Background. Both-bone diaphyseal forearm fractures constitute up to 5.4% of all fractures in children under 16 years of age in the United Kingdom. Most can be managed with closed reduction and cast immobilisation. Surgical fixation options include flexible intramedullary nailing and plating. However, the optimal method is controversial. Objectives. The main purpose of this study was to systematically search for and critically appraise articles comparing functional outcomes, radiographic outcomes and complications of nailing and plating for both-bone diaphyseal forearm fractures in children. Methods. A literature search of MEDLINE (PubMed), EMBASE and Cochrane library databases using specific search terms and limits was undertaken. The critical appraisal checklist (adapted from Critical Appraisal Skills Programme-CASP, Oxford; Guyatt et al) for an article on treatment was used to aid assessment. Results. All 7 studies identified were retrospective, comparative and non-randomized. They all included patients with similar baseline characteristics. There were no statistically significant differences in group outcomes for range of forearm movement, time to fracture union and complication rates. Less operative time and better cosmesis was noted in the IM nailing groups. Some studies showed post-operative radial bow was significantly abnormal in the IM nailing groups, but did not affect forearm movement. Conclusion. Based on similar functional and radiographic outcomes, nailing seems to be a safe and effective option when compared to plating for forearm fractures in children. However, critical appraisal of the studies in this review identified some methodological deficiencies and further prospective, randomized trials are recommended

Titanium Elastic Nails have been around for the last 40 years, but it has never been introduced properly in the Pacific especially in Samoa in the management of femoral & in severely displaced forearm fractures in the paediatric age group & also Adult upper limb Trauma. This paper looks at the cases treated in TTM Hospital (Apia, Samoa) from June 2019- June 2023, looking at common injury patterns, indications for fixation and the cost benefit to the family and hospital, in terms of early rehabilitation and improving the length of stay in hospital pre-Tens nail era from 6–8 weeks to 1–2 weeks in hospital. 29 cases were treated with TENs concept during this period, 17 femoral fractures, 10 forearm fractures & 1 humerus fracture. Lastly this is very useful skill and tool to have in every hospital in the Pacific Islands, through proper training to prevent long term complications

The widely used Fracture Risk Assessment Tool (FRAX) estimates a 10-year probability of major osteoporotic fracture (MOF) using age, sex, body mass index, and seven clinical risk factors, including prior history of fracture. Prior fracture is a binary variable in FRAX, although it is now clear that prior fractures affect future MOF risk differently depending on their recency and site. Risk of MOF is highest in the first two years following a fracture and then progressively decreases with time – this is defined as imminent risk. Therefore, the FRAX tool may underestimate true fracture risk and result in missed opportunities for earlier osteoporosis management in individuals with recent MOF. To address this, multipliers based on age, sex, and fracture type may be applied to baseline FRAX scores for patients with recent fractures, producing a more accurate prediction of both short- and long-term fracture risk. Adjusted FRAX estimates may enable earlier pharmacologic treatment and other risk reduction strategies. This study aimed to report the effect of multipliers on conventional FRAX scores in a clinical cohort of patients with recent non-hip fragility fractures. After obtaining Research Ethics Board approval, FRAX scores were calculated both before and after multiplier adjustment, for patients included in our outpatient Fracture Liaison Service who had experienced a non-hip fragility fracture between June 2020 and November 2021. Patients age 50 years or older, with recent (within 3 months) forearm (radius and/or ulna) or humerus fractures were included. Exclusion criteria consisted of patients under the age of 50 years or those with a hip fracture. Age- and sex-based FRAX multipliers for recent forearm and humerus fractures described by McCloskey et al. (2021) were used to adjust the conventional FRAX score. Low, intermediate and high-risk of MOF was defined as less than 10%, 10-20%, and greater than 20%, respectively. Data are reported as mean and standard deviation of the mean for continuous variables and as proportions for categorical variables. A total of 91 patients with an average age of 64 years (range = 50-97) were included. The majority of patients were female (91.0%), with 73.6% sustaining forearm fractures and 26.4% sustaining humerus fractures. In the forearm group, the average MOF risk pre- and post-multiplier was 16.0 and 18.8, respectively. Sixteen percent of patients (n = 11) in the forearm group moved from intermediate to high 10-year fracture risk after multiplier adjustment. Average FRAX scores before and after adjustment in the humerus group were 15.7 and 22.7, respectively, with 25% (n = 6) of patients moving from an intermediate risk to a high-risk score. This study demonstrates the clinically significant impact of multipliers on conventional FRAX scores in patients with recent non-hip fractures. Twenty-five percent of patients with humerus fractures and 16% of patients with forearm fractures moved from intermediate to high-risk of MOF after application of the multiplier. Consequently, patients who were previously ineligible for pharmacologic management, now met criteria. Multiplier-adjusted FRAX scores after a recent fracture may more accurately identify patients with imminent fracture risk, facilitating earlier risk reduction interventions

Infection and re-fracture are well-described complications following open paediatric forearm fractures. The purpose of this paper is to determine if patient, injury, and treatment characteristics can be used to predict the occurrence of these complications following the surgical management of paediatric open forearm fractures. This is an IRB-approved retrospective review at a single-institution paediatric level 1 trauma centrefrom 2007–2013 of all open forearm fractures. Medical records were reviewed to determine the type of open fracture, time to administration of initial antibiotics, time from injury to surgery, type of fixation, length of immobilisation, and complications. Radiographs were studied to document fracture characteristics. 262 patients with an average age of 9.7 years were reviewed. There were 219 Gustillo-Anderson Type 1 open fractures, 39 Type 2 fractures, and 4 Type 3 fractures. There were 9 infections (3.4%) and 6 re-fractures (2.3%). Twenty-eight (10.7%) patients returned to the operating room for additional treatment; 21 of which were for removal of implants. Contaminated wounds, as documented within the medical record, had a greater chance of infection (21% vs 2.2%, p=0.002). No difference in infection rate was seen with regard to timing of antibiotics (p=0.87), timing to formal debridement (p=0.20), Type 1 versus Type 2 or 3 open fractures (3.4% vs 5.0%, p=0.64), 24 hours vs. 48 hours of post-operative IV antibiotics (5.2% vs 3.5%, p=0.53), or when comparing diaphyseal, distal, and Monteggia fracture patterns (3.6 vs 2.9% vs 5.9%, p=0.81). There was no difference in infection rate when comparing buried or exposed intramedullary implants (3.5% vs 4.2%, p>0.99). Rate of re-fracture was not increased based on type of open wound (p>0.99) or fracture type (0.4973), although 5 of the 6 re-fractures were in diaphyseal injuries. In this series of open paediatric both bone forearm fractures, initial wound contamination was a significant risk factor for subsequent infection. The rate of infection did not vary with timing of antibiotics or surgery, type of open fracture, or length of post-operative antibiotics. A trend to higher re-fracture rates in diaphyseal injuries was noted. Surgeons should consider planned repeat irrigation and debridement for open forearm fractures with obviously contaminated wounds to reduce the subsequent infection risk

Background and Aims:. Forearm fractures are common in the paediatric population and most are treated in a moulded plaster of Paris (POP) cast. It is our concern that many casts applied by our registrars are sub-optimal and that we need to improve our training process. The aim of our study was to review the adequacy of forearm cast application in paediatric patients at our institution and to identify if there is a need for a more formal training program with regard to plaster cast application. Methods:. A retrospective review of control x-rays of forearm fractures treated at our institution was undertaken. X-rays that were reviewed were done as part of the routine treatment protocol. X-ray measurements to assess POP application were the cast index and the gap index. A cast index of > 0.81 and Gap index of > 0.15 were regarded as an indication of poor cast application. Results:. Adequate control X-rays of twenty eight patients with a forearm fracture were available. The average patient age range was 5–12 years. There were thirteen distal metaphyseal fractures, nine diaphyseal fractures and six Salter-Harris type fractures. Of the 28 patients, 20 patients had a poor cast index and 17 patients had poor gap index. In 12 patients both the gap and the cast index were unacceptable. Conclusion:. Our study suggests that paediatric forearm plaster cast application by registrars at our institution is inadequate. This indicates a need for a strategy to improve the training in plaster cast application amongst our registrars

Introduction and aims. Cast immobilisation of paediatric forearm fractures has traditionally used plaster of Paris. Recently, synthetic casting materials have been used. There have been no studies comparing the efficacy of these two materials. The aim of this study is to investigate whether one material is superior for paediatric forearm fracture management. Methods. A single-centre prospective randomised trial of patients presenting to the Women's and Children's Hospital with acute fractures of the radius and/or ulna was undertaken. Patients were enrolled into the study on presentation to the Emergency Department and randomised by sealed envelope into either a fiberglass or plaster of Paris group. Patients then proceeded to a standardised method of closed reduction and cast immobilisation. Clinical follow-up occurred at one and six weeks post-immobilisation. A patient satisfaction questionnaire was completed following cast removal at six weeks. All clinical complications were recorded and cast indexes were calculated. Results. Initially 50 patients were recruited to the study, with equal randomisation. There were no significant differences between the patient demographics of the two groups. The results from this sample indicated an increase in clinical complications involving the plaster of Paris casting group. These complications included soft areas of plaster requiring revision, loss of reduction with some requiring re-manipulation and a high rate of cast spliting due to material swelling. The fractures that loss reduction had increased cast indices. Fibreglass casts were also preferred by patient and their families, with many observational comments regarding the light-weight and durable nature of the material. Conclusions. Cast immobilisation of paediatric forearm fractures is a common orthopaedic treatment. There is currently no evidence regarding the best material for casting. This study suggests that both clinical outcomes and patient satisfaction are superior with fiberglass casts, we are continuing this study to enable greater power with our results

Distal radius and ulna fractures are a common paediatric injury. Displaced or angulated fractures require manipulation under anaesthetic (MUA) with or without Kirchner (K) wire fixation to improve alignment and avoid malunion. After treatment a proportion redisplace requiring further surgical management. This study aimed to investigate whether the risk of redisplacement could be reduced by introducing surgical treatment guidelines to ascertain whether MUA alone or the addition of K wire fixation was required. A cohort of 51 paediatric forearm fractures managed either with an MUA alone or MUA and K wire fixation was analysed to determine fracture redisplacement rates and factors which predisposed to displacement. Guidelines for optimal management were developed based on these findings and published literature and implemented for the management of 36 further children. A 16% post-operative redisplacement rate was observed within the first cohort. Redisplacement was predicted if an ‘optimal reduction’ of less than 5° of angulation and/or 10% of translation was not achieved and no K wire fixation utilised. Adoption of the new guidelines resulted in a significantly reduced redisplacement rate of 6%. Implementation of departmental guidelines have reduced redisplacement rates of children's forearm fractures at Great Western Hospital

Introduction. Displaced distal radius fractures in children have been treated in above elbow plaster casts since the last century. Cast index has been calculated previously, which is a measure of the sagittal cast width divided by the coronal cast width measurement at the fracture site. This indicates how well the cast was moulded to the contours of the forearm. We retrospectively analysed the cast index in post manipulation radiographs to evaluate its relevance in redisplacement or reangulation of distal forearm fractures. Study Design. Consecutive radiographic analysis. Materials and methods. 156 consecutive paediatric patients (114M : 42F), with a mean age of 9.8 years (range 2-15 years), presenting with forearm fractures were studied. All patients were manipulated in OR and a moulded above elbow cast was applied. The cast index was measured on immediate post manipulation radiographs. Results. Displacement of the fracture within the original plaster cast occurred in 30 patients (19%), 22/114 males; 8/42 females. The cast index in the 30 patients requiring a second procedure (mean 0.92, SD=0.08) was significantly more than the cast index (mean 0.77, SD=0.07) in the others (p< .001). Discussion. A high cast index in post manipulation radiographs indicates increased risk of re-displacement of the fracture and these patients should be kept under close review. Conclusion. Cast index is a valuable tool to assess the quality of moulding of the cast following closed manipulation of distal radius fractures in children. The maximum acceptable cast index should be 0.82

Methicillin– resistant Staphylococcus aureus (MRSA) infected gap non –union of long bones fractures is a challenge to manage. Treatment options are limited such a Ilizarov bone transport, vascularized bone free transfer etc. These techniques have complications and require expertise. We present a rare case with MRSA infected nonunion and bone defect 5cm of ulna which was managed with the induced membrane formation. A 33-years old male presented to outpatient department, 2 months after internal fixation on both left bone forearm fractures (Gustillo I). There was pus discharge from the operative site of ulna. Culture results: MRSA, C-Reactive Protein (CRP): 2,58 (0–5), Erythrocyte Sedimentation Rate (ESR): 42 (0–20). Intravenous (iv) Teicoplanin and Rifampicin were administrated and after one month no topic symptoms and CRP- ESR were normal. One month later he had again actively draining sinus (CRP: 1,47 ESR:22). The implant (ulna) was removed and a gap 5 cm was created at the fracture site (necrotic-infected bone debrided), which was filled by cemented spacer (Tobramycin and vancomycin). An external fixator was applied to ulna. Radius was not involved. Post op. iv the same antibiotics for 4 weeks. At the end of 8 weeks, the spacer was removed and the gap was filled with autologous cancellous bone graft (iliac crest). After 5 months the patient was reviewed. No any clinical and functional problems. Radiographics and CT-images were showed osseous consolidation. This technique (called as ‘Masquelet’) gives promising result in the management of infected long bone defects in upper extremity

3D printing an additive manufacturing technique, allowing for rapid prototyping in many industries. To date, medical applications have generally been within a research or industry environment, as the costs (expertise, software and equipment) have been prohibitive. We have established a means by which 3D printing of bones can be achieved quickly, cost-effectively and accurately from standard computer tomography (CT) digital imaging and communications in medicine (DICOM) data. CT DICOM data of a malunited forearm fracture were manipulated using open-source software (no cost) and a 3D model was produced by selective-laser-sintering. The entire process took 7 days (total cost £77). This process and the resultant model were then assessed for overall accuracy. This sequential methodology provides ready and economical access to a technology that is valuable for preoperative templating/rehearsal in complex 3D reconstructive cases

Purpose:. Paediatric forearm fractures are commonly seen and treated by closed reduction and plaster cast application in theatre. Historically, cast application has been subjectively evaluated for its adequacy in maintaining fracture reduction. More recently emphasis has been placed on objectively evaluating the adequacy of cast application using indicators such as the Canterbury index (CI). The CI has been used in predicting post-reduction, re-displacement risk of patients by expressing the casting and padding indices as a ratio. The CI has been criticized for not including cast 3 point pressure, fracture personality and lack of standardization of X-ray views as well as practical requirement of physical measurement using rulers. The aim of this study was to determine whether subjective evaluation of these indices, on intra-operative fluoroscopy and the day 1 to 7 postoperative X-ray, was accurate in predicting a patient's ultimate risk of re-displacement, following reduction and casting. Materials and Methods:. In total, 22 X-rays from 11 patients were evaluated by 20 orthopaedic registrars and 8 consultants, before and after a tutorial on the Canterbury index. Results:. Formal tutorial did not show an increased subjective predictive accuracy. No clear correlation could be demonstrated between CI and the clinical outcome. Conclusion:. Value of the CI in clinical practice is doubtful due to various confounding factors. The CI has been used due to lack of other available systems, and ideally a system should be sought which incorporates fracture personality, cast 3 point pressure and standardisation of X-Rays

All children with a fracture of both bones of the forearm who underwent general anaesthetic manipulation and plaster (GAMP) at the Launceston General Hospital over a four-year period from 2005–2008 were reviewed. Casting technique was determined according to the treating surgeon, with three casting techniques used: flexion, extension and a mid-flexed position. The primary end-point was defined as re-manipulation or progression to open reduction and internal fixation. The secondary end-point of residual angulation was also assessed. A total of 123 patients with 124 fractures were treated with GAMP. Seventy-seven cases were treated in a traditional flexion cast, 28 in extension and 19 were treated in a dorsoradial slab in a mid-flexed position. Ten patients required repeat intervention. Six failures were initially cast in flexion, four were in the mid flexed position and none of the fractures in the extension group required re-manipulation. The difference between the groups was statistically significant (p<0.001). There was significantly greater residual angulation at follow up in the flexed group compared to the extension group for both the radius (p=0.049) and the ulna (p=0.046). Closed reduction and cast immobilisation with the elbow extended is a safe and more effective technique in maintaining position in both bone forearm fractures in children

Softcast is an attractive alternative to POP for unstable forearm fractures, providing a comfortable, water-resistant splint that can be removed without a plaster saw. Unreinforced Softcast has, however, only been recommended for buckle fractures. A laboratory study was undertaken to compare standardised POP, Softcast and reinforced Softcast splints at clinically relevant endpoints. The load at clinical failure of a 6-wrap Softcast forearm splint was 504N in bending, 202N in kinking, and 11Nm in torsion (equalling 30.4%, 26% and 42.2% of the equivalent values for a circumferential 4-wrap POP). Softcast was however stronger in all modes than a fibreglass-reinforced Softcast splint, such has been recommended for acute fractures. Furthermore, the load to failure in all modes exceeds that which can be exerted by body weight in many paediatric patients. Softcast demonstrated complete recovery of its original shape on unloading, and was 4% lighter than POP. A 6-wrap Softcast splint provides adequate mechanical stability and protection for paediatric patients up to 20kg, not engaged in high-risk activities. The primary risk is not of fracture angulation and loss of position, but temporary indentation of the splint, causing discomfort or pain. Considering its ease of removal, Softcast may be preferable for younger paediatric patients

Australian Doctors for Africa was formed in 2005 to provide some focus on the orthopaedic needs of the east coast of Africa. With the support of the college and the AOA, and in response to requests for assistance, the size and scope of the organisation has increased. ADFA has four active projects based primarily around the provision of orthopaedic services and teaching, along with the supply of medical, surgical and hospital equipment. Each location has different needs and is the subject of a different three-year development partnership. In Addis Ababa, Ethiopia the programme is mainly teaching the trainee orthopaedic surgeons, coordinating the visits of volunteers from other organisations and providing hospital equipment. A container of hospital beds, crutches, wheelchairs and splints have just arrived. An orthopaedic team led by Dr Tony Jeffries visited for two weeks in September 2009 to teach the operative management of forearm fractures, improve the sterile technique in the operating theatres and deliver and install an intramedullary nailing set. In Hargeisa Somaliand, ADFA is involved with the Faculty of Medicine of the University of Western Australia to develop a curriculum with School of Medicine and provide medical staff for clinical teaching. In Bosaso, Puntland, Northern Somalia, we, together with Rotary, are assisting with the construction of new theatre wards and furnishing with hospital beds and equipment. Here, the orthopaedic service is consulting and operating rather than teaching. In Madagascar we have been building up the talipes screening and plaster treatment service, providing container loads of medical and surgical equipment and conducting bi-annual orthopaedic operating visits. The next visit is in November 2009 with orthopaedics, gastroenterology and urology specialists from ADFA

We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the cast index and padding index and correlated these measurements with the incidence of fracture redisplacement. Phase II assessed these indices for their value in clinical decision making. Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1

Aims. To evaluate the results of Elastic Stable Intramedullary Nailing (ESIN) for displaced, unstable paediatric forearm diaphyseal fractures. Method. A retrospective, consecutive series study of 60 patients treated with ESIN between February 1996 and July 2005. Results. There were 43 (72%) boys and 17 (28%) girls with median age of 11.5 years (range: 2.6-15.9). 54 (90%) patients had a closed injury and 6 (10%) sustained a Grade I open injury. Seven patients had an isolated radius fracture. 49 (82%) fractures were stabilised with both bone ESIN, 10 (16%) with radial and one with isolated ulnar ESIN by standard technique under tourniquet control. All but two patients were protected with an above elbow cast. Thirty-six cases (60%) were primary procedures and 24 (40%) were performed due to re-displacement following a MUA. 36 patients (60%) required a minimal open reduction. Average hospital stay was 1.8 days (1-8 days). Average length of immobilisation was 5.4 weeks (3-9 weeks). Average time for clinical fracture union was 5.7 weeks (3-13 weeks). ESIN were removed after mean period of 33.8 weeks (approx: 7.9 months). One patient had a forearm compartment syndrome and required formal fasciotomy. One patient had ulnar delayed union and one had ulnar non-union. Five patients had transient superficial radial nerve neuropraxia. Ten had soft tissue irritation leading to early nail removal in two patients and two had superficial wound infection. Three patients sustained a re-fracture with the nail in situ following a new injury. 53 (88%) patients had full elbow and wrist movements on discharge. Seven patients had restriction of forearm rotations of less than 15°. Conclusion. Good clinical outcome, transitory and modest complications; quick and safe nail removal; and better cosmesis compared to plating makes ESIN an attractive treatment option for displaced, unstable paediatric forearm diaphyseal fractures

Introduction

In response to the COVID-19 pandemic, there was a rapidly implemented restructuring of UK healthcare services. The The Royal National Orthopaedic Hospital, Stanmore, became a central hub for the provision of trauma services for North Central/East London (NCEL) while providing a musculoskeletal tumour service for the south of England, the Midlands, and Wales and an urgent spinal service for London. This study reviews our paediatric practice over this period in order to share our experience and lessons learned. Our hospital admission pathways are described and the safety of surgical and interventional radiological procedures performed under general anaesthesia (GA) with regards to COVID-19 in a paediatric population are evaluated.