Ultrasound or C-arm? A comparative study of surgical intervention for adolescent metaphyseal-diaphysis junction fracture of the distal radius using external fixator

Ultrasound or C-arm? A comparative study of surgical intervention for adolescent metaphyseal-diaphysis junction fracture of the distal radius using external fixator | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Ultrasound or C-arm? A comparative study of surgical intervention for adolescent metaphyseal-diaphysis junction fracture of the distal radius using external fixator Shuai Liu, Yeming Zhou, Shuo Wang, Saroj rai, Pan Hong, Tianyou Xin This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3848001/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Metaphyseal-diaphysis junction (MDJ) is defined as the distal third of the radius subtracted from the square over the radial physis. Because of its unique anatomy, unstable fracture in MDJ poses challenges for a successful conservative method. Multiple modes of surgeries have been reported for MDJ fracture of the distal radius in children after failed manual reduction and casting. This study is to investigate the clinical effects of closed reduction and external fixation for MDJ fractures in children using fluoroscopy versus ultrasound. Ninety-six patients were divided into the ultrasound (US) group and the C-arm (CA) group. According to our results, the surgical duration was significantly shorter in the US group (24.40 ± 6.12, min) compared with the CA group (32.11 ± 9.23, min), P < 0.001. Images taken during the surgery were significantly less in the US group (2.66 ± 1.19) than the CA group (9.52 ± 3.15), P < 0.001. As for the complications, residual angulation, and clinical function of forearms, there was no significant difference between the two groups. Figures Figure 1 Figure 2 Figure 3 Introduction Conservative approach remains first-line choice for distal radial fracture in children[ 1 ]. Because of its unique anatomy, unstable fracture in metaphyseal-diaphysis junction (MDJ) poses challenges for successful conservative method[ 2 , 3 ]. The definition of MDJ varies in different literature[ 2 , 3 , 4 , 5 ]. In this study, consistent with earlier reports[ 4 , 6 ], MDJ is defined as the distal third of radius subtract the square over the radial physis, see Fig. 1 . Multiple modes of surgeries have been reported for MDJ fracture of distal radius in children after failed manual reduction and casting. Closed reduction with retrograde or antegrade elastic stable intramedullary nail (ESIN), retrograde Kirschner wire (KW), open reduction and plate osteosynthesis, closed reduction and external fixation (EF) have been reported in the past few years[ 2 – 9 ]. Although EF is primarily used in open fracture and temporary immobilization, it remains a feasible choice for pediatric patients due to faster fracture healing rate in children[ 4 ]. Closed reduction and external fixation was implemented under fluoroscopy. In contrast, ultrasound could provide real-time monitoring of the reduction process without ionizing radiation. Therefore, this study is to investigate the clinical effects of closed reduction and external fixation for MDJ fractures in children using fluoroscopy versus ultrasound. Methods Study population In all, 96 patients treated surgically using external fixator in Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology or Wuxi Ninth People’s Hospital Affiliated to Soochow University, between January 2018 and Janauary 2023 were reviewed retrospectively. All patients were divided into two groups as ultrasound (US) group and C-arm (CA) group. Inclusion criteria were as follows: 1. age between 10 and 14 years old at the time of surgery; 2. unstable fracture in MDJ of distal radius with or without ulnar fracture after failed conservative treatment; 3. injury to surgery less than 7 days; 4. with open physis and clearly visible on X-ray. Exclusion criteria were as follows: 1. pathological or open fracture; 2. earlier fracture at the same limb; 3. neuromuscular or metabolic disease; 4. severely comminuted fracture. Patient information including age, sex, operative side, duration from injury to surgery, presence of ulnar fracture, duration of surgery, hospital stay, image of intraoperative X-ray was retrieved from hospital database. Functional outcome was evaluated using Gartland-Werley score[ 10 ] at every follow-up visit, and radiograph of wrist and full-length forearm was taken as well. Surgical technique After the introduction of brachial plexus block or general anesthesia, surgery was performed as follows without the usage of pneumatic tourniquet. (1) In the US group, manual reduction was tried before the placement of Schanz pins. Physis was identified under ultrasound; two Schanz pins were placed in the distal fragment without violating the physis, and the other two Schanz pins were placed in the proximal diaphysis. If acceptable alignment is not achieved after three attempts of manual reduction, a KW or mosquito forceps was used as a lever to facilitate the reduction. Ultrasound was adopted to monitor the reduction process in real-time fashion, see Fig. 2 . (2) In the CA group, physis was identified under fluoroscopy; two Schanz pins were placed in the distal fragment without violating the physis, and the other two Schanz pins were placed in the proximal diaphysis. KW or mosquito forceps was used to facilitate the reduction if the manual reduction was not satisfactory, see Fig. 3 . The diameter of Schanz pin ranged from 3 to 4 mm. A short or long-arm slab was applied after surgery for 2–3 weeks to alleviate the swelling and pain. EF was routinely removed in 4–8 weeks at out-patient visit according to the clinical and radiological evidence of fracture healing. A short arm brace was applied for additional 4 weeks after the removal of EF. Follow-up All patients in our study were followed up for more than 6 months. Patients were followed up in out-patient department at 1st month, 2nd month, 3rd month, 6th month, 12th month postoperatively. After the first year, the patient was follow-up annually. Radiological and clinical evaluation was recorded and collected at every out-patient visit. Data analysis All data in this study was processed by SPSS statistical package program (SPSS 19.0 version; Data were presented as mean ± SD (range), median (range), or n (%). χ2-test (categorical data) or Student’s t-test (continuous data) was used to compare theresults from two groups. Besides, a P-value of < .05 was considered significantly different. Results In all, 96 patients with MDJ fracture treated with EF were reviewed retrospectively, see Table 1 . Patients were divided into US group (50 patients, age 10.90 ± 1.71 years old) and CA group (46 patients, 11.72 ± 2.34 years old). Regarding the sex, fracture side, combined injury of ulnar fracture, duration from injury to surgery, there was no significant difference between the two group. However, the surgical duration was significantly shorter in the US group (24.40 ± 6.12, min) compared with the CA group (32.11 ± 9.23, min), P < 0.001. Images taken during the surgery was significantly less in the US group (2.66 ± 1.19) than the CA group (9.52 ± 3.15), P < 0.001. Table 1 Demographic and clinical parameters of children with distal radial fracture involving metaphyseal diaphyseal junction in US and CA group Parameters US group N = 50 CA group N = 46 P Value Age, years 10.90 ± 1.71 11.72 ± 2.34 0.093 Sex, male/female Male: 46 (92.00%) Female: 4 (8.00%) Male: 37 (80.43%) Female: 9 (19.57%) 0.098 Body weight (Kg) 42.64 ± 6.79 43.20 ± 9.11 0.777 Fracture side, L/R L: 31 (62.00%) R: 19 (38.00%) L: 26 (56.52%) R: 20 (43.48%) 0.585 Combined ulnar fracture (%) 25 (50.00%) 28 (60.87%) 0.200 Duration of surgery, min 24.40 ± 6.12 32.11 ± 9.23 0.000* Images taken during the operation 2.66 ± 1.19 9.52 ± 3.15 0.000* From injury to surgery (d) 9.86 ± 7.99 9.65 ± 7.90 0.398 Data shown as mean ± SD or N(%). a χ 2 -test for categorical data or Student’s t-test for continuous data. *<.01 As for the complications, residual angulation, clinical function of forearms, there was no significant difference between the two group, see Table 2 . Table 2 Follow-up data for children with radial MDJ fracture in the US and CA group Parameter US N = 50 CA N = 46 P Value Hardware removal, weeks 5.74 ± 0.80 5.89 ± 0.79 0.286 Follow-up, months 16.96 ± 5.57 16.83 ± 2.78 0.469 Pin tract infection (%) 4 (8.00%) 5 (10.87%) 0.630 Tendon Irritation (%) 0 (0.00%) 0 (0.00%) / Forearm pronation (°) 80.22 ± 4.53 79.02 ± 4.74 0.207 Forearm supination (°) 85.26 ± 4.40 86.13 ± 5.13 0.410 DASH score 0.08 ± 0.30 0.11 ± 0.33 0.637 AP view Angulation(°) 2.16 ± 1.59 2.52 ± 1.69 0.292 Volar tilt(°) 2.40 ± 1.85 2.54 ± 1.79 0.656 Gartland–Werley score 0 1 2 3 27 (54.00%) 18 (36.00) 4 (8.00%) 1 (2.00%) 21 (45.65%) 14 (30.43%) 9 (19.57%) 2 (4.35%) 0.341 Data shown as mean ± SD or N(%). a χ 2 -test for categorical data or Student’s t-test for continuous data. Discussion Ultrasound monitoring proved to be an effective approach in real-time monitoring reduction process of MDJ fracture of distal radius in children, and it delivered similar clinical outcomes with fluoroscopy, with less X-ray radiation. Conservative method remains the preferred choice for distal radial fracture in children[ 11 , 12 ]. However, in older children, failed conservative approach usually leads to surgical intervention. MDJ is an special anatomic site in distal radius, manual reduction followed by casting or splinting does not always delivers satisfactory outcomes in older children and adolescents[ 2 – 8 ]. Retrograde KW or pre-bent ESIN, antegrade ESIN, open reduction and plating have been reported for this condition[ 5 – 8 ]. However, the placement of KW might be difficult, because the tendon irritation is a nuisance in unburied KW scenario. Retrograde ESIN have been reported by certain authors[ 3 , 5 , 6 ], however, the precision curving is not easy, and the hardware requires secondary surgery under general anesthesia or brachial plexus block. Antegrade ESIN is hard to be removed during the secondary surgery[ 2 ]. Plating requires long incision and increased risk of blood loss, infection, and cosmetic problems. Therefore, in our study, EF was employed to stabilize and maintain the fracture after closed reduction. Ultrasound has been used for the diagnosis of pediatric fractures for years[ 13 , 14 ]. Besides, it has been reported as real-time monitoring tool in certain pediatric fractures including lateral condylar fracture of humerus, supracondylar fracture of humerus, diaphysial fracture of femur[ 15 – 19 ]. Besides, the application of ultrasound is forearm is feasible with relatively short learning curve[ 20 , 21 ]. Physis is identifiable and reduction process could be clearly monitored on the screen[ 22 , 23 ]. In order to facilitate the reduction process with lower radiation, ultrasound as a tool was adopted in our hospital. The learning curve of ultrasound in forearm is not long, and it could easily be mastered by orthopedic surgeons. Moreover, the diagnosis and management of forearm fractures haven been reported in earlier publication[ 20 – 23 ]. Surely, in these studies, the application of ultrasound is to detect the fracture, and provide rough evaluation of reduction[ 22 , 23 ]. Fluoroscopy is indispensable in orthopedic operating room, and most fracture surgeries require fluoroscopy to guide placement of implant and ascertain reduction of fracture[ 24 ]. Ionizing radiation is hazardous, and correlated with increased risk of cancer, especially in children[ 25 , 26 ]. Therefore, it is necessary to minimize the exposure to intraoperative radiation without jeopardizing surgical outcomes. There were certain limitations in our study. Firstly, it is a retrospective study with relatively small sample size; secondly, other surgical methods such as ESIN, KW and plating were not included in this investigation; lastly, the mastery of ultrasound might pose a challenge for orthopedic surgeons familiar with fluoroscopy. More in-depth investigations on the application of ultrasound in pediatric fractures are warranted in the future. Conclusion Real-time ultrasound assisted closed reduction and external fixation for MDJ fractures of distal radius in children is a feasible alternative, with less surgical duration and less intraoperative radiation than traditional fluoroscopy assisted surgeries. Declarations Ethical Approval This study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG no: IORG0003571) on November 20, 2019. Written consents to participate in this study were obtained from the legal guardians of every patient.  Consent for publication: Written consents were obtained from the legal guardians of every patient in this study for publication of this paper. Conflicts of interest : The authors have no conflicts of interest to declare. Funding Sources : None Acknowledgements : None References Asadollahi S, Ooi KS, Hau RC. Distal radial fractures in children: risk factors for redisplacement following closed reduction. J Pediatr Orthop. 2015;35(3):224–228. Lam A, Gordon AM, Thabet AM, Abdelgawad AA. Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?. Tech Hand Up Extrem Surg. 2023;27(3):161–164. Published 2023 Sep 1. Wu R, Wen Y, Wang C, Liu T, Yu J. Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study. BMC Musculoskelet Disord. 2023;24(1):922. Published 2023 Nov 30. Li J, Rai S, Tang X, Ze R, Liu R, Hong P. Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator. BMC Musculoskelet Disord. 2020;21(1):365. Published 2020 Jun 9. Yang L, Wang S, Xu J, et al. Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children. Orthop Surg. 2023;15(12):3223–3230. Chaoyu L, Guoqiang J, Wenqiang X, Lian M, Jing S, Yong L. Precision shaping of elastic stable intramedullary nail for the treatment of metaphyseal diaphysis junction fracture of the distal radius in children: a preliminary report in two centers. BMC Musculoskelet Disord. 2023;24(1):237. Published 2023 Mar 29. Wang R, Chen D, Tang Y, et al. A Novel Method for Treating Distal Radius Diaphyseal Metaphyseal Junction Fracture in Children. Med Sci Monit. 2023;29:e939852. Published 2023 Jul 3. 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Published 2023 Oct 31. Yang X, Li L, Tang X, Xiang B, Wen T. Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children?. Medicine (Baltimore). 2021;100(12):e24324. Wu Z, Yi X, Li Y, et al. Decreased Radiation Exposure Using Ultrasound-Assisted Reduction and Fixation of Femoral Shaft Fractures in Children: A Pilot Study. Ultrasound Med Biol. 2020;46(11):3154–3161. Wu Y, Lu R, Liao S, Ding X, Su W, Wei Q. Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures. J Orthop Surg Res. 2021;16(1):588. Published 2021 Oct 12. Snelling PJ, Jones P, Bade D, et al. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023;388(22):2049–2057. Chen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care. 2007;23(8):528–531. Wellsh BM, Kuzma JM. Ultrasound-guided pediatric forearm fracture reductions in a resource-limited ED. Am J Emerg Med. 2016;34(1):40–44. Auten JD, Naheedy JH, Hurst ND, Pennock AT, Hollenbach KA, Kanegaye JT. Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images. Am J Emerg Med. 2019;37(5):832–838. Prod'homme M, Sans-Merce M, Pitteloud N, Damet J, Lascombes P. Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study. J Child Orthop. 2018;12(5):550–557. Buchberger B, Scholl K, Krabbe L, Spiller L, Lux B. Radiation exposure by medical X-ray applications. Ger Med Sci. 2022;20:Doc06. Published 2022 Mar 31. Reid JR, States LJ. Ionizing Radiation Use and Cancer Predisposition Syndromes in Children. J Am Coll Radiol. 2018;15(9):1238–1239. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3848001","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":266397766,"identity":"75fee4a6-5a50-4f1a-bb10-13ed32aa43a0","order_by":0,"name":"Shuai Liu","email":"","orcid":"","institution":"Department of Pediatric Orthopedics, Wuxi 9th People’s Hospital Affiliated to Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Shuai","middleName":"","lastName":"Liu","suffix":""},{"id":266397767,"identity":"c3c2cd6c-4ae4-458f-9c85-b92b13afb168","order_by":1,"name":"Yeming Zhou","email":"","orcid":"","institution":"Second Clinical College, Tongji Medical College, Huazhong University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Yeming","middleName":"","lastName":"Zhou","suffix":""},{"id":266397768,"identity":"dc86d20f-c05d-49a0-b58c-c9204b6a9b00","order_by":2,"name":"Shuo Wang","email":"","orcid":"","institution":"Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan","correspondingAuthor":false,"prefix":"","firstName":"Shuo","middleName":"","lastName":"Wang","suffix":""},{"id":266397769,"identity":"7df9b5d6-c6b3-4432-b1e1-f8b8b58191e4","order_by":3,"name":"Saroj rai","email":"","orcid":"","institution":"Al Ahalia Hospital","correspondingAuthor":false,"prefix":"","firstName":"Saroj","middleName":"","lastName":"rai","suffix":""},{"id":266397770,"identity":"0c329ea2-cfb1-43f1-b3e4-19398bb0da94","order_by":4,"name":"Pan Hong","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA9UlEQVRIiWNgGAWjYBACAygtx8bMfvBBBYjJzNxAlBZjfnaeZIMzYC2MxGlJnNnPYCYB1sJAQIs5e+/h1wU1dxg3HGZIqzhQcTiavx2o5UfFNpxaLHvOpVnPOPaM2eAw47EbB86k5c44zNjA2HPmNm6H3cgxM+ZhO8xmALTl9sc2m9wGoBZmxjZCWv4d5gFqMSs42CaRO58ILcaPedsOS0g2M5gxHATasoGgljNnzJhn9h024GfmSZYA+WUjUMtBvH453mP8ueDb4fo2/uMHPwBDLHfe+cMHH/yowK0FCNikMYQO4FMPBMyfCSgYBaNgFIyCkQ4AjUBfvB7eM9IAAAAASUVORK5CYII=","orcid":"","institution":"Department of Orthopaedic Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan","correspondingAuthor":true,"prefix":"","firstName":"Pan","middleName":"","lastName":"Hong","suffix":""},{"id":266397771,"identity":"45a5cf61-392a-4362-a3a9-1631d582023a","order_by":5,"name":"Tianyou Xin","email":"","orcid":"","institution":"Department of Ultrasonic Diagnosis, Wuxi 9th People’s Hospital Affiliated to Soochow University","correspondingAuthor":false,"prefix":"","firstName":"Tianyou","middleName":"","lastName":"Xin","suffix":""}],"badges":[],"createdAt":"2024-01-09 10:59:12","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3848001/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3848001/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49547676,"identity":"0bd70491-9303-476f-af93-e5fe82a9b27c","added_by":"auto","created_at":"2024-01-12 19:23:26","extension":"jpg","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":37230,"visible":true,"origin":"","legend":"\u003cp\u003eRadiological and schematic image of MDJ fracture in distal radial\u003c/p\u003e","description":"","filename":"Figure1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3848001/v1/caeb8544a5e390015cf78bee.jpg"},{"id":49547678,"identity":"16b89792-33d7-4f96-a3f2-d250e5344329","added_by":"auto","created_at":"2024-01-12 19:23:26","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":122417,"visible":true,"origin":"","legend":"\u003cp\u003e10-year-old boy received EF under ultrasound\u003c/p\u003e\n\u003cp\u003eA. Lateral view of distal radius before surgery\u003c/p\u003e\n\u003cp\u003eB. AP view of distal radius before surgery\u003c/p\u003e\n\u003cp\u003eC. Image on US before reduction\u003c/p\u003e\n\u003cp\u003eD. Image on US after reduction\u003c/p\u003e\n\u003cp\u003eE. AP view of distal radius after surgery\u003c/p\u003e\n\u003cp\u003eF. Lateral view of distal radius after surgery\u003c/p\u003e\n\u003cp\u003eG. AP view of distal radius after hardware removal\u003c/p\u003e\n\u003cp\u003eH. Lateral view of distal radius after hardware removal\u003c/p\u003e","description":"","filename":"Figure2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3848001/v1/821edbe96e4f5cd9987da685.jpg"},{"id":49547677,"identity":"dfa52cc2-323e-4dbe-98fa-550482c7a27c","added_by":"auto","created_at":"2024-01-12 19:23:26","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":89640,"visible":true,"origin":"","legend":"\u003cp\u003e12-year-old boy received EF under fluoroscopy\u003c/p\u003e\n\u003cp\u003eA. AP view of distal radius before surgery\u003c/p\u003e\n\u003cp\u003eB. Lateral view of distal radius before surgery\u003c/p\u003e\n\u003cp\u003eC. Image on fluoroscopy before reduction\u003c/p\u003e\n\u003cp\u003eD. Image on fluorsocopy after KW prying\u003c/p\u003e\n\u003cp\u003eE. AP view of distal radius after surgery\u003c/p\u003e\n\u003cp\u003eF. Lateral view of distal radius after surgery\u003c/p\u003e\n\u003cp\u003eG. AP view of distal radius after hardware removal\u003c/p\u003e\n\u003cp\u003eH. Lateral view of distal radius after hardware removal\u003c/p\u003e","description":"","filename":"Figure3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-3848001/v1/e4a2a8d397d245c015da3a24.jpg"},{"id":49784039,"identity":"9c2222de-7244-4a18-8c26-450d63d8d253","added_by":"auto","created_at":"2024-01-18 02:38:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":462730,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3848001/v1/ed8221cd-7eed-4002-9be6-eb7015d41db6.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Ultrasound or C-arm? A comparative study of surgical intervention for adolescent metaphyseal-diaphysis junction fracture of the distal radius using external fixator","fulltext":[{"header":"Introduction","content":"\u003cp\u003eConservative approach remains first-line choice for distal radial fracture in children[\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Because of its unique anatomy, unstable fracture in metaphyseal-diaphysis junction (MDJ) poses challenges for successful conservative method[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. The definition of MDJ varies in different literature[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. In this study, consistent with earlier reports[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], MDJ is defined as the distal third of radius subtract the square over the radial physis, see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMultiple modes of surgeries have been reported for MDJ fracture of distal radius in children after failed manual reduction and casting. Closed reduction with retrograde or antegrade elastic stable intramedullary nail (ESIN), retrograde Kirschner wire (KW), open reduction and plate osteosynthesis, closed reduction and external fixation (EF) have been reported in the past few years[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7 CR8\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Although EF is primarily used in open fracture and temporary immobilization, it remains a feasible choice for pediatric patients due to faster fracture healing rate in children[\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eClosed reduction and external fixation was implemented under fluoroscopy. In contrast, ultrasound could provide real-time monitoring of the reduction process without ionizing radiation. Therefore, this study is to investigate the clinical effects of closed reduction and external fixation for MDJ fractures in children using fluoroscopy versus ultrasound.\u003c/p\u003e "},{"header":"Methods","content":" \u003cp\u003eStudy population\u003c/p\u003e \u003cp\u003e In all, 96 patients treated surgically using external fixator in Wuhan Union Hospital, Tongji Medical College, Huazhong University of Science and Technology or Wuxi Ninth People\u0026rsquo;s Hospital Affiliated to Soochow University, between January 2018 and Janauary 2023 were reviewed retrospectively. All patients were divided into two groups as ultrasound (US) group and C-arm (CA) group.\u003c/p\u003e \u003cp\u003eInclusion criteria were as follows: 1. age between 10 and 14 years old at the time of surgery; 2. unstable fracture in MDJ of distal radius with or without ulnar fracture after failed conservative treatment; 3. injury to surgery less than 7 days; 4. with open physis and clearly visible on X-ray.\u003c/p\u003e \u003cp\u003eExclusion criteria were as follows: 1. pathological or open fracture; 2. earlier fracture at the same limb; 3. neuromuscular or metabolic disease; 4. severely comminuted fracture.\u003c/p\u003e \u003cp\u003ePatient information including age, sex, operative side, duration from injury to surgery, presence of ulnar fracture, duration of surgery, hospital stay, image of intraoperative X-ray was retrieved from hospital database. Functional outcome was evaluated using Gartland-Werley score[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e] at every follow-up visit, and radiograph of wrist and full-length forearm was taken as well.\u003c/p\u003e \u003cp\u003eSurgical technique\u003c/p\u003e \u003cp\u003eAfter the introduction of brachial plexus block or general anesthesia, surgery was performed as follows without the usage of pneumatic tourniquet.\u003c/p\u003e \u003cp\u003e(1) In the US group, manual reduction was tried before the placement of Schanz pins. Physis was identified under ultrasound; two Schanz pins were placed in the distal fragment without violating the physis, and the other two Schanz pins were placed in the proximal diaphysis. If acceptable alignment is not achieved after three attempts of manual reduction, a KW or mosquito forceps was used as a lever to facilitate the reduction. Ultrasound was adopted to monitor the reduction process in real-time fashion, see Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e(2) In the CA group, physis was identified under fluoroscopy; two Schanz pins were placed in the distal fragment without violating the physis, and the other two Schanz pins were placed in the proximal diaphysis. KW or mosquito forceps was used to facilitate the reduction if the manual reduction was not satisfactory, see Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe diameter of Schanz pin ranged from 3 to 4 mm. A short or long-arm slab was applied after surgery for 2\u0026ndash;3 weeks to alleviate the swelling and pain. EF was routinely removed in 4\u0026ndash;8 weeks at out-patient visit according to the clinical and radiological evidence of fracture healing. A short arm brace was applied for additional 4 weeks after the removal of EF.\u003c/p\u003e \u003cp\u003eFollow-up\u003c/p\u003e \u003cp\u003eAll patients in our study were followed up for more than 6 months. Patients were followed up in out-patient department at 1st month, 2nd month, 3rd month, 6th month, 12th month postoperatively. After the first year, the patient was follow-up annually. Radiological and clinical evaluation was recorded and collected at every out-patient visit.\u003c/p\u003e \u003cdiv id=\"Sec2\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eAll data in this study was processed by SPSS statistical package program (SPSS 19.0 version; Data were presented as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (range), median (range), or n (%). χ2-test (categorical data) or Student\u0026rsquo;s t-test (continuous data) was used to compare theresults from two groups. Besides, a P-value of \u0026lt;\u0026thinsp;.05 was considered significantly different.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eIn all, 96 patients with MDJ fracture treated with EF were reviewed retrospectively, see Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Patients were divided into US group (50 patients, age 10.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71 years old) and CA group (46 patients, 11.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34 years old). Regarding the sex, fracture side, combined injury of ulnar fracture, duration from injury to surgery, there was no significant difference between the two group. However, the surgical duration was significantly shorter in the US group (24.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.12, min) compared with the CA group (32.11\u0026thinsp;\u0026plusmn;\u0026thinsp;9.23, min), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Images taken during the surgery was significantly less in the US group (2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19) than the CA group (9.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographic and clinical parameters of children with distal radial fracture involving metaphyseal diaphyseal junction in US and CA group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS group N\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCA group N\u0026thinsp;=\u0026thinsp;46\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e10.90\u0026thinsp;\u0026plusmn;\u0026thinsp;1.71\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e11.72\u0026thinsp;\u0026plusmn;\u0026thinsp;2.34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.093\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSex, male/female\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMale: 46 (92.00%)\u003c/p\u003e \u003cp\u003eFemale: 4 (8.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMale: 37 (80.43%)\u003c/p\u003e \u003cp\u003eFemale: 9 (19.57%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.098\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBody weight (Kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e42.64\u0026thinsp;\u0026plusmn;\u0026thinsp;6.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e43.20\u0026thinsp;\u0026plusmn;\u0026thinsp;9.11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.777\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFracture side, L/R\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eL: 31 (62.00%)\u003c/p\u003e \u003cp\u003eR: 19 (38.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eL: 26 (56.52%)\u003c/p\u003e \u003cp\u003eR: 20 (43.48%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.585\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCombined ulnar fracture (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e25 (50.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e28 (60.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.200\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDuration of surgery, min\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32.11\u0026thinsp;\u0026plusmn;\u0026thinsp;9.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eImages taken during the operation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.000*\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFrom injury to surgery (d)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.86\u0026thinsp;\u0026plusmn;\u0026thinsp;7.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9.65\u0026thinsp;\u0026plusmn;\u0026thinsp;7.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.398\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData shown as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or N(%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eχ\u003csup\u003e2\u003c/sup\u003e-test for categorical data or Student\u0026rsquo;s t-test for continuous data.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e*\u0026lt;.01\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAs for the complications, residual angulation, clinical function of forearms, there was no significant difference between the two group, see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFollow-up data for children with radial MDJ fracture in the US and CA group\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameter\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eUS N\u0026thinsp;=\u0026thinsp;50\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eCA N\u0026thinsp;=\u0026thinsp;46\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHardware removal, weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e5.74\u0026thinsp;\u0026plusmn;\u0026thinsp;0.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.89\u0026thinsp;\u0026plusmn;\u0026thinsp;0.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.286\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFollow-up, months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e16.96\u0026thinsp;\u0026plusmn;\u0026thinsp;5.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16.83\u0026thinsp;\u0026plusmn;\u0026thinsp;2.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.469\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePin tract infection (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e4 (8.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5 (10.87%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.630\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTendon Irritation (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0 (0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0 (0.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e/\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForearm pronation (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80.22\u0026thinsp;\u0026plusmn;\u0026thinsp;4.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e79.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.74\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.207\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eForearm supination (\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e85.26\u0026thinsp;\u0026plusmn;\u0026thinsp;4.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e86.13\u0026thinsp;\u0026plusmn;\u0026thinsp;5.13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.410\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDASH score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.08\u0026thinsp;\u0026plusmn;\u0026thinsp;0.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.11\u0026thinsp;\u0026plusmn;\u0026thinsp;0.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAP view Angulation(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.16\u0026thinsp;\u0026plusmn;\u0026thinsp;1.59\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.52\u0026thinsp;\u0026plusmn;\u0026thinsp;1.69\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.292\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVolar tilt(\u0026deg;)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.40\u0026thinsp;\u0026plusmn;\u0026thinsp;1.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.54\u0026thinsp;\u0026plusmn;\u0026thinsp;1.79\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.656\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGartland\u0026ndash;Werley score 0\u003c/p\u003e \u003cp\u003e1\u003c/p\u003e \u003cp\u003e2\u003c/p\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e27 (54.00%)\u003c/p\u003e \u003cp\u003e18 (36.00)\u003c/p\u003e \u003cp\u003e4 (8.00%)\u003c/p\u003e \u003cp\u003e1 (2.00%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21 (45.65%)\u003c/p\u003e \u003cp\u003e14 (30.43%)\u003c/p\u003e \u003cp\u003e9 (19.57%)\u003c/p\u003e \u003cp\u003e2 (4.35%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.341\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData shown as mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD or N(%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003e\u003csup\u003ea\u003c/sup\u003eχ\u003csup\u003e2\u003c/sup\u003e-test for categorical data or Student\u0026rsquo;s t-test for continuous data.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eUltrasound monitoring proved to be an effective approach in real-time monitoring reduction process of MDJ fracture of distal radius in children, and it delivered similar clinical outcomes with fluoroscopy, with less X-ray radiation.\u003c/p\u003e \u003cp\u003eConservative method remains the preferred choice for distal radial fracture in children[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. However, in older children, failed conservative approach usually leads to surgical intervention. MDJ is an special anatomic site in distal radius, manual reduction followed by casting or splinting does not always delivers satisfactory outcomes in older children and adolescents[\u003cspan additionalcitationids=\"CR3 CR4 CR5 CR6 CR7\" citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Retrograde KW or pre-bent ESIN, antegrade ESIN, open reduction and plating have been reported for this condition[\u003cspan additionalcitationids=\"CR6 CR7\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. However, the placement of KW might be difficult, because the tendon irritation is a nuisance in unburied KW scenario. Retrograde ESIN have been reported by certain authors[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e], however, the precision curving is not easy, and the hardware requires secondary surgery under general anesthesia or brachial plexus block. Antegrade ESIN is hard to be removed during the secondary surgery[\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Plating requires long incision and increased risk of blood loss, infection, and cosmetic problems. Therefore, in our study, EF was employed to stabilize and maintain the fracture after closed reduction.\u003c/p\u003e \u003cp\u003eUltrasound has been used for the diagnosis of pediatric fractures for years[\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Besides, it has been reported as real-time monitoring tool in certain pediatric fractures including lateral condylar fracture of humerus, supracondylar fracture of humerus, diaphysial fracture of femur[\u003cspan additionalcitationids=\"CR16 CR17 CR18\" citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Besides, the application of ultrasound is forearm is feasible with relatively short learning curve[\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Physis is identifiable and reduction process could be clearly monitored on the screen[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. In order to facilitate the reduction process with lower radiation, ultrasound as a tool was adopted in our hospital. The learning curve of ultrasound in forearm is not long, and it could easily be mastered by orthopedic surgeons. Moreover, the diagnosis and management of forearm fractures haven been reported in earlier publication[\u003cspan additionalcitationids=\"CR21 CR22\" citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Surely, in these studies, the application of ultrasound is to detect the fracture, and provide rough evaluation of reduction[\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFluoroscopy is indispensable in orthopedic operating room, and most fracture surgeries require fluoroscopy to guide placement of implant and ascertain reduction of fracture[\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Ionizing radiation is hazardous, and correlated with increased risk of cancer, especially in children[\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e]. Therefore, it is necessary to minimize the exposure to intraoperative radiation without jeopardizing surgical outcomes.\u003c/p\u003e \u003cp\u003eThere were certain limitations in our study. Firstly, it is a retrospective study with relatively small sample size; secondly, other surgical methods such as ESIN, KW and plating were not included in this investigation; lastly, the mastery of ultrasound might pose a challenge for orthopedic surgeons familiar with fluoroscopy. More in-depth investigations on the application of ultrasound in pediatric fractures are warranted in the future.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eReal-time ultrasound assisted closed reduction and external fixation for MDJ fractures of distal radius in children is a feasible alternative, with less surgical duration and less intraoperative radiation than traditional fluoroscopy assisted surgeries.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthical Approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was approved by the Ethics Committee of Tongji Medical College, Huazhong University of Science and Technology (IORG no: IORG0003571) on November 20, 2019. Written consents to participate in this study were obtained from the legal guardians of every patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten consents were obtained from the legal guardians of every patient in\u003c/p\u003e\n\u003cp\u003ethis study for publication of this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest\u003c/strong\u003e: The authors have no conflicts of interest to declare.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding Sources\u003c/strong\u003e: None\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e: None\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAsadollahi S, Ooi KS, Hau RC. Distal radial fractures in children: risk factors for redisplacement following closed reduction. J Pediatr Orthop. 2015;35(3):224\u0026ndash;228.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLam A, Gordon AM, Thabet AM, Abdelgawad AA. Antegrade Flexible Nailing for Pediatric Metaphyseal-diaphyseal Junction Distal Radius Fracture, is it Safe?. Tech Hand Up Extrem Surg. 2023;27(3):161\u0026ndash;164. Published 2023 Sep 1.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu R, Wen Y, Wang C, Liu T, Yu J. Elastic stable intramedullary nailing versus Kirschner wire in the treatment of pediatric metaphyseal-diaphyseal junction fractures of the distal radius: a case-control study. BMC Musculoskelet Disord. 2023;24(1):922. Published 2023 Nov 30.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi J, Rai S, Tang X, Ze R, Liu R, Hong P. Fixation of delayed distal radial fracture involving metaphyseal diaphyseal junction in adolescents: a comparative study of crossed Kirschner-wiring and non-bridging external fixator. BMC Musculoskelet Disord. 2020;21(1):365. Published 2020 Jun 9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang L, Wang S, Xu J, et al. Clinical Outcomes of Minimally Invasive Fixation with Pre-Bent Elastic Stable Intramedullary Nails for the Treatment of Distal Radius Metaphyseal Diaphysis Junction Fractures in Children. Orthop Surg. 2023;15(12):3223\u0026ndash;3230.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChaoyu L, Guoqiang J, Wenqiang X, Lian M, Jing S, Yong L. Precision shaping of elastic stable intramedullary nail for the treatment of metaphyseal diaphysis junction fracture of the distal radius in children: a preliminary report in two centers. BMC Musculoskelet Disord. 2023;24(1):237. Published 2023 Mar 29.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang R, Chen D, Tang Y, et al. A Novel Method for Treating Distal Radius Diaphyseal Metaphyseal Junction Fracture in Children. Med Sci Monit. 2023;29:e939852. Published 2023 Jul 3.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKrohn C. Double Pre-Bending of an Intramedullary Nail Is the Minimal Invasive Osteosynthesis Solution for Dia-Metaphyseal Fractures of the Radius in Children: Technical Note and Case Series. Children (Basel). 2022;9(4):579. Published 2022 Apr 18.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAbulsoud MI, Mohammed AS, Elmarghany M, et al. Intramedullary Kirschner wire fixation of displaced distal forearm fractures in children. BMC Musculoskelet Disord. 2023;24(1):746. Published 2023 Sep 21.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChangulani M, Okonkwo U, Keswani T, Kalairajah Y. Outcome evaluation measures for wrist and hand: which one to choose?. Int Orthop. 2008;32(1):1\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLaaksonen T, Kosola J, Nietosvaara N, Puhakka J, Nietosvaara Y, Stenroos A. Epidemiology, Treatment, and Treatment Quality of Overriding Distal Metaphyseal Radial Fractures in Children and Adolescents. J Bone Joint Surg Am. 2022;104(3):207\u0026ndash;214.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWang G, Huo L, Xu Y, et al. Clinical observation on the treatment of displaced distal radial and ulnar fractures in children by closed manipulation combined with splinting. Front Surg. 2023;10:1199437. Published 2023 Sep 19.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKatzer C, Wasem J, Eckert K, Ackermann O, Buchberger B. Ultrasound in the Diagnostics of Metaphyseal Forearm Fractures in Children: A Systematic Review and Cost Calculation. Pediatr Emerg Care. 2016;32(6):401\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTsou PY, Ma YK, Wang YH, Gillon JT, Rafael J, Deanehan JK. Diagnostic accuracy of ultrasound for upper extremity fractures in children: A systematic review and meta-analysis. Am J Emerg Med. 2021;44:383\u0026ndash;394.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eShih CA, Huang MT, Chern TC, et al. The use of ultrasound for monitoring reduction and ulnar nerve subluxation in pediatric humeral supracondylar fractures. Eur J Radiol. Published online November 14, 2023.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKnight J, Alves-Pereira F, Keen CE, Jaremko JL. 2D vs. 3D Ultrasound Diagnosis of Pediatric Supracondylar Fractures. Children (Basel). 2023;10(11):1766. Published 2023 Oct 31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eYang X, Li L, Tang X, Xiang B, Wen T. Can intraoperative ultrasound visualize the closed reduction and elastic intramedullary nail fixation processes of double forearm fractures in children?. Medicine (Baltimore). 2021;100(12):e24324.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu Z, Yi X, Li Y, et al. Decreased Radiation Exposure Using Ultrasound-Assisted Reduction and Fixation of Femoral Shaft Fractures in Children: A Pilot Study. Ultrasound Med Biol. 2020;46(11):3154\u0026ndash;3161.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWu Y, Lu R, Liao S, Ding X, Su W, Wei Q. Application of ultrasound in the closed reduction and percutaneous pinning in supracondylar humeral fractures. J Orthop Surg Res. 2021;16(1):588. Published 2021 Oct 12.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSnelling PJ, Jones P, Bade D, et al. Ultrasonography or Radiography for Suspected Pediatric Distal Forearm Fractures. N Engl J Med. 2023;388(22):2049\u0026ndash;2057.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eChen L, Kim Y, Moore CL. Diagnosis and guided reduction of forearm fractures in children using bedside ultrasound. Pediatr Emerg Care. 2007;23(8):528\u0026ndash;531.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eWellsh BM, Kuzma JM. Ultrasound-guided pediatric forearm fracture reductions in a resource-limited ED. Am J Emerg Med. 2016;34(1):40\u0026ndash;44.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAuten JD, Naheedy JH, Hurst ND, Pennock AT, Hollenbach KA, Kanegaye JT. Comparison of pediatric post-reduction fluoroscopic- and ultrasound forearm fracture images. Am J Emerg Med. 2019;37(5):832\u0026ndash;838.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eProd'homme M, Sans-Merce M, Pitteloud N, Damet J, Lascombes P. Intraoperative 2D C-arm and 3D O-arm in children: a comparative phantom study. J Child Orthop. 2018;12(5):550\u0026ndash;557.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBuchberger B, Scholl K, Krabbe L, Spiller L, Lux B. Radiation exposure by medical X-ray applications. Ger Med Sci. 2022;20:Doc06. Published 2022 Mar 31.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eReid JR, States LJ. Ionizing Radiation Use and Cancer Predisposition Syndromes in Children. J Am Coll Radiol. 2018;15(9):1238\u0026ndash;1239.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3848001/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3848001/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eMetaphyseal-diaphysis junction (MDJ) is defined as the distal third of the radius subtracted from the square over the radial physis. Because of its unique anatomy, unstable fracture in MDJ poses challenges for a successful conservative method. Multiple modes of surgeries have been reported for MDJ fracture of the distal radius in children after failed manual reduction and casting. This study is to investigate the clinical effects of closed reduction and external fixation for MDJ fractures in children using fluoroscopy versus ultrasound. Ninety-six patients were divided into the ultrasound (US) group and the C-arm (CA) group. According to our results, the surgical duration was significantly shorter in the US group (24.40\u0026thinsp;\u0026plusmn;\u0026thinsp;6.12, min) compared with the CA group (32.11\u0026thinsp;\u0026plusmn;\u0026thinsp;9.23, min), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Images taken during the surgery were significantly less in the US group (2.66\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19) than the CA group (9.52\u0026thinsp;\u0026plusmn;\u0026thinsp;3.15), P\u0026thinsp;\u0026lt;\u0026thinsp;0.001. As for the complications, residual angulation, and clinical function of forearms, there was no significant difference between the two groups.\u003c/p\u003e","manuscriptTitle":"Ultrasound or C-arm? A comparative study of surgical intervention for adolescent metaphyseal-diaphysis junction fracture of the distal radius using external fixator","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-12 19:23:22","doi":"10.21203/rs.3.rs-3848001/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"117c1160-9ea2-409c-a925-3ce75d675e69","owner":[],"postedDate":"January 12th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-01-18T02:30:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-12 19:23:22","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3848001","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3848001","identity":"rs-3848001","version":["v1"]},"buildId":"_2-kVJe1T_tPrBINL-cwx","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}