The Controversy Continues: Commentary on an article by Ryan M. Zimmerman, MD, et al.: “Surgical Management of Pediatric Radial Neck Fractures”

第一作者：Roger Cornwall

2013-11-21 点击量：598 　　我要说

Contemporary pediatric fracture textbooks are replete with conflicting recommendations regarding the management of displaced radial neck fractures in children, with the controversy fueled largely by the poor results that often follow open treatment of these fractures. While most authors have recommended using an algorithm progressing from closed to percutaneous to open reduction techniques, the details of management vary widely. Quoting all of the same retrospective studies, different experts have offered different summaries of what to do and when. While 30° of angulation is widely considered an indication for reduction¹, some argue that residual angulation of 45° after closed reduction is acceptable², citing the risks of open reduction. Others, however, urge surgeons to “not hesitate to operate on the displaced fracture and reduce it into an anatomic position” if closed treatment fails³. The definitions of open surgery vary as well, with some authors warning that “open reduction should be avoided if at all possible,”⁴ and others stating that “whenever possible, internal fixation should be avoided.”² Is it the open reduction, the internal fixation, or the severity of the fracture that predisposes the patient to a poor result? We are all afraid of radial neck fractures that need surgery, but why? And what should we do with them? These are the questions that Zimmerman et al. attempted to answer in the present study. Do they succeed? Yes and no. This study is an exemplary retrospective review of an injury and its treatments, but it is also an excellent example of the many limitations of this type of research, on which much orthopaedic trauma knowledge is based.

Zimmerman et al. present the results of a retrospective review of 151 pediatric cases treated in the operating room for a displaced radial neck fracture. While this series is the largest of its kind, the patients were treated by twenty-one different surgeons and without a standardized algorithm or approach, as evidenced by the twenty-two different procedural combinations used once the patients reached the operating room. This variety in treatment strategies does not take into account the variation in indications for treating a child in the operating room, a limitation of any retrospective evaluation of a series of operative procedures performed by multiple different surgeons determining the indications for surgical treatment. The fractures were ultimately reduced by one of nine different techniques. The authors correctly point out that this variation in care is the most striking finding of their study.

Modifiable predictors of poor outcome following radial neck fractures also remain unclear. The authors found that an age of ten years or more, greater initial fracture displacement, and a time to surgery of two days or less were predictors of a poor outcome. Readers who do not venture past the abstract might be tempted to delay surgery past two days, modifying the only one of those three variables that they can alter. However, the authors correctly point out in the discussion that the timing of surgery was likely affected by selection bias, as the most severe fractures probably were evaluated sooner, and that “delaying surgery is not advocated.” This reasoning, however, is precisely what prevents any retrospective study from demonstrating a link between open reduction of radial neck fractures and poor outcome. Only the worst fractures undergo open reduction so, once again, is it the fracture or the treatment that leads to a poor outcome? The question is still not clearly answered by even this large series.

Another question that remains unanswered is the effect of final fracture alignment on outcome. Nearly all fractures had osseous union with angulation of ≤30° and translation of ≤25%, making it difficult to stratify functional results on the basis of final fracture alignment. Nonetheless, the authors still reported a 31% rate of unsatisfactory results. Thus, if successful union with acceptable alignment in 98% of patients leads to a satisfactory outcome in only 69%, what other variables are leading to the poor results? Also, the authors developed their own stringent criteria for satisfactory results, based on prior studies outlining definitions for a functional range of motion of the elbow and forearm. However, this system, like radiographic measurements, does not take into account patient-reported functional outcomes, a limitation that the authors highlight. Thus, the relationship between provider-based parameters and the child’s functional outcome remains unclear.

分享到：