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Displaced Wrist Fractures Can Be Treated Without Surgery in Young Children
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Posted on: 03/15/2012
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When a bone is broken, separated, and off-angle, the treatment is usually with surgery to separate the ends of the bone and realign them. This type of reduction procedure cannot be done without sedating the patient in an operating room.
The procedure may be a closed reduction, which does not require an incision to realign the bones. Or it may be an open reduction, in which case the surgeon must cut the arm open to get down to the bone and complete the reduction process.
In either reduction procedure, it may be necessary to use pins to hold the bones together. This is called internal fixation. Internal fixation and is often needed to keep the bone fragments together until healing takes place. Redisplacement (bones shifting apart) is a common problem with displaced bone fractures, especially without internal fixation. The more unstable the fracture is and the more force placed on the bones by muscle contractions, the greater the risk of redisplacement.
Whether an open or closed reduction, this approach increases the cost of care including hospital time and the surgeon's time -- not to mention the patient's time and risk of complications. That's why the orthopedic surgeons who wrote this article tried a new nonsurgical approach for overriding distal radial fractures.
Overriding tells us the bones separated and moved toward each other. Instead of the ends of the fractured pieces moving apart, they now overlap. The radius is one of the two bones in the forearm. The distal end is at the wrist while the proximal end is located up at the elbow.
What is this new approach? They allowed the fracture to heal in the shortened position without surgical manipulation to restore alignment before healing. All children (54 cases) were ten years old or younger and treated within 72 hours of the injury. A fiberglass cast was applied from just below the elbow down to the wrist and including the hand.
Everyone was followed at regular intervals for one full year. At first, the follow-up appointments were close together (one week, two weeks, six weeks). In many cases, the cast was removed, replaced, and remolded when the initial swelling went down.
The cast was removed permanently when all trace of pain and tenderness was gone. A second sign that it was time to remove the cast was an X-ray showing the formation of a solid bone callus at the fracture site.
Results of treatment were measured based on wrist motion and strength. Everyone had full wrist motion without pain and good grip strength. Function was excellent as all the children had returned to full function and play without limitations or restrictions on what they could do or how they could do it.
The absence of any deformities and/or tenderness was also noted. There were no refractures, redisplacement, nonunions, or damage to the growth plates. Any shortness present at first was self-corrected during the healing process.
The surgeons also did a cost analysis comparing four different ways this problem could be treated. These four situations included: 1) child received a short-arm cast in the physician's office without reduction. 2) Child was sedated but still awake (called conscious sedation) while in the hospital emergency room. The fracture was treated with a closed reduction. 3) Child was anesthetized (put into a deep sleep) and the fracture was reduced without the use of internal fixation. 4) Child was asleep with a general anesthesia. Fracture was closed without an incision. Pins were used to hold the bone together.
They found that each successive treatment (options two through four) costs more and more compared to this conservative, nonoperative approach (option number one). For example, the most involved treatment (number 4: closed reduction under general anesthesia with internal fixation) cost eight and a half times more than closed treatment with cast only. Even the closed reduction under conscious sedation was 4.7 times more expensive compared with the proposed non-manipulative management of this problem.
In summary, the authors of this study show that surgical treatment to reduce overriding distal radial (wrist) fractures may not be necessary in young children. They show complete healing and bone remodeling in young children (under the age of 11) with this technique.
They suggest that this type of closed, conservative care is cost-effective, time-efficient, and safe with excellent results. Surgeons do not need to pursue aggressive treatment when the growth plates are still open. And since the distal wrist growth areas provide 80 per cent of the total forearm length, young children can and do self-correct. In all cases reported, parents agreed they would choose the same treatment approach if they had to do it over again.
Future studies are needed to find the line between acceptable and unacceptable limits as to when this approach can be used. There are times when the fracture may be too overlapping and the forearm too shortened to use this more conservative approach. Right now, these surgeons are using an angulation correction within 20 degrees of normal but the exact cutoff for best results remains unknown.
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References:
Scott N. Crawford, MD, et al. Closed Treatment of Overriding Distal Radial Fractures without Reduction in Children. In The Journal of Bone and Joint Surgery. February 1, 2012. Vol. 94A. No. 3. Pp. 246-252.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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