Sticks and Stones

[lawmed]

There is a good chance that you made right decision to wait and allow the bones to heal after having them set rather than have an open reduction.
I am sorry that your rom is limited but risk of an infection from surgery is great. If you now are going to have a surgical break and repair by a specialist you may be better off.

I disagree. Without seeing the initial x-rays it is impossible to tell whether an open reduction and fixation with plates and screws was advisable, but the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation). When indicated, the sooner done the better. It is odd that you describe not being able to move your arm. Was the fracture "mid-shaft", or closer to the wrist/elbow?

[deadlock]

I disagree. Without seeing the initial x-rays it is impossible to tell whether an open reduction and fixation with plates and screws was advisable, but the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation). When indicated, the sooner done the better. It is odd that you describe not being able to move your arm. Was the fracture "mid-shaft", or closer to the wrist/elbow?

Could you please provide one or two sources where the statistis indicate open reduction of pediatric ulnar and radius, humerus or supracondylar fracture has a better result than closed reduction with pinnning?

[lawmed]

Could you please provide one or two sources where the statistis indicate open reduction of pediatric ulnar and radius, humerus or supracondylar fracture has a better result than closed reduction with pinnning?

Your question is broad beyond the scope of the question in this case. ALL unstable fractures must be fixated either with pins, external fixation or ORIF. I assume you may be asking whether growth plate activity affects the decision in a child. First, I am assuming the individual here was in his late teens at least. Second, as i said, we need to know the location of the fractures. Here are some guidelines according to age for ulanr and radial fractures:
- initial considerations:
- angular / rotational deformity: (growth will not correct rotational deformity)
- age
- distance from physis
- direction of angulation
- amount of deformity
- bayonette apposition
- generally bayonette opposition will require operative reduction (either closed with a Kapandji K wire levering technique
or in some situations, an open reduction and fixation with K wires will be required);
- historically, overriding of a both bones forearm fracture was acceptable if...
- there was no deviation of radius and ulna toward each other;
- there was no encroachment of the interosseous space;
- pt is less than 10 yrs of age;
- in pts < 6 yrs of age:
- upto 15 deg of angulation is acceptable, especially if frx is distal;
- 5 deg of rotation may also be acceptable;
- between ages of 6-10 yrs:
- less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis;
- bayonet apposition may be acceptable, although end to end apposition is preferred;
- acceptable angulation is less than 15 deg, however, even more angulation
may be preferable to resorting to open reduction;
- this is especially true if the reduction allows physiologic pronation and supination;
- pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be required;

See: http://www.wheelessonline.com/ortho/...ne_forearm_frx

[deadlock]

Your question is broad beyond the scope of the question in this case. ALL unstable fractures must be fixated either with pins, external fixation or ORIF. I assume you may be asking whether growth plate activity affects the decision in a child. First, I am assuming the individual here was in his late teens at least. Second, as i said, we need to know the location of the fractures. Here are some guidelines according to age for ulanr and radial fractures:
- initial considerations:
- angular / rotational deformity: (growth will not correct rotational deformity)
- age
- distance from physis
- direction of angulation
- amount of deformity
- bayonette apposition
- generally bayonette opposition will require operative reduction (either closed with a Kapandji K wire levering technique
or in some situations, an open reduction and fixation with K wires will be required);
- historically, overriding of a both bones forearm fracture was acceptable if...
- there was no deviation of radius and ulna toward each other;
- there was no encroachment of the interosseous space;
- pt is less than 10 yrs of age;
- in pts < 6 yrs of age:
- upto 15 deg of angulation is acceptable, especially if frx is distal;
- 5 deg of rotation may also be acceptable;
- between ages of 6-10 yrs:
- less than 10 deg of angulation should remodel especially if frx is close to distal epiphysis;
- bayonet apposition may be acceptable, although end to end apposition is preferred;
- acceptable angulation is less than 15 deg, however, even more angulation
may be preferable to resorting to open reduction;
- this is especially true if the reduction allows physiologic pronation and supination;
- pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be required;

See: http://www.wheelessonline.com/ortho/...ne_forearm_frx

Here's my point. YOU are making way too many assumptions! This is what you missed:
The injury and delayed treatment. He broke it at an away game then went to an ER at home.

His doctor did a closed reduction(why didn't you ask what the timeline was??)

No matter what you THINK- the bones may have healed incorrectly for many reasons, including the break close to the physis. If that was the case, open reduction is contraindicated.

This is what you said, lawmed:

"the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation)"

And you know that IS NOT true statement.

BTW- I don't need your quotes from unknown websites. Thank you.

[lawmed]

Here's my point. YOU are making way too many assumptions! This is what you missed:
The injury and delayed treatment. He broke it at an away game then went to an ER at home.

His doctor did a closed reduction(why didn't you ask what the timeline was??)

Don't be absurd. Just how long do you think a football team stays out of town for an away game? He was seen within 72 hours....not weeks later. Further, it would make no difference. Even if healing had begun but the fracture was displaced or unstable, the procedure would be done.

No matter what you THINK- the bones may have healed incorrectly for many reasons, including the break close to the physis. If that was the case, open reduction is contraindicated.

You are 100% WRONG. It would be the exact opposite. The closer to the epiphysis the more urgent the correct stabilization.

"the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation)"

I stand by that statement...possibly because of giving anesthesia at the largest free standing trauma center in the world for the past 8 years.

BTW- I don't need your quotes from unknown websites. Thank you.

If you are unfamiliar with Duke University and Wheeless' Textbook of Orthopaedics, then there is no reference I can provide that will satisfy you. If you do not want credible references then do not waste my time asking for them.

[deadlock]

Don't be absurd. Just how long do you think a football team stays out of town for an away game? He was seen within 72 hours....not weeks later. Further, it would make no difference. Even if healing had begun but the fracture was displaced or unstable, the procedure would be done.

You are 100% WRONG. It would be the exact opposite. The closer to the epiphysis the more urgent the correct stabilization.

"the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation)"

I stand by that statement...possibly because of giving anesthesia at the largest free standing trauma center in the world for the past 8 years.

If you are unfamiliar with Duke University and Wheeless' Textbook of Orthopaedics, then there is no reference I can provide that will satisfy you. If you do not want credible references then do not waste my time asking for them.

I suggest that before you start with your ”I disagree” you find out what you are talking about.

Have you ever heard of external fixation? They still do this but maybe it isn't in YOUR textbook. (See Salter and Harris system used to classify growth plate injuries)

In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. Period.

Open reduction is the choice after an unsuccessful closed reduction.

You don’t know the age. You assumed it was a teenager.
You don’t know the length of time from the break until he saw “his doctor” at “his hospital”.
You assumed that the fracture is displaced and can only be seen on x-ray.

You don't know the literature and quote textbook for this forum case you know nothing about. This isn't "a tell all you read in textbooks medical forum". It's a legal forum. And you just like to use it for a platform to pretend you are a medical malpractice legal expert. If you don't know how to screen a case, pass.

And Lawmed, your pontification is for naught.... SOL is run (stands for statute of limitations)

[deadlock]

"the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation)"

I stand by that statement...possibly because of giving anesthesia at the largest free standing trauma center in the world for the past 8 years.

If you are unfamiliar with Duke University and Wheeless' Textbook of Orthopaedics, then there is no reference I can provide that will satisfy you. If you do not want credible references then do not waste my time asking for them.

Point to the page, paragraph in Your Duke University and Wheeless' Textbook of Orthopedics where it backs your statement. And I don't mean a page of "Here are some guidelines according to age for ulanr and radial fractures:" from which you cut and paste meaningless info.

[deadlock]

Lawmed-

Don't be absurd. Just how long do you think a football team stays out of town for an away game? He was seen within 72 hours....not weeks later.

He was on a football team? And the team returned from their out of town game when?

Lawmed-

You are 100% WRONG. The closer to the epiphysis the more urgent the correct stabilization.

and

"the majority of fractures of both the ulna and the radius ARE stabilized by ORIF (open reduction internal fixation)"

I stand by that statement...possibly because of giving anesthesia at the largest free standing trauma center in the world for the past 8 years.

Congratulations on working at the LARGEST free standing trauma center in the world for 8 years!

Lawmed, there is a difference betweeen textbook and peer reviewed studies.

Journal of Pediatric Orthopaedics. 25(3):309-313, May/June 2005.
Smith, Vinson A MD *+; Goodman, Howard J MD +; Strongwater, Allan MD +; Smith, Brian MD *
Abstract:
Both-bone forearm fractures of the radius and ulna are a common injury in children. Closed reduction and casting has historically been the primary means of treatment in over 90% of these fractures. Unstable and irreducible fractures, however, often pose a therapeutic challenge, with little data available to compare outcomes. The authors performed a retrospective review of 50 children with both-bones fractures treated with closed reduction and cast immobilization, open reduction and internal fixation (ORIF), or intramedullary (IM) nailing. Complications were tabulated and separated by treatment modality and subdivided into minor/major complications. Statistical regression was performed. There were 54 operations in 50 patients with both-bones fractures. All fractures healed within 8 to 10 weeks, except for two delayed unions and one nonunion. The complication rate was 5% for closed treatment, 33% for ORIF, and 42% for IM nailing. Complication rates were significantly different between the closed and operative groups. When comparing treatments in pediatric both-bones fractures, there are significantly more complications with operative techniques. Patients with ORIF had more major complications, often requiring a return to the operating room. IM nailing, when done correctly, is as acceptable and safe a form of treatment.


or this

Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis.

Do TT,
Strub WM,
Foad SL,
Mehlman CT,
Crawford AH.
Department of Pediatric Orthopaedics, Children's Hospital Medical Center, Cincinnati, Ohio, USA. Twee.do@chmcc.org
The inherent ability of pediatric metaphyseal radius fractures to heal and remodel made us question the need for immediate anatomic reduction under conscious sedation. We believe that isolated closed distal radius fractures with 15 degrees of angulation and 1 cm of shortening will heal well and remodel completely without clinical or functional sequelae. Time and expense can be decreased by splinting and follow-up without the need for immediate anatomic reduction in the emergency room. In order to answer this question, we retrospectively evaluated 34 pediatric metaphyseal wrist fractures that lost position after attempted reduction and healed in their angulated or shortened position. We looked at the time to healing, time to remodeling and any residual clinical or functional deficits. We then did a comparison cost analysis with time matched patients who had complete but minimally displaced fractures of the distal radius that were treated by immediate splinting with orthopaedic follow-up. Our results showed that skeletally immature patients with open physes, isolated injuries, dorsovolar and radioulnar angulations less than 15 degrees and less than 1 cm of shortening will heal and be out of cast within an average of 6 weeks and completely remodel within an average of 7.5 months. The average time in the emergency room was 2 h less with no reduction. The cost of the emergency room visit with attempted reduction was 50% more than splinting with early referral (US dollars 536 versus US dollars 270). None of our patients had significant clinical deformities or residual functional deficits.

Consider that you confused "open reduction" with "OPEN FRACTURE".

I hope you don't mix and match anesthetic agents like you do words.

[lawmed]

Goodbye...if you want proper information regarding your case, email me the particulars in a private message.

If you are now 14 years of age or younger, which Deadlock insists on assuming you are, a cast or external fixation with pins or wires may have been appropriate, depending on the fx site. Congratulations on being a bright and self sufficient 14 year old to inquire about a medical malpractice case on this board.

If you were older than 12 years of age when you were playing football at away games, thus now older than 14, please note the somewhat irrational amount of verosity which Deadlock places in his posts. Quite likely of an organic nature. Actually you can note this regardless of your age. Also note that his studies do not define the ages of the subjects. The truth is, no one can tell you for sure what should or should not have been done either at the initial injury, or for the seondary surgical treatment without knowing your history and viewing your x-rays. Not even someone who actually determines these things for a living.

Lawmed, there is a difference betweeen textbook and peer reviewed studies. Consider that you confused "open reduction" with "OPEN FRACTURE".
I hope you don't mix and match anesthetic agents like you do words.

1. No shit. 2.No. 3.See #2

There IS a difference in reading unapplicable peer review articles, then applying thier meaningless conclusions to a entirely different scenario and actually knowing what you are talking about. You are a dangerous resource for the uninformed and would best keep silent rather than "make up" advice without basis.

AGAIN (not that it will make any difference) pts > 12 yrs of age:
- no angulatory or rotational deformity is considered acceptable;
- more aggressive treatment is required, including open reduction and compression plating may be required;

In the literature the best results for pediatric supracondylar humerus fractures have been achieved by closed reduction and wire fixation. Period..

Who cares? He didn't break his humerus. AND he was NOT a pediatric patient so let that go already.

Are you on medication>?

[lawmed]

Point to the page, paragraph in Your Duke University and Wheeless' Textbook of Orthopedics where it backs your statement. And I don't mean a page of "Here are some guidelines according to age for ulanr and radial fractures:" from which you cut and paste meaningless info.

Welcome to WheelessOnline.com, the premier website for the busy orthopaedist. Duke University Medical Center's Division of Orthopaedic Surgery, in conjunction with Data Trace Internet Publishing, LLC are proud to present Wheeless' Textbook of Orthopaedics. This is the most comprehensive, unparalleled, dynamic online medical textbook in existence. Looking through our 11,000 pages with more than 5,000 images, you'll find this key reference in an easy to read outline format. Each topic is fully searchable by alphabetical, anatomical and keyword searches, or just click on a particular part of the Skeleton for easy access. Wheeless' Textbook of Orthopaedics is updated daily.