1. Pediatric Fractures of the Forearm, Wrist and Hand
John A. Heflin, MD
Original Author: Amanda Marshall, MD; March 2004
Revised:
Steven Frick, MD; August 2006
John A. Heflin, MD; April 2011

2. Pediatric Forearm Fractures
Approximately 40% of children’s long-bone fractures
Most from fall to an outstretched hand
Ulna susceptible to direct blow
“night-stick” fracture
Forearm fracture incidence increasing
Increased sporting activity
Increased body weight
Neurologic injury rare (<1%)

3. Pediatric Forearm Fracture Locations
Proximal
Least common (approx 4%) due to decreased lever arm and increased soft tissue envelope
Mid-shaft
Account for % of both bone fractures
Distal
Account for >75% of radius and/or ulna fractures
Approx 14% in distal physis

4. Pediatric Forearm Fracture Types
Plastic Deformation
No cortical disruption
Stress higher than elastic limit of bone
Incomplete “Greenstick” Fractures
One cortex intact
Include buckle or torus type fractures
Complete Fractures
No cortex intact
Most unstable

5. 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 ADL’s need 50 degrees supination, 50 degrees pronation

6. 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:
Approx 90 degrees pronation
Approx 90 degrees supination

7. Plastic deformation

8. 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 limit pronation/supination
Chamay: Jour. Biomechanics
3:263,1970

9. 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 older than 8 years
Requires considerable force, applied slowly
Place in well-molded long arm cast for 4 to 6 weeks

10. Incomplete (Greenstick) Fracture

11. Incomplete (Greenstick) Fractures
Minimally displaced fractures:
Immobilized in a well-molded long arm cast
Unacceptable alignment:
Apply pressure to apex 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

12. Complete Fracture

13. Complete Fracture
Almost no intrinsic stability to length, linear, or rotational alignment
Muscle forces more of a deforming factor
Typically has greater soft tissue injury
Cruess R:OCNA 4:969,1973

14. Closed Reduction Method
Conscious sedation/Bier block/general anesthesia
Traction/counter-traction
Reproduce/exaggerate deformity to unlock fragments
Reduce/lock fragments using periosteal hinge
Correct rotational deformity

15. 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 weeks if healing adequate
Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees

16. Excellent Reduction with Well Molded Cast

17. How Much Angulation is too Much?
Depends on fracture, location, age, stability
Closed reduction should be attempted for any angulation greater than 20 degrees
Angulation encroaching on interosseous space may limit rotation
Any angulation that is clinically apparent

18. Acceptable Limits Angulation Malrotation Shortening
< 9 years: 15 degrees
≥ 9 years: 10 degrees
Malrotation
< 9 years: 45 degrees
≥ 9 years: 30 degrees
Shortening
Usually not a problem
includes bayonette apposition
Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop Surg 1998; 6:

19. 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 deformities:
Physeal growth: correction of degree per month, or ~10 degrees per year
Rotational deformities will not remodel

20. 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 fractures
Consider re-manipulation for angular deformity exceeding 10 degrees in children > 8 years
Overriding (bayonette) apposition acceptable in children <8 years

21. Maintaining Reduction
Appropriately molded cast most important
3-point mold
Well formed ulnar border
Good interosseous mold
However… it’s much easier to maintain a good reduction than a marginal one

22. Forearm Fractures - Complications
If headed for malunion…
Malunion
Most common
Refracture
13-14% radial/ulnar shaft
% distal radius
Compartment syndrome
Synostosis
very rare
Neurologic injury
uncommon (<1%)
Do not hesitate to stabilize.
Davis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:
Tischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir 1982;107:

23. Rotational Malunion
Remember, these will not remodel…

24. Cast Burns- can occur during cast removal if blade dull or improper technique used

25. Indications for Internal Fixation
Open fractures
Compartment syndrome
Inability to maintain acceptable reduction
Multi-trauma
Floating elbow
Neurologic/vascular compromise
Re-fracture with displacement

26. Implant Choice for Pediatric Diaphyseal Forearm Fractures
IM nails 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

27. Intramedullary Fixation
Single bone fixation may 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

28. Intramedullary Fixation

29. Intramedullary Fixation
Ulna: insert rod 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 Lister's tubercle (not recommended)

30. Inserting Radial Rod

31. 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

32. IM Fixation Complications
Infection
Delayed union
Non-union
Prominent hardware
Hardware migration
Loss of reduction
Compartment syndrome

33. 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 compartment syndrome
Usually 3.5mm DCP type plate
At least 3 screws above and below fracture

34. Plate Fixation

35. 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 injury = less risk of infection

36. Open Metadiaphyseal Fractures
Irrigation and debridement in the OR
Plate and screws or percutaneous cross pinning
Antibiotics for 24 hours

37. Implant Removal
In younger children, hardware usually removed (plates or IM fixation)
Can consider removal of IM fixation at 3-6 months 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

38. Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury
Usually at junction of middle and distal thirds
Distal fragment typically angulated towards ulna
Closed treatment for most
Carefully assess DRUJ post reduction, clinically and radiographically

39. Galeazzi Equivalent
Radial shaft fracture with distal ulnar physeal injury instead of DRUJ injury
Distal ulnar physeal injuries have a high incidence of growth arrest

40. Galeazzi Fracture

41. Galeazzi Equivalent
Distal ulnar epiphysis

42. Previous Injury Following Closed Reduction
Distal ulnar epiphysis

43. Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast

44. Distal Radius Fractures
Most common fracture in children
28-30% of all fractures
Metaphyseal most frequent
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

45. Distal Radius Fractures
Metaphyseal
Physeal
Salter II most common
Torus
Greenstick
Complete
Volar angulation with dorsal displacement most common

46. Differences? Metaphyseal Physeal Less compromise of carpal tunnel
Less pain
Physeal
More compromise of the structures in the carpal tunnel
More pain
Sensory changes

47. Associated Injuries
Distal ulnar metaphyseal fracture or ulnar styloid avulsion
Distal ulnar physeal injury
High incidence 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):

48. Nondisplaced 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

49. Displaced Distal Radius Physeal Fractures-Treatment
Closed reduction usually not difficult
Traction with finger traps (reduce shear)
Gentle dorsal push
Immobilize
Well molded cast / splint above or below elbow (surgeon preference)
3-4 weeks immobilization

50. Physeal Injury Reduction Maneuver
Use finger trap for
traction
Majority of correction achieved with traction
Gentle push to complete reduction

51. Treatment Recommendations - Reduction Attempts?
“Repeated efforts at 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, Children’s Fractures 2005.

52. Treatment Recommendations
“For 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.

53. Remodeling Potential - 12 yo Male
Presented 10 days after fracture – no reduction, splinted in ED and now with early healing – no additional reduction
At 6 months – extensive remodeling of deformity noted

54. Residual Angulation and
Complete Remodeling
Sagittal plane:
Apex volar remodels ~ 0.9 degrees per month
Coronal Plane:
Radial deviation remodels ~ 0.8 degrees per month
Thus, of residual angulation needs around 5 years to completely remodel
Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:

55. Displaced Distal Radius Fractures – Care after Closed Reduction
Radiograph within one week to check reduction
Do not re-manipulate 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

56. Distal Radius Fractures – Potential Complications
Growth arrest
Unusual after distal radius physeal 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

57. Growth Arrest following Distal Radius Fracture
Injured and uninjured wrists after premature physeal closure
Injury films

58. 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

59. Distal Radius Conclusions
Most common physeal plate injury (39%)
Increased incidence of growth plate abnormalities 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).

60. Distal Radius Fracture – Indications for Operative Treatment
Inability to obtain acceptable reduction
Open fractures
Displaced intra-articular fractures
Associated soft tissue injuries
Soft tissue interposition
Associated fractures (SC humerus)
Associated acute carpal tunnel syndrome or compartment syndrome

61. Distal Radius – Fixation Options
Smooth K-wire fixation usually adequate
Avoid physis when possible
Some fractures require plate fixation
Intra-articular fractures
Older pediatric/adolescent patients
External fixation for severe soft tissue injury

62. Carpal Injuries in Children
Unusual / uncommon in children
Scaphoid fracture most common carpal fracture
Still less than 1% of all upper extremity fractures
Capitate / Lunate / Hamate fractures can occur (rare)
Carefully check carpal bones on every wrist film
Comparison films of uninjured wrist helpful

63. 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 the scaphoid nonunion ?

64. Scaphoid Fractures
Not always obvious on plain films

65. 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 cast 4-6 weeks
Displaced fracture – ORIF
> 1 mm displacement, 10 degrees angulation

66. Scaphoid Fixation
Compression screw fixation is treatment of choice for displaced scaphoid fracture
Import to achieve anatomic reduction

67. Hand Fractures Metacarpal and phalangeal fractures
If displaced, attempt closed reduction
Correct both angulation and rotation
Immobilize for 3-4 weeks
Indications for ORIF
Open fractures
Displaced intra-articular fractures
Inability to obtain / maintain reduction

68. Phalangeal Fractures (Epidemiology)
43% proximal phalanx
Commonly physeal – 37% of all physeal fractures
Usually SH II (54%)
30% affect small finger
20% affect the thumb

69. 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

70. Mallet 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

71. Open Physeal Fractures
“Seymore’s 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

72. Phalangeal Neck Fractures
Distal fragment rotated and extended
Blocks IP joint flexion
Limited remodeling potential
Closed reduction and percutaneous pinning
Malunion may require osteotomy and pinning

73. Middle and Proximal Phalangeal Fractures
Most are SH I or SH II injuries
Majority treated with closed management
Buddy taping and/or position of function cast
ORIF for displaced intra-articular fractures (SH III) or instability

74. Can use pencil in webspace or flex MP to 90 and push radially to reduce

75. Reduce and Fix Displaced Intra-articular Fractures

76. MCP Joint Dislocations
Most common dislocation in pediatric hand
Dorsal dislocations cause hyperextended appearance
Metacarpal head palpable in palm
Often require operative reduction
Index finger most often irreducible

77. Metacarpal Fractures 10-39% of pediatric hand fractures
Most commonly in y/o
Most can be treated non-operatively

78. Metacarpal Neck Fractures
Most common in small and ring fingers
“Boxer’s Fracture”
Closed management for most
Accept progressively less angulation from small finger to index
Small degrees
Index degrees

79. Metacarpal Fractures by Location
Base fractures
13-20%
CMC dislocations
Rare, can occur with base fractures
Shaft fractures
Rare, 10-14%
Neck fractures
56-70% (most common)
Physeal / epiphyseal fractures
18%
Cornwall, R: Hand Clin 2006, 22, pp 1-10.

80. Metacarpal Shaft Fractures
Rare, especially index
Spiral pattern – torsional mechanism
High incidence of rotational deformity
Significant shortening can occur
High energy injuries can have compartment syndrome
Slower healing
4-6 week immobilization

81. Intramedullary Nails for Metacarpals
1 Elastic stable intramedullary nail
No immobilization required
Indications:
Sagittal >45, Frontal >10, Shortening >2 mm, any rotational malalignment

82. Metacarpal Base Fracture and CMC Dislocations
Compartment syndrome can occur
Splints rather than casts initially
Radiographs may be difficult to interpret
CT may be helpful
Can be combined with CMC dislocation or isolated injury

83. Bibliography (Forearm)
Davis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:
Fernandez FF et al: Failures and complications in intramedullary nailing of children's forearm fractures. J Child Orthop 2010; 4(2):159-67
Fischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir 1982;107:
Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop Surg 1998; 6:
Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10:
Rang MC: Children's Fractures, 3rd ed. Philadelphia: JB Lippincott, 2005, pp
Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal forearm fractures in children. J PediatR Orthop 1996; 16( 2):
Reinhardt KR, et al: Comparison of Intramedullary Nailing to Plating for Both-Bone Forearm Fractures in Older Children. JPO 2008; 28(4)

84. Bibliography (Hand)
Light TR. Carpal Injuries in Children. Hand Clin 2000; 16(4):
Cornwall, R: Finger metacarpal fractures and dislocations in children. Hand Clin 2006; 22(1):1-10.
Papadonikolakis K, et al: Fractures of the phalanges Hand Clinics 2006; 22(1)
Kaiser MM et al: Intramedullary nailing for metacarpal 2-5 fractures. JPO-B 2009; 18(6):
Yeh PC, Dodds SD: Pediatric Hand Fractures. Techniques in Orthopaedics 2009; 24(3):

85. Thank You
If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an to
OTA
about
Questions/Comments
Return to
Pediatrics
Index