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Introduction
  • Characterized by
    • fracture of the distal radius at the distal metaphyseal-diaphyseal junction with concominant disruption of the distal radioulnar joint (DRUJ)
    • disruption of the DRUJ in a pediatric patient can consist of a dislocation or, more commonly, a displaced ulnar physeal injury
  • Epidemiology
    • incidence
      • relatively rare injury, less frequent than in adults
      • often missed injury pattern (up to 41%)
    • demographics
      • peak incidence 9 to 13 years old
  • Pathophysiology
    • pathoanatomy
      • axial loading in combination with extremes of forearm rotation (pronation or supination)
        • pronation produces an apex dorsal radial fracture with the distal ulna displaced dorsally
        • supination produces an apex volar radial fracture with the distal ulna displaced volarly
  • Associated injuries
    • nerve injuries are rare
Anatomy
  • DRUJ
    • osteology
      • possesses poor bony conformity in order to allow some translation with rotatory movements
    • ligamentous
      • ligament structures are critical in stabilizing the radius as it rotates about the ulna during pronation and supination
      • triangular fibrocartilage complex (TFCC) is a critical component to DRUJ stability
    • biomechanics
      • the joint is most stable at the extremes of rotation
Presentation
  • Symptoms
    • wrist and forearm pain
    • radial deformity
    • limitation of wrist motion
    • ulnar head prominence or deformity can sometimes be seen 
  • Physical exam
    • pain with movement or palpation of the wrist
    • DRUJ instability may be appreciated by local tenderness and instability to testing of the DRUJ
      • compare to contralateral side
    • careful examination for nerve injury
Imaging
  • Radiographs
    • required views
      • AP and true lateral radiographs
        • true lateral radiograph is essential in determining the direction of displacement
    • additional views
      • contralateral radiographs often helpful for comparison
    • findings
      • displaced distal radial shaft fracture
      • DRUJ disruption
        • may be subtle and radiographs must be scrutinized
        • additional signs of DRUJ instability include
          • ulnar styloid fracture
          • widened DRUJ on posteroanterior view
          • greater than or equal to 5mm radial shortening
Treatment
  • Nonoperative
    • closed reduction with long arm casting
      • indications
        • indicated as first line of treatment
          • in younger patients (higher likelihood of successful nonoperative treatment than in adults)
      • reduction
        • requires anatomic reduction of both the radius fracture and the DRUJ
      • immobilization
        • place in above elbow cast in supination
  • Operative
    • open reduction internal fixation +/- DRUJ pinning
      • indications
        • unable to obtain anatomic closed reduction
        • irreducible DRUJ due to interposed tendon or periosteum
      • technique
        • radial fixation can be done with volar plate of flexible IMN (see below)
    • ORIF, soft tissue reconstruction of DRUJ and TFCC, +/- corrective osteotomy
      • indications
        • chronic DRUJ instability (a rare consequence of a missed injury)
    • corrective osteotomy with soft tissue reconstruction of DRUJ and TFCC
      • indications
        • DRUJ subluxation is caused by a radial malunion
          • a corrective osteotomy is also required in addition to reconstruction, otherwise a soft tissue reconstruction of the DRUJ alone will fail
Technique
  • ORIF with volar plating, +/- DRUJ pinning
    • approach
      • dorsal approach to DRUJ to remove interposed material if unable to obtain closed reduction
      • volar approach for ORIF(with plate) 
    • open reduction
      • irreducible DRUJ requires an open reduction to remove interposed material
      • reduction can be blocked by interposed
        • tendon
          • ECU most common interposed tendon
        • periosteum
    • DRUJ stability
      • following fixation, test DRUJ
        • if unstable, pin ulna to radius in supination
        • if unstable with large ulnar styloid fragment, fix ulnar styloid and splint in supination
  • ORIF with flexbile intramedullary nailing, +/- DRUJ pinning
    • approach
      • percutaneous (with IMN) of radius fracture 
    • open reduction
      • same as above
    • DRUJ stability
      • same as above
Complications
  • Malunion/nonunion
  • Chronic DRUJ instability
    • chronic DRUJ instability (a rare consequence of a missed injury)
  • Superficial radial nerve plasy
    • can be seen with IMN
  • Extensor pollicus longus
    • can be seen with IMN
 

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