Is casting of displaced paediatric distal forearm fractures non-inferior to reduction under general anaesthesia? Study protocol for a pragmatic, randomized, controlled non-inferiority multicentre trial (the casting trial).

BACKGROUND: Treatment of displaced distal forearm fractures in children has traditionally been closed reduction and pin fixation, although they might heal and remodel without surgery with no functional impairment. No randomized controlled trials have been published comparing the patient-reported functional outcome following non-surgical or surgical treatment of displaced paediatric distal forearm fractures. METHODS: A multicentre non-inferiority randomized controlled trial. Children aged 4-10 years with a displaced distal forearm fracture will be offered inclusion, if the on-duty orthopaedic surgeon finds indication for surgical intervention. They will be allocated equally to non-surgical treatment (intervention) or surgical treatment of surgeon's choice (comparator). Follow-up will be 4 weeks and 3, 6, and 12 months. The primary outcome is the between-group difference in 12 months QuickDASH score. We will need a sample of 40 patients to show a 15-point difference with 80% power. DISCUSSION: The results of this trial may change our understanding of the healing potential of paediatric distal forearm fractures. If non-inferiority of non-surgical treatment is shown, the results may contribute to a reduction in future surgeries on children, who in turn can be treated without the risks and psychological burdens associated with surgery. TRIAL REGISTRATION: www. CLINICALTRIALS: gov (ID: NCT05736068). Date of registry: 17 February 2023.

The methodological quality was low and conclusions discordant for meta-analyses comparing proximal humerus fracture treatments: a meta-epidemiological study.

OBJECTIVE: To investigate the association between methodological quality and reported conclusions of meta-analyses comparing operative with non-operative treatments for proximal humerus fractures. STUDY DESIGN AND SETTING: Cross-sectional meta-epidemiological study. We searched EMBASE, PubMed, The Cochrane Library, and Web of Science for systematic reviews with meta-analyses comparing non-operative with operative treatments for proximal humerus fractures. Methodological quality was assessed using AMSTAR2 and the reported conclusions were scored for three outcome domains (functional outcome, quality of life, and harm) on a scale from 1 to 6. The Mann-Whitney and Kruskal-Wallis tests were used to investigate the association between methodological quality and reported conclusions. RESULTS: We included 21 systematic reviews: 19 pairwise meta-analyses and 2 network meta-analyses, although there are only 8 published randomized controlled trials. Most (n = 18) of the meta-analyses were rated as critically low quality, while the remaining 1 was rated as high quality. The conclusions were discordant for all three outcome domains, even for meta-analyses reporting similar inclusion criteria. We could not perform most of the statistical tests due to the predominantly critically low quality. CONCLUSION: The methodological quality was so predominantly critically low that it was not possible to evaluate the association between methodological quality and reported conclusions.

A closed-claim analysis of complaints after paediatric antebrachial fractures.

INTRODUCTION: Antebrachial fractures in children (AFC) are common and account for one third of all paediatric fractures. The Danish Patient Compensation Association (PCA) receives complaints from patients who believe that they have sustained injuries due to potential malpractice or unfortunate circumstances. Case files on AFC from the PCA were assessed to identify causality and factors contributing to complaints and potential malpractice. METHODS: A closed-claim analysis was performed in 138 cases with the diagnosis codes DS52.2 through DS52.6. RESULTS: The most frequent complaints were fracture re-displacement (n = 49) and dissatisfaction with an otherwise correctly treated injury (n = 30). Doctor's delay due to missed primary diagnosis was found to be a median of 63 days. Complaints about surgery were almost equally distributed between K-wire and intramedullary nails, and unequally distributed for conservative treatment between splinting (n = 29) and casting (n = 10). Two thirds of the in-juries were unacknowledged and evaluated as light injuries or no injury. One third of the complaints were acknowledged; the majority of which were both-bone fractures. CONCLUSIONS: Two thirds of all complaints were due to normal fracture sequelae; thus, patient anticipation should be accommodated by thorough patient information. Mid-diaphyseal fractures of the forearm are overrepresented among the acknowledged complaints. Casting seems to be preferred to splinting. However, more awareness of these fractures using routinely performed radiographs at the first visit to the emergency room and at follow-up could avoid complaints as well as doctor's delay. FUNDING: none. 
TRIAL REGISTRATION: not relevant.

Stability and migration across femoral varus derotation osteotomies in children with neuromuscular disorders.

Background and purpose - Studies have indicated that one-third of children with cerebral palsy (CP) develop dislocation of the hip that needs surgical intervention. When hip dislocation occurs during childhood surgical treatment consists of tenotomies, femoral varus derotation osteotomy (VDRO), and acetabuloplasty. Relapse is observed in one-fifth of cases during adolescence. In this prospective cohort study, we performed a descriptive evaluation of translation and rotation across VDROs in children with neuromuscular disorders and syndromes by radiostereometric analysis (RSA). We assessed "RSA stability" and migration across the VDROs. Patients and methods - Children with a neuromuscular disorder were set up for skeletal corrective surgery of the hip. RSA follow-ups were performed postoperatively, at 5 weeks, and 3, 6, and 12 months after surgery. Results - 27 femoral VDROs were included; 2 patients were excluded during the study period. RSA data showed stability across the VDRO in the majority of cases within the first 5 weeks. At the 1-year follow-up, the mean translations (SD) of the femoral shaft distal to the VDRO were 0.51 (1.12) mm medial, 0.69 (1.61) mm superior, and 0.21 (1.28) mm posterior. The mean rotations were 0.39° (2.90) anterior tilt, 0.02° (3.07) internal rotation, and 2.17° (2.29) varus angulation. Interpretation - The migration stagnates within the first 5 weeks, indicating stability across the VDRO in most patients.