title: Think twice before re-manipulating distal metaphyseal forearm fractures in children.
abstract: BACKGROUND
  Treatment of displaced paediatric distal forearm fractures is not always successful. Re-occurrence of angular deformity is a frequent complication. No consensus exists when to perform secondary manipulations. The purpose of this study was to analyse the long-term outcome of re-angulated paediatric forearm fractures to determine if re-manipulations can be avoided.
  
  
  METHODS
  Children who underwent closed reduction for distal forearm fractures and presented with re-angulation at follow-up were included in this retrospective cohort study. We compared those that were re-manipulated to those managed conservatively. Re-angulation was defined as ≥15° of angulation on either the AP or lateral view. Children were reviewed after 1-8 years post injury. Outcome measures were residual angulation on radiographs, active range of motion, grip strength, Visual Analogue Scales (satisfaction, cosmetics and pain) and the ABILHANDS-kids questionnaire.
  
  
  RESULTS
  Sixty-six children (mean age of 9.6 years) were included. Twenty-four fractures were re-manipulated and 42 fractures had been left to heal in angulated position. At time of re-angulation, children <12 years in the conservative group had similar angulations to those re-manipulated. Children ≥12 years in the re-manipulation group had significantly greater angulations than children in the conservative group. At final follow-up, after a mean of 4.0 years, near anatomical alignment was seen on radiographs in all patients. Functional outcome was predominantly excellent. There was no significant difference in functional, subjective or radiological outcomes between treatment groups.
  
  
  CONCLUSIONS
  Re-manipulation of distal forearm fractures in children <12 years did not improve outcomes, deeming re-manipulations unnecessary. Children ≥12 years in the conservative group achieved satisfactory outcomes despite re-angulations exceeding current guidelines. Based on observed remodelling, we now accept up to 30° angulation in children <9 years; 25° angulation in children aged 9-<12; 20° angulation in children ≥12 years, when re-angulation occurs. We conclude that clinicians should be more reluctant to perform re-manipulations.
authors.affiliation: Erasmus University (Faculty of Medicine and Health Sciences) and Erasmus Medical Centre, Rotterdam, The Netherlands.
authors.forename: Kasper C
authors.initials: KC
authors.lastname: Roth
authors.forename: Katharina
authors.initials: K
authors.lastname: Denk
authors.forename: Joost W
authors.initials: JW
authors.lastname: Colaris
authors.forename: Ruurd L
authors.initials: RL
authors.lastname: Jaarsma
mesh_terms: D000293:Adolescent; D002370:Casts, Surgical; D002648:Child; D005260:Female; D005543:Forearm Injuries / Q000503:physiopathology / Q000601:surgery; D018737:Hand Strength; D006801:Humans; D008297:Male; D010147:Pain Measurement; D011885:Radius Fractures / Q000503:physiopathology / Q000601:surgery*; D016059:Range of Motion, Articular; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome; D014458:Ulna Fractures / Q000503:physiopathology / Q000601:surgery*; D014955:Wrist Joint / Q000503:physiopathology