ABSTRACT
Purpose: Distal radius fractures (DRFs) are common pediatric injuries typically treated with closed reduction and casting. A substantial number of these fractures fail nonsurgical management, occasionally requiring surgical intervention. Risk factors associated with an unsuccessful initial closed reduction (UIR) attempt or loss of reduction (LOR) after a successful closed reduction remain poorly characterized. Methods: This was a retrospective investigation of pediatric patients with displaced DRFs treated by closed reduction and casting at a single children's hospital from 2013 to 2017. Patient factors (age, sex, and body mass index) and radiographic measurements (fracture type, fracture displacement, associated ulna fracture, and cast index) were evaluated to determine risk factors for UIR and LOR. Results: We identified 159 children (118 boys, mean age, 11 ± 3 years) with DRFs who underwent closed reduction and casting. An initial acceptable reduction was achieved in 81% of patients, and LOR occurred in 21.7%. Higher initial fracture translation in the sagittal or coronal plane and higher initial angulation in the coronal plane were associated with higher fluoroscopy times. Higher initial translation in the sagittal plane was independently associated with UIR. After closed reduction, residual translation in the sagittal plane and cast index were independent predictors for LOR. Fractures that were completely displaced in the sagittal plane were 6.2 times less likely to undergo an acceptable initial reduction, and fractures with any residual postreduction translation in the sagittal plane were 4.7 times more likely to demonstrate LOR. Conclusions: The most important factors predicting failure of nonsurgical management of pediatric DRFs are translation in the sagittal plane and cast index greater than 0.80. To optimize patient outcomes, these variables should be recognized by the treating provider and emphasized during simulation training of orthopedic and plastic surgery residents. Type of study/level of evidence: Prognostic III.
ABSTRACT
BACKGROUND: The prognosis of Legg-Calvé-Perthes disease (LCPD) is dependent upon several factors, with the length and severity of the fragmentation stage among the most important. Previous retrospectively collected data from a single center have suggested that early proximal femoral varus osteotomy (PFO) may shorten the length of fragmentation and allow 34% of patients to bypass fragmentation altogether resulting in less femoral head deformity. The purpose of this study was to validate these findings in a prospectively collected multicenter cohort. METHODS: Patients with LCPD treated with early PFO (during Waldenström stage I) were prospectively followed with serial radiographs at 3-month intervals until a minimum of 2-year follow-up. Waldenström stages and lateral pillar class were determined by mode assessments from 3 pediatric orthopaedic surgeons. The duration of fragmentation was defined as the interval between the first radiographs demonstrating features of stage IIa and stage IIIa. "Complete" bypass was defined as the absence of stage IIa or IIb findings on sequential radiographs with no development of femoral head deformity or collapse. "Partial" bypass was defined as the absence of advanced features of fragmentation and femoral head collapse (stage IIb). RESULTS: Forty-six patients (80% male individuals) with initial stage LCPD and a mean age of 8.2±1.2 years were identified. The weighted kappa statistics for Waldenström staging and lateral pillar classifications showed excellent (0.833) and substantial (0.707) agreement, respectively. Ninety-eight percent of patients (45/46) underwent some period of fragmentation lasting between 91 and 518 days; the median duration was 206 days (interquartile range, 181 to 280). One patient (2%) bypassed fragmentation completely; 8 patients (17%) demonstrated partial bypass. Patients who completely or partially bypassed fragmentation experienced significantly less severe lateral pillar collapse (P=0.016) and shorter fragmentation duration (P=0.001). CONCLUSIONS: In this prospective multicenter cohort, we found a lower rate of fragmentation bypass than previously reported. Nonetheless, our data support the previous contention that early PFO may shorten fragmentation and minimize collapse in LCPD compared with historical controls. Further study with larger cohorts and a more rigorous definition of what constitutes bypass is warranted to clarify the effect of early PFO on the reparative biology of LCPD. LEVEL OF EVIDENCE: Level IV-therapeutic study.