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ORIGINAL ARTICLE

Risk Factors for Redisplacement of Pediatric Distal


Forearm and Distal Radius Fractures
Alexander Georey McQuinn, BMBS, B.Phys and Ruurd Lukas Jaarsma, MD, PhD, FRACS

Background: Fractures of the distal forearm and distal radius


represent the most common types of fracture in the pediatric
population, with the majority treated by closed reduction and
cast. Redisplacement has been known to occur in up to 39% of
cases. There have been numerous risk factors and radiologic
indices put forward as methods of predicting redisplacement,
but this topic remains a matter of debate. This retrospective
study aims to further assess the signicance of the many factors
in redisplacement after treatment with closed reduction.
Methods: This retrospective study included 155 children with
distal radius and forearm fractures. Age, sex, location of fracture, angulation, displacement, an associated ulna fracture,
obliquity of fracture, and accuracy of reduction were measured
for assessment as potential risk factors. In addition, the cast
index, padding index, Canterbury index, second metacarpalradius index, gap index, and 3-point index were measured on
postreduction radiographs.
Results: Redisplacement occurred in 33 of the 155 cases (21.3%).
Initial displacement and accuracy of the reduction were identied as signicant risk factors for redisplacement. Initial displacement of >50% (of the radius width) was signicantly
associated with redisplacement (odds ratio of 5.4). Failure to
achieve anatomic reduction was signicantly higher in the redisplacement group (odds ratio 3.9). The only radiologic index
that diered signicantly between groups was the cast index,
with more patients without redisplacement meeting the cut-o
value (60% vs. 32%, P = 0.010).
Discussion: Initial displacement of >50% and inability to achieve anatomic reduction are major risk factors for redisplacement. Given its eectiveness and ease of clinical application, the
cast index remains the most useful measure of cast molding.
Level of Evidence: Level IIRetrospective prognostic study.
Key Words: fracture, forearm, distal radius, closed reduction,
redisplacement
(J Pediatr Orthop 2012;32:687692)

From the Department of Orthopaedic Surgery, Flinders Medical Centre,


Bedford Park, SA, Australia.
No internal/external funding received for this project from any source.
None of the authors received nancial support for this study.
The authors declare no conict of interest.
Reprints: Alexander Georey McQuinn, BMBS, B.Phys, Department of
Orthopaedic Surgery, Flinders Medical Centre, Flinders Drive,
Bedford Park, SA 5042, Australia. E-mail: alexmcq@gmail.com.
Copyright r 2012 by Lippincott Williams & Wilkins

J Pediatr Orthop

ractures of the forearm and distal radius represent the


most common type of fracture in the pediatric population.1,2 The mechanism of injury is that of a direct fall
in the majority of cases.2,3 Fractures in the pediatric
population dier from those in adults, due to the ability
for increased bone remodeling while the physes remain
open.2,3 Closed reduction in a molded cast has traditionally been the primary form of treatment.35 In some
reports, although, the incidence of redisplacement has
been found to be as high as 39%.6 Although some authors have advocated the use of operative methods of
xation such as percutaneous pinning in cases of severe
angulation or displacement,7,8 other reports have shown
similar cost and complication rates between closed reduction and percutaneous pinning.6
The risk factors associated with fracture redisplacement have been reported on previously; however,
there is no clear consensus on which factors are the most
important in predicting treatment failure. Risk factors
have been grouped into fracture, surgeon, and patient
factors,1 with many of the fracture-related and surgeonrelated factors being objectively measurable. Some of the
factors that have previously been related to risk of redisplacement are complete initial displacement,8,9 quality
of reduction,4,9,10 obliquity of fracture,9 and use of conscious sedation or hematoma block without general anesthesia.8 A variety of measures of the quality of plaster
molding and position have been described, including the
cast index,11 padding index,12 Canterbury index,12 second
metacarpal-radius angle,13 gap index,14 and 3-point index.9 These various radiologic indices have been put
forward as a method of predicting treatment failure, although evidence to show a single index as a standalone
predictive measure is lacking.1
This retrospective study of pediatric distal forearm and
distal radius fractures aims to further assess the signicance
of the many fracture-related and surgeon-related factors in
redisplacement after treatment with closed reduction.

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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McQuinn and Jaarsma

represent a 24-month period from March 2008 to March


2010. None of the included cases had associated neurovascular injuries. Intra-articular fractures, open fractures,
and fractures associated with another fracture on the
ipsilateral side were excluded.
Radiographs taken at initial presentation were analyzed for various measurements such as location of
fracture, angulation, displacement (dened as translational displacement of distal fragment relative to proximal fragment), associated ulna fracture, and obliquity of
fracture. The obliquity of the fracture was measured by
taking the maximum fracture angle on either anteroposterior or lateral projections (ie, a true transverse
fracture would have an obliquity angle of 0 degree).
The quality of initial reduction was classied as
anatomic, good, or fair. This method has been used previously by Alemdaroglu et al9 and describes initial reduction as anatomic (complete anatomic fracture
reduction with no translation or angulation), good (< 10
degrees of dorsal angulation or r2 mm of translation), or
fair (less than a good reduction, with translation of between 2 and 5 mm or angulation of between 10 and 20
degrees or any radial deviation of <5 degrees or a combination of 5 to 10 degrees of dorsal angulation and
r2 mm of translation). At the time of closed reduction,
the radiographs taken after cast application were used for
measurement of the various radiologic indices.
The indices measures were cast index,11 padding
index,12 Canterbury index,12 second metacarpal-radius
angle,13 gap index,14 and 3-point index.9 The formulae
used for measurement of these indices are summarized
and depicted in Table 1 and Figure 1, respectively. As
TABLE 1. Radiologic Indices Formulae, Descriptions, and
Cut-off Values
Description
Cast index

Inner diameter of cast on lateral (at


fracture site)/inner diameter of cast on
AP (at fracture site)
Padding index
Dorsal gap on lateral (at fracture site)/
maximum interosseus space on AP
Canterbury index Cast index+padding index
Second
Angle created by bisection of the long
metacarpalaxis of the second metacarpal and long
radius index
axis of the radius on AP radiographs
Gap index
[(Radial fracture-site gap+ulnar
fracture-site gap)/inner diameter of cast
in AP plane]+[(dorsal fracture-site
gap+volar fracture-site gap)/inner
diameter of cast in lateral plane]
Three-point index [(Distal radial gap+ulnar fracture-site
gap+proximal radial gap)/contact
between fracture fragments in
transverse projection]+[(distal dorsal
gap+volar fracture-site gap+proximal
dorsal gap)/contact between fracture
fragments in sagittal projection]

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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some of these indices have been validated for use in only


specied fracture locations, fractures outsides of these
parameters were not included for analysis (eg, the 3-point
index has been validated for distal 1/3 radius fractures but
not epiphyseal or middle 1/3 fractures9).
The follow-up lms were then reviewed for assessment of angulation and displacement. Redisplacement
was dened as >10 degrees angulation or >50% displacement on follow-up imaging.5,9,13,14 Operative records were used to identify follow-up treatment in these
patients, and in the cases of further intervention, the nature of this was recorded. To be included in the study,
patients must have had follow-up radiographs at least
once in the period 5 to 10 days after reduction. All of the
data were collected by a single investigator (A.G.M.).
For statistical analysis, the sample is described using
mean and standard deviation for continuous variables
and percentages for categorical variables. The MannWhitney U test and w2 tests were used to evaluate dierences between the groups. Data collection was entered
into a Microsoft Excel spreadsheet (Microsoft; Redmond,
Washington, DC). SPSS version 17.0 (SPSS; Chicago, IL)
was used to run the statistical queries.

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

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Pediatric Distal Forearm and Radius Fractures

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].

between groups (P = 0.028). Overall, 60% of this group


had anatomic reduction compared with only 27% in the
redisplacement group. The odds ratio for nonanatomic
reduction as a risk factor is 3.9 (95% CI, 1.7-8.9;
P = 0.001), which was also statistically signicant.
Data related to the various radiologic index formulae are shown in Table 4. The cast index was signicantly higher in the redisplacement group than the
no redisplacement group (0.83 0.07 vs. 0.78 0.09,
P = 0.010), with the proportion of cases meeting the
cut-o being signicantly lower. After correction for the

dierences in displacement (ie, analysis of only those


patients with >50% displacement, thereby eliminating
the dierence between groups), this remained statistically
signicant (P = 0.040). The Canterbury index was also
signicantly higher in the redisplacement group (P =
0.012); however, this nding lost statistical signicance
after correction for dierences in displacement (P =
0.59), and there was no dierence in the proportion of
cases meeting the cut-o. For all other indices, there was
no signicant dierence between the 2 groups.

TABLE 2. Comparison of Potential Risk Factors (Independent


Variables) Between Groups

The results of our study show that the degree of


initial displacement and quality of reduction are signicant factors with regard to risk of redisplacement of
fractures in this population. These ndings have been
shown in previous studies7,8,9,15; however, our study
showed that it is not only fractures with complete initial
displacement that are at signicant risk of redisplacement.
Fractures with >50% displacement (dened as <50%
bony apposition between proximal and distal fracture
fragments on the radius) were shown to be more prone to
redisplacement. This nding, in conjunction with a previous study that showed similar outcomes,15 suggests that
all fractures with >50% displacement should be treated

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

Values are shown as mean (standard deviation).


P values obtained using Mann-Whitney U test.

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TABLE 3. Comparison of Potential Risk Factors (Categorical


Variables) Between Groups
No Redisplacement
(n = 122)
Sex, male
Associated
ulna #
Fracture location (on
Middle 1/3
Distal 1/3
Epiphyseal*
Initial displacement
0%-25%
26%-50%
51%-75%
76%-100%
> 100%
Reduction accuracy
Anatomic
Good
Fair

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)

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TABLE 4. Radiologic Indices Data


No
Redisplacement Redisplacement
Cast index
Padding index
Canterbury index

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

Values are shown as total number of cases (percentage of group).


P values obtained using w2 test.
*Epiphyseal fractures include fractures with physeal involvement, as described
by Salter and Harris.18 In this sample, all of the fractures were Salter-Harris
type II injuries.

as high risk for redisplacement. Given this, any fracture


with >50% displacement should be followed up closely
in the initial postreduction period, and repeat closed reduction or percutaneous pinning should be considered if
redisplacement occurs (an example of the latter is shown
in Fig. 2). In cases of complete initial displacement, percutaneous pinning after closed reduction should be considered, as this has been shown to reduce the risk of
redisplacement.7,8
Anatomic reduction accuracy has previously been
shown to be a signicant factor in treatment failure.4,9,10
The results from our study show this once again. Given
the importance of this factor in achieving a satisfactory
outcome, the development of minimum acceptable reduction standards may be benecial to aid in the prevention of
redisplacement. If there were guidelines regarding the
maximum amount of displacement and angulation that
is considered acceptable (which may vary depending on
patient demographics such as age), this would guide the
clinician further in their decision-making process. If closed
reduction did not achieve these minimum acceptable
standards, then proceeding to percutaneous pinning could
be recommended to avoid redisplacement.
The need to avoid redisplacement is further emphasized when the medical, social, and nancial repercussions are considered. Medically, a repeat procedure
would entail the administration of another anesthetic that
could contribute to morbidity and complications. The
emotional eect of a repeat procedure and hospital stay
on the young patient and their family is dicult to
quantify but should not be ignored. In addition, the
nancial cost to patient, family, and institution must be
considered. On the basis of local experience and other
quoted sources,16 it is estimated that a repeat fracture

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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.

reduction in theatre with associated brief hospital stay


would cost a minimum $500 to $1000, which is a signicant gure.
The results from the radiologic indices data were
mixed, and the cast index was the only index that was
signicantly worse in the redisplacement group. This was
the rst index devised for this purpose, and there are
multiple studies that have shown that it is a predictor of
treatment failure.11,12,17 The key components to adequate
fracture xation are proper molding, thin and uniform
padding, and 3-point xation.12 It has been theorized that
the cast index is able to assess the quality of some of these
components, in particular plaster molding, as the ratio of
plaster diameter in lateral and anteroposterior planes
certainly diers between a correctly and poorly molded
plaster. The cut-o gure for this index has been supported by validation studies,12 and this gives an objectively measurable quantication of adequate cast
molding.
The other indices have evidence to support their use,
but in this study they were not found to dier between the
redisplacement group and the group with no redisplacement. Of these, the index that seems theoretically to be
most sound is the 3-point index, which uses the principle
of 3-point xation. Alemdaroglu et al9 found it to be a
good measure for predicting displacement in their prospective study. In their study, all patients were placed in
below elbow casts after closed reduction, and this diers
from our study where the practice at our institution is for
the arm to generally be placed in an above elbow cast.
Alemdaroglu et al9 also stated that short-arm (below
elbow) casts are more dependent on 3-point xation, and
this may have contributed to the lack of signicant results
for the 3-point index in our study. A dierent issue entirely
is the clinical applicability of the index. The complexity of
the 3-point index calculation makes its use in the clinical
setting less realistic than in the research setting. In terms of
ease of clinical application, the cast index and also the
r

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Pediatric Distal Forearm and Radius Fractures

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.

second metacarpal radius angle are the 2 indices most


clinicians would nd most useful.
There are some limitations to our study, of which
the retrospective study design is probably the most important. The follow-up intervals were similar in all
patients in our study, as part of the inclusion criteria
required follow-up to occur at least once in the 5- to
10-day postreduction period. The patients excluded due
to inadequate data were not negligible in number, but this
was unavoidable, as meaningful interpretation of the data
requires the full availability of initial, postreduction, and
follow-up lms. The only dierence between groups was
with regard to degree of fracture displacement. This is a
positive nding in that it supports the theory that initial
displacement is a risk factor for redisplacement; however,
it must also be considered as a possible factor in any other
dierences found between groups after treatment. To
counter this dierence, statistical analyses for treatment
parameters were corrected for this dierence, with the
statistical signicance of our main ndings unaected.
Another important factor to consider is that because
of the nature of the study, long-term follow-up of all
r

2012 Lippincott Williams & Wilkins

patients was not able to be achieved. This raises the issues


of whether there were further cases of fracture redisplacement at a later stage than the follow-up period and also
regarding the outcomes of the redisplaced fractures that
were managed without acute intervention (ie, patients
managed with close observation for further displacement).
The majority of patients were actually followed up to
6-weeks postreduction; hence, in these cases, it could be
said that the fracture had united and displacement was
very unlikely to occur after this time. However, given the
incomplete and variable data available over this longer
follow-up period, these statistics were not included. It
could therefore be viewed that this study is limited to that
of an assessment of risk factors for early redisplacement.
Given the lack of long-term follow-up, the authors are not
able to comment further on the long-term radiologic and
functional outcomes of the 19 patients that were managed
with observation alone; however, it should be noted that
all these patients showed no worsening of displacement on
available follow-up lms. These cases could therefore be
viewed as a subset of borderline cases that met the strict
criteria for redisplacement in this study but were judged by
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the clinician to be within an acceptable range to allow for


management with close observation, with the view that
bony remodeling would occur.
Epiphyseal injuries were included for the initial
analysis of risk factors. This diers from the approach of a
number of previous studies in this area. There are numerous arguments for their inclusion. The rst is that they
are common injuries, forming up to 18% of bone injuries
in this population.18 Another reason is that the vast majority of these injuries and treated by closed reduction,
essentially dealt with in the same manner as metaphyseal
fractures.19,20 The major dierence in terms of follow-up
with these injuries is regarding the risk of premature
growth plate closure, although in Salter-Harris type II injuries of this region (the classication subtype to which all
the epiphyseal injuries in our study belonged), the incidence of this has been shown to be extremely low.21,22 In
any case, this complication is monitored for and identied
at a later timeframe than the period of follow-up for redisplacement.21 Further analysis of the data showed that
the results of this study were not altered in any meaningful
way by the inclusion of these cases. Where the use of radiologic indices has not been validated in this subgroup of
fractures, these patients were excluded from analysis.
In conclusion, this study found that initial fracture
displacement of >50% and inability to achieve anatomic
reduction were the most important risk factors for redisplacement after closed reduction. In addition, the cast
index diered signicantly betweens group with redisplacement and with no redisplacement. Given it is a
simple and practical measure of cast molding, its use in
clinical practice should be encouraged.
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