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Trauma: M. M. Zamzam and K. I. Khoshhal Displaced fracture of the distal radius in children: FACTORS RESPONSIBLE FOR REDISPLACEMENT AFTER CLOSED REDUCTION J Bone Joint Surg Br 2005; 87-B: 841-843 [Abstract] [Full text] [PDF]

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Response to Alemdaroğlu, Iltar and Atlihan

Production Department   (3 October 2005)

Response to Messrs Sambandam and Gul

Production Department   (3 October 2005)

Response to Mr Bhutta

Production Department   (3 October 2005)

Letter from Alemdaroğlu, İltar and Atlihan

Bahadır Alemdaroğlu, Serkan İltar, Doğan Atlıhan   (8 September 2005)

Fractures of the distal radius in children

Senthil Nathan Sambandam, Arif Gul   (12 July 2005)

Letter from Mr Bhutta

Mohammed A Bhutta, NG A.   (7 July 2005)

Response to Drs Agarwal and Agarwal

Production Department   (22 June 2005)

Response to Mr Todkar

Production Department   (22 June 2005)

Response to Gella and Gollapenne

Production Department   (22 June 2005)

Letter from Gella and Gollapenne

Sreenadh Gella, R R Gollapenne   (16 June 2005)

Distal radial fractures in children

Manoj Todkar   (16 June 2005)

Reducing redisplacement in fractures of the distal radius

Anil Agarwal, Rachna Agarwal   (16 June 2005)

Response to Alemdaroğlu, Iltar and Atlihan 3 October 2005
Production Department Send letter to journal: Re: Response to Alemdaroğlu, Iltar and Atlihan production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Response to Messrs Sambandam and Gul 3 October 2005
Production Department Send letter to journal: Re: Response to Messrs Sambandam and Gul production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Response to Mr Bhutta 3 October 2005
Production Department Send letter to journal: Re: Response to Mr Bhutta production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Letter from Alemdaroğlu, İltar and Atlihan 8 September 2005
Bahadır Alemdaroğlu, MD Ankara Education and Research Hospital, Ankara, Turkey, Serkan İltar, Doğan Atlıhan Send letter to journal: Re: Letter from Alemdaroğlu, İltar and Atlihan balemdaroglu{at}yahoo.com.tr Bahadır Alemdaroğlu, et al.	Sir, We read this article with interest. This was a didactic study of redisplacement of fractures of the radius in children after closed reduction. The authors found these factors responsible: age, not using general anaesthesia and complete initial displacement. Their criterion of 20º angulation is unacceptable as one can accept only 10º of radial angulation, while up to 30º-35º A-P angulation can be accepted.1 The initial stability of a transverse fracture and an oblique fracture or a smooth fracture line and rough fracture line will be considerably different. Casting technique should have been detailed as it is very important for ensuring stability of completely displaced fractures. For example, in fractures of the distal radius a mild wrist flexion and a little ulnar deviation may prevent most malalignments and redisplacements. Above elbow casts may cause more circulatory problems. The greater the initial swelling the more likely it would be to allow redisplacement for initially completely displaced fractures when it subsides. We recommend reduction combined with an above elbow cast and on the fourth day this is changed to a well-moulded and positioned short arm cast with deep sedation or local blocks. B. ALEMDAROGLU, MD S. ILTAR D. ATLIHAN Ankara Education and Research Hospital, Ankara, Turkey. 1. Wilkins KE, O'Brien E. Fractures of the metaphysis of the distal radius and ulna: acceptable limits of reduction. In: Rockwood CA, Wilkins KE, Beaty JH, ed. Fractures in Children. Vol 3. Philadelphia, etc: Lippincott-Raven Publishers, 1996:486-7.
Fractures of the distal radius in children 12 July 2005
Senthil Nathan Sambandam, MS MRCS University Hospital of North Staffordshire, Arif Gul Send letter to journal: Re: Fractures of the distal radius in children sam_senthil2002{at}yahoo.co.in Senthil Nathan Sambandam, et al.	Sir, We read this article with interest. The management of fractures of the distal radius in children is a controvsersial topic. However, there are a few areas in which we feel that the authors have not made themselves clear. In the Patients and Methods section the authors mention the distal radius, but do not clarify whether it is the metaphyseal area or the distal third of the radius to which they are referring. As the behaviour of the fracture is different in these two areas with respect to remodelling, growth disturbance and immobilisation techniques, we feel it is necessary to know the exact site of the fracture. The authors have also not discusseded the cast index,1 which is an important variable contributing to the displacement, nor have they described the nature of the ulnar fracture. This an important variable because previous studies have highlighted increased displacement of the radius if the ulnar fracture is displaced, rather than a greenstick.2 The authors recommend routine pinning of the distal radial fracture if it is completely displaced. All studies on factors determining displacement were retrospective.3,4,5,6 We do not have enough evidence concerning the reliability of these predictive factors. There are only two prospective studies7,8 which compare routine pinning with remanipulation of redisplaced fractures. In fact, there are reports of premature closure of the distal radius physis associated with pinning.9 With the limited evidence available we believe that it would be inappropriate to routinely pin the completely displaced radial fracture under anaesthesia. This should only be done if the fracture redisplaces in the cast. S. SAMBANDAM, MS, MRCS A. GUL University Hospital of North Staffordshire, Stoke on Trent, UK. 1. Chess DG, Hyndman JC, Leahey JL, Brown DC, Sinclair AM. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop 1994;14:211-13. 2. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop Relat Res 1976;(120):172-83. 3. Haddad FS, Williams RL. Forearm fractures in children: avoiding redisplacement. Injury 1995;26:691-2. 4. Voto SJ, Weiner DS, Leighley BL. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop 1990;10:79-84. 5. Proctor MT, Moore DJ, Paterson JMH. Redisplacement after manipulation of distal radial fractures in children. J Bone Joint Surg [Br] 1993;75-B:453-4 6. Zamzam MM, Khoshhal KI. Displaced fracture of the distal radius in children: factors responsible for redisplacement after closed reduction. J Bone Joint Surg [Br] 2005;87-B:841-3. 7. McLauchlan GJ, Cowan B, Annan IH, Robb JE. Management of completely displaced metaphyseal fractures of the distal radius in children: a prospective, randomised controlled trial. J Bone Joint Surg [Br] 2002;84-B:413-17. 8. Choi KY, Chan WS, Lam TP, Cheng JC. Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: a report of 157 cases. J Bone Joint Surg [Br] 1995;77-B:797-801. 9. Gibbons CL, Woods DA, Pailthorpe C, Carr AJ, Worlock P. The management of isolated distal radius fractures in children. J Pediatr Orthop 1994;14:207-10.
Letter from Mr Bhutta 7 July 2005
Mohammed A Bhutta, SHO Trauma & Orthopaedics Manchester Royal Infirmary, NG A. Send letter to journal: Re: Letter from Mr Bhutta aqeelbhutta{at}hotmail.com Mohammed A Bhutta, et al.	Sir, We read this article with interest. We would like clarification of the experience of the junior doctors who undertook all primary reductions, given that the high rate of redisplacement may also be attributed to this. We would also have appreciated data on the degree of primary reduction achieved in each anaesthetic group, rather than ‘perfect’ and ‘imperfect’. The fact that if these were close to the criteria for remanipulation and Kirschner wiring, the smallest amount of redisplacement would require further intervention, and with larger patient numbers it would produce a significant result. This might also add to the explanation for the higher rate of redisplacement in patients manipulated under a haematoma block. We agree that all completely displaced fractures should undergo closed reduction under general anaesthesia in order to ensure patient comfort and adequate application of a cast. However, this should be with senior supervision. The lower rate of redisplacement in the group undergoing general anaesthesia may be attributed to a younger population (mean age 5.5 years) in whom there are more favourable outcomes.1 Finally, with respect to the use of Kirschner wires (K-wires) to stabilise distal radial fractures, we feel that remanipulation under general anaesthesia by a senior surgeon of a fracture which has already begun to heal produces a similar result without the risks of K-wire damage to the epiphyseal growth plate, pin site infection and further general aneasthesia for removal of the wires. M. A. BHUTTA Manchester Royal Infirmary, Manchester, UK. 1. Zimmerman R, Gschwentner M, Kralinger F, et al. Long-term results following pediatric distal forearm fractures. Arch Orthop Trauma Surg 2004;124:179-86.
Response to Drs Agarwal and Agarwal 22 June 2005
Production Department Send letter to journal: Re: Response to Drs Agarwal and Agarwal production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Response to Mr Todkar 22 June 2005
Production Department Send letter to journal: Re: Response to Mr Todkar production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Response to Gella and Gollapenne 22 June 2005
Production Department Send letter to journal: Re: Response to Gella and Gollapenne production{at}jbjs.org.uk Production Department	Mr Zamzam has chosen not to respond to this letter.
Letter from Gella and Gollapenne 16 June 2005
Sreenadh Gella, SHO Orthopaedics Pinderfields General Hospital, Wakefield, UK, R R Gollapenne Send letter to journal: Re: Letter from Gella and Gollapenne mrgella{at}hotmail.co.uk Sreenadh Gella, et al.	Sir, We read this paper with interest and would like the authors to clarify a few points. They state that all the initial reductions were carried out by junior doctors, but there was no mention of whether or not they used moulding, which plays a crucial role in maintaining the reduction when the initial fracture is unstable. There was also no mention of the fracture configuration (transverse, oblique, spiral or comminuted), which determines stability. There was variability in the methods of anaesthesia used for the children. We could not understand why an initially well-reduced fracture under sedation or haematoma block did badly after a good reduction compared with under general anaesthesia. The initial displacement of the fracture is the single most predictive factor for redisplacement,1 and some authors regard the amount of initial translation to determine the redisplacement.2 It would be helpful if the authors could deduce from their extensive study the minimal initial displacement that put the reduction in jeopardy. S. GELLA, SHO R. R. GALLAPENNE Pinderfields General Hospital, Wakefield, UK. 1. Mani GV, Hui PW, Cheng JC. Translation of the radius as a predictor of outcome in distal radial fractures of children. J Bone Joint Surg [Br] 1993;75-B:808-11. 2. Choi K Y, Chan W S, Lam T P, Cheng J C. Percutaneous Kirschner-wire pinning for severely displaced distal radial fractures in children: a report of 157 cases. J Bone Joint Surg [Br] 1995;77-B:797-801.
Distal radial fractures in children 16 June 2005
Manoj Todkar, Orthopaedic Trainee Nuffield Orthopaedic Centre, Oxford Send letter to journal: Re: Distal radial fractures in children mtodkar{at}hotmail.com Manoj Todkar	Sir, I read this article with great interest. I agree with the authors about the factors responsible for redisplacement of distal radial fractures. The authors state that redisplacement occured in fractures which were reduced under sedation or local haematoma block. In children it is very difficult to achieve sufficient relaxation with sedation or local hematoma blocks. These methods should be used only when the patient is unfit for general anaesthesia (especially in completely displaced fractures). Another factor which can influence the stability of fracture is the position of the forearm. Distal radial fractures are usually stable in pronation and proximal radial fractures in supination. Injury to radioulnar joints can also add to instability of forearm fractures.These should be excluded in all cases with redisplacement.1 M. TODKAR Nuffield Orthopaedic Centre, Oxford, UK. 1. Perron AD, Hersh RE, Brady WJ, Keats TE. Orthopedic pitfalls in the ED: Galeazzi and Monteggia fracture-dislocation Am J Emerg Med 2001;19(3):225-8.
Reducing redisplacement in fractures of the distal radius 16 June 2005
Anil Agarwal, Consultant Orthopaedician, Delhi , Rachna Agarwal Send letter to journal: Re: Reducing redisplacement in fractures of the distal radius rachna_anila{at}yahoo.co.in Anil Agarwal, et al.	Sir, We read this article with interest. We fell that the authors should have defined the term ‘distal radius’ more precisely. Although it was not stated in the article, it appears that they chose the metaphyseal distal radial fracture as their subject of study. The position of immobilisation in distal radial metaphyseal fractures remains controversial. There has been mounting evidence in support of a neutral or supine position rather than a prone one.1,2,3 Positioning the limb in supination also eliminates brachioradialis.4 The rate of fracture redisplacement in the authors' series is quite high (25%). It is often difficult to apply a well-moulded cast after reduction in a displaced fracture with gross swelling in the limb, especially by a junior doctor. When the swelling subsides, the cast becomes loose. There is hardly any hold on fracture fragments and subsequently there is loss of reduction or redisplacement. At our institution we prefer the application of a primary dorsal/volar-radial slab. This slab is progressively tightened with a crepe bandage at early follow-up visits as the swelling subsides and is later converted into a cast. The maintenance of reduction is monitored by serial radiographs. This method allows for the swelling and permits assessment of the neurovascular status of the limb. Any redisplacement can be detected and dealt with easily. We have experienced significantly lower rates of redisplacement even in fractures that were initially completely displaced with this supervised protocol. A. AGARWAL R. AGARWAL Delhi, India. 1. Deffer PA, Schonholtz G, Litchman HM. Displaced forearm fractures in children. Bull Hosp Joint Dis 1963;24:42-7. 2. Gupta RP, Danielsson LG. Dorsally angulated solitary metaphyseal greenstick fractures in the distal radius. J Pediatr Orthop 1990;10:90-2. 3. Rodriguez-Merchan EC. Pediatric fractures of the forearm. Clin Orthop Rel Res 2005;432:65-72. 4. Pollen AG. Fractures and dislocations in children. Baltimore: Williams & Wilkins, 1973.