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Comparing Forearm Refractures in Children

Posted on: 10/11/2007
Children play in such a way that arm fractures, particularly forearm fractures are quite common. The two bones in the forearm, the radius and the ulna bear the brunt of force when a child falls and puts his or her hand out to break the fall.

Usually, the treatment is a closed treatment with a cast, meaning that no surgery is needed. These bones heal quickly and usually are just as strong as they were before the fracture. Two earlier studies done in Europe found children had a 5 percent refracture rate of the forearm, particularly if they had a sustained a greenstick fracture, a partial break much like a wet twig breaks partially when bent. In the study, 75 percent of the children with refractures had greenstick fractures in the radius, ulna, or both. As well, 96 percent had a persistent angulation, a remaining angle at the break of the bone.

The authors of this study wanted to discover what were the risk factors for a forearm refracture in children by looking at how severe the initial fracture was, the location of the fracture, how obvious the fracture was on x-rays after healing, and any angulation left by the fracture. To do this, they looked back at patients who were treated between 1998 and 2005 and they found 63 patients who had refractured one or both of the forearm bones. This group was compared to 169 patients who had not refractured a bone.

The average age of the patients was 9 years in both groups, among both boys and girls. Among the refracture group, 46 percent had a refracture of the radius, 5 percent of the ulna, and 49 percent refractured both bones. Among the control group, 53 percent had fractured only the radius, 1 percent the ulna, and 46 percent both bones.

Initial treatment included casting the arm alone for most patients: 57 percent in the refracture group, and 66% in the control group. Some children needed a closed reduction, during which the physician manipulates the bone back into place. This happened in 33 percent of the refracture group and 29 percent of the control group. Finally, 8 percent of the refracture group and 5 percent of the control group required an open reduction, or surgery to align the bones.

When looking at the location of the fracture, the refractured breaks were closest to the elbow in 8 percent, in the middle section of the bone in 30 percent, and closer to the wrist in 62 percent. In the control group, the fracture locations were 3 percent, 12 percent, and 85 percent, respectively. The researchers also looked at how obvious the fracture by x-ray, after it healed. For the refracture group, the fracture lines in the radius were clearly visible by x-ray in 42 percent compared with 24 percent of the controls. In the ulna, the fracture lines were visible in 50 percent versus 21 percent, respectively.

Because the unexpected can happen, particularly when children are involved, 5 of the patients overall experienced a second fracture, but not a refracture of the original break, meaning it was not in the same place.

Earlier studies of similar refractures recommended that doctors apply splints to the fractured arms after the casting period. They found that arms from which casts were removed before 6 weeks were at a higher risk of refracture.

After examining the findings, the researchers concluded that children who have fractures closest to the wrist have a greater risk of refracturing the bone within 18 months of the fracture. The authors acknowledge that although the bones can heal rapidly, there is still an increased risk for fracture and they recommend that one way to reduce the risk is to examine the fracture line on the x-ray after cast removal. At this point, a decision should be made as to whether a splint would be necessary to protect the bones for a longer period. "Distal forearm fractures that are casted are by no means 'healed.' Distal fractures that are casted for 4 to 6 weeks of treatment generally benefit from an additional 4 to 6 weeks of treatment in a removable splint," they write in their article.

The authors go on to recommend that further splinting should be done for another 8 to 12 weeks, as well as maintaining the restriction on high-risk activities.

References:
Avi C. Baitner, MD, et al. The Healing Forearm Fracture, A Matched Comparison of Forearm Refractures. In Journal of Pediatric Orthopedics. October/November 2007. Vol. 27. No. 7. Pp. 743-747.

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