CORR Insights®: Do We Need to Stabilize All Reduced Metaphyseal Both-bone Forearm Fractures in Children with K-wires?

Where Are We Now? “Doctor, does my child really need to go under anesthesia and have wires drilled into his bone?” “Will fixing his wrist with wires make his arm perfect?” “We do not have a very good health insurance; how much is it going to cost to do surgery on him versus just putting him into a cast?” These are all valid questions and parental anxieties that pediatric orthopaedic surgeons come across every day when treating the most frequently encountered fracture in pediatric orthopaedics [7]. We draw lines and measure angles for ourselves and for the anxious parent in front of us. But do the radiographic measures we provide offer adequate management guidance to choose from among casting in situ, performing a closed reduction and casting, or doing a closed reduction and percutaneous pinning? More importantly, do those lines and angles accurately predict the loss of motion and ability to function, or the development of upper extremity pain as this child grows into adulthood? Historically, the management of pediatric fractures was heavily biased toward nonsurgical methods [1], but present-day practice is more aggressive and favors more permissive surgical indications [9]. The question that Diederix et al. [6] have appropriately asked in their study is whether our patients would be better served had they not been subjected to surgery. To answer this, the authors interrogated their own initial conclusions from a previously published study [3], which favored performing K-wire fixation using a 7-month follow-up [3]. But at 5-year follow-up, the authors found that there was no difference in the eventual outcome between children treated with an above elbow cast alone compared with those treated with additional K-wire fixation. This study proved that time is truly a great healer. Perhaps we are operating too often. Where Do We Need To Go? Our goal should be to reduce a fracture and maintain the reduction to a point where, after healing and remodeling, no major restriction of wrist motion or forearm rotation is seen. And for patients who experience a loss of reduction, future research is needed to establish the influence of (skeletal) age, sex, severity of initial displacement, and the direction of malunion angulation on the clinical result. This information will help the surgeon to weigh risk and reward when contemplating surgery; we can’t forget that we treat patients, not radiographs. Research must be directed at obtaining more concrete guidelines to justify performing a surgical intervention. As pediatric wrist fracture management increasingly involves surgery, we need to ponder whether inadequacies in our present collective casting techniques may contribute to the need to stabilize these fractures with K-wires. We may still find valuable lessons in studies with results showing that redisplacement of a distal forearm fracture seldom occurs if the cast is well molded [2, 8]. We need to revisit how we teach casting techniques; if we can do this more effectively, we may find we can get away with fewer operations in children with wrist fractures. I fear that our residents who see so many pinning procedures of so many metaphyseal distal radius fractures will graduate believing this is the only way to treat these fractures. They will, in turn, pass that belief onto the next generation. How Do We Get There? We need to do more collaborative studies between adult hand surgeons and pediatric orthopaedic surgeons in the future. The modern world is well connected, and medical records are better maintained. If an adult develops wrist or elbow pain or loss of motion and provides a remote history of a childhood injury, we as a profession need to put in a more collaborative effort into connecting the dots. An award-winning [5] paper by Crawford et al. [4] is well worth rereading. In it, a treatment protocol for pediatric distal radial fractures was used in which the fracture was left shortened in an overriding position and a cast was applied by gently correcting only angulation without an attempt at anatomic fracture reduction, which yielded good results. As a practitioner whose training straddled continents, it struck me that in the message conveyed in that paper, North America had just rediscovered what the Indian subcontinent already knew: That sometimes, Mother Nature does not require surgical assistance. As healers, it is imperative that we are aware of this profound truth. We must stay grounded and continue to exercise prudence before we replace the old but apt with the shiny and new. We must keep the sacredness of the surgical covenant that exists between surgeon and patient paramount and not let it get swayed by the winds of economic and technological change [11]. In a zeitgeist that is smothered with conflicting data, let us strive to avoid cloaking our surgical indications with the legitimacy of a science that might be convenient to quote, but not necessarily true. It may make a good case to obtain better data from countries where surgery is not an expectation whether because of cost, parental expectations, or resource constraints in that country. Information gleaned from such a study might help us answer the anxious, questioning parent more convincingly and help treat the child using best practices. Surgery in pediatric trauma is justified if you can either mobilize earlier as a result of performing it—as in a long bone fracture—or better maintain joint congruency to help prevent osteoarthritis, as in an intraarticular fracture. But in a fracture that has a high potential to remodel and achieve a functional level that would in time be the same with or without surgery, it warrants tightening our indications to operate, so we do right by the patient and the parent and do not unnecessarily feed the medical-industrial complex [10].