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J Pediatr Orthop
METHODS
This study was performed retrospectively using data
obtained from the hospitals surgical and specialty services
database. Children aged 15 and below who had sustained
a fracture of the distal radius or forearm, treated with
closed reduction under general anesthesia, were included.
After closed reduction, the majority of patients were
immobilized in an above elbow cast. The data collected
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Cut-o
Values*
0.8
0.3
1.1
> 01
0.15
0.8
*All indices except the second metacarpal radius angles are ratios and therefore do not have units applied to them.
AP indicates anteroposterior.
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RESULTS
There were 175 patients who met the above inclusion criteria. Twenty of these patients were excluded,
as there was insucient imaging or follow-up data
available, with a nal sample size of 155 patients. Redisplacement occurred in 33 of the 155 cases (21.3%). Of
these, 3 had remanipulation under anesthesia, 6 had
percutaneous pinning with Kirschner wires, 4 had an intramedullary titanium elastic nail (TENS nail) inserted,
and 1 had plate and screw xation. Nineteen patients had
no acute intervention but were monitored clinically and
radiologically for further redisplacement. There was no
further displacement found in these cases on follow-up
imaging, and the subanatomic position was left for
natural remodeling.
The descriptive statistics of the sample are shown
in Tables 2 and 3. There was no dierence between the
group with redisplacement and the group with no redisplacement with regard to age, sex, presence of associated
ulna fracture, fracture location, fracture angulation, or
obliquity of fracture. The only signicant dierence between the groups regarding initial parameters was the
level of initial displacement. The group with redisplacement had signicantly higher levels of initial displacement
than the group with no redisplacement (P < 0.001).
Further analysis of these data showed that the proportion
of cases with >50% initial displacement in the redisplacement group was more double that of the no redisplacement group (23/33 or 70% vs. 36/122 or 30%), with
an odds ratio of 5.4 (95% condence interval [CI], 2.412.5; P < 0.001). In addition, the accuracy of reduction
was signicantly better in the group with no redisplacement (P < 0.001). This remained statistically signicant
after correction for the dierences in displacement
r
J Pediatr Orthop
a
b
a
a
b
c
h
f
g
FIGURE 1. Radiographic indices used to assess quality of cast application after closed reduction. A, Cast index: a/b. B, Padding
index: a/b. C, Second metacarpal-radius angle (this image depicts an angle >0 degree). D, Gap index: [(a+b)/c]+[(d+e)/f].
E, Three-point index: [(a+b+c)/d]+[(e+f+g)/h].
DISCUSSION
Age
Angulation (degree)
on lateral
Angulation (degree)
on AP
Obliquity of # line
(degree)
No Redisplacement
(n = 122)
Redisplacement
(n = 33)
9.23 ( 2.8)
25.0 ( 11.9)
9.55 ( 3.0)
27.9 ( 14.1)
0.55
0.44
9.18 ( 8.5)
12.0 ( 8.9)
0.42
13.4 ( 11.6)
14.7 ( 13.1)
0.55
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Redisplacement
(n = 33)
85 (69.7)
60 (49.2)
23 (69.7)
21 (63.6)
0.99
0.20
radius)
19 (15.6)
86 (70.5)
17 (13.9)
2 (6.1)
26 (78.8)
5 (15.1)
0.37
56
30
16
11
9
(45.9)
(24.6)
(13.1)
(9.0)
(7.4)
73 (59.8)
48 (39.3)
2 (1.6)
8
2
8
7
8
Second metacarpal-radius
angle (degree)
(24.2)
(6.1)
(24.2)
(21.2)
(24.2)
< 0.001
9 (27.2)
15 (45.5)
9 (27.2)
< 0.001
Gap index
Three-point index
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0.78
63/105
0.17
97/105
0.95
91/105
1.8
(0.09)
(60.0)
(0.10)
(92.4)
(0.15)
(86.7)
(4.8)
0.83
9/28
0.18
25/28
1.01
23/28
1.6
(0.07)
(32.1)
(0.09)
(89.3)
(0.12)
(82.1)
(6.7)
0.001
0.010
0.424
0.699
0.550
0.012
0.659
71/103
0.14
74/86
0.91
33/86
(68.9)
(0.04)
(86.0)
(0.21)
(38.4)
23/31
0.13
24/26
1.01
10/26
(74.2)
(0.04)
(92.3)
(0.40)
(38.4)
0.081
0.515
0.382
1.000
The values on the top line are represented as mean (standard deviation); the
bottom value is the number of cases with a satisfactory index/total number of cases
(percentage of total cases for that group).
Values of indices are ratios, except for the second metacarpal-radius angle,
which is measured in degrees.
J Pediatr Orthop
FIGURE 2. Example of redisplacement after closed reduction. A, Initial prereduction radiograph. B, In a cast after closed reduction. C, Dorsal redisplacement found on review of 7-days postreduction. D, Subsequent fixation using percutaneous pinning
with Kirschner wires.
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