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Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 35-39|Aakash Mugalur1, Binoti A Sheth2 Authors :Aakash Mugalur[1], Binoti A Sheth[2] [1] Narayani Hospital and Research Centre, Vellore, India [2] Dept of Orthopaedics, LTMGH, Sion, Mumbai, India Address of Correspondence Dr Aakash Mugalur, #492, 9th Cross, 8th Main, T K Layout, Mysore, Karnataka-570009. India Email: […]

Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 33-34|Sanika Milind Kulkarni 1, Shekhar Malve 2, Rajiv Negandhi 2 Authors :Sanika Milind Kulkarni [1], Shekhar Malve [2], Rajiv Negandhi [2] [1]Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli, India. [2]Dept of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India. Address of […]

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

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Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 35-39|Aakash Mugalur1, Binoti A Sheth2

Authors :Aakash Mugalur[1], Binoti A Sheth[2]

[1] Narayani Hospital and Research Centre, Vellore, India
[2] Dept of Orthopaedics, LTMGH, Sion, Mumbai, India

Address of Correspondence
Dr Aakash Mugalur, #492, 9th Cross, 8th Main, T K Layout, Mysore, Karnataka-570009. India
Email: orthoaakash@gmail.com

Abstract

Background: The normal anatomical radial bow is of crucial importance to the normal range of motion of the forearm and to the strength generated by the muscles. The restoration of the normal amount and location of the radial bow is of crucial importance in functional outcome of forearm fractures. Few studies exist on characteristics of radial bow in Indians.
Materials and methods: In this prospective observational clinic-radiological study we aimed to establish the normal characteristics of the radial bow in the Indian population, and compare the radial bow of the injured limb with the normal contralateral side to establish a co-relation of the radial bow with rotational movements of forearm and to establish whether remodelling had any effect on the characteristics of radial bow. We used modified Schmetisch & Richards method to establish the characteristics of radial bow. The proposed sample size was 100 patients under the age of 14 years, but only 86 patients completed of the study.
Results: The mean of the site of maximum radial bow was at 61.68 % and that of the magnitude of radial bow was 7.62 % of the total radial length. The location and magnitude of radial bow have a significant correlation with forearm rotation .A negative correlation exists between the location of maximum radial bow and the magnitude of the radial bow but it is not statistically significant.
Conclusion: The characteristics of radial bow in our are comparable to that of the western literature. In forearm fractures every effort must be made to restore the radial bow close to the values of the normal limb for better functional outcome. Multicentric studies with larger sample size and a longer follow-up might add value to the available data.
Key Words: Radial bow, forearm, fracture, radius, ulna

Introduction
Forearm fractures are the very common fractures in children and account for about 40 percent of all pediatric fractures. [1,2] Despite their apparent simplicity they still continue to be a challenge to the treating orthopedician owing to the treatment complexity and the risk of complications.[3] Most patients in the pediatric age group need not be and should not be treated by open reduction and internal fixation.[4] The aim of the line of management, whether conservative or operative is to achieve optimal reduction of the fracture and to restore functionality to the injured limb. Despite enormous remodelling potential in the paediatric population, malunion is not uncommon and has a strong bearing on functional outcome. Pronation and supination movements add to the dexterity of the upper limb and are very important in the activities of daily living. These are complex movements influenced by numerous factors. Of the many factors the normal anatomical radial bow is of crucial importance to the normal range of motion of the forearm and to the strength generated by the muscles.[5] Alteration of the normal bowing may result from forearm fractures. While axial deformities are easily recognised, changes of bowing may be subtle and minor fractures which may influence it are frequently missed. Apart from appropriate reduction and rotational alignment, it is equally important to restore the radial bow comparable to the normal side for optimal treatment of forearm fractures. Studies show that restoration of the normal radial bow is related to the functional outcome. A good functional result is associated with restoration of the normal amount and location of the radial bow.[6] Estimation of the radial bow of the unaffected forearm and comparison of the injured limb with it can be useful for optimising reduction by non operative or operative management. To the best of our knowledge we did not find any literature delineating the characteristics of the radial bow in the Indian population. In our study we aimed to establish the characteristics of the radial bow with respect to the Indian population, compare the radial bow of the reduced injured limb with the normal side and follow it up to establish a co-relation with remodelling, to measure rotational movements of the forearm and establish a co-relation between the radial bow and rotational movements. We also wanted to evaluate the effect of remodelling of the isolated ulna fractures on the radial bow.
Materials and methods: The study was a prospective observational study with the intended sample size of 100 patients in the paediatric age group( 0 – 14 yrs ) with forearm fractures .The study was conducted at our institute and parents of the patients gave a formal consent and were free to withdraw their children from the study at any given point of time. Clearance from the institutional ethics committee was obtained before starting with the study. The first 100 Patients aged less than 14 years with radius or ulna or both forearm bones fractures with no previous history of fractures in either forearm bones were included in the study. Patients aged more than 14 years, history of fracture of either bones of either forearm, patients with pre-existing deformity and co-existing elbow and wrist injuries, with neurological deficit affecting the forearms were primarily excluded from the study. The primary line of management was closed reduction and casting. The patients were followed up clinico-radiologically on weekly basis in the first one month to assess for loss of reduction and cast related complications. Since eight patients showed loss of reduction beyond the acceptable criteria, requiring surgical intervention they were secondarily excluded from the study to negate the effect of the possible stiffness arising of surgery. Six patients were lost to follow up over the period of time. The remaining Eighty six patients were followed up clinico-radiologically at 1, 3, 9 monthly intervals. At every visit a standardised anteroposterior view of the forearm was obtained. The point of maximum radial bow and maximum radial bow were measured as percentage of the total radial length for comparability using the modified Schemitsch and Richards method.[6] Two measurements were taken independently by two observers and a mean of the values were taken to avoid inter observer bias. The pronation–supination movements and deformity were also assessed clinically at follow up. The data was tabulated and analysed using SPSS13.0 software.
Results: We had 71 % male and 29 % female patients with 24% of the fractures occurring in the age group of four to six years. Fall on outstretched hand was the mode of trauma in majority of the patients ( 91 %). The characteristics of the radial bow and the pronation and supination movements in our study are enlisted in Table 1. There is a statistically significant positive co-relation between the maximum radial bow and the prono-supination movements (Table 2 & 3). There is a statistically significant negative co-relation between the point of the maximum radial bow and the prono-supination movements (Table 4). We found a negative co-relation between the maximum radial bow and the point of the maximum radial bow but it was statistically insignificant.(Table 5)
Discussion: In our study the male to female ratio was 2.448 to 1 with a significant male preponderance. The increased male preponderance in our study could be associated with increased outdoor and sports activity in male children in our subcontinent and hence increased risk and vulnerability for the fractures. 24 % of the fractures occurred in the age group of 4-6 years with no significant predilection to fracture in any specific age group in the rest of the study group. Forearm shaft fractures have been shown to occur most commonly in the 12 to 16 year old age group which are a challenging group to treat.[1] The difference in the distribution of the fractures when compared to other studies could be attributed to the low sample size and the sampling method of including the first hundred patients as the study group. In our study the predominant mode of trauma was fall on outstretched hands (91 %) while the rest were due to direct impact. This is in acceptance with the published data on the mechanism of injury in forearm fractures where the indirect transmitted force is implicated in most of the forearm fractures. The primary mechanism of injury associated with radial and ulnar shaft fractures is a fall on outstretched hand that transmits indirect force to the bones of the forearm.[7]With respect to the location and magnitude of the radial bow, our results are comparable with the results of M Firl[8] and Schemitsch.[6] The minor differences in values could be due to the differences in the study group. The study group of M Firl although had pediatric population they didn’t represent a normal population as they had suspected injury to forearm. The other contributing factor could be the difference in the race. Both the papers analysed Western population. We couldn’t find any published data on normal radial bow in the Indian population. We used the modified method of Schemitsch & Richards[6, 8] to measure the radial bow as we could express it as a percentage of the total radial length and the results could be compared. Measurement of the radial bow in a singular plane, although representing a simplification, gives clinically significant information[8] and can be applied in the clinical scenario owing to the simplicity and reproducibility. Measurement of the bow on the normal side and comparing it with the affected side can help to diagnose plastic deformation of the radius in the absence of obvious fracture of the radius and serve as a guide for optimum reduction in the treatment of the fractures of the forearm.( Figure 1 and 2) The mean supination in our study was 93 degrees and the mean pronation was 89.97 degrees. The mean values of pronation and supination is not comparable in various studies. The average arc of normal forearm motion for the Mayo[9] group was 68 degrees of pronation to 74 degrees of supination. In a study by Rickert et al[10] the arc of motion was from 75 degrees of pronation to about 100 degrees of supination. In yet another study by Boone and Azen[11] it ranged from 77 degrees of pronation to 83 degrees of supination. Though it has been traditionally taught that 50 degrees of pronation and supination represent adequate forearm motion [9], it has been observed that losing 20 to 30 degrees of either pronation or supination carries the potential for significant functional impact upon important activities of daily living [12]. Prono-supination movements assume even greater importance in the Indian scenario. An “all or none” phenomenon exists whereby a small deviation from the norm of the radial bow, a good functional result could be expected in terms of rotational movements of the forearm, but once a certain point was reached there was a rapid decline in the outcome.[6] Statistical analysis has shown that a change in the location of the maximum radial bow is of greater functional significance than a change in the value of the maximum radial bow.[7] We opine that both the location and magnitude of the radial bow have a significant correlation with forearm rotation and hence has a significant effect on functional outcome. We compared isolated ulna fractures with radius-ulna & radius fractures to evaluate the effect of isolated ulna fractures on radial bow if any. In our study we observed that there is no statistically significant difference between both the groups. We conclude that isolated ulna fractures do not affect the magnitude and location of the radial bow in a statistically significant manner. We in our study also analysed the relation between the magnitude and location of the radial bow. We observed a negative correlation between the location of maximum radial bow and the magnitude of the radial bow but it was not statistically significant. Even earlier studies have failed to establish a significant correlation between the magnitude and location of the maximum radial bow. However it must be noted that they are related to functional outcome and to each other to differing degrees.[6] We followed up the maximum radial bow and the location of maximum radial bow for a period of nine months. We did not find any significant change in the value of maximum radial bow or its location during this observation period either on the fractured side or on the normal side. Despite our short follow up of nine months we opine it is important to achieve the normal radial bow on the fractured side at the initial setting itself as the remodelling process does not alter the location or the maximum value of the bow significantly. M Firl et al[8] state that the length of the radius and the value of maximum radial bow clearly increase with age but the location of maximum radial bow remained a constant. One of the reasons which could be responsible for this discrepancy between our study and the available literature could be the short follow up period of nine months in our study. We found a negative correlation between the location of the maximum radial bow and range of supination. The corelation was statistically significant throughout the duration of the study. We also established a negative co-relation between the location of maximum radial bow and pronation. The correlation was negative at every follow up, but it was statistically significant at three and nine months. In our study we found a positive co-relation between the maximum radial bow and rotational movements of the forearm. The co-relation was positive at one, three and nine monthly intervals and it was statistically significant. To evaluate the effect of radial bow in further detail on forearm rotation requires further follow up and linear regression analysis. But that was beyond the scope of our present study. But it has been found that the relation between the radial bow and rotational movements is not linear.[6] Although we have established a correlation between the radial bow and rotational movements of forearm it must be noted that radial bow is not the only factor rotational movements of the forearm are dependent on. There are many other contributory factors which are difficult to be excluded completely in clinical scenario. Small sample size and a short follow-up were among the drawbacks of the study. Further we evaluated patients in a particular subset of Indian patients. Large multicentric studies with a larger sample size and a longer follow up are necessary to further delineate the characteristics of radial bow in Indian population.

Conclusion:
The characteristics of the radial bow of the Indian population match that of the western population. Restoration of the radial bow characteristics is very important in the management of forearm fractures. Every effort must be made to restore the characteristics of radial bow in forearm fractures for a better functional outcome.

References

1. Cheng JC, Ng BK, Ying SY, et al. A 10 year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999;19: 344-350.
2. Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001; 26:908-915.
3. Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop Relat Res 1976; 120: 172-184.
4. Canale ST. Fractures and Dislocations in Children:Canale ST, Beaty JH. Campbell’s Operative Orthopaedics, vol 2, 11th edition, Mosby Elsevier;2008. p.1545-1556.
5. Richards RR. Chronic disorders of the forearm. J Bone Joint SurgAm. 1996; 78-A: 916-30.
6. Schemitsch EH, Richards RR. The effect of malunion on functional outcome after plate fixation of fractures of both bones of the forearm in adults. J Bone Joint SurgAm. 1992; 74-A:1068-78.
7. Atkas S, Saridogan K, Moralar U, et al. Patterns of single segment nonphyseal extremity fractures in children. Int Orthop 1999;23:345-347
8. Firl M, Wünsch L. Measurement of bowing of the radius. J Bone Joint SurgBr. 2004;86-B:1047-9.
9. Morrey BF, Askew LJ, Chao EY. A biomechanical study of normal elbow motion. J Bone Joint Surg Am 1981; 63: 872-877.
10. Rickert M, Burger A, Gunther CM, et al. Forearm rotation in healthy adults of all ages and both sexes. J Shoulder Elbow Surg 2008; 17: 271-275.
11. Boone DC, Azen SP. Normal range of motion of joints in male subjects. J Bone Joint Surg Am 1979; 61: 756-759.
12. Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna: Beaty JH, Kasser JR et al. Rockwood and Wilkin’ Fractures in Children, 7th edition, Lippincott Williams & Wilkins; 2010. p.347-404.

How to Cite this Article:Mugalur A, Sheth BA. Clinico-radiological significance of restoration of radial bow in pediatric forearm fractures: An Indian perspective. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):35-39.

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Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

Volume 2 | Issue 1 | Jan-Apr 2016 | Page 33-34|Sanika Milind Kulkarni 1, Shekhar Malve 2, Rajiv Negandhi 2

Authors :Sanika Milind Kulkarni [1], Shekhar Malve [2], Rajiv Negandhi [2]

[1]Bharati Vidyapeeth Deemed University Medical College and Hospital, Sangli, India.
[2]Dept of Orthopaedics, Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India.

Address of Correspondence
Ms Sanika Kulkarni
Post Graduate Institute of Swasthiyog Pratishthan, Miraj, Maharashtra, India.
Email: sani0209@gmail.com

Abstract

Background: In India, clubfoot is quite commonly seen. Consanguineous marriage is one of the etiological factors associated with clubfoot deformity. Consanguineous marriage is a fairly common sight, especially in rural areas in India. As there is no study from India which mentions relationship of consanguinity and clubfoot, the present study was conducted.
Aim: The aim of the study was to find if there was any significant correlation between relationship of consanguinity and clubfoot, and divide them based on degree of consanguinity.
Material and Method: The study was conducted from 2010 to 2015 at tertiary institute. The total number of cases which were considered of idiopathic variety of clubfoot was 406. Out of these, the cases were divided into presence or absence of consanguinity, and also the degree of consanguinity. A detailed history about consanguinity was taken.
Result: According to the data and classification, 140 patients were born out of consanguineous marriage. This states that about 34.4% of the cases had consanguineous marriage. After classification into degrees, it was found that there were no cases of first degree consanguinity, 25 cases of second degree and maximum number of cases i.e. 115 cases with third degree consanguinity.
Conclusion: Thus it can be concluded that consanguinity is significantly seen in cases with idiopathic clubfoot. So, we need to create awareness regarding consequences of consanguineous marriages, particularly in rural and developing areas.
Keywords: Consanguinity, clubfoot

Introduction
India, being a culturally diverse nation, with various religions and castes, is a land with people following different customs. With various backgrounds, follow various belief systems and mind-sets. People from rural places, tribes, and low socio-economic areas, believe that marriage of their son/daughter within the family would make them safer and secure in life and thus getting them married to their relatives.
Clubfoot is one of the commonest congenital anomalies seen in orthopaedic practice. Prevalence of Clubfoot in Asian countries is about 1.5/100 children.
According to a study from India, in Sindhudurg District of Maharashtra, India, the prevalence of Clubfoot is 1.8/1000 new borns. (1) One of the etiologies mentioned in the literature of Clubfoot, is consanguineous marriage. Although Clubfoot is quite common in India, there are very few studies mentioning the prevalence of consanguinity in Clubfoot cases.

Aims
To determine the prevalence and degree of consanguinity in patients with idiopathic congenital talipes equinovarus.

Material and Method
This study was done in a tertiary care hospital, with a dedicated Pediatric Orthopaedic unit. We do see large number of cases here, of clubfoot, coming from backward areas, rural places and low socio-economic statuses, where the literacy and education is low.

We collected data from the year 2010 to 2015, of clubfoot cases that came to the hospital for advice and treatment. In all these cases, we selected the cases of idiopathic clubfoot. They consisted of treated and untreated cases of idiopathic clubfoot. At the time of consultation, detailed history of child with perinatal period, and also marital history of parents was taken. Any consanguineous marriage found in the history was noted and mentioned in detail.

We omitted all the cases other than idiopathic variety, such as Arthrogryposis, Meningomyelocele, and Syndromic cases.
We included all the cases of treated or untreated cases of idiopathic clubfoot and divided them by presence or absence of consanguinity. Then the cases with consanguineous marriage were further classified into degrees.
For classification of degrees of consanguinity, we referred to the NHS National Genetics and Genomics Education Centre (4) through their website (www.geneticseduction.nhs.uk)
From this source, we found information about classification of consanguinity into degrees. Degree of consanguinity is determined by the degree of relationship between the two individuals. That in turn is determined by the shared amount of genes in the relatives. As half of the genes in a person are inherited from each parent, and shared with the sibling, marriage with parent, sibling or child, is first-degree consanguinity. Sharing one-quarter proportion of genes with aunt/uncle, niece/nephew, grandchild/grandparent, marriage with one of these relations is second-degree consanguinity. The third degree of consanguineous marriage is with the relations sharing one-eighth proportion of genes, i.e. with first cousins, or great grandparents.
Following is the classification of consanguinity into degrees:
First Degree: marriage with Parent, Child, or Sibling.
Second Degree: marriage with Aunt/Uncle, Niece/Nephew, Grandparent/Grandchild
Third Degree: marriage with First Cousins.

Result
From the years 2010 to 2015, at our institute we saw 457 cases of clubfoot. Out of these, 39 were cases of non-idiopathic variety. So we excluded them. Out of the remaining 418 cases, 240 cases had come at neonatal age and 178 cases had come at different ages, for treatment. Out of these 418 cases of idiopathic clubfoot, 12 parents were not willing to share their marital history. So, after excluding them, our final data comprised of 406 cases, which were then classified into degrees of consanguinity.
So with the final sample size of 406 cases, 230 cases were presented to us at neonatal ages while 168 were late presenters (Age 3 months to 10 years).
In this study, out of 406 cases, there were 272 males and 134 females. Out of these patients, 282 had unilateral clubfoot, and 124 cases had bilateral. With respect to consanguinity, there were 140 children born out of consanguineous marriage. This accounts to about 34.4% of patients with consanguineous marriage of parents. According to the above-mentioned classification, there were 0% cases of first-degree consanguinity, about 18% i.e. 25 cases with second-degree consanguinity. Majority of them 82% i.e. 115 cases had third-degree consanguinity. This way, the commonest degree was the third, and within the third degree of consanguinity, all the marriages were found to be between respective children of brother and sister.
Consanguineous marriages are more prevalent in rural areas than urban. These have been very commonly associated with low age at marriage, low educational level of mother, and low occupational status of the father.
Association of consanguinity and pediatric disorders is well established. Parental consanguinity has been linked with various risks including stillbirths, perinatal mortality, congenital birth defects [DDH, CTEV], malformations, mental retardation, and neonatal diabetes mellitus.
Parental consanguinity increases the autosomal recessive conditions through the expression of the recessive deleterious alleles, especially in the offspring of first-degree consanguineous marriages.
In our study, we have attempted to establish the correlation of clubfoot and consanguineous marriage. In previous study made by Shrinivas and Nataraj (3) they have established consanguineous marriage as one of the factors causing clubfoot.
Our study demonstrates, that almost one-third of the cases of CTEV that came to our outpatient clinic have consanguineous marriage of parents. These findings are similar to the study done by Sahin at al. (2), which demonstrated similar percentage of cases of clubfoot and consanguinity.
There is no direct relation of sex or number of feet affected (unilateral or bilateral), with consanguinity.

Conclusion
The result of the presented study reveals that there is a significantly high proportion of consanguinity in clubfoot patients. There is an urgent need to inform the people, properly about the anticipated deleterious effects of inbreeding in societies where inter-relation marriage is widely practiced. Further etiological studies that look into the association of consanguinity and clubfoot are needed to support the finding and clarify the significance of such an association.

References

1. The Mode of Inheritance and Other Variables in Idiopathic Talipes Equinovarus.
Dr. R. S. Kulkarni. Civil Hospital Sindhudurg, Sindhudurgnagari, Maharashtra State, India. The Journal of Maharashtra Orthopaedic association, Vol 3-year 1, March 2006.
2. Consanguineousmarriageand increased risk of idiopathic congenital talipes equinovarus: a case-control study in a rural area. Sahin O, Yildirim C, Akgun RC, Haberal B, Yazici AC, Tuncay IC. J Pediatr Orthop. 2013 Apr-May;33(3):333-8. doi: 10.1097/BPO.0b013e3182784af4. PMID: 23482273.
3. Parental consanguinity and associated factors in congenital talipes equinovarus.
Sreenivas T, Nataraj AR. Foot (Edinb). 2012 Mar; 22(1):2-5. doi: 10.1016/j.foot.2011.08.001. Epub 2011 Sep 15. PMID: 21920728
4. NHS National Genetics and Genomics Education Centre website (www.geneticseduction.nhs.uk).

How to Cite this Article:Kulkarni SM, Malve S, Negandhi R. Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India. International Journal of Paediatric Orthopaedics Jan-April 2016;2(1):33-34.

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Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

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Clinico-Radiological Significance of Restoration of Radial Bow in Pediatric Forearm Fractures: An Indian Perspective

Authors :Aakash Mugalur[1], Binoti A Sheth[2]

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

Prevalence and Degree of Consanguinity in Idiopathic Clubfoot in India

Authors :Sanika Milind Kulkarni [1], Shekhar Malve [2], Rajiv Negandhi [2]

Abstract

References

(Abstract) (Full Text HTML) (Download PDF)

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