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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 35  |  Issue : 3  |  Page : 1579-1584

Outcome of management of diaphyseal forearm fracture in children during the coronavirus disease 2019 crisis


1 Department of Orthopedic Surgery, Faculty of Medicine, Menoufia University, Menoufia, Egypt
2 Department of Orthopedic Surgery, Assiut University, El Eman General Hospital, Assiut, Egypt

Date of Submission11-Apr-2022
Date of Decision16-May-2022
Date of Acceptance22-May-2022
Date of Web Publication29-Oct-2022

Correspondence Address:
Melad M Youseff Bashta
Mahmoud Rashwan Street, Assiut
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/mmj.mmj_126_22

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  Abstract 


Background
Fractures in children are common scenarios facing orthopedic surgeons. Forearm fractures in childhood account for 25% of all other injuries.
Objectives
This study aims to evaluate the outcome of management of diaphyseal forearm fracture in children under 12 years old during the coronavirus disease 2019 (COVID-19) crisis and how (COVID-19) affect our choice of management.
Patients and methods
This study was held on 50 patients; 25 of the children were managed at Menoufia University Hospitals and 25 children were managed at Al Iman General Hospital in Assiut from June 2020 to June 2021. All the patients were subjected to history, physical examination, plain radiograph anteroposterior and lateral views of the forearm from the elbow to the wrist. Method of treatment: of the 50 patients, 17 patients were treated by conservative management and 33 patients by surgical interventions.
Results
In our study, 17 (32%) cases were managed conservatively by closed reduction above-the-elbow plaster cast (CRAEPC) and 33 (68%) cases were managed operatively by different methods. Based on the Price and colleagues criteria, the functional outcome of our study was calculated, which showed excellent results in 34 (68%) patients, good in 13 (26%), fair in three (6%), and no poor results. All operated cases had general anesthesia on supine position.
Conclusion
Management of diaphyseal both-bone fracturess in children below 12 years, either conservative or operative, was not affected by COVID-19, that is the role of management is the same pre-COVID-19 and during COVID-19, but methods of follow-up depends on recent communication technology of social media.

Keywords: coronavirus disease 2019, diaphyseal forearm fracture, WHO


How to cite this article:
Mohamed BZ, Youseff Bashta MM, Eid TA, El-Behiry AM. Outcome of management of diaphyseal forearm fracture in children during the coronavirus disease 2019 crisis. Menoufia Med J 2022;35:1579-84

How to cite this URL:
Mohamed BZ, Youseff Bashta MM, Eid TA, El-Behiry AM. Outcome of management of diaphyseal forearm fracture in children during the coronavirus disease 2019 crisis. Menoufia Med J [serial online] 2022 [cited 2024 Mar 29];35:1579-84. Available from: http://www.mmj.eg.net/text.asp?2022/35/3/1579/359655




  Introduction Top


Since the first case of the novel coronavirus disease (COVID) was reported in Wuhan, China in December 2019, viral infection has spread at an alarming rate. On January 30, 2020, the WHO announced COVID as a Public Health Emergency of International Concern, and by March 11, 2020, it was officially declared a pandemic[1].

Orthopedic daily practice has been profoundly revolutionized by the pandemic. Most elective surgeries have been deferred ensuring that personal protective equipment, ICU beds, and additional workforce would be redistributed to tackle the COVID-19 emergency. On the other hand, conditions including severe trauma, musculoskeletal tumors, and infections, still necessitate urgent care and cannot be delayed. As surgery requires working in a confined space in close contact with the patient, the risk of infection transmission during the procedure and generally in the context of patient care is reasonably high[2].

During the COVID pandemic, there will be an increased emphasis on nonsurgical strategies. Patients who need urgent orthopedic management, such as serious traumatic injuries or tumors, will be managed according to the typical standard of care. The COVID pandemic will more dramatically affect practice regarding elective procedures and the ensuing follow-up[2].

Forearm bone fractures are the third most common fractures in children accounting for 30–40% of all fractures[3]. More than 75% of forearm fractures are distal third fractures. These fractures occur most commonly in children of age group 6 to 10 years, males being more involved than females[4]. Fall on outstretched hand especially during play has been found to be the commonest mechanism of injury in these fractures, other mechanisms include road traffic accidents[5].

Treatment depends on the type of fracture. Most of the forearm fractures are treated by closed reduction (CR) and immobilization with variable outcome. Both national (80%) and international (58.8%) literature shows marked variation in the outcome of conservative management of forearm fractures[6].

Operative management becomes popular due to complications of conservative treatment, which includes redisplacement, compartment syndrome, residual deformation, and loss of mobility. The criterion for acceptable reduction varies with the position of fracture and age.

Younger children have more remodeling capacity; therefore, a greater degree of angulations and malrotation is acceptable. Children whose radiographic evaluation exceeds certain criteria should be considered for operative treatment [Table 1][7],[8],[9],[10],[11].
Table 1: Recommended acceptable alignment parameters for both-bone pediatric forearm fracture

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The aim of the present study was to evaluate the outcome of management of diaphyseal forearm fracture in children under 12 years old during the COVID-19 crisis and how COVID-19 affect our choice of management


  Patients and methods Top


Approval for the study was granted by the Local Ethics Committee and informed consent was obtained from the parents of all the patients. This was a prospective study that was conducted on 50 children with diaphyseal fracture forearm who were treated with different methods of management and how COVID-19 crisis affected our choice of management. Twenty-five of the children were managed at Menoufia University Hospitals and 25 children were managed at Al Eman General Hospital in Assiut, our cases were studied from June 2020 to June 2021.

Patients with the following criteria were included in the present study; both male and female sex of age less than or equal to 12 years with diaphyseal forearm fractures during the COVID-19 crisis. While patients above 12 years old, with multiple fractures, open fractures, neurovascular compromise or pathological fractures, metaphyseal and epiphyseal fractures, and Monteggia and Galeazzi fractures were excluded from our study.

All patients in the present study were subjected to history taking from the patient and his parents, including the date of injury, mechanism of injury, and details of initial and subsequent treatment. Examination of the patient generally and locally to the forearm and examination of skin condition, tenderness, associated injury, and general evaluation of patient fitness for operative intervention was done. Plain radiograph anteroposterior and lateral views of the forearm from the elbow to the wrist were done.

Method of treatment: of the 50 patients 17 patients were treated by conservative management and 33 patients by surgical intervention. Side of injury of the 50 patients who were included in this study: 30 patients have fractures of both bones on the right side and 20 on the left side.

Follow-up of patients was done by clinical examination (for assessment of any complications till complete bone healing, disappearance of pain, and full range of motion ROM), radiological evaluation (anteroposterior and lateral radiographs by serial radiograph according to the condition of the case to reduce the number of visits to hospital as possible during COVID-19) and recording of residual complications such as nonunion, refracture, malunion, pinning infection, and infected wound.

The results had been evaluated for each of the following: amount of any persistent deformity, return of full function, and the time of radiographic union 'bridging callus formation in 3-4 cortices.'Based on Price and colleagues, criteria [Table 2][12].
Table 2: Functional outcome criteria

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Example for a case of our study treated surgically by CR and elastic rods fixation is given in [Figure 1].
Figure 1: A case of male patients 11 years with right both-bone forearm fracture treated by closed reduction and fixation by elastic rods.

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Statistical analysis

Data were analyzed using the Statistical Package for the Social Sciences (SPSS) software program (version 26). (SPSS Inc. Released 2015. IBM SPSS statistics for Windows, version 23.0; IBM Corp., Armonk, New York, USA). Qualitative variable recorded as frequencies and percentages and compared by χ2 test. Quantitative measure is presented as means ± SD and compared by Student's t test. A two-tailed P value less than or equal to 0.05 was considered statistically significant.


  Results Top


The present study showed that most cases were males (80%) with a mean age of 7.65 ± 2.48; most patients were complaining of deformity (38%) on the right side (60%) and the most affected site is mid-shaft (52%). Based on the Price and colleagues, criteria, functional outcome of our study was calculated, which showed excellent results in 34 (68%) patients, good in 13 (26%), fair in three (6%), and no poor results. All patients with excellent results had lost 10° or less of forearm rotation. In 13 patients with good results, seven patients had lost 11–30° of forearm rotation, while the other six had lost 10° or less but were grouped under good rather than excellent outcome as the patients had mild complaints of pain and fatigue with strenuous activities.

In detail, we reported excellent functional outcome in eight patients treated by CR above the elbow plaster cast (AEPC); 17 patients were treated by CR K-wires, seven patients by CR elastic rods, and two patients were treated by open reduction internal fixation (ORIF) with plates.

There was good functional outcome in seven patients treated by CRAEPC, five patients by CR K-wires, and one patient treated by ORIF with plates while fair functional outcome was reported in two patients treated by CRAEPC and one patient treated by CR elastic rod. All the fractures were closed fractures. Full union was achieved in our cases. From our cases, 17 cases were treated with conservative method by CRAEPC and 33 cases were treated by the surgical method.

Demographic data of our study: sex, age, complaints, side of fracture, and site of fracture are shown in [Table 3].
Table 3: Demographic data of our study

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The present study showed that 39 (88%) patients had no complications and 11 (22%) patients had complications; five (10%) patients had conservative management and six (12%) patients had surgical management. Details are provided in [Table 4].
Table 4: Complications recorded in our study according to the method of treatment

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Functional outcomes of our study according to the methods of treatment are based on the Price and colleagues criteria [Table 5].
Table 5: Functional outcome in all patient's study according to the method of treatment based on Price et al.[12], criteria

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  Discussion Top


Our study was conducted on 50 children with diaphyseal fracture of the forearm who were treated with different methods of management during the COVID-19 crisis.

Of the children 25 were managed at Menoufia University Hospitals and 25 children were managed at Al Eman General Hospital in Assiut; our cases were studied from June 2020 to June 2021.

During the coronavirus pandemic, there will be increased emphasis on managing children with nonoperative strategies and minimizing outpatient visits[13].

There are special recommendations for the Care of Pediatric Orthopedic Patients. During the COVID-19 pandemic to decrease the risk infection of COVID such as minimizing in person visits, maximizing follow-up through video or teleconference, and performing follow-up imaging only if likely to make significant change to care[14].

Most diaphyseal fractures in children are treated by CR and casting. where acceptable CR cannot be achieved or maintained in patients with completely unstable forearm fractures, surgical intervention is required[15].

Certain studies have argued that even with 100% displacement of the radius and ulna, CR and casting is an excellent treatment choice for children 9 years old and younger[6],[16]. Daruwalla[17] reviewed 53 displaced forearm fractures in children with an average of 3 years of follow-up and found that all the patients were asymptomatic and had no limitations in their activities even though 6% of them had lost more than 30° of forearm rotation.

Mhatre et al.[18] reviewed 30 children with both-bone forearm fracture and found that excellent in 24 (80%) patients, good in four (13.33%), fair in two (6.6%), and no poor results with conservative management during the severe acute respiratory syndrome coronavirus 2 pandemic 2020 and found that nonoperative treatment of both-bone diaphyseal forearm fracture with CR casting has well to excellent functional outcomes in children in the age group of 4–15 years.

There is a growing trend toward intramedullary fixation of forearm fractures in children. It was reported that there is an increase in the rate of complications following nonoperative treatment compared with operative treatment, which could be the reason that they have become more surgical. Complications included redisplacement, decrease in the range of motion, delayed union, residual deformity, and refracture[19].

Intramedullary fixation has been the preferred method in recent studies[20]. This surgery offers stable fixation without disturbance of the periosteal blood supply or removal of the hematoma, which contributes to fracture healing. The percutaneous use of K-wires or Steinmann pins requires no dissection or special instrumentation, as the insertion landmarks are subcutaneous and easily palpable. Excellent clinical and functional results have been achieved in other studies through the use of K-wires for intramedullary fixation of diaphyseal forearm fractures in children[21].

Based on Price and colleagues, criteria, functional outcome of our study was calculated, which showed excellent results in 34 (68%) patients, good in 13 (26%), fair in three (6%), and no poor results.

In detail, we reported excellent functional outcome in 8 patients treated by CRAEPC, 17 patients were treated by CR K-wires, seven patients by CR elastic rods, and two patients were treated by ORIF with plates. Good functional outcome in seven patients was treated by CRAEPC, five patients by CR K-wires, and one patient was treated by ORIF with plates while fair functional outcome was reported in two patients treated by CRAEPC and one patient was treated by CR elastic rod.

Abalo et al.[22] treated 184 children with displaced forearm fractures with K-wire fixation. Based on Anderson criteria, in their study 27% of the patients attained excellent, 45% satisfactory, and 23% unsatisfactory results. In 5% of the patients union failed. Many authors have stated that fractures of forearm bones in children occur around the age of 10 years[23]. In our study, the age of the studied cases ranged from 3 to 12 years with a mean of 8 years.

Many studies have reported that the incidence of pediatrics forearm fractures was more common in males than in females[24].

This observation can be explained by the fact that males are more involved in sports and traffics than females so they are more prone to injuries. In our study, there were 40 males and 10 females. However, some authors did not use postoperative immobilization and allowed an early postoperative motion[24]. Others advised the use of postoperative immobilization for a brief period[21],[25].

Supplemental plaster cast immobilization after intramedullary fixation is still recommended, as the rotational stability of pediatric forearm fractures treated by intramedullary pinning is still under investigation. This idea is supported by Luhmann et al.[20] and Shoemaker et al.[21]. We used postoperative immobilization in the form of long arm cast for 4–8 weeks in order to protect the fracture until a sufficient amount of callus is formed to prevent redisplacement.

The mean time to union in our study was 7.24 ± 1.33 weeks (the earliest was 4 weeks and the latest was 10 weeks). This was similar to the results obtained by Ali et al.[23], Ahmad et al.[24], Kose et al.[26], and Ali and Khadrawe[27].

The most common functional deficit after malunited forearm fractures is particularly reduced motion of pronation and supination. More authors[12],[28],[29] arrived at a similar conclusion as Price et al.[12] have suggested that when malunion is greater than 10° angulation in the middle third; rotation can be limited by 20–30°. Daruwalla[17] recommended 10° as the maximum acceptable angulation for older children and proximal shaft fractures. Matthews et al.[29] found similar results in a cadaveric study.

Caruso et al[30] reported that only two of 17 patients with persistent malunion (defined as an angulation of 20°) noted a functional or cosmetic problem.

In the current study, complications were detected in 11 (22%) patients; five (10%) patients with conservative management and six (12%) patients with surgical methods. Calder et al.[31] reported a 16% complication rate, Lascombes et al.[32] reported 20%, Luhmann et al.[20] reported 24%, Shoemaker et al.[21] reported 25% complication rate while Cullen et al.[33] reported 50% complication rate. On the other hand, no complications were reported in the series of studies by Verstreken et al.[34] and Amit et al.[35].

Sinikumpu et al.[36] found that the complications associated with cast immobilization include disuse osteopenia, muscle atrophy, skin breakdown, and elbow stiffness.


  Conclusion Top


There is not a unique consensus about fracture management and treatment of both-bone forearm fracture in children. Current literature agrees on the conservative treatment as a gold standard between defined parameters. Exceeding these parameters, surgical treatment is indicated, with special regard to patient's age, fracture pattern, and surgeon experience. This trend may be the result of a new technology, family and surgeon intolerance of remaining deformity. Further studies are necessary to create univocal guidelines about the optimal treatment, considering new techniques and available technologies.

Management of diaphyseal both bones in children below 12 years, either conservative or operative, id not affected by COVID-19, that is the role of management is the same pre-COVID-19 and during COVID; but the strategy of follow-up became different and depended on the recent communication technology of social media, which decrease direct contact with patients and their relatives and this led to a decrease in the risk of infection by COVID.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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