< 9 yrs
< 1 cm
> 9 yrs.
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Average 4.1 of 42 Ratings
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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?
Accept the deformity, cast change and follow-up in 3 weeks
Closed reduction and cast application, follow-up in 1 week
Closed reduction and percutaneous fixation
Closed reduction and flexible intramedullary rod fixation
Open reduction and internal fixation with a plate and screws
Select Answer to see Preferred Response
After failed initial treatment with closed reduction and casting, displaced distal radius/forearm fractures should be treated with repeat closed reduction. Percutaneous fixation can decrease the risk of re-displacement.
Approximately 20-25% of distal radius metaphyseal fractures re-displace early after closed reduction and casting. Significant displacement can lead to poor functional and cosmetic outcomes. Indications for surgical fixation of distal forearm fractures in adolescents >10 years old include: angulation >20 degrees and rotation >30 degrees.
McLauchlan et al., in their prospective randomized, controlled trial, showed that K-wire fixation and casting was superior to closed manipulation (MUA) and casting for displaced distal radius fractures when comparing outcomes of loss of reduction and number of radiographs. Of the 33 patients in the MUA group, seven had to undergo a second procedure to correct recurrent displacement, compared to one of the 35 in the K-wire group who required exploration for recovery of a migrated pin.
Kamat et al. present a retrospective review of 1001 pediatric distal forearm fractures that required closed reduction to identify factors associated with re-displacement. They found the cast index (CI) - or ratio of sagittal (lateral) and coronal (AP) inner cast diameters - to be the only significant predictor. CI > 0.8 was associated with a significantly higher rate of displacement (26%) than CI <= 0.8 (5.6%). Previous studies have reported an ideal CI of 0.7.
Illustration A shows a distal radius fracture with dorsal displacement and apex volar angulation. Illustration B shows a distal radius fracture after closed reduction and temporary percutaneous fixation with a smooth k-wire.
Answer 1: The current amount of angulation is unacceptable for a child > 10 years.
Answer 2: The fracture has re-displaced once despite the first attempt at closed reduction in a well-molded cast. It is likely to re-displace and would benefit from fixation to stabilize the fracture.
Answer 4: The fracture is too distal to control the distal fragment with a flexible intramedullary rod.
Answer 5: Closed reduction will likely be sufficient to reduce the fracture. Open reduction should be reserved for cases where an adequate closed reduction cannot be achieved.
McLauchlan GJ, Cowan B, Annan IH, Robb JE
J Bone Joint Surg Br. 2002 Apr;84(3):413-7. PMID: 12002503 (Link to Abstract)
Kamat AS, Pierse N, Devane P, Mutimer J, Horne G.
J Pediatr Orthop. 2012 Dec;32(8):787-91. PMID: 23147621 (Link to Abstract)
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Average 2.0 of 22 Ratings
What is the most common fracture in children younger than 16-years-old?
Distal radius fractures are the most common fracture type in children less than 16-years-old.
Fractures are a common occurrence in children and adolescents. Fractures of the distal radius are the most common (22.7%), followed by fractures of the phalanges of the hand (18.9%), and fractures of the carpal/metacarpal region (8.3%). Distal radius fractures can occur in the diaphysis, metaphysis, or epiphysis. The majority are treated with closed reduction and casting.
Landin reviews the epidemiology of childhood fractures. According to his statistics, boys have a 42% risk of sustaining a fracture prior to age 16, while females have a 27% risk. Distal radius fractures were the most common, followed by hand fractures.
Illustration A shows a Salter-Harris II fracture of the distal radius with associated greenstick ulna fracture.
Answer 1: Fractures of the phalanges of the hand account for 18.9% of fractures.
Answer 2: Fractures of the distal femur account for 1.6% of fractures.
Answer 3: Fractures of the clavicle account for 8.1% of fractures.
Answer 5: Supracondylar fractures account for 3.3% of fractures.
J Pediatr Orthop B. 1997 Apr;6(2):79-83. PMID: 9165435 (Link to Abstract)
Average 2.0 of 38 Ratings
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?
Long arm cast immobilization
Short arm cast immobilization
Cast index greater than 0.85
Conscious sedation during reduction
Plaster cast immobilization
Pediatric both bone forearm fractures are generally treated with closed reduction and immobilization given the innate ability of the bone to remodel. Guidelines will vary by author, but fractures at any level in children less than 9 years of age, complete displacement, 15 degrees of angulation, and 45 degrees of malrotation are acceptable. In children 9 years of age and older, 30 degrees of malrotation, 10 degrees of angulation for proximal fractures, and 15 degrees for more distal fractures are acceptable. The cast index is defined as the sagittal width of the cast divided by the coronal width. If the fracture involves the physis, repeated closed reductions are not recommended due to potential injury of the physis. Therefore it is important to recognize acceptable alignment, know the potential for remodeling at certain ages, and the importance of a well-molded cast. Webb et al conducted a prospective, randomized study of 113 children who sustained fractures of the distal forearm. Patients were randomized to long arm or short arm casting. There was no difference in fracture displacement throughout the course of treatment. Loss of reduction was associated with poorly molded casts in both groups. The average cast index of patients who lost reduction was 0.79 compared to 0.70 in patients who did not lose reduction. Patients with short arm casts missed fewer school days and experienced less difficulty with activities of daily living. An example of the cast index from Webb's article is shown in Illustration A.
Webb GR, Galpin RD, Armstrong DG
J Bone Joint Surg Am. 2006 Jan;88(1):9-17. PMID: 16391244 (Link to Abstract)
Average 3.0 of 36 Ratings
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?
Layers of thickness of casting material
Water temperature used to dip casting material
Placing the limb on a pillow during the cast curing process
Fiberglass overwrapping of plaster casts
Type of fracture pattern
Causes for thermal burns during cast application are multi-factorial.
Halanski et al. evaluated the internal and external temperature changes that occured during cast application on limb models. They found that excessively thick plaster, dip-water temperature of >24 degrees C, placing the limb on a pillow during the curing process, and fiberglass overwrapping all increase the risk for thermal injury.
Lavalette et al. in a similiar study using a glass tube filled with water to simulate an extremity found that if the temperature of the dip water was higher than 24 degrees Celsius, thickness of the cast was greater than eight ply, and if the pillow was used to limit the dissipation of heat from the cast, temperatures became high enough to cause skin burns.
Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ
J Bone Joint Surg Am. 2007 Nov;89(11):2369-77. PMID: 17974878 (Link to Abstract)
Lavalette R, Pope MH, Dickstein H.
J Bone Joint Surg Am. 1982 Jul;64(6):907-11. PMID: 7085719 (Link to Abstract)
Average 3.0 of 34 Ratings
Isolated pronation of the forearm will most likely achieve reduction of what type of fracture in a 7-year-old boy?
Supination injury resulting in an apex-volar greenstick both bone forearm fracture
Pronation injury resulting in an apex-dorsal greenstick both bone forearm fracture
Supination injury resulting in an apex-dorsal greenstick both bone forearm fracture
Complete both bone forearm fracture with bayonete apposition of both the radius and ulna
Distal radius fracture with 25 degrees of apex-dorsal angulation
Noonan et al discuss the anatomy, diagnosis, treatment, and outcome in pediatric forearm and distal radius fractures in their review article. With regards to reduction and casting, the authors state that greenstick forearm fractures are usually supination injuries with apex-volar angulation (Illustration A), which can be reduced with varying degrees of forearm pronation. As a rule of thumb, most pediatric both bone fractures can be temporarily reduced by pointing the palm in the direction of the deformity. Complete both bone forearm fractures with bayonette apposition require traction to aide in reduction, and malaligned distal radius fractures can be reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation.
Noonan KJ, Price CT.
J Am Acad Orthop Surg. 1998 May-Jun;6(3):146-56. PMID: 9689186 (Link to Abstract)
Average 4.0 of 39 Ratings
HPI - A 14-year old male presents on the same day as a left wrist injury. Injury films are shown (excuse poor quality). Closed reduction is performed, and a splint is placed. Post reduction films are shown below immediately after the reduction and after 5 days when the patient returns to clinic.
Now that the patient returns 5 days later, how would you treat him based on the Post-procedure P2 films below?
HPI - 10 year old girl fall on ground 3 weeks ago. She was treated with closed reduction and long arm case in full pronation. She is now 3 weeks out and presents with the radiographs shown.
How would you treat this fracture now that it is 3 weeks out from the fracture.
HPI - Fall from 2-3 meters from a tree, trauma to the elbow and wrist
How would you treat this fracture
HPI - fall on out stretched hand, distal radius and ulna fracture
How would you treat this fracture?
HPI - fall at home pain and deformity left wrist.child is comfortable (parents not)
How would you treat?
HPI - 7 weeks imobillisation (primary long arm cast then short arm cast)
5 days after removing cast new accident, refracture
reduction , imobillisation- diastasis on radius ,sclerotic bone
What is your suggestion for treatment?
HPI - Sustained distal radius physeal fracture 3 weeks ago. Treated with closed reduction and application of splint. Presented 3 weeks later with dorsal displacement of the physes.
How would you treat this patient at this time?
HPI - h/o fall down while playing
sustained injury to right forearm
How will you treat this injury?
HPI - Fall on the ground
How would you treat this patient?