Sat., 10/6/12 Pediatric Fractures, PAPER #110, 3:29 pm OTA-2012
Both-Bone Forearm Fractures in Children and Adolescents: Which Fixation Strategy is Superior? A Systematic Review
Keith D. Baldwin, MD, MSPT, MPH; Martin J. Morrison III, MD;
Lauren A. Tomlinson, BS; John M. Flynn, MD
The Children’s Hospital of Philadelphia, Department of Orthopaedic Surgery,
Philadelphia, Pennsylvania, USA
Background/Purpose: Forearm fractures are a common injury in children and adolescents. There are many debates in the field of pediatric orthopaedics, including when to operate, what constitutes an acceptable reduction, and at what age does remodeling capability inherent to children become less effective. In general, the most common indications for surgical fixation in children and adolescents are open fractures, and the inability to maintain an acceptable closed reduction in a cast. Although operative management of these fractures has become increasingly more common over the last decade, the optimum fixation strategy is the subject of debate. The purpose of this study was to determine the difference in outcomes (union, complication rate, perioperative outcomes, and functional outcomes) of pediatric patients with a forearm fracture operatively treated with intramedullary nail fixation versus open reduction and plate fixation.
Methods: We performed a systematic review of the English literature for studies comparing plate and screw (P & S) fixation with intramedullary (IM) fixation in children and adolescents using computerized databases (PubMed, EMBASE, and Cochrane). Outcomes of interest were fracture union, complications, functional outcomes, perioperative variables, cosmesis, and need for hardware removal. We performed a meta-analysis using a DerSimonian and Laird random effects model. Publication bias and study quality were also assessed.
Results: 12 constituting 525 patients between the ages of 3 and 17 years were found. No differences were found between fixation strategies in terms of union or complications (total or major complications). Delayed unions and nonunions were rare, and slightly more common in the IM group, although the difference was not statistically significant. Refractures and scar-related problems were more common in the P & S group, and infection and hardware-related problems were more common in the IM group. Outcomes were excellent in nearly 9 of 10 patients regardless of fixation strategy. Operative time was greater in the P & S group as was cost. Cosmesis was superior in the IM group (P <0.001), and hardware removal was more common in the IM group (P <0.001).
Conclusions: IM nailing and P & S constructs are acceptable options in the fixation of pediatric forearm fractures. The literature fails to demonstrate a difference between IM fixation and P & S constructs. These results suggest that complication rates are similar, although the type of complication may vary. IM fixation provides improved cosmesis, but in general requires a second operation to remove hardware.
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• The FDA has not cleared this drug and/or medical device for the use described in this presentation (i.e., the drug or medical device is being discussed for an “off label” use). ◆FDA information not available at time of printing. Δ OTA Grant.