Among the skeletally immature patients, 44 of the 51 patients (86%) sustained the injury via a low-energy mechanism and 37 (73%) were male (Table 4). In comparison, of the 42 skeletally mature patients, 37 (88%) sustained the injury through a high-energy mechanism and 29 (69%) were male.
The most common fracture pattern was an intraarticular fracture of the distal radius, accounting for 52% of all fractures in skeletally mature patients. The next most frequent fracture pattern in the skeletally mature group was comminuted followed by extraarticular fractures. In comparison, torus and Salter-Harris II fractures accounted for 31% and 29% of injuries in the skeletally immature group, respectively (Table 2).
Treatment modalities in the skeletally immature group consisted of closed reduction and immobilization in a long arm cast 92% of the time. All fractures in the skeletally mature group were treated operatively. Of the treatment modalities used to stabilize these fractures, 70% involved open reduction-internal fixation with plating.
Although unilateral distal radius fractures are common, the incidence of bilateral injuries remains unclear. Only scattered case reports exist describing bilateral distal radius fractures. Two of these reports describe the injury in an adolescent athlete and in an adult after a fall from a height; both injuries were treated nonoperatively [12, 13]. We therefore retrospectively examined various demographic parameters in 93 patients with bilateral distal radius fractures and stratified these data into skeletally immature and mature groups to identify differences in rates of associated injuries at time of presentation, mechanism of injury, fracture patterns, and treatment modalities.
Our study is limited by its lack of patient followup data. Specifically, owing to poor patient compliance and followup records from the clinic, we can make no conclusions regarding frequency of complications (eg, stiffness, malunion, nonunion, arthritis, growth arrest, range of motion, grip strength, infection) arising from these fractures, nor can we determine patient satisfaction or iatrogenic complications. Furthermore, owing to the lack of information regarding postoperative complications and healing, we cannot compare the superiority of one treatment approach over another. Although all clinically associated injuries at the time of initial trauma were documented in the patient chart, there may have been minor associated injuries missed secondary to poor patient followup. Nonetheless, our data provide useful information regarding the demographic differences between skeletally mature and immature patients and the fracture patterns and associated injuries incurred in bilateral distal radius fractures. Specifically, the physician should be careful in urgently identifying acute carpal tunnel syndrome and compartment syndrome in adult patients with bilateral injuries, as missed injuries can lead to permanent upper extremity dysfunction.
The presence of bilateral long bone fractures has been associated with substantial complications and predicts a greater number of associated injuries . Our findings suggest a higher rate of associated injuries in the skeletally mature group of patients when compared with the skeletally immature: 38% versus 4%, respectively. The most frequent associated injury was a long bone fracture followed by acute carpal tunnel syndrome, which required urgent release at the time of operative fixation. In addition, two adult patients had volar forearm compartment syndrome develop, which required urgent decompression. The incidence of acute carpal tunnel syndrome is found more commonly in patients with comminuted or dislocated fractures. In isolated injuries, the development of acute compartment syndrome occasionally occurs in high-energy injuries before surgical intervention, with the interval of occurrence reported to range from 12 to 54 hours after injury . The incidence of serious complications or co-occurring injuries in children however rarely has been reported [17, 24].
Among all patients with bilateral injuries, 71% were male with a mean age of 22.5 years. This is in contrast to the majority of unilateral injuries, which typically are sustained by older female patients with osteoporotic bones [10, 20, 23]. This discrepancy is consistent with other bilateral long bone fractures, which also are found in predominantly young male populations . We found 88% of the skeletally mature patients had a high-energy mechanism of injury, most commonly from a motor vehicle accident. In contrast, 86% of the bilateral injuries occurring in skeletally immature patients were sustained through a low-energy mechanism. This pattern is similar to that in an epidemiologic study identifying the growing trend of unilateral distal radius fractures in skeletally mature young males via high-energy injuries .
In the skeletally immature patients, nondisplaced torus and Salter-Harris II physeal fractures were most common. This is in accordance with their unilateral counterparts where Salter-Harris type II fractures comprise the majority of distal radial physeal fractures . Of the skeletally mature group, 52% of the fractures were intraarticular and 25% were comminuted, suggesting a much higher amount of energy imparted to the extremity. The high rate of intraarticular fractures with bilateral involvement is consistent with unilateral adult distal radius fractures, where a large percentage of the fractures also are intraarticular .
The treatment modality for 92% of skeletally immature patients consisted of closed reduction and immobilization. Because most of these injuries were nondisplaced and as such inherently stable once reduced, they remained amenable to nonoperative management, which remains the standard of care for most unilateral fractures in this age group. We performed surgery in patients we judged had unstable fractures with metaphyseal comminution or intraarticular derangement. The reported duration of immobilization in distal radius fractures in skeletally immature patients ranges from 3 to 6 weeks, with redisplacement rates reported at 8% [6, 24]. These findings suggest, in skeletally immature patients with bilateral distal radius fractures, the mechanism of injury and fracture patterns are similar to those sustained as isolated injuries. All of our patients with bilateral distal radius fractures in the skeletally mature group underwent operative intervention. Skeletally mature patients, unlike the skeletally immature patients, do not maintain the same potential for growth and remodeling; therefore the indications for surgical intervention remain more stringent. In addition, the need for prolonged immobilization in skeletally mature patients may compromise wrist motion and hand function.
Bilateral distal radius fractures may occur in skeletally immature patients as a result of a low-energy mechanism with minimal associated injuries. The fracture pattern and treatment are similar to those for a unilateral distal radius fracture in this age group. In contrast, bilateral distal radius fractures in skeletally mature patients are a result of a high-energy mechanism, creating unstable fracture patterns and concurrent injuries necessitating operative fixation. The data presented here do not address the indications for surgical treatment for bilateral distal radius fractures; treatment of these fractures requires using selection criteria such as skeletal maturity, associated injuries, and fracture pattern. Given that distal radius fractures are a common injury and with limited information regarding bilateral involvement, understanding the demographic variables and associated injuries may improve awareness and treatment of concomitant injuries.
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