizinde (%8.3) başlangıçta kısmi yer değiştirme, üçünde (%20) tam yer değiştirme vardı. Yeniden manipülasyon gerektiren tam yer değiştirmeli kırıkların tümüne ek olarak K-teli ile tespit uygulanmıştı. Yeniden tedavi gerektiren kırıklarda ikinci manipülasyon öncesi ortalama açılanma derecesi 17.1±5.8°, son radyografik incelemelerde 4.7±6.0° bulundu. Salter-Harris tip II yaralanması olan tüm hastalarda (n=22) mükemmel kırık redüksiyonu sağlandı ve hiçbirinde tekrar manipülasyon gerekmedi. Bununla birlikte, ilk redüksiyonun kalitesi ile yer değiştirmenin tekrarlaması arasında ilişki bulunmadı. İzole distal radius kırığı olan (n=58) ve radius ve ulna kırığının birlikte görüldüğü (n=32) olgular arasında tekrar manipülasyon oranı ve son açılanma derecesi açısından anlamlı fark bulunmadı (p>0.05). Son radyografilerde, başlangıçta tam yer değiştirmiş kırıklarda, kısmi yer değiştirmiş olanlara göre açılanma anlamlı derecede daha fazlaydı (8.2±7.1° ve 4.2±5.7°; p=0.024) idi; ancak, bu fark klinik olarak önemli bulunmadı. Hiçbir hastada radial kısalma veya K-teline bağlı herhangi bir komplikasyon görülmedi. Çıkarımlar: Sonuçlarımız, yer değiştirmenin tekrarlaması ve yeniden manipülasyon gereksiniminde açılanma derecesi ve ilk redüksiyonun kalitesi dışında başka faktörlerin de etkili olduğunu düşündürmektedir. Yer değiştirmiş kırıklarda seçici K-teli tespitinin yer değiştirmenin tekrarı ve yeniden manipülasyon oranlarını azaltmadığı görülmektedir.

Selective Kirschner wiring for displaced distal radial fractures in children

Objectives: This study was designed to evaluate our departmental policy of plaster immobilization and selective Kirschner (K) wiring for the management of displaced distal radius fractures in children. Methods: On a retrospective basis, we evaluated a consecutive series of 112 childhood displaced distal radius fractures (108 patients; 77 boys, 31 girls; mean age 10.5±2.6 years; range 5 to 16 years) presenting with clinical deformity during a two-year period. There were 97 incompletely displaced (86.6%), and 15 completely displaced (13.4%) fractures. All the fractures were managed with manipulation under general anesthesia and plaster immobilization. Additionally, K-wire fixation was performed following manipulation in seven (46.7%) of the completely displaced fractures. The mean follow-up period was 1.1 years (range 10 weeks to 2 years). Results: The mean angulation of fractures prior to manipulation was 21.5±10.1°, it decreased to 2.4±4.8° following manipulation. Remanipulation was required in 11 fractures (9.8%) based on clinical and radiographic findings of redisplacement. Of these, eight fractures (8.3%) were incompletely displaced, and three fractures (20%) were completely displaced. All completely displaced fractures that required remanipulation had been additionally treated with K-wire fixation. Fractures requiring further treatment had a mean angulation of 17.1±5.8° prior to remanipulation, and a mean residual angulation of 4.7±6.0° at final radiographic assessment. A perfect fracture reduction was achieved in all the patients with a Salter-Harris II injury (n=22), and none of these patients required remanipulation. However, the quality of initial reduction was not associated with the development of redisplacement. There was no significant difference between isolated distal radius fractures (n=58) and combined radius and ulna fractures (n=32) with respect to remanipulation rate and final angulation (p>0.05). Final radiographs showed a significantly greater angulation in fractures which were initially completely displaced in comparison with those that were incompletely displaced (8.2±7.1° vs. 4.2±5.7°; p=0.024), but this was not of clinical significance. None of the patients had radial shortening and no K-wire related complications were encountered. Conclusion: Our data suggest that there should be other factors involved in the development of redisplacement and the need for remanipulation other than the degree of fracture displacement and the quality of initial reduction. Selective K-wire fixation in displaced fractures does not seem to decrease redisplacement and remanipulation rates.

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1. Khosla S, Melton LJ 3rd, Dekutoski MB, Achenbach SJ, Oberg AL, Riggs BL. Incidence of childhood distal forearm fractures over 30 years: a population-based study. JAMA 2003;290:1479-85.
2. Jones IE, Cannan R, Goulding A. Distal forearm fractures in New Zealand children: annual rates in a geographically defined area. N Z Med J 2000;113:443-5.
3. Hughston JC. Fractures of the forearm in children. J Bone Joint Surg [Am] 1962;44:1678-93.
4. Fuller DJ, McCullough CJ. Malunited fractures of the forearm in children. J Bone Joint Surg [Br] 1982;64:364-7.
5. Friberg KS. Remodelling after distal forearm fractures in children. I. The effect of residual angulation on the spatial orientation of the epiphyseal plates. Acta Orthop Scand 1979;50:537-46.
6. Friberg KS. Remodelling after distal forearm fractures in children. II. The final orientation of the distal and proximal epiphyseal plates of the radius. Acta Orthop Scand 1979;50(6 Pt 2):731-9.
7. Do TT, Strub WM, Foad SL, Mehlman CT, Crawford AH. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B 2003;12:109-15.
8. Daruwalla JS. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res 1979;(139):114-20.
9. Houshian S, Holst AK, Larsen MS, Torfing T. Remodeling of Salter-Harris type II epiphyseal plate injury of the distal radius. J Pediatr Orthop 2004;24:472-6.
10. Zimmermann R, Gschwentner M, Pechlaner S, Gabl M. Remodeling capacity and functional outcome of palmarly versus dorsally displaced pediatric radius fractures in the distal one-third. Arch Orthop Trauma Surg 2004;124:42-8.
11. Turner RG, Faber KJ, Athwal GS. Complications of distal radius fractures. Orthop Clin North Am 2007;38:217-28.
12. Proctor MT, Moore DJ, Paterson JM. Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg [Br] 1993;75:453-4.
13. Zamzam MM, Khoshhal KI. Displaced fracture of the distal radius in children: factors responsible for redisplacement after closed reduction. J Bone Joint Surg [Br] 2005;87:841-3.
14. Batra S, McMurtrie A, Batra M, Gul A, Kanvinde R. Distal radius fracture management in the emergency departments in UK: are we doing enough? Int J Clin Pract 2007;61:1131-6.
15. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury 1995;26:691-2.
16. Choi KY, Chan WS, Lam TP, Cheng JC. Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children. A report of 157 cases. J Bone Joint Surg [Br] 1995;77:797-801.
17. Voto SJ, Weiner DS, Leighley B. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 1990;10:79-84.
18. Muratlı HH, Yağmurlu MF, Yüksel HY, Aktekin CN, Biçimoğlu A, Tabak AY. Treatment of childhood unstable radius distal methaphysis fractures with closed reduction and percutaneous Kirschner wires. [Article in Turkish] Acta Orthop Traumatol Turc 2002;36:52-7.
19. Gofton W, Liew A. Distal radius fractures: nonoperative and percutaneous pinning treatment options. Orthop Clin North Am 2007;38:175-85. 20. McLauchlan GJ, Cowan B, Annan IH, Robb JE. Manage- ment of completely displaced metaphyseal fractures of the distal radius in children. A prospective, randomised controlled trial. J Bone Joint Surg [Br] 2002;84:413-7.
21. Hargreaves DG, Drew SJ, Eckersley R. Kirschner wire pin tract infection rates: a randomized controlled trial between percutaneous and buried wires. J Hand Surg [Br] 2004;29:374-6.
22. Miller BS, Taylor B, Widmann RF, Bae DS, Snyder BD, Waters PM. Cast immobilization versus percutaneous pin fixation of displaced distal radius fractures in children: a pro- spective, randomized study. J Pediatr Orthop 2005;25:490-4.
23. Yung PS, Lam CY, Ng BK, Lam TP, Cheng JC. Percutaneous transphyseal intramedullary Kirschner wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm fracture in children. J Pediatr Orthop 2004;24:7-12.
24. Gambhir AK, Fischer J, Waseem M. Management of completely displaced metaphyseal fractures of the distal radius in children. J Bone Joint Surg [Br] 2003;85:463.
25. Abraham A, Handoll HH, Khan T. Interventions for treating wrist fractures in children. Cochrane Database Syst Rev 2008;(2):CD004576.