Per-Henrik Randsborg

Fractures in Children: Epidemiology and Activity-specific Fracture Rates

BACKGROUND Approximately one-third of pediatric fractures occur during sport or recreational activity. In this paper, we investigate the incidence and causes of pediatric fractures in our region and quantify the fracture rate per exposure time for the most common sport and recreational activities. METHODS We prospectively evaluated all children younger than sixteen years who presented to our institution with a new fracture within a twelve-month period. Exposure time to the most common childhood activities was measured by means of interviewing random parents from the study population. The main outcome measures were the annual fracture incidence in the population and fracture rates per 10,000 hours of exposure to various sports and recreational activities. RESULTS A total of 1403 fractures were included. The overall annual incidence was 180.1 fractures per 10,000 children younger than sixteen years. The distal part of the radius was most often fractured (436 fractures, 31.1%). Snowboarding was associated with the highest activity-specific fracture rate, estimated to be 1.9 (95% confidence interval [CI], 1.16 to 2.60) fractures per 10,000 hours of exposure. In comparison, the fracture rate per 10,000 hours of exposure was 0.79 (CI, 0.42 to 1.09) for handball, 0.44 (CI, 0.35 to 0.52) for soccer, and 0.35 (CI, 0.23 to 0.47) for trampolining. CONCLUSIONS The distal part of the radius is the most common fracture site in childhood. Fracture rates differ between various physical activities. The fracture rate for snowboarding was four times higher compared with that for other common childhood sport and recreational activities in our region.

Distal radius fractures in children: substantial difference in stability between buckle and greenstick fractures

Background and purpose Numerous follow-up visits for wrist fractures in children are performed without therapeutic consequences. We investigated the degree to which the follow-up visits reveal complications and lead to change in management. The stability of greenstick and buckle fractures of the distal radius was assessed by comparing the lateral angulation radiographically. Patients and methods The medical records of 305 distal radius fractures in patients aged less than 16 years treated at our institution in 2006 were reviewed, and any complications were noted. The fracture type was determined from the initial radiographs and the angulation on the lateral films was noted. Results Only 1 of 311 follow-ups led to an active intervention. The greenstick fractures had more complications than the buckle fractures. The lateral angulation of the buckle fractures did not change importantly throughout the treatment. The greenstick fractures displaced 5° on average, and continued to displace after the first 2 weeks. On average, the complete fractures displaced 9°. Conclusion Buckle fractures are stable and do not require follow-up. Greenstick fractures are unstable and continue to displace after 2 weeks. Complete fractures of the distal radius are uncommon in children, and highly unstable. A precise classification of fracture type at the time of diagnosis would identify a smaller subset of patients that require follow-up.

Long-term patient-reported outcome after fractures of the clavicle in patients aged 10 to 18 years.

Background: Fractures of the clavicle are common among adolescents and have traditionally been treated nonoperatively. Recent literature has demonstrated less satisfactory results than expected after conservative management of displaced fractures in adults. The purpose of this study was to evaluate the long-term patient-reported outcome after clavicle fractures in older children and adolescents. Methods: Children aged 10 to 18 years who sustained a fracture of the clavicle between 2006 and 2008 were identified in our institution’s computerized files. The radiographs were examined and the fracture patterns, degree of dislocation, and shortening were measured. Medical records were reviewed and the patient-reported outcome was assessed using the Oxford Shoulder score and the Quick version of the Disability of Arm, Shoulder, and Hand questionnaire, and specific and general satisfaction scores. Results: A total of 185 patients (median age, 14.4 y) with 172 midshaft and 13 lateral fractures were included in the study. Sixty-five (37.8%) of the midshaft fractures were displaced, and 9 of these were operated. There was one case of nonunion and one delayed union. One hundred twenty-two (70.9%) of the patients with a midshaft fracture responded to the questionnaires on an average 4.7 years after injury. Overall results were good to excellent for the majority of nonoperatively treated patients; however, shortening of the fracture had a negative effect on the Oxford Shoulder score (P=0.02), the cosmetic satisfaction score (P=0.02), and the overall satisfaction score (P=0.01). Conclusions: The long-term patient-reported outcome after nonoperatively treated fractures of the clavicle in adolescents is good to excellent for the majority of the patients, and nonunion is rare. However, shortening of the fracture had a small negative effect on the outcome. Conservative management should remain the mainstay of management for fractures of the clavicle in this age group. Level of Evidence: Level IV—retrospective case series.

Supracondylar fractures of the humerus in children

BACKGROUND Supracondylar humerus fractures are common in children. Severe complications are rare. We present an overview of treatment options and prognosis. MATERIAL AND METHODS The article is based on a non-systematic search in PubMed and experience from our own clinical research. RESULTS The injury is usually caused by falling from a height with the arm in extension. The mean age is about 6 years. Undisplaced fractures are treated conservatively with a cast. Displaced fractures should not be treated with a cast alone, as this may cause malunions and permanent neurovascular complications. The rate of complications after traction of displaced fractures is substantially lower than for immobilisation in cast alone. Traction and percutaneous pinning yield similar results, but percutaneous pinning is less expensive--mainly because it shortens the hospital stay. In addition, the risk of cubitus varus deformity seems to be reduced. Today the treatment of choice is closed reduction and percutaneous pinning. Choice of pin configuration is at the surgeons discretion. Crossed pins are more common than two lateral pins, although medial pins can affect the ulnar nerve. However, the affection is almost always transient. Deep infection after percutaneous pinning is very rare. INTERPRETATION Percutaneous pinning of displaced supracondylar humerus fractures in children is cheap and the results are good.

Epidemiology and patient-reported outcome after juvenile osteochondritis dissecans in the knee

BACKGROUND This study describes the epidemiology and patient reported outcomes following juvenile osteochondritis dissecans (JOCD) of the knee. METHODS Medical records and radiographs of patients aged 10-18years diagnosed with JOCD between 2010 and 2016 were retrospectively reviewed. The lesions were classified according to the International Cartilage Repair Societys classification. The results were evaluated with the Knee injury and Osteoarthritis Outcome Score (KOOS), the Lysholm score and a Visual Analogue Scale (VAS) for pain. RESULTS Seventy patients with 87 JOCDs were identified. The annual incidence was 11.5 (95% confidence interval 10.7-12.2) per 100,000 inhabitants younger than 19years. Fifty-two (74.3%) of the 70 patients returned the questionnaires on average 48months (five to 117) after diagnosis. The median Lysholm score was 84 for patients with grade I-II lesions and 80 for patients with grade III-IV lesions. The median Lysholm score was 84.5 for patients who were treated conservatively and 79.5 for patients who were treated operatively. The median VAS score was 2.0 for all groups, except for patients treated conservatively (median score 1.5). Conservative treatment was successful in 78% of grade I-II lesions. There was a fivefold increased risk of failing conservative treatment with a stage III-IV lesion, compared to stage I-II (Odds ratio=5.5, p=0.02). CONCLUSIONS The results following JOCD are good to excellent for the majority of patients. Grade I-II lesions are successfully treated conservatively in 78% of cases. Grade III-IV lesions have a high failure rate. LEVEL OF EVIDENCE Level III, retrospective cohort.

Plate fixation versus intramedullary nailing of completely displaced midshaft fractures of the clavicle: a prospective randomised controlled trial.

Aims This is a prospective randomised controlled trial comparing the functional outcomes of plate fixation and elastic stable intramedullary nailing (ESIN) of completely displaced midshaft fractures of the clavicle in the active adult population. Patients and Methods We prospectively recruited 123 patients and randomised them to either plate fixation or ESIN. Patients completed the Quick Disabilities of the Arm, Shoulder and Hand (DASH) score at one to six weeks post‐operatively. They were followed up at six weeks, three and six months and one year with radiographs, and their clinical outcome was assessed using both the DASH and the Constant Score. Results Plate fixation provided a faster functional recovery during the first six months compared with ESIN, but there was no difference after one year. The duration of surgery was shorter for ESIN (mean 53.4 minutes, 22 to 120) than for plate fixation (mean 69.7 minutes, 35 to 106, p < 0.001). The recovery after ESIN was slower with increasing fracture comminution and with open reduction (p < 0.05). Conclusion Both methods return the patients to their pre‐injury functional levels, but plate fixation has a faster recovery period in comminuted fractures than ESIN. ESIN has a shorter operative time and lower infection and implant rates of failure when using 2.5 mm nails or wider, suggesting that this is the preferred method in mid‐shaft fractures with no comminution, whereas plate fixation is the superior method in comminuted fractures.

The economic burden of outpatient appointments following paediatric fractures

INTRODUCTION Paediatric fractures are common and frequently followed-up. The aim of this study is to quantify the private costs for the affected families, as well as the costs for society due to paediatric fracture clinic follow-up appointments. PATIENTS AND METHODS 295 paired parent and surgeon questionnaire regarding the cost related to a scheduled follow-up appointment for an upper limb fracture in children aged 6-13 years were collected prospectively over 7 months. In addition, the medical appropriateness of the appointment and whether or not the control changed the management of the fracture was investigated. RESULTS The direct cost of attending a paediatric upper limb fracture clinic was estimated to €48.5 while the cost for society due to productivity loss was €78.4 per consultation. In 89.2% of the cases the surgeons found the appointment necessary, it was deemed unnecessary or inconclusive in 10.6%. The treatment plan was altered in 6.8%, and an extra follow up was scheduled in 5.8%. Fractures of the clavicle were most often regarded as unnecessary to follow up clinically or radiologically by the surgeons. DISCUSSION The direct cost for the affected families and the costs for society due to productivity loss of paediatric fracture follow-up appointments are noticeable. Although most patients and surgeons deem these controls as valuable, they lead to a change in treatment plan in only 12.6% of the cases. A stringent management protocol can safely reduce the number of clinical and radiographical follow-ups.

School-related fractures.

BACKGROUND Introduction of daily PE classes has been proposed as a measure to reduce childhood obesity. At the same time, the prevalence of activity-related fractures among children is increasing. Previously, we have found that the fracture rate per 10,000 hours of activity amounted to 1.9 for snowboarding, 0.79 for handball, 0.44 for football and 0.35 for trampolining. The purpose of the study is to describe the prevalence of school-related fractures, as well to investigate whether PE exposes schoolchildren aged 6-16 to a heightened risk of fractures when compared to other activities. MATERIAL AND METHOD Fractures in children aged 6-16 resident in the catchment area of Akershus University Hospital were recorded over a 12-month period. Information on fractures sustained at school, defined as fractures that occurred during school hours, during supervised after-school activities (SFO) or on the way to or from school, was retrieved from the records. The fractures were classified according to activity, time of the school day when the injuries occurred and their anatomical location. RESULTS Of a total of 1,144 fractures registered among children aged 6-16, altogether 422 (37%) were school-related, equivalent to 8.5 per 1000 children. Of these, 257 (61%) were in boys. Altogether 276 (65.4%) fractures occurred outdoors, 135 (32%) occurred during breaks and 94 (22.3%) during PE classes. The fracture rate for PE amounted to 0.29 fractures per 10,000 hours (95% CI: 0.22-0.33). INTERPRETATION The fracture rate for PE classes is lower than for a number of other common leisure activities. As a measure to increase childrens physical activity, the introduction of daily PE classes will be a beneficial alternative with a view to the risk of injury.

Compensation after treatment for anterior cruciate ligament injuries: a review of compensation claims in Norway from 2005 to 2015

PurposeTo assess the most common reasons for complaints following anterior cruciate ligament (ACL) injuries reported to the Norwegian System of Patient Injury Compensation (NPE), and to view these complaints in light of the ACL reconstructions (ACL-Rs) reported to the Norwegian Knee Ligament Registry (NKLR).MethodData from the NPE and the NKLR were collected for the study period (2005–2015). The age and gender and type of complaint and reason for granted compensation were collected from the NPE, while the graft choice and total number of ACL-R were collected from the NKLR. Risk for successful grant was estimated for graft type.Results18,810 primary ACL-Rs were reported to the NKLR during the study period. A hamstring graft was used in 12,437 (66.1%) but the bone-patellar tendon-bone (BPTB) became the graft of choice at the end of the study period. 240 patients filed a complaint to the NPE, of which 101 were granted compensation. The odds ratio for a claim being granted following a hamstring graft was 2.9 compared to that of a BPTB graft (p = 0.002) The most common reason for compensation was a hospital-acquired infection in 39 patients (38.6%) followed by inadequate surgical technique (27, 26.7%) and delayed diagnosis (13, 12.9%). Of the 39 patients with infection, 27 had received a hamstring graft and six a BPTB graft (two patients were not reconstructed, data missing for three patients). Of the 27 patients who were granted compensation due to inadequate surgical technique, 24 had received a hamstring graft and three a BPTB graft.ConclusionInfection and inadequate surgical technique are the most common causes for granted compensation from the NPE following ACL injury. Hamstring grafts have a threefold risk of complication that yields compensation from the NPE compared to BPTB grafts. This information is relevant for patients and surgeons when choosing graft type. The trend of increased use of BPTB grafts is warranted based on the results from this study.Level of evidenceLevel III.

Calcar screws and adequate reduction reduced the risk of fixation failure in proximal humeral fractures treated with a locking plate: 190 patients followed for a mean of 3 years

BackgroundFixation of proximal humeral fractures (PHF) with locking plates has gained popularity over conservative treatment, but surgery may be complicated with infection, non-union, avascular necrosis (AVN) of the humeral head and fixation failure. Failure to achieve structural support of the medial column has been suggested to be an important risk factor for fixation failure. The aims of this study were to examine the effect of calcar screws and fracture reduction on the risk of fixation failure and to assess long-term shoulder pain and function.MethodsThis was a single-centre retrospective study of 190 adult PHF patients treated with a locking plate between 2011 and 2014. Reoperations due to fixation failure were the primary outcome. Risk factors for fixation failure were assessed using the Cox regression analysis. Postoperative shoulder pain and function were assessed by the Oxford Shoulder Score (OSS).ResultsThirty-one of 190 (16%) patients underwent a reoperation: 14 (7%) due to fixation failure, 10 (5%) due to deep infection and 2 (1%) due to AVN. The absence of calcar screws and fixation with residual varus malalignment (head-shaft angle < 120°) both increased the risk of fixation failure with an adjusted hazard ratio (95% CI) of 8.6 (1.9–39.3; p = 0.005) and 4.9 (1.3–17.9; p = 0.02), respectively. The median (interquartile range) OSS was 40 (27–46).ConclusionThe use of calcar screws, as well as the absence of postoperative varus malalignment, significantly reduced the risk of fixation failure. We, therefore, recommend the use of calcar screws and to avoid residual varus malalignment to improve the medial support of proximal humeral fractures treated with a locking plate.