Pediatric Fractures of the Forearm, Wrist and Hand

1. Pediatric Fractures of the Forearm, Wrist and Hand John A. Heflin, MD Original Author: Amanda Marshall, MD; March 2004 Revised: Steven Frick, MD; August 2006 John A. Heflin, MD; April 2011

2. Pediatric Forearm Fractures • Approximately 40% of children’s long-bone fractures • Most from fall to an outstretched hand • Ulna susceptible to direct blow • “night-stick” fracture • Forearm fracture incidence increasing • Increased sporting activity • Increased body weight • Neurologic injury rare (<1%)

3. Pediatric Forearm Fracture Locations • Proximal • Least common (approx 4%) due to decreased lever arm and increased soft tissue envelope • Mid-shaft • Account for 18 - 20% of both bone fractures • Distal • Account for >75% of radius and/or ulna fractures • Approx 14% in distal physis

4. Pediatric Forearm Fracture Types • Plastic Deformation • No cortical disruption • Stress higher than elastic limit of bone • Incomplete “Greenstick” Fractures • One cortex intact • Include buckle or torus type fractures • Complete Fractures • No cortex intact • Most unstable

5. Goals of Treatment • Restore alignment and clinical appearance • Limit injury to local soft tissues • Prevention of further injury • Pain relief • Regain functional forearm rotation • For ADL’s need 50 degrees supination, 50 degrees pronation

6. Pediatric Forearm • Primary ossification centers at 8 weeks gestation in both radius and ulna • Distal physisprovide most (80%) of longitudinal growth • Distal epiphyses of radius appears at age 1 • Distal epiphyses of distal ulna appears at age 5 • Normal forearm rotation: • Approx 90 degrees pronation • Approx 90 degrees supination

7. Plastic deformation

8. Plastic Deformation of the Forearm • Fixed deformation remains when bone stressed beyond elastic limit • Most common in forearm • May be ulna and/or radius • Periosteum remains intact • Usually no periosteal callus • Deformation can limit pronation/supination Chamay: Jour. Biomechanics 3:263,1970

9. Plastic Deformation • Remodeling not as reliable • Reduce when: • Obvious clinical deformity • Greater than 20 degrees of angulation • Prevents reduction of a concomitant fracture • Prevents full pronation-supination in a child >4 years • Any child older than 8 years • Requires considerable force, applied slowly • Place in well-molded long arm cast for 4 to 6 weeks

10. Incomplete (Greenstick) Fracture

11. Incomplete (Greenstick) Fractures • Minimally displaced fractures: • Immobilized in a well-molded long arm cast • Unacceptable alignment: • Apply pressure to apex of fracture to restore alignment and clinical appearance • Slightly overcorrect (5-10 degrees) • Completing fracture decreases risk of recurrence of deformity and may facilitate reduction • Apex dorsal deformity not well tolerated

12. Complete Fracture

13. Complete Fracture • Almost no intrinsic stability to length, linear, or rotational alignment • Muscle forces more of a deforming factor • Typically has greater soft tissue injury Cruess R:OCNA 4:969,1973

14. Closed Reduction Method • Conscious sedation/Bier block/general anesthesia • Traction/counter-traction • Reproduce/exaggerate deformity to unlock fragments • Reduce/lock fragments using periosteal hinge • Correct rotational deformity

15. Closed Reduction Method • Optimal forearm immobilization position in rotation: • Apex volar: pronation • Apex dorsal: supination • Maintain cast for 4 to 6 weeks or until radiographic evidence of union • Conversion to a short arm cast at 3 to 4 weeks if healing adequate • Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees

16. Excellent Reduction with Well Molded Cast

17. How Much Angulation is too Much? • Depends on fracture, location, age, stability • Closed reduction should be attempted for any angulation greater than 20 degrees • Angulation encroaching on interosseous space may limit rotation • Any angulation that is clinically apparent

18. Acceptable Limits • Angulation • < 9 years: 15 degrees • ≥ 9 years: 10 degrees • Malrotation • < 9 years: 45 degrees • ≥ 9 years: 30 degrees • Shortening • Usually not a problem • includes bayonette apposition Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop Surg 1998; 6:146-156

19. Remodeling Potential –Variables to Consider • Age of child • Distance from fracture to physis • Distal metaphyseal fractures most forgiving • Proximal forearm fractures: much less remodeling • Angular deformities: • Physeal growth: correction of 0.8 - 1 degree per month, or ~10 degrees per year • Rotational deformities will not remodel

20. After Closed Reduction and Casting • Weekly radiographs for 3 weeks to confirm acceptable alignment and rotation • Can re-manipulate up to 3 weeks after injury for shaft fractures • Consider re-manipulation for angular deformity exceeding 10 degrees in children > 8 years • Overriding (bayonette) apposition acceptable in children <8 years

21. Maintaining Reduction • Appropriately molded cast most important • 3-point mold • Well formed ulnar border • Good interosseous mold • However… it’s much easier to maintain a good reduction than a marginal one

22. Forearm Fractures - Complications If headed for malunion… • Malunion • Most common • Refracture • 13-14% radial/ulnar shaft • 1.5-2.7% distal radius • Compartment syndrome • Synostosis • very rare • Neurologic injury • uncommon (<1%) Do not hesitate to stabilize. Davis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:172-184 Tischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir1982;107:138-48.

23. Rotational Malunion Remember, these will not remodel…

24. Cast Burns- can occur during cast removal if blade dull or improper technique used

25. Indications for Internal Fixation • Open fractures • Compartment syndrome • Inability to maintain acceptable reduction • Multi-trauma • Floating elbow • Neurologic/vascular compromise • Re-fracture with displacement

26. Implant Choice for Pediatric Diaphyseal Forearm Fractures • IM nails or K-wire (2 mm typically) • Good stabilization • Minimal soft tissue dissection • Easy removal of implants • Augmented with short term above elbow cast immobilization • Older children (10 years and above) may be better treated as adults with plates and screws

27. Intramedullary Fixation • Single bone fixation may be attempted for both bone fracture • Stabilize second if still unstable • Either bone can be fixed first • Start with the less comminuted and less displaced fracture • Usually easier to begin from the ulna due to straight shape of the bone

28. Intramedullary Fixation

29. Intramedullary Fixation • Ulna: insert rod in lateral surface of proximal ulna (olecranon) • Alternate entry point: tip of olecranon (not recommended) • Radius: insert rod just proximal to the radial styloid • Avoid injury to the superficial radial nerve • Alternate entry point: just proximal to Lister's tubercle (not recommended)

30. Inserting Radial Rod

31. Intramedullary Fixation • Pre-bend radial nail • To restore bow • Mini - open reduction if necessary • Tap rod across fracture site • Pushing and plunging may cause deep swelling • Leave 1cm nail flush against metaphysis

32. IM Fixation Complications • Infection • Delayed union • Non-union • Prominent hardware • Hardware migration • Loss of reduction • Compartment syndrome

33. Plate Fixation • Provides absolute stability when there is bony apposition • Can be used to bridge comminution • More commonly used in older pediatric patients • Use if concern for compartment syndrome • Releases the compartments thus decreasing the chance of a compartment syndrome • Usually 3.5mm DCP type plate • At least 3 screws above and below fracture

34. Plate Fixation

35. Open Fractures • Immediate operative stabilization of open fractures in both adults and children does not increase the infection rate • Timing of antibiotics very important • Closer to time of injury = less risk of infection

36. Open Metadiaphyseal Fractures • Irrigation and debridement in the OR • Plate and screws or percutaneous cross pinning • Antibiotics for 24 hours

37. Implant Removal • In younger children, hardware usually removed (plates or IM fixation) • Can consider removal of IM fixation at 3-6 months if solid healing on radiographs • In older children (>10 years), plates and screws often not removed unless symptomatic • Can remove at 6 to 9 months if fracture completely healed

38. Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury • Usually at junction of middle and distal thirds • Distal fragment typically angulated towards ulna • Closed treatment for most • Carefully assess DRUJ post reduction, clinically and radiographically

39. Galeazzi Equivalent • Radial shaft fracture with distal ulnar physeal injury instead of DRUJ injury • Distal ulnar physeal injuries have a high incidence of growth arrest

40. Galeazzi Fracture

41. Galeazzi Equivalent Distal ulnar epiphysis

42. Previous Injury Following Closed Reduction Distal ulnar epiphysis

43. Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast

44. Distal Radius Fractures • Most common fracture in children • 28-30% of all fractures • Metaphyseal most frequent • 62% of radius fractures • Distal radial physis second • 14% of radius fractures • Simple falls most common mechanism • Rapid growth may predispose, with weaker area at metaphysis

45. Distal Radius Fractures • Metaphyseal • Physeal • Salter II most common • Torus • Greenstick • Complete • Volar angulation with dorsal displacement most common

46. Differences? • Metaphyseal • Less compromise of carpal tunnel • Less pain • Physeal • More compromise of the structures in the carpal tunnel • More pain • Sensory changes

47. Associated Injuries • Distal ulnar metaphyseal fracture or ulnar styloid avulsion • Distal ulnar physeal injury • High incidence of growth disturbance • Up to 50% • Median or ulnar nerve injury • Rare • Acute carpal tunnel syndrome • Also rare • More common in dorsal angulated physeal injuries Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal forearm fractures in children. J PediatR Orthop 1996; 16( 2): 195-200.

48. Nondisplaced Distal Radius Fractures - Treatment • Below elbow immobilization • 3 weeks • Torus fractures are stable injuries • Still need to treat • Can treat with a removable forearm splint

49. Displaced Distal Radius Physeal Fractures-Treatment • Closed reduction usually not difficult • Traction with finger traps (reduce shear) • Gentle dorsal push • Immobilize • Well molded cast / splint above or below elbow (surgeon preference) • 3-4 weeks immobilization

50. Physeal Injury Reduction Maneuver Use finger trap for traction Gentle push to complete reduction Majority of correction achieved with traction