Health-economic evaluation of orthogeriatric co-management for patients with forearm or humerus fractures: an analysis of insurance claims data from Germany.

Orthogeriatric co-management (OGCM) describes a collaboration of orthopedic surgeons and geriatricians for the treatment of fragility fractures in geriatric patients. While its cost-effectiveness for hip fractures has been widely investigated, research focusing on fractures of the upper extremities is lacking. Thus, we conducted a health economic evaluation of treatment in OGCM hospitals for forearm and humerus fractures.In a retrospective cohort study with nationwide health insurance claims data, we selected the first inpatient stay due to a forearm or humerus fracture in 2014-2018 either treated in hospitals that were able to offer OGCM (OGCM group) or not (non-OGCM group) and applied a 1-year follow-up. We included 31,557 cases with forearm (63.1% OGCM group) and 39,093 cases with humerus fractures (63.9% OGCM group) and balanced relevant covariates using entropy balancing. We investigated costs in different health sectors, length of stay, and cost-effectiveness regarding total cost per life year or fracture-free life year gained.In both fracture cohorts, initial hospital stay, inpatient stay, and total costs were higher in OGCM than in non-OGCM hospitals. For neither cohort nor effectiveness outcome, the probability that treatment in OGCM hospitals was cost-effective exceeded 95% for a willingness-to-pay of up to €150,000.We did not find distinct benefits of treatment in OGCM hospitals. Assigning cases to study groups on hospital-level and using life years and fracture-free life years, which might not adequately reflect the manifold ways these fractures affect the patients' health, as effectiveness outcomes, might have underestimated the effectiveness of treatment in OGCM hospitals.

Pediatric Forearm Fractures: Investigating the Functional Outcomes of Titanium Elastic Nailing for Unstable Both-Bone Fractures.

Introduction: Diaphyseal forearm fractures pose a common challenge in children and adolescents, impacting forearm function due to rotational deformities and angulation. The landscape of pediatric forearm fracture treatment has seen limited progression, with increased surgical intervention adoption driven by factors such as functional implications, technological advancements, societal expectations, and legal concerns. Materials and Methods: This study enrolled consecutive children aged 5-16 years with forearm fractures presenting between August 2018 and January 2020, requiring surgical intervention. The study assessed functional outcomes and complications in children treated with titanium elastic nailing. Results: Sixteen patients underwent surgery for both-bone forearm fractures. Elastic nailing was the primary intervention, with 75% undergoing closed nailing. Patients' ages ranged from 5 to 15 years, with 87.5% being male. The study evaluated fracture characteristics, surgical procedures, post-operative care, and complications. Conclusion: The study demonstrates promising outcomes for flexible intramedullary nailing in pediatric forearm fractures. Despite the observed complications, the majority of cases achieved excellent results in fracture union and patient recovery, supporting the efficacy of this technique. Larger cohorts are needed for a comprehensive understanding of its applicability and outcomes in pediatric forearm fracture management.

Interlocking intramedullary nail for forearm diaphyseal fractures in adults-A systematic review and meta-analysis of outcomes and complications.

PURPOSE: The purpose of this systematic review is to examine the outcomes, complications, and potential advantages of using anatomical interlocking intramedullary nails (IMN) in the treatment of radius and ulnar shaft diaphyseal fractures in adults. METHODS: Medline, Embase, Web of Science, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched between January 2000 and January 2023. Studies meeting criteria were observational or randomized controlled trials evaluating outcomes in IMN for adult diaphyseal forearm fractures. Standardized data extraction was performed and a quality assessment tool was used to evaluate individual study methodology. Descriptive statistics for interventions, functional outcomes, and complications were reported. Meta-analysis was performed for patient-reported outcome measures and operative time. RESULTS: A total of 29 studies involving 1268 patients were included with 764 (60%) undergoing IMN, 21% open reduction and internal fixation (ORIF), and 9% hybrid fixation. There was no significant difference between groups in DASH and Grace-Eversmann scores. Operative time was significantly shorter in IMN compared with ORIF. The DASH scores were: 13.1 ± 6.04 for IMN, 10.17 ± 3.98 for ORIF, and 15.5 ± 0.63 in hybrids. Mean operative time was 65.3 ± 28.7 in ORIF and 50.8 ± 17.7 in IMN. Complication rates were 16.7% in the IMN group, 14.9% in ORIF, and 6.3% in hybrid constructs. There were 11 cases of extensor pollicis rupture in the IMN group. Average IMN pronation and supination were 78.3° ± 7.9° and 73° ± 5.0°, respectively. Average ORIF pronation and supination was 82.15° ± 1.9° and 79.7° ± 4.5°, respectively. CONCLUSIONS: Similar functional outcomes and complication rates along with shorter operative times can be achieved with IMN compared with ORIF. The use of IMN is promising, however, higher quality evidence is required to assess appropriate indications, subtle differences in range of motion, implant-related complications, and cost-effectiveness. Trail Registration PROSPERO (International Prospective Register of Systematic Reviews) (ID: CRD42022362353).

Diaphyseal forearm fracture management in adolescent patients from 2011 to 2020: A multicenter study of surgery and regional anesthesia trends.

BACKGROUND: Diaphyseal forearm fractures are common traumatic injuries among children. There has been much debate on the use of intramedullary nailing (IMN) or plate fixation in the adolescent population (10-16 years of age). Furthermore, as ultrasound technology has advanced, the safety and efficacy of ultrasound-guided axillary brachial plexus block for children has dramatically improved. Therefore, anesthesia options for adolescent patients have increased in recent years. This study aimed to investigate recent surgical and regional anesthesia trends of diaphyseal forearm fractures in patients 10 to 16 years of age in Japan through a multicenter epidemiological survey from 2011 to 2020. METHODS: This retrospective, multicenter study included 226 pediatric patients with diaphyseal forearm fracture aged 10-16 years treated from January 2011 to December 2020. We divided the patients into four groups according to the period in which they were treated: early (2011-2013), middle (2014-2016), late (2017-2019), and COVID-19 (2020). Information from medical records was used to investigate the number of surgeries, types of anesthesia administered, and internal fixation methods used for diaphyseal forearm fracture in adolescent patients during each period. RESULTS: The number of surgeries was generally constant in each period but decreased during the COVID-19 period. In the early, middle, late, and COVID-19 periods, the percentages of surgeries performed under regional anesthesia were 67.7, 85.5, 87.0, and 100% respectively (p = 0.003). During the same periods, the percentages of patients receiving IMN were 41.5, 49.3, 58.0, and 66.7%, respectively (p = 0.033). CONCLUSION: The use of IMN and regional anesthesia to treat diaphyseal forearm fracture in patients 10 to 16 years of age steadily increased during the study period from 2011 to 2020. These results indicate that regional anesthesia is safe, effective, and well-tolerated by adolescent patients. The treatment strategy for diaphyseal forearm fractures in adolescents using regional anesthesia in combination with IMN worked well and was effective during COVID-19. Our evidence suggests this trend will continue. We anticipate that our findings can be extrapolated for upper extremity fractures in adolescent patients beyond the Tokai region of Japan where the study was based.

"Preventing nail migration by stack nailing in forearm fractures" - A technical note.

Diaphyseal forearm fractures are typically treated with open reduction and plate fixation, which has been proven to be the most effective method in numerous trials. However, the risk of periosteal stripping, haemorrhage evacuation, nonunion, and infection is always present and may cause a delayed union and other surgical consequences. Although intramedullary nails have been mentioned in the literature for forearm bone fractures, issues regarding their common complication of nail migration, especially of the ulnar fracture, before the fracture has been consolidated is an issue, and has not been addressed. We describe a case of IM nail migration of Ulna who presented to us, during the follow up, before the fracture had consolidated. The procedure described is short and consistent with the outstanding cosmetic and functional results.

Opportunistic hand radiographs to screen for low forearm bone mineral density: a prospective and retrospective cohort study.

BACKGROUND: Low bone mineral density affects 53% of women over age 65 in the US, yet many are unaware and remain untreated. Underdiagnosis of forearm osteoporosis and related fragility fractures represent missed warning signs of more deadly, future fractures. This study aimed to determine if hand radiographs could serve as early, simple screening tools for predicting low forearm bone mineral density (BMD). METHODS: We evaluated posterior-anterior (PA) hand radiographs (x-rays) and Dual-energy X-ray absorptiometry (DXA) scans of 43 participants. The ratio of the intramedullary cavity to total cortical diameter of the second metacarpal (second metacarpal cortical percentage (2MCP)) was used as a potential diagnostic marker. Mixed-effects linear regression was performed to determine correlation of 2MCP with BMD from various anatomic regions. Repeated measures ANOVAs were used to compare BMD across sites. An optimal 2MCP cutoff for predicting forearm osteopenia and osteoporosis was found using Receiver Operating Curves. RESULTS: 2MCP is directly correlated with BMD in the forearm. The optimal 2MCP of 48.3% had 80% sensitivity for detecting osteoporosis of the 1/3 distal forearm. An 2MCP cutoff of 50.8% had 84% sensitivity to detect osteoporosis of the most distal forearm. Both 2MCP cutoffs were more sensitive at predicting forearm osteoporosis than femoral neck T-scores. CONCLUSIONS: These findings support the expansion of osteoporosis screening to include low-cost hand x-rays, aiming to increase diagnosis and treatment of low forearm BMD and fractures. Proposed next steps include confirming the optimal 2MCP cutoff at scale and integrating automatic 2MCP measurements into PAC systems.

Trends and projection of forearm fractures including elbow fractures of the Olecranon in Sweden: an analysis of 363 968 fractures using public aggregated data.

BACKGROUND: Forearm and olecranon fractures are a common orthopaedic injury. This study aimed to analyse whether the incidence of forearm injury is changing and identifying trends in the number of forearm and olecranon fractures using public aggregated data in Sweden. METHODS: The number of forearm and olecranon fractures as defined by the number of registered diagnoses with the ICD-10 code of S52 were collected and normalized per 100,000 inhabitants and stratified per sex, age, and month. Age-adjusted incidence for forearm and olecranon fractures were calculated using the direct method. Poisson regression was used to analyse monthly, seasonal and yearly change in forearm and olecranon fracture incidence. Logistical regression was used to predict future trends of forearm and olecranon fractures. RESULTS: The findings revealed a slight decreasing trend in forearm and olecranon fractures. The average incidence rate during the study period was 333 with women having a higher incidence rate than men. More fractures occurred in the winter months. Fluctuations in the number of forearm and olecranon fractures were observed during 2020 which may be influenced by the COVID-19 pandemic. Based on current data, forearm and olecranon fractures are expected to decrease in Sweden by 2035. CONCLUSION: This study describes the trend of forearm and olecranon fractures among individuals according to sex and age in Sweden using easily obtainable data. Trends in forearm and olecranon fractures are dependent on sex and age but generally show a decreasing trend. More precise studies are needed in order to properly quantify the specific incidence of various subtypes of forearm and olecranon fractures and associated risk factors.

Epidemiology of forearm fractures in women and men in Norway 2008-2019.

The purpose of this paper is to describe rates of forearm fractures in adults in Norway 2008-2019. Incidence rate of distal forearm fractures declined over time in both sexes. Forearm fracture constitute a significant health burden and prevention strategies are needed. PURPOSE: To assess age- and sex-specific incidence rates, and time trends for forearm fractures in Norway, and compare these with incidence rates in other Nordic countries. METHODS: Data on all patients aged 20-107 years with forearm fractures treated in Norwegian hospitals from 2008 to 2019 was retrieved from the Norwegian Patient Registry. Fractures were identified based on International Classification of Disease 10th revision code S52. Age- and sex-specific incidence rates and changes in incidence rates were calculated. RESULTS: We identified 181,784 forearm fractures in 45,628,418 person-years. Mean annual forearm fracture incidence rates per 100,000 person-years were 398 (95% CI 390-407) for all, 565 (95% CI 550-580) for women, and 231 (95% CI 228-234) for men above 20 years. Mean annual number of forearm fractures was 15,148 (95% CI 14,575-15,722). From 2008 to 2019, age-adjusted total incidence rates of forearm fractures S52 diagnoses declined by 3.5% (incidence rate ratio (IRR) of 0.997 (95% CI 0.994-0.999)) in men. The corresponding decline in women was not significant (IRR: 0.999 (95% CI 0.997-1.002)). In the same period, the age-adjusted incidence rates of distal forearm fractures declined by 7.0% in men (IRR = 0.930; 95% CI 0.886-0.965) and 4.7% in women (IRR = 0.953; 95% CI 0.919-0.976). The incidence rates of distal forearm fractures were similar to rates in Sweden and Finland. CONCLUSION: Age-adjusted incidence rates of distal forearm fractures in both sexes declined over time.

Clinical and Radiological Outcomes of Paediatric Forearm Fractures of the Radius and Ulna Following Fixation by Intramedullary Nailing or Plating: A Systematic Review.

Ipsilateral forearm fractures of both the radius and ulna in children are one of the most common forms of injuries in this population. They often result from axial loading on the hand and wrist following a fall on an outstretched hand. These injuries can often be managed either conservatively or operatively. Non-operative management involves the use of cast immobilisation after satisfactory closed reduction. Most fractures managed conservatively have been noted to have a successful outcome. Surgical options of management include the use of intramedullary nailing (IMN), plates and screws, hybrid techniques and rarely external fixators. The purpose of this systematic review is to critically analyse the functional and radiological outcomes as well as the probability of developing a complication in children that have undergone either IMN or plating of both the radius and ulna in the paediatric population. A comprehensive electronic database search from April 2014 until April 2022 was conducted. Studies from PubMed, EMBASE and Cochrane electronic databases were retrieved. A total of 260 cohort studies with children between the ages of 5 to 17 years old were identified. After the application of both inclusion and exclusion criteria, six articles with a total of 409 patients relevant to this review were identified and analysed. There were no significant inconsistencies statistically in functional and radiological outcomes. Overall complication rate and time to fracture union were similar. Intramedullary nailing was noted to have a shorter operative and anaesthetic time, longer fluoroscopic exposure, and a better cosmetic outcome. Differences in bowing, radial bow magnitude and location had no overall bearing on rotation and daily activity. Considering the methodological limitations of this study, a larger sample size and higher level of evidence such as randomized control studies will yield a more conclusive result to resolve controversies. Based on currently available evidence, both plating and intramedullary nailing are excellent treatment modalities in both-bone forearm fractures.

Modifiable and non-modifiable risk factors for failure of non-operative treatment of pediatric forearm fractures: Where can we do better?

Introduction: Distal third forearm fractures are common fractures in children. While outcomes are generally excellent, some patients fail initial non-operative management and require intervention. The purpose of this study is to identify independent risk factors associated with failure of closed reduction. Methods: We conducted a retrospective review of distal third forearm fractures in children treated with closed reduction and casting. Patients were divided into two cohorts-those who were successfully closed reduced and those who failed initial non-operative management. Demographic characteristics, cast type, cast index, radiographic fracture, soft tissue characteristics, and quality of reduction were analyzed between groups. Results: A total of 207 children treated for distal third forearm fractures were included for analysis. A total of 190 (91.8%) children maintained their reduction while 17 (8.2%) failed initial non-operative management. Modifiable risk factors associated with loss of reduction on univariate analysis included the use of a long arm cast (p = 0.003), increased post-reduction displacement (p = 0.02), and increased post-reduction angular deformity (p = 0.01). Non-modifiable risk factors included increased body mass index (p = 0.02), increased presenting fracture displacement (p = 0.002), and increased width of the soft tissue envelope at the fracture site (p = 0.0001). The use of long arm casts (13% vs 2%, odds ratio = 6.44) and soft tissue width (60.6 vs 50.4 mm, odds ratio = 1.1) remained significant risk factors for loss of reduction after multivariate analysis. Conclusion: Both larger soft tissue envelope at the site of the fracture and long arm cast immobilization are independently associated with an increased risk of failing initial closed reduction in distal third forearm fractures in the pediatric population. Level of evidence: level III Case Control Study.

Complications and Revision Surgery of Forearm Fractures.

Nonunion or malunion of forearm fractures may result in restricted range of motion or persistent pain, leading to limitations in activities of daily living. Complications may also present in the form of ectopic bone growth or persistent infections. A systematic method to evaluate complications resulting from forearm fractures is helpful to both determine the cause for the failure and plan for adequate reconstruction.

The impact of both-bone forearm fractures on acute compartment syndrome: An analysis of predisposing factors.

OBJECTIVES: Acute compartment syndrome (ACS) is a severe medical condition that, if left untreated, can cause permanent nerve and muscle damage, and may even require amputation. The objective of this study was to identify the risk factors associated with the development of ACS in patients with both-bone fractures of the forearm. METHODS: Between November 2013 and January 2021, a retrospective data collection was conducted on 611 individuals who experienced both-bone forearm fractures at a level 1 trauma center. Among these patients, 78 patients were diagnosed with ACS, while the remaining 533 patients did not have ACS. Based on this division, the patients were categorized into two groups: the ACS group and the non-ACS group. Demographics (including factors such as age, gender, body mass index, crush injury, etc.), comorbidities (including conditions such as diabetes, hypertension, heart disease, anemia, etc.), and admission lab results (including complete blood count, comprehensive metabolic panel, and coagulation profiles, etc.) were analyzed using univariate analysis, logistic regression, and ROC curve analysis. RESULTS: Predictors of ACS were identified through the final multivariable logistic regression analysis, which revealed that crush injury (p < 0.001, OR = 10.930), the levels of neutrophils (NEU) (p < 0.001, OR = 1.338) and the levels of creatine kinase (CK) (p < 0.001, OR = 1.001) were significant risk factors. Additionally, age (p = 0.045, OR = 0.978) and albumin (ALB) level (p < 0.001, OR = 0.798) were found to provide protective effects against ACS. Furthermore, the receiver operating characteristic (ROC) curve analysis determined cut-off values for NEU and CK to predict ACS: 7.01/L and 669.1 U/L respectively. CONCLUSIONS: Our study identified crush injury, NEU, and CK as significant risk factors for ACS in patients with both-bone forearm fractures. We also determined the cut-off values of NEU and CK, allowing for the individualized evaluation of ACS risk and the implementation of early targeted treatments.

Forearm fractures - are we counting them all? An attempt to identify and include the missing fractures treated in primary care.

OBJECTIVE: Norway has a high incidence of forearm fractures, however, the incidence rates based on secondary care registers can be underestimated, as some fractures are treated exclusively in primary care. We estimated the proportion of forearm fracture diagnoses registered exclusively in primary care and assessed the agreement between diagnosis for forearm fractures in primary and secondary care. DESIGN: Quality assurance study combining nationwide data from 2008 to 2019 on forearm fractures registered in primary care (Norwegian Control and Payment of Health Reimbursement) and secondary care (the Norwegian Patient Registry). SETTING AND PATIENTS: Forearm fracture diagnoses in patients aged ≥20 treated in primary care (n = 83,357) were combined with injury diagnoses for in- and outpatients in secondary care (n = 3,294,336). MAIN OUTCOME MEASURES: Proportion of forearm fractures registered exclusively in primary care, and corresponding injury diagnoses for those registered in both primary and secondary care. RESULTS: Of 189,105 forearm fracture registrations in primary and secondary care, 13,948 (7.4%) were registered exclusively in primary care. The proportion ranged from 4.9% to 13.5% on average between counties, but was higher in some municipalities (>30%). Of 66,747 primary care forearm fractures registered with a diagnosis in secondary care, 62% were incident forearm fractures, 28% follow-up controls, and 10% other fractures or non-fracture injuries. CONCLUSION: An overall small proportion of forearm fractures were registered only in primary care, but it was larger in some areas of Norway. Failing to include fractures exclusively treated in primary care could underestimate the incidence rates in these areas.

Norwegian forearm fracture incidence based on secondary care may be underestimated by not including fractures treated exclusively in primary care.The mean proportion of forearm fractures exclusively handled in primary care is 7% and varies from 5% to 14% between counties.Fractures treated in primary care can be considered for more accurate national incidence rates. Correct fracture diagnosis needs further investigation.

Below- versus above-elbow cast treatment of displaced distal forearm fractures in children: A systematic review and meta-analysis of randomized controlled trials.

Objectives: Distal forearm fractures are the most common pediatric fractures. This study aimed to investigate the effectiveness of below-elbow cast treatment for displaced distal forearm fractures in children compared to above-elbow cast through meta-analysis of randomized controlled trials. Methods: Several databases from January 1, 2000 until October 1, 2021 were searched for randomized controlled trials that assessed below versus above-elbow cast treatment of displaced distal forearm fractures in pediatric patients. The main meta-analysis comparison was based on the relative risk of loss of fracture reduction between children undergoing below versus above-elbow cast treatment. Other outcome measures including re-manipulation and cast-related complications were also investigated. Results: Nine studies were eligible of the 156 articles identified, with a total of 1049 children. Analysis was undertaken for all included studies with a sensitivity analysis conducted for studies with high quality. In the sensitivity analysis, the relative risks of loss of fracture reduction (relative risk = 0.6, 95% confidence interval = 0.38, 0.96) and re-manipulation (relative risk = 0.3, 95% confidence interval = 0.19, 0.48) between the below and above-elbow cast groups were in favor of below-elbow cast and statistically significant. Cast-related complications were in favor of below-elbow cast but did not attain statistical significance (relative risk = 0.45, 95% confidence interval = 0.05, 3.99). Loss of fracture reduction was noted in 28.9% of patients treated with above-elbow cast and 21.5% in below-elbow cast. Re-manipulation was attempted in 48.1% versus 53.8% of children who lost fracture reduction in the below-elbow cast and above-elbow cast groups, respectively. Conclusion: Below-elbow cast treatment was favored, with statistical significance, in terms of loss of fracture reduction and re-manipulation, and was not associated with a higher risk of cast-related complications. The accumulative evidence currently does not support above-elbow cast treatment and below-elbow cast treatment should be the mainstay for displaced distal forearm fractures in children. Level of evidence: Level I, meta-analysis of therapeutic level I studies.

Evaluation of the Functional Outcome of Both Bone Forearm Fractures in the Pediatric Population With the Titanium Elastic Nailing System in a Tertiary Care Center.

Background Forearm fractures are one of the most common injuries in the pediatric population. Diaphyseal fractures of the forearm, in particular, are among the most common injuries treated in the pediatric population. The incidence of both bone forearm fractures has increased in the past decade. Methodology This is a hospital-based retrospective study conducted from June 2020 to December 2022 at R. L. Jalappa Hospital and Research Centre in the orthopedics department after obtaining clearance from the institutional ethics committee. Once inclusion and exclusion criteria are met, participants with both bone forearm fractures were treated with the Titanium Elastic Nailing System (TENS). Data were entered and analyzed using IBM Corp. Released 2011, IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp, Armonk, NY, USA). Results Thirty patients were included in the study, with a mean age of 8.80 years. The majority were boys constituting 67% and girls constituting 33%. A road traffic accident was the mechanism of injury in the majority of patients (40%). The distal one-third forearm was the most common site fractured (63%). The mean flexion (active) at the elbow improved from 110°at at four weeks to 142° at 24 weeks. A restriction of about 23° in elbow extension at four weeks normalized to 0° at 24 weeks. The range of palmar flexion improved from 44° at four weeks to 68° at 24 weeks. The range of wrist dorsiflexion improved significantly over time from 46° at four weeks to 86° at 24 weeks. Complications such as delayed union and skin irritation were noted in two participants (6%). Conclusions Both bone forearm fractures treated with TENS have shown good results in terms of bony union and functional outcomes with the least complications.

Clinical Follow-Up without Radiographs Is Sufficient after Most Nonoperatively Treated Distal Radius Fractures in Children.

Distal forearm fractures are common in children and are usually treated nonoperatively. No consensus has been reached on how to perform clinical and radiographic follow-up of these fractures. Our aim was to study whether radiographic and clinical follow-up is justified. We included 100 consecutive patients with non-operatively treated distal forearm fractures who were treated at Oulu University Hospital in 2010-2011. The natural history of the fractures during the nonoperative treatment was analyzed by measuring the potential worsening of the alignment during the follow-up period. The limits of acceptable fracture position were set according to the current literature using "strict" or "wide" criteria for alignment. We determined the rate of worsening fracture position (i.e., patients who reached the threshold of unacceptable alignment). In relation to splinting, we evaluated how many patients benefited from clinical follow-up. Most of the fractures (98%) preserved acceptable alignment during the entire follow-up period when wide criteria were used. The application of stricter criteria for alignment in radiographs showed loss of reduction in 19% of the fractures. Worsening of the alignment was recognized at a mean of 13 days (range 5-29) after the injury. One in three (32%) patients needed some intervention due to splint loosening or failure. Radiographic follow-up of nonoperatively treated distal forearm fractures remains questionable. Instead, clinical follow-up is important, as 32% of patients needed their splints fixed.

Longer time of implantation using the buried pin technique for intramedullary nailing would decrease refracture in the diaphyseal forearm fracture in children-retrospective multicenter (TRON) study.

BACKGROUND: Intramedullary nailing using Kirschner wires in pediatric diaphyseal forearm fractures is often performed as a less invasive treatment than plate fixation, but it remains controversial whether the tips of Kirschner wires are buried or exposed. The purpose of this study was to investigate the relationship between whether the tips are buried or exposed and complications, especially of refracture. METHODS: Data of 405 patients under 16 years who underwent surgical treatment for diaphyseal forearm fractures in our 11 hospitals between 2010 and 2020 were collected. Finally, 143 patients who underwent intramedullary nailing with at least 6-month follow-up were analyzed. We investigated difference in complication rates depending on whether the Kirschner wire tips were buried (Group B: n = 79) or exposed (Group E: n = 64). Regarding refractures, we also examined time of onset and status of bone union before the refracture occurred. RESULTS: The duration before implant removal in Group B was more than 4 times longer than that in Group E (mean 187.9 vs. 41.4 days, p<0.001), although there was no significant difference in the progression of bone union between the two groups. Regarding postoperative complications, Group B had a significantly lower rate of refractures than Group E (7.9% vs. 32.8%, p<0.001), although the rate of irritation pain was significantly higher (15.2% vs. 1.6%, p = 0.006). The infection rate was also lower in Group B than Group E, but not significantly so (3.8% vs. 10.9%, p = 0.112). Refractures between 3 and 9 months after surgery accounted for 66.7% of all refractures, and those within 3 months accounted for 14.5% of all fractures. There was no significant difference in the status of bone union before the refracture occurred between patients with and without refracture. CONCLUSIONS: The present study showed that longer time of implantation using the buried pin technique for intramedullary nailing reduces refracture of pediatric diaphyseal forearm fractures. Because of the risk of refracture during remodeling, we recommend the implantation of intramedullary nailing for 6-9 months and the instruction for the patients and the parents to pay more attention to refracture at least within 9 months postoperatively. LEVEL OF EVIDENCE: Level Ⅲ, Multicenter retrospective study.

The effects of maximal radial bowing on forearm rotation in pediatric diaphyseal forearm fractures.

PURPOSE: To evaluate the effects of radial bowing on forearm rotation in forearm fractures compared with healthy children. METHODS: A retrospective study was conducted on children aged 1-16 years old. Group 1 was children with history of diaphyseal forearm fractures, and group 2 was healthy children. Children in group 1 with ≤ 70° forearm pronation and/or ≤ 80° supination on affected side are defined as "case." In group 2, children with forearm pronation > 70° and/or supination > 80° are defined as "control." Radial bowing was measured on AP radiograph of the forearm; maximal radial bowing (MRB) and location of the maximal radial bowing (LMRB) were recorded. RESULTS: Total of 112 children were included (group 1 = 70, group 2 = 42). In group 1, there were 28 children with ≤ 70° forearm pronation and/or ≤ 80° forearm supination (case group). In group 2, there were 33 children with > 70° forearm pronation and > 80° forearm supination (control group). Mean age of case and control group was 11.08 ± 3.02 and 7.85 ± 3.93 years, respectively. Average MRB was 6.15 ± 1.93% and LMRB was 61.94 ± 9.41% in case group. In control group, average MRB was 7.23 ± 1.03% and LMRB was 62.08 ± 4.24%. There was statistically significant correlation between children with ≤ 70° forearm pronation and MRB (P = 0.034) compared with control group. Also, there was statistically significant correlation between children with ≤ 80° forearm supination and MRB (P = 0.023) compared with control group. For ROC curve analysis, MRB ≤ 6.84% showed the association with ≤ 70° forearm pronation (72.2% sensitivity and 73.8% specificity) and MRB ≤ 5.75% associated with ≤ 80° forearm supination (54.6% sensitivity and 84.9% specificity). CONCLUSIONS: Children with MRB ≤ 6.84% can result in ≤ 70° forearm pronation, and MRB ≤ 5.75% can be presented with ≤ 80° forearm supination.

Management of gunshot-related forearm bone defect by sequential internal fixation and deferred bone grafting: experience from a tertiary hospital in Mogadishu.

Gunshot-related forearm fractures are rare injuries, usually incurring bone defect. The aim of the study was to report clinical and radiological results for sequential internal fixation and bone grafting in acute civilian forearm gunshot fractures with bone defect. The procedure involves staged techniques consisting of bone debridement, soft-tissue closure and temporary intramedullary Kirschner wire fixation, followed by deferred bone grafting. To our knowledge, the present study is the first to investigate this surgical sequence in such injuries. Between June 2018 and September 2019, 6 civilian cases (5 male, 1 female) with a mean age of 26 years (range, 19-36 years) were operated on by sequential internal fixation and bone grafting for acute forearm gunshot fractures with segmental bone defect. Demographics, injury characteristics and surgical features were recorded. The Tang classification system was used to evaluate clinical and radiological results at final follow-up. Mean follow-up was 27 months (range: 21-32 months). Defect location was in the radius in 4 patients and in the ulna in 2, with a mean defect size of 3.75 cm (range, 2-8 cm). Union was achieved in 5 patients, at a mean 7 months (range, 4-10 months). Functional outcome was excellent in 4 patients, good in 1 and fair in 1. Sequential internal fixation and bone grafting seems a reliable option in the treatment of acute forearm gunshot fractures with bone defect. LEVEL OF EVIDENCE: Level IV - Retrospective study.