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Pediatric Fractures of the Forearm, Wrist and Hand

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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

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