Goniometric Estimation of Treatment Efficiency in Pediatric Midshaft Forearm Fracture Patients

Introduction. The overall forearm fracture rate is extremely high in pediatric population, significantly being composed of forearm midshaft fractures. Conservative vs. operative treatment are the two competing approaches being introduced for treatment of these fractures depending on the type and localization of the fracture as well as on the age of children. Objective measurements of ROM and correct interpretation of the results can have a substantial impact on the development of the scientific basis of therapeutic interventions.

Aim of the study. 1) to evaluate ROM in elbow and wrist joints using goniometry, comparing conservatively and operatively treated forearm fracture patients with healthy controls; 2) to estimate limitation of ROM that causes subjective complaints; 3) to determine if potential limitations of ROM can be the main argument for choice of treatment method despite the age and gender of the child.

Materials and methods. Stratified randomized controlled prospective clinical trial from 2010 to 2012 was performed including comparable groups of conservatively and operatively treated boys and girls (age 7-15 years), 6 months after forearm midshaft fracture, compared to similar groups of children without fractures. Total number of respondents was 180 children (30 in each group). Length of immobilization for all treated children was 4 weeks (28 ± 2 days). None of the included patients was administered to special rehabilitation course. During follow-up active ROM of elbow (flexion, extension, pronation, supination) and wrist (flexion, extension, abduction and adduction) joint was assessed using standard plastic goniometer. All measurements were performed by one person, the same tool, twice for each patient. All children together with parents filled questionnaires about self-estimation of functional status (PedsQL v3.0) before (all groups) and after trauma (treated patients only). Each parent signed informed consent of the participation in the research, hospital’s ethical committee gave the approval for the study.

Results. All fractures consolidated. Statistically significant differences were detected comparing both non-operated and operated patients to controls. Both - conservative and operative treatment predicted higher level of ROM limitation rate, compared to controls. Conservative treatment predisposes patients to significantly higher ROM limitation - 75.0 %, compared to operated patients - 31.7%. Most of limitations in all four treated groups were asymptomatic: 77.8 % in conservative groups; 63.2 % in operated groups; and 100 % in controls groups. Subjective complaints of ROM limitations in conservatively treated children were about elbow flexion, elbow pronation and supination and wrist extension. Operated children complained of limited elbow flexion, elbow supination and wrist extension. There were no gender differences amon g conservatively and operatively treated groups, both girls and boys had 53.3 % limitation rate. Dominant hand was injured more often (ratio = 1.14:1). No statistically significant differences were found in all three age groups (7-9 years, 10-12 years and 13-15 years) in both genders, comparing to other age groups of the same gender.

Conclusions. The results of this study indicate superior effectiveness of elastic stable intramedullary nailing over conservative approach. Frequency of ROM limitations performing surgical stabilization is more than twice lower than that of conservatively treated children. Only moderate (>200) limitations of ROM cause subjective complaints. Although compensatory capacities of a growing child are high and therefore most limitations of ROM are asymptomatic and do not reduce quality of life, it advocates surgical treatment to become the golden standard for midshaft forearm fracture treatment in pediatric population. The age and gender of a child does not influence frequency and severity of ROM limitations therefore should not be considered as the main arguments while choosing treatment method.