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Distal Radius Fractures - Pediatric

Topic updated on 04/17/16 7:07pm
Introduction
  • Pediatric distal radius fracture radiographEpidemiology
    • incidence
      • common - forearm fractures in total account for approximately 40% of all pediatric long bone fractures
      • distal radius (and ulna) is the most common site of pediatric forearm fractures.
      • male > female
    • demographics
      • most common during metaphyseal growth spurt
      • peak incidence occurring from: 
        • 10-12 years of age in girls
        • 12-14 years of age in boys
      • most common fracture in children under 16 years old 
  • Pathophysiology
    • mechanism
      • usually fall on an outstretched hand
      • often during sports or play
    • remodeling
      • remodeling greatest closer to physis and in plane of joint (wrist) motion
        • sagittal plane (flexion/extension)
Anatomy
  • Distal radius physis
    • contributes 75% growth of the radius
    • contributes 40% of entire upper extremity 
    • growth at a rate of ~ 5.25mm per year
Classification
  • Relation to distal physis
    • Physeal considerations 
    • Salter-Harris I     
    • Salter-Harris II     
    • Salter-Harris III   
    • Salter-Harris IV  
    • Salter-Harris V
  • Metaphysis (distal) (62%)
    • complete (Distal Radius fracture) 
      • apex volar (Colles' fracture) 
      • apex dorsal (Smith's fracture)
    • incomplete (Torus/Buckle fracture)  
      • typically unicortical
  • Diaphysis (20%)
    • both bone forearm fracture 
    • isolated radial shaft fracture
    • isolated ulnar shaft fracture
    • plastic deformation
      • incomplete fracture with deforming force resulting in shape change of bone without clear fracture line
      • thought to be due to a large number of microfractures resulting from a relatively lower force over longer time compared to mechanism for complete fractures 
    • greenstick fracture
      • incomplete fracture resulting from failure along tension (convex) side
        • typically plastic deformation occurs along compression side
  • Fracture with dislocation / associated injuries
    • Monteggia fracture  
      • ulnar shaft fracture with radiocapitellar dislocation
    • Galeazzi fracture  
      • radius fracture (typically distal 1/3) with associated DRUJ injury, often dislocation
Presentation
  • History
    • wide range of mechanism for children, often fall during play or other activity
    • rule out child abuse
      • mechanism or history appears inconsistent with injury
      • multiple injuries, especially different ages
      • child's affect
      • grip marks/ecchymosis
  • Symptoms
    • pain, swelling, and deformity
  • Physical exam
    • gross deformity may or may not be present
    • ecchymosis and swelling
    • inspect for puncture wounds suggesting open fracture
    • although uncommon, compartment syndrome and neurovascular injury should be evaluated for in all forearm fractures.
Imaging
  • Radiographs
    • recommended views
      • AP and lateral of wrist
      • AP and lateral of forearm
      • AP and lateral of elbow
    • findings
      • in addition to fracture must evaluate for associated injuries
        • scapholunate joint
        • DRUJ
        • ulnar styloid
        • elbow injuries
  • CT
    • indications
      • useful characterize fracture if intra-articular
      • however use sparingly in children given concerns regarding increased longitudinal effects of radiation
Treatment
 
"Classically" Acceptable Angulation for Closed Reduction in Pediatric Forearm Radius Fractures
 
(controversial with ongoing discussion)
 
Shaft / Both bone fx
Distal radius/ulna
Age Acceptable Bayonetting

Acceptable Angulations

Malrotation* Dorsal Angulation

< 9 yrs

< 1 cm

15-20°

45°

30 degrees

> 9 yrs.

< 1 cm

10°

30°

20 degrees

  • Bayonette apposition, or overlapping, of less than 1 cm, does not block rotation and is acceptable in patients less than 10 years of age.
  • General guidelines are that deformities in the plane of joint motion are more acceptable, and distal deformity (closer to distal physis) more acceptable than mid shaft.
  • The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the diaphysis can block 20-30 degrees of rotation. 
  • *Rotational deformities do not remodel and are increasingly being considered as not acceptable.
 
  • Nonoperative
    • immobilization in short arm cast for 2-3 weeks without reduction
      • indications
        • greenstick fracture with < 10 deg of angulation
        • torus/buckle fracture
          • studies ongoing to treat minimally displaced or torus fractures with pre-fabricated removable wrist splint, no cast
    • closed reduction under conscious sedation followed by casting
      • indications
        • greenstick fracture with > 10-20 degrees of angulation
        • Salter-Harris I with unacceptable alignment
        • Salter-Harris II with unacceptable alignment
      • technique (see below)
        • reduction technique determined by fracture pattern
      • acceptable criteria (see table above)
        • acceptable angulations are controversial in the orthopedic community. 
        •  accepted angulation is defined on a case by case basis depending on
          • the age of the patient
          • location of the fracture
          • type of deformity (angulation, rotation, bayonetting).
      • outcomes
        • short-arm (SAC) vs long-arm casting (LAC)
          • good SAC (proper cast index = sagital/coronal widths) considered equal to LAC for distal radius fractures
            • conservative treatment though often utilizes LAC to reduce impact of variable cast technique/quality
          • no increased risk of loss of reduction with (good) short arm vs. long arm casting 
        • cast index
          • loss of reduction is associated with increasing cast index
      • follow-up
        • all forearm fractures serial radiographs should be taken every 1 to 2 weeks initially to ensure the reduction is maintained.
  • Operative
    • closed reduction and percutaneous pinning (CRPP)
      • indications
        • unstable patterns with loss of reduction in cast
        • Salter-Harris I or II fractures in the setting of NV compromise
          • CRPP reduces need for tight casting in setting with increased concern for compartment syndrome
        • any fractures unable to reduce in ED but are successfully reduced under anesthesia in the OR
    • open reduction and internal fixation
      • indications
        • displaced Salter-Harris III and IV fractures of the distal radial physis/epiphysis unable to be closed reduced
        • irreducible fracture closed
          • often periosteum or pronator quadratus block to reduction
Treatment Techniques
  • Closed Reduction
    • timing
      • avoid delayed reduction of greater than 1 week after injury
      • for physeal injuries, generally limit to one attempt to reduce growth arrest
    • reduction technique
      • gentle steady pressure for physeal reduction
      • for complete metaphyseal fractures re-create deformity to unlock fragments, then use periosteal sleeve to aid reduction
      • traction can be counter-productive due to thick periosteum
  • Casting
    • usually consists of a long arm cast (conservative approach) for 6 to 8 weeks with the possibility of conversion to a short arm cast after 2-4 weeks depending on the type of fracture and healing response.
      • may utilize well molded short arm cast with adequate cast index instead of long arm cast initially
  • CRPP 
    • approach
      • avoid dorsal sensory branch of radial nerve, typically with small incision
    • reduction
      • maintain closed reduction during pinning
    • fixation
      • radial styloid pins
        • usually 1 or 2 radial styloid pins, entry just proximal to physis preferred
        • if stability demands transphyseal pin, smooth wires utilized
        • for intra-articular fractures, may pin distal to physis transversely across epiphysis 
      • dorsal pins
        • may also utilize dorsal pin, especially to restore volar tilt
        • for DRUJ injuries, or severe fractures unable to stabilize with radial pins alone, pin across ulna and DRUJ
    • postoperative considerations
      • followup in clinic for repeat imaging to assess healing and position
      • pin removal typically in clinic once callus formation verified on radiograph
        • may consider sedation or removal of pins in OR for children unable to tolerate in clinic
      • must immobilize radio-ulnar joints in long arm cast if stabilizing DRUJ
      • may supplement with external fixator for severe injuries
Complications
  • Casting Thermal Injury
    • thermal injury may occur if: 
      • dipping water temperature is > 24C (75F)
      • more than 8 layers of plaster are used
      • during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from the exothermic reaction
      • fiberglass is overwrapped over plaster
  • Malunion
    • most common complication
  • Physeal arrest
    • from initial injury or repeated/late reduction attempts
    • isolated distal radial physeal arrest can lead to ulnocarpal impaction, TFCC injuries, DRUJ injury
    • distal ulnar physis most often to arrest
  • Ulnocarpal impaction
    • from continued growth of ulna after radial arrest
  • TFCC injuries
  • Neuropathy
    • Median nerve most commonly affected

 

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Qbank (8 Questions)

TAG
(OBQ12.134) An 11-year old boy presents to fracture clinic 1 week after sustaining a displaced metaphyseal distal radius fracture that was managed with closed reduction and cast application. While the initial post-reduction radiographs showed near anatomic alignment with a well molded cast, radiographs 1 week later show 22 degrees of apex volar angulation and dorsal re-displacement. What is the best management at this time? Topic Review Topic

1. Accept the deformity, cast change and follow-up in 3 weeks
2. Closed reduction and cast application, follow-up in 1 week
3. Closed reduction and percutaneous fixation
4. Closed reduction and flexible intramedullary rod fixation
5. Open reduction and internal fixation with a plate and screws

PREFERRED RESPONSE ▶
TAG
(OBQ12.243) What is the most common fracture in children younger than 16-years-old? Topic Review Topic

1. Hand phalanges
2. Femoral shaft
3. Clavicle
4. Distal radius
5. Supracondylar

PREFERRED RESPONSE ▶
TAG
(OBQ10.196) An 8-year-old boy fell while riding his bike and landed on his outstretched arm. Radiographs are provided in Figure A. Which of the following increases the risk of displacement following closed reduction and casting? Topic Review Topic
FIGURES: A          

1. Long arm cast immobilization
2. Short arm cast immobilization
3. Cast index greater than 0.85
4. Conscious sedation during reduction
5. Plaster cast immobilization

PREFERRED RESPONSE ▶
TAG
(OBQ09.251) You are preparing to cast a child with a both-bone forearm fracture in the emergency room. During cast application, all of the following are directly related to the risk of thermal injury EXCEPT? Topic Review Topic

1. Layers of thickness of casting material
2. Water temperature used to dip casting material
3. Placing the limb on a pillow during the cast curing process
4. Fiberglass overwrapping of plaster casts
5. Type of fracture pattern

PREFERRED RESPONSE ▶
TAG
(OBQ05.97) Isolated pronation of the forearm will most likely achieve reduction of what type of fracture in a 7-year-old boy? Topic Review Topic

1. Supination injury resulting in an apex-volar greenstick both bone forearm fracture
2. Pronation injury resulting in an apex-dorsal greenstick both bone forearm fracture
3. Supination injury resulting in an apex-dorsal greenstick both bone forearm fracture
4. Complete both bone forearm fracture with bayonete apposition of both the radius and ulna
5. Distal radius fracture with 25 degrees of apex-dorsal angulation

PREFERRED RESPONSE ▶
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