小儿骨骺双骨前臂骨折早期转为肘下石膏固定是否会对患者报告的结果和活动度产生不利影响?

IF 4.2 2区 医学 Q1 ORTHOPEDICS
Linde Musters, Kasper C Roth, Leon W Diederix, Pim P Edomskis, Joyce L Benner, Max Reijman, Denise Eygendaal, Joost W Colaris
{"title":"小儿骨骺双骨前臂骨折早期转为肘下石膏固定是否会对患者报告的结果和活动度产生不利影响?","authors":"Linde Musters, Kasper C Roth, Leon W Diederix, Pim P Edomskis, Joyce L Benner, Max Reijman, Denise Eygendaal, Joost W Colaris","doi":"10.1097/CORR.0000000000003100","DOIUrl":null,"url":null,"abstract":"<p><strong>Background: </strong>For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.</p><p><strong>Questions/purposes: </strong>In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?</p><p><strong>Methods: </strong>In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.</p><p><strong>Results: </strong>At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).</p><p><strong>Conclusion: </strong>In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.</p><p><strong>Level of evidence: </strong>Level I, therapeutic study.</p>","PeriodicalId":10404,"journal":{"name":"Clinical Orthopaedics and Related Research®","volume":null,"pages":null},"PeriodicalIF":4.2000,"publicationDate":"2024-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11419443/pdf/","citationCount":"0","resultStr":"{\"title\":\"Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?\",\"authors\":\"Linde Musters, Kasper C Roth, Leon W Diederix, Pim P Edomskis, Joyce L Benner, Max Reijman, Denise Eygendaal, Joost W Colaris\",\"doi\":\"10.1097/CORR.0000000000003100\",\"DOIUrl\":null,\"url\":null,\"abstract\":\"<p><strong>Background: </strong>For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.</p><p><strong>Questions/purposes: </strong>In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?</p><p><strong>Methods: </strong>In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.</p><p><strong>Results: </strong>At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).</p><p><strong>Conclusion: </strong>In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.</p><p><strong>Level of evidence: </strong>Level I, therapeutic study.</p>\",\"PeriodicalId\":10404,\"journal\":{\"name\":\"Clinical Orthopaedics and Related Research®\",\"volume\":null,\"pages\":null},\"PeriodicalIF\":4.2000,\"publicationDate\":\"2024-10-01\",\"publicationTypes\":\"Journal Article\",\"fieldsOfStudy\":null,\"isOpenAccess\":false,\"openAccessPdf\":\"https://www.ncbi.nlm.nih.gov/pmc/articles/PMC11419443/pdf/\",\"citationCount\":\"0\",\"resultStr\":null,\"platform\":\"Semanticscholar\",\"paperid\":null,\"PeriodicalName\":\"Clinical Orthopaedics and Related Research®\",\"FirstCategoryId\":\"3\",\"ListUrlMain\":\"https://doi.org/10.1097/CORR.0000000000003100\",\"RegionNum\":2,\"RegionCategory\":\"医学\",\"ArticlePicture\":[],\"TitleCN\":null,\"AbstractTextCN\":null,\"PMCID\":null,\"EPubDate\":\"2024/5/7 0:00:00\",\"PubModel\":\"Epub\",\"JCR\":\"Q1\",\"JCRName\":\"ORTHOPEDICS\",\"Score\":null,\"Total\":0}","platform":"Semanticscholar","paperid":null,"PeriodicalName":"Clinical Orthopaedics and Related Research®","FirstCategoryId":"3","ListUrlMain":"https://doi.org/10.1097/CORR.0000000000003100","RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":null,"EPubDate":"2024/5/7 0:00:00","PubModel":"Epub","JCR":"Q1","JCRName":"ORTHOPEDICS","Score":null,"Total":0}
引用次数: 0

摘要

背景:对于儿童前臂远端骨折而言,肘部以下石膏是一种适当的治疗方法,可以克服肘部以上石膏带来的不适和不必要的肘部固定。我们之前进行的随机对照试验(RCT)比较了肘上石膏和早期转用肘下石膏两种治疗方法,结果表明,在短期随访中,两种治疗方法在再移位风险或功能预后方面没有差异。尽管对儿童双骨前臂骨折后进行较长时间随访的研究很少,但这些研究非常重要,因为生长发育可能会影响结果:在对早前的一项研究进行的二次分析中,我们提出了以下问题:(1)对于前臂骨骺骨折程度较轻且稳定的儿童,过早将肘部以上石膏转为肘部以下石膏是否会导致临床和放射学结果更差?(2)7.5年的随访中,骨不连是否会导致较差的临床结果?在本研究中,我们评估了至少随访5年的儿童,这些儿童曾被纳入先前的一项RCT研究。随访时间的中位数(范围)为 7.5 年(5.2 到 9.9 年)。这项研究的患者来自四家不同城市医院的急诊科。2006年1月至2010年8月期间,我们共治疗了128例双骨前臂骨骺缩小骨折患者。所有 128 名患者均符合条件,其中 24% 的患者(31 人)因在最短随访时间前死亡或数据不完整而被排除,剩下 76% 的患者(97 人)进行了二次分析。随访组的流失率与纳入人群相当。符合条件的患者被邀请进行二次功能和放射学评估。主要结果是与未受伤的对侧手臂相比,前臂旋转的差异。次要结果是 ABILHAND-kids 和 QuickDASH 问卷、与对侧前臂相比肘部和腕部屈伸的损失、JAMAR 握力比以及残余畸形的放射学评估。研究对患儿、家长和临床医生均不设盲区:结果:在 7.5 年的随访中,ABILHAND-kids 问卷调查得分没有差异(肘部以上石膏:41 ± 2.4 与肘部以上/肘部以下石膏:41 ± 2.4 与肘部以上/肘部以下石膏:41 ± 2.441±2.4)与(41.7±0.7);(41.7±0.7)与(41.7±0.7):41.7±0.7,平均差异 -0.7 [95% 置信区间 (CI) -1.4 至 0.04];p = 0.06)、QuickDASH(肘部以上石膏:5.8±9.6 与肘部以下石膏:5.8±9.6 与肘部以上/肘部以下石膏:5.8±9.65.8 ± 9.6,而肘上/肘下石膏为 2.9 ± 6.0,平均差异为 2.9 [95% CI -0.5 至 6.2];p = 0.92)和握力(肘上石膏为 0.9 ± 0.2,而肘上/肘下石膏为 1 ± 0.2,平均差异为 -0.04 [95% CI -1 至 0.03];p = 0.24)。功能结果显示无差异(前臂旋转损失:肘上石膏组为 7.9 ± 17.7,而肘上/肘下石膏组为 4.1 ± 6.9,平均差异为 3.8 [95% CI -1.7 至 9.4];P = 0.47;运动弧度:肘上石膏组为 152° ± 21°,而肘上/肘下石膏组为 155° ± 11°,平均差异为 -2.5 [95% CI -9.3 to -4.4];p = 0.17;腕关节屈伸损失:肘上石膏组为 1.0° ± 5.0°,而肘上/肘下石膏组为 0.6° ± 4.2°,平均差异为 0.4° [95% CI -1.5° to 2.2°];p = 0.69)。二次随访结果显示,与 7 个月时的旋转情况相比,两组患者的前臂旋转情况均有所改善。在放射学分析中,唯一的差异在于 AP 尺骨(肘上石膏:6° ± 3° 与肘下石膏:6° ± 3° 与肘上石膏:6° ± 3°):6°±3°与肘上/肘下石膏组相比:5° ± 2°,平均相差 1.8° [0.7° 至 3°];p = 0.003),尽管这可能与临床无关。其他参数没有差异。13名在7个月随访时出现持续性骨不连的患儿在7.5年随访时的功能结果与未出现骨不连的患儿相比没有临床相关性差异。前臂旋转损失:骨结合不良组为5.5ׄ° ± 9.1°,无骨结合不良组为6.0° ± 13.9°,平均差异为0.4(95% CI为-7.5至8.4;P = 0.92):鉴于上述结果,我们建议外科医生在治疗儿童前臂骨骺双骨减少性骨折时,应及早转用肘下石膏。这项研究表明,即使是有继发性骨折移位的患者,也会发生重塑。即使是持续性骨不连,这些患者的最终效果也大多良好至优秀。未来的研究,如荟萃分析或大型前瞻性观察研究,将有助于确定骨骼年龄、性别、桡骨和尺骨的错位成角严重程度和方向对临床结果的影响。此外,类似的系统性综述还有助于明确小儿下肢骨折的可接受角度:证据级别:I级,治疗性研究。
本文章由计算机程序翻译,如有差异,请以英文原文为准。
Does Early Conversion to Below-elbow Casting for Pediatric Diaphyseal Both-bone Forearm Fractures Adversely Affect Patient-reported Outcomes and ROM?

Background: For distal forearm fractures in children, it has been shown that a below-elbow cast is an adequate treatment that overcomes the discomfort of an above-elbow cast and unnecessary immobilization of the elbow. For reduced diaphyseal both-bone forearm fractures, our previous randomized controlled trial (RCT)-which compared an above-elbow cast with early conversion to a below-elbow cast-revealed no differences in the risk of redisplacement or functional outcomes at short-term follow-up. Although studies with a longer follow-up after diaphyseal both-bone forearm fractures in children are scarce, they are essential, as growth might affect the outcome.

Questions/purposes: In this secondary analysis of an earlier RCT, we asked: (1) Does early conversion from an above-elbow to a below-elbow cast in children with reduced, stable diaphyseal forearm fractures result in worse clinical and radiological outcome? (2) Does a malunion result in inferior clinical outcomes at 7.5 years of follow-up?

Methods: In this study, we evaluated children at a minimum of 5 years of follow-up who were included in a previous RCT. The median (range) duration of follow-up was 7.5 years (5.2 to 9.9). The patients for this RCT were included from the emergency departments of four different urban hospitals. Between January 2006 and August 2010, we treated 128 patients for reduced diaphyseal both-bone forearm fractures. All 128 patients were eligible; 24% (31) were excluded because they were lost before the minimum study follow-up or had incomplete datasets, leaving 76% (97) for secondary analysis. The loss in the follow-up group was comparable to the included population. Eligible patients were invited for secondary functional and radiographic assessment. The primary outcome was the difference in forearm rotation compared with the uninjured contralateral arm. Secondary outcomes were the ABILHAND-kids and QuickDASH questionnaire, loss of flexion and extension of the elbow and wrist compared with the contralateral forearm, JAMAR grip strength ratio, and radiological assessment of residual deformity. The study was not blinded regarding the children, parents, and clinicians.

Results: At 7.5-year follow-up, there were no differences in ABILHAND-kids questionnaire score (above-elbow cast: 41 ± 2.4 versus above/below-elbow cast: 41.7 ± 0.7, mean difference -0.7 [95% confidence interval (CI) -1.4 to 0.04]; p = 0.06), QuickDASH (above-elbow cast: 5.8 ± 9.6 versus 2.9 ± 6.0 for above-/below-elbow cast, mean difference 2.9 [95% CI -0.5 to 6.2]; p = 0.92), and grip strength (0.9 ± 0.2 for above-elbow cast versus 1 ± 0.2 for above/below-elbow cast, mean difference -0.04 [95% CI -1 to 0.03]; p = 0.24). Functional outcomes showed no difference (loss of forearm rotation: above-elbow cast 7.9 ± 17.7 versus 4.1 ± 6.9 for above-/below-elbow cast, mean difference 3.8 [95% CI -1.7 to 9.4]; p = 0.47; arc of motion: above-elbow cast 152° ± 21° versus 155° ± 11° for the above/below-elbow cast group, mean difference -2.5 [95% CI -9.3 to -4.4]; p = 0.17; loss of wrist flexion-extension: above-elbow cast group 1.0° ± 5.0° versus 0.6° ± 4.2° for above/below-elbow cast, mean difference 0.4° [95% CI -1.5° to 2.2°]; p = 0.69). The secondary follow-up showed improvement in forearm rotation in both groups compared with the rotation at 7 months. For radiographical analysis, the only difference was in AP ulna (above-elbow cast: 6° ± 3° versus above/below-elbow cast: 5° ± 2°, mean difference 1.8° [0.7° to 3°]; p = 0.003), although this is likely not clinically relevant. There were no differences in the other parameters. Thirteen patients with persistent malunion at 7-month follow-up showed no clinically relevant differences in functional outcomes at 7.5-year follow-up compared with children without malunion. The loss of forearm rotation was 5.5ׄ° ± 9.1° for the malunion group compared with 6.0° ± 13.9° in the no malunion group, with a mean difference of 0.4 (95% CI of -7.5 to 8.4; p = 0.92).

Conclusion: In light of these results, we suggest that surgeons perform an early conversion to a below-elbow cast for reduced diaphyseal both-bone forearm fractures in children. This study shows that even in patients with secondary fracture displacement, remodeling occurred. And even in persistent malunion, these patients mostly showed good-to-excellent final results. Future studies, such as a meta-analysis or a large, prospective observational study, would help to establish the influence of skeletal age, sex, and the severity and direction of malunion angulation of both the radius and ulna on clinical result. Furthermore, a similar systematic review could prove beneficial in clarifying the acceptable angulation for pediatric lower extremity fractures.

Level of evidence: Level I, therapeutic study.

求助全文
通过发布文献求助,成功后即可免费获取论文全文。 去求助
来源期刊
CiteScore
7.00
自引率
11.90%
发文量
722
审稿时长
2.5 months
期刊介绍: Clinical Orthopaedics and Related Research® is a leading peer-reviewed journal devoted to the dissemination of new and important orthopaedic knowledge. CORR® brings readers the latest clinical and basic research, along with columns, commentaries, and interviews with authors.
×
引用
GB/T 7714-2015
复制
MLA
复制
APA
复制
导出至
BibTeX EndNote RefMan NoteFirst NoteExpress
×
提示
您的信息不完整,为了账户安全,请先补充。
现在去补充
×
提示
您因"违规操作"
具体请查看互助需知
我知道了
×
提示
确定
请完成安全验证×
copy
已复制链接
快去分享给好友吧!
我知道了
右上角分享
点击右上角分享
0
联系我们:info@booksci.cn Book学术提供免费学术资源搜索服务,方便国内外学者检索中英文文献。致力于提供最便捷和优质的服务体验。 Copyright © 2023 布克学术 All rights reserved.
京ICP备2023020795号-1
ghs 京公网安备 11010802042870号
Book学术文献互助
Book学术文献互助群
群 号:481959085
Book学术官方微信