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Updated: Jun 12 2021

Distal Radius Fractures - Pediatric

4.3

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  • summary
    • Distal Radius Fractures are the most common site of pediatric forearm fractures and generally occur as a result of a fall on an outstretched hand with the wrist extended.
    • Diagnosis is made with radiographs of the wrist. 
    • Treatment is generally closed reduction and casting for the majority of fractures. Surgical intervention is indicated for significantly displaced or angulated fractures in patients approaching skeletal maturity. 
  • Epidemiology
    • 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 (male 2-3 times more common than 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
  • Etiology
    • Pathophysiology
      • mechanism
        • usually fall on an outstretched hand, extended at wrist
        • often during sports or play
      • remodeling
        • greatest closer to physis and in plane of joint (wrist) motion
          • sagittal plane (flexion/extension)
        • least for rotational deformity
  • 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
    • Metaphyseal fracture most common, followed by physeal
  • 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)
        • unicortical, non-displaced
    • Diaphysis (20%)
      • both bone forearm fracture
      • isolated radial shaft fracture
      • isolated ulnar shaft fracture
      • plastic deformation
        • deforming force over time 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 mechanisms for children, often fall during play or other activity, outstretched hand
      • 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 if tender about elbow, or diaphyseal fractures present
      • findings
        • in addition to fracture must evaluate for associated injuries
          • scapholunate interval
          • DRUJ (distal radio-ulnar joint)
          • ulnar styloid
          • elbow injuries
    • CT scan
      • indications
        • useful to characterize fracture if intra-articular
        • use sparingly in children given concerns of increased longitudinal effects of radiation
  • Treatment
    • General principles
      • 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.
        • "Classically" Acceptable Angulation for Closed Reduction in Pediatric Forearm Radius Fractures
        • Shaft / Both bone fx
        • Distal radius/ulna
        • Age
        • Acceptable Bayonetting
        • Acceptable Angulations
        • Malrotation
        • Dorsal Angulation
        • < 10 years
        • < 1 cm
        • 15-20°
        • 45°
        • 30 degrees
        • > 10 years
        • None
        • 10°
        • 30°
        • 20 degrees
    • Nonoperative
      • immobilization in short arm cast for 2-3 weeks without reduction
        • indications
          • unicortical or bicortical fracture with < 10 deg of angulation
          • torus/buckle fracture
            • ongoing shift towards treating buckle fractures with pre-fabricated removable wrist splint, no cast, and limited follow-up
      • closed reduction under conscious sedation followed by casting
        • indications
          • > 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 close to 0.7 for good cast) 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 poor cast index
        • follow-up
          • all forearm fractures serial radiographs should be taken every 1 to 2 weeks initially to ensure reduction is maintained.
          • if concern for physeal injury, must follow child at least until growth seen on radiographs to confirm no growth arrest
    • Operative
      • closed reduction and percutaneous pinning (CRPP)
        • indications
          • unstable patterns unable to reduce initially, or with loss of reduction in cast at follow-up
          • Salter-Harris I or II fractures in the setting of neurovascular (NV) compromise
            • CRPP reduces need for tight casting in setting with increased concern for compartment syndrome
          • fractures unable to reduce in emergency department (ED) but successfully closed reduced under anesthesia in the operating room (OR) may be pinned for added stability
      • 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 chance of 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
      • historically consisted of a long arm cast 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 cast for shorter periods, 3-4 weeks, depending on child's age and healing on imaging
      • multiple high quality studies show fractures of distal third may be immobilized with a properly molded short arm cast.
      • special case of fratured distal radius with intact ulna: extreme ulna deviation of wrist helps keep radius fracture out to length.
    • 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
        • follow-up 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
      • risk factors for thermal injury include:
        • 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
    • Cast Saw Injury
      • if bivalving or univalving cast, must ensure proper technique to avoid injury
      • extra caution if cutting cast while child is sedated or under anesthesia
      • cool saw blade frequently to ensure not overheating
    • Loss of Reduction
      • poor cast index, increased initial displacement, and incomplete reduction are all risk factors for loss of reduction
    • 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
      • Uncommon in children, but must examine for acute carpal tunnel syndrome
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