1、Pediatric Fractures of the Forearm, Wrist and Hand,John A. Heflin, MDOriginal Author: Amanda Marshall, MD; March 2004 Revised: Steven Frick, MD; August 2006 John A. Heflin, MD; April 2011,Pediatric Forearm Fractures,Approximately 40% of childrens long-bone fractures Most from fall to an outstretched
2、 hand Ulna susceptible to direct blow “night-stick” fracture Forearm fracture incidence increasing Increased sporting activity Increased body weight Neurologic injury rare (1%),Pediatric Forearm Fracture Locations,Proximal Least common (approx 4%) due to decreased lever arm and increased soft tissue
3、 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,Pediatric Forearm Fracture Types,Plastic Deformation No cortical disruption Stress higher than elastic limit of bone Incomplete “Greenstick” Fractures On
4、e cortex intact Include buckle or torus type fractures Complete Fractures No cortex intact Most unstable,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 ADLs need 50 degree
5、s supination, 50 degrees pronation,Pediatric Forearm,Primary ossification centers at 8 weeks gestation in both radius and ulna Distal physis provide 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:
6、 Approx 90 degrees pronation Approx 90 degrees supination,Plastic deformation,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 l
7、imit pronation/supination,Chamay: Jour. Biomechanics 3:263,1970,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 ol
8、der than 8 years Requires considerable force, applied slowly Place in well-molded long arm cast for 4 to 6 weeks,Incomplete (Greenstick) Fracture,Incomplete (Greenstick) Fractures,Minimally displaced fractures:Immobilized in a well-molded long arm cast Unacceptable alignment: Apply pressure to apex
9、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,Complete Fracture,Complete Fracture,Almost no intrinsic stability to length
10、, linear, or rotational alignment Muscle forces more of a deforming factor Typically has greater soft tissue injury,Cruess R:OCNA 4:969,1973,Closed Reduction Method,Conscious sedation/Bier block/general anesthesia Traction/counter-traction Reproduce/exaggerate deformity to unlock fragments Reduce/lo
11、ck fragments using periosteal hinge Correct rotational deformity,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
12、weeks if healing adequate Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees,Excellent Reduction with Well Molded Cast,How Much Angulation is too Much?,Depends on fracture, location, age, stability Closed reduction should be attempted for any angulation greater tha
13、n 20 degrees Angulation encroaching on interosseous space may limit rotation Any angulation that is clinically apparent,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 apposit
14、ion,Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop Surg 1998; 6:146-156,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 de
15、formities: Physeal growth: correction of 0.8 - 1 degree per month, or 10 degrees per year Rotational deformities will not remodel,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 frac
16、tures Consider re-manipulation for angular deformity exceeding 10 degrees in children 8 years Overriding (bayonette) apposition acceptable in children 8 years,Maintaining Reduction,Appropriately molded cast most important 3-point mold Well formed ulnar border Good interosseous mold However its much
17、easier to maintain a good reduction than a marginal one,Forearm Fractures - Complications,Malunion Most common Refracture 13-14% radial/ulnar shaft 1.5-2.7% distal radius Compartment syndrome Synostosis very rare Neurologic injury uncommon (1%),If headed for malunion,Do not hesitate to stabilize.,Da
18、vis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:172-184 Tischer W. Forearm fractures in childhood (authors transl). Zentralbl Chir 1982;107:138-48.,Rotational Malunion,Remember, these will not remodel,Cast Burns- can occur during cast removal if blad
19、e dull or improper technique used,Indications for Internal Fixation,Open fractures Compartment syndrome Inability to maintain acceptable reduction Multi-trauma Floating elbow Neurologic/vascular compromise Re-fracture with displacement,Implant Choice for Pediatric Diaphyseal Forearm Fractures,IM nai
20、ls 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,Intramedullary Fixation,Single bone fixation m
21、ay 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,Intramedullary Fixation,Intramedullary Fixation,Ulna: insert rod
22、 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 Listers tubercle (not recommended),Inserting Radial R
23、od,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,IM Fixation Complications,Infection Delayed union Non-union Prominent hardware Hardware
24、migration Loss of reduction Compartment syndrome,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
25、 compartment syndrome Usually 3.5mm DCP type plate At least 3 screws above and below fracture,Plate Fixation,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 inju
26、ry = less risk of infection,Open Metadiaphyseal Fractures,Irrigation and debridement in the OR Plate and screws or percutaneous cross pinning Antibiotics for 24 hours,Implant Removal,In younger children, hardware usually removed (plates or IM fixation) Can consider removal of IM fixation at 3-6 mont
27、hs 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,Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury,Usually at junction of middle and distal thirds Distal fragment
28、typically angulated towards ulna Closed treatment for most Carefully assess DRUJ post reduction, clinically and radiographically,Galeazzi Equivalent,Radial shaft fracture with distal ulnar physeal injury instead of DRUJ injuryDistal ulnar physeal injuries have a high incidence of growth arrest,Galea
29、zzi Fracture,Galeazzi Equivalent,Distal ulnar epiphysis,Previous Injury Following Closed Reduction,Distal ulnar epiphysis,Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast,Distal Radius Fractures,Most common fracture in children 28-30% of all fractures Metaphyseal most freque
30、nt 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,Distal Radius Fractures,Metaphyseal Physeal Salter II most common Torus Greenstick Complete Volar angulation with dorsal displ
31、acement most common,Differences?,Metaphyseal Less compromise of carpal tunnel Less pain Physeal More compromise of the structures in the carpal tunnel More pain Sensory changes,Associated Injuries,Distal ulnar metaphyseal fracture or ulnar styloid avulsion Distal ulnar physeal injury High incidence
32、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.,No
33、ndisplaced 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,Displaced Distal Radius Physeal Fractures-Treatment,Closed reduction usually not difficult Traction with finger traps (r
34、educe shear) Gentle dorsal push Immobilize Well molded cast / splint above or below elbow (surgeon preference) 3-4 weeks immobilization,Physeal Injury Reduction Maneuver,Use finger trap for traction,Gentle push to complete reduction,Majority of correction achieved with traction,“Repeated efforts at
35、reduction do nothing more than grate the plate away.” “These injuries unite quickly, so that attempts to correct malposition after a week are liable to do more damage to the plate than good.”,Rang, Childrens Fractures 2005.,Treatment Recommendations - Reduction Attempts?,Treatment Recommendations,“F
36、or Salter-Harris type I and II injuries in children younger than 10 years of age, angulation of up to 30 can be accepted. In children older than 10 years, up to 15 of angulation is generally acceptable.”,Armstrong et al, Skeletal Trauma, 1998.,Remodeling Potential - 12 yo Male,Presented 10 days afte
37、r fracture no reduction, splinted in ED and now with early healing no additional reductionAt 6 months extensive remodeling of deformity noted,Sagittal plane: Apex volar remodels 0.9 degrees per month Coronal Plane: Radial deviation remodels 0.8 degrees per month Thus, 30-350 of residual angulation n
38、eeds around 5 years to completely remodel,Residual Angulation and Complete Remodeling,Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10: 705-712.,Displaced Distal Radius Fractures Care after Closed Reduction,Radiograph within one week to check reduction Do not re-mani
39、pulate physeal fractures after 5-7 days for fear of further injury to physis Metaphyseal fractures may be re-manipulated for 2-3 weeks if alignment lost Expect significant remodeling of any residual deformity,Distal Radius Fractures Potential Complications,Growth arrest Unusual after distal radius p
40、hyseal injury Around 4-5% Malunion Will typically remodel Follow for one year prior to any corrective osteotomy Shortening Usually not a problem Resolves with growth,Remodeling at 2 years,Growth Arrest following Distal Radius Fracture,Injury films,Injured and uninjured wrists after premature physeal
41、 closure,Distal Radius Growth Arrest,Relatively rare (approx 4%) Related To: Severity of trauma Amount of displacement Repeated attempts at reduction Re-manipulation or late manipulation,Distal Radius Conclusions,Most common physeal plate injury (39%) Increased incidence of growth plate abnormalitie
42、s with 2 or more reductions Distal radius growth arrest rate 4-5% Acceptable alignment: 50% apposition 30 angulation Accept malreduced fractures upon late presentation (over 7 days).,Distal Radius Fracture Indications for Operative Treatment,Inability to obtain acceptable reduction Open fractures Di
43、splaced intra-articular fractures Associated soft tissue injuries Soft tissue interposition Associated fractures (SC humerus) Associated acute carpal tunnel syndrome or compartment syndrome,Distal Radius Fixation Options,Smooth K-wire fixation usually adequate Avoid physis when possible Some fractur
44、es require plate fixation Intra-articular fractures Older pediatric/adolescent patients External fixation for severe soft tissue injury,Carpal Injuries in Children,Unusual / uncommon in children Scaphoid fracture most common carpal fracture Still less than 1% of all upper extremity fractures Capitat
45、e / Lunate / Hamate fractures can occur (rare) Carefully check carpal bones on every wrist film Comparison films of uninjured wrist helpful,Acute Distal Radius Metaphyseal Fracture in a 13 year Skateboarder,Patient gave history of a fall sustained one year ago with a “bad wrist sprain” Did you note
46、the scaphoid nonunion ?,Scaphoid Fractures,Not always obvious on plain films,Scaphoid Fractures - Treatment,Tender snuff box Immobilize until tenderness resolves If still tender at 1-2 weeks Repeat x-ray Confirmed fracture If non-displaced, immobilize in above elbow cast for 6 weeks then short arm c
47、ast 4-6 weeks Displaced fracture ORIF 1 mm displacement, 10 degrees angulation,Scaphoid Fixation,Compression screw fixation is treatment of choice for displaced scaphoid fracture Import to achieve anatomic reduction,Hand Fractures,Metacarpal and phalangeal fractures If displaced, attempt closed redu
48、ction Correct both angulation and rotation Immobilize for 3-4 weeks Indications for ORIF Open fractures Displaced intra-articular fractures Inability to obtain / maintain reduction,Phalangeal Fractures (Epidemiology),43% proximal phalanx Commonly physeal 37% of all physeal fractures Usually SH II (5
49、4%) 30% affect small finger 20% affect the thumb,Distal Phalangeal Fractures,Very common Usually crush injuries Address any associated nail bed injuries If open give appropriate antibiotics, I&D If distal end amputated: May heal by secondary intent Can attach amputated part as composite graft,Mallet
50、 Finger,Salter Harris III injury of distal phalanx Extension splint for 6 weeks ORIF or pinning for: Large articular fragments (25%) DIP incongruity/volar subluxation,Open Physeal Fractures,“Seymores fracture” Associated with nail bed lacerations Germinal matrix can be incarcerated in physis Requires nail bed repair, I&D, antibiotics Commonly get infected Often requires pinning,
