Presentation on theme: "Pediatric Fractures of the Forearm, Wrist and Hand"— Presentation transcript:
1Pediatric Fractures of the Forearm, Wrist and Hand د. رائد كساب
2Pediatric Forearm Fractures- Radial and Ulnar Shafts Approximately 4% of children’s fracturesMiddle and proximal radius more protected by musculature than distalUlna subcutaneous and susceptible to trauma when raised for self protectionMost fractures are from fall on an outstretched arm
3EPIDEMIOLOGYThese injuries are very common: They make up 40% of all pediatric fractures (only 4% are diaphyseal fractures), with a 3/1 male predominance in distal radius fractures.80% occur in children >5 years of age.The peak incidence corresponds to the peak velocity of growth when the bone is weakest owing to a dissociation between bone growth and mineralization.15% have ipsilateral supracondylar fracture.1% have neurologic injury, most commonly median nerve.Of pediatric forearm fractures, 60% occur in the distal metaphyses of the radius or ulna, 20% in the shaft, 14% in the distal physis, and <4% in the proximal third
4Forearm Developmental Anatomy Primary ossification centers at 8 weeks gestation in both radius and ulnaDistal physes provide most of longitudinal growthDistal epiphyses of radius appears radiographically at age 1, of distal ulna at age 5Proximal and middle radius connected to ulna by intraosseous membrane
5Forearm Developmental Anatomy The radial and ulnar shafts ossify during the eighth week of gestation.The distal radial epiphysis appears at age 1 year (often from two centers); the distal ulnar epiphysis appears at age 5 years; the radial head appears at age 5 to 7 years; the olecranon appears at age 9 to 10 years. These all close between the ages of 16 and 18 years.The distal physis accounts for 80% of forearm growth.With advancing skeletal age, there is a tendency for fractures to occur in an increasingly distal location owing to the distal recession of the transition between the more vulnerable wider metaphysis and the more narrow and stronger diaphysis.
6OsteologyThe radius is a curved bone, cylindric in the proximal third, triangular in the middle third, and flat distally with an apex lateral bow.The ulna has a triangular shape throughout, with an apex posterior bow in the proximal third..
7OsteologyThe proximal radioulnar joint is most stable in supination where the broadest part of the radial head contacts the radial notch of the ulna and the interosseous membrane is most taut. The annular ligament is its major soft tissue stabilizer.The distal radioulnar joint (DRUJ) is stabilized by the ulnar collateral ligament, the anterior and posterior radioulnar ligaments, and the pronator quadratus muscle. Three percent of distal radius fractures have concomitant DRUJ disruption.The periosteum is very strong and thick in the child. It is generally disrupted on the convex fracture side, whereas an intact hinge remains on the concave side. This is an important consideration when attempting closed reduction.
8BiomechanicsThe posterior distal radioulnar ligament is taut in pronation, whereas the anterior ligament is taut in supination.The radius effectively shortens with pronation and lengthens with supination.The interosseous space is narrowest in pronation and widest in neutral to 30 degrees of supination. Further supination or pronation relaxes the membrane.The average range of pronation/supination is 90/90 degrees (50/50 degrees necessary for activities of daily living).Middle third deformity has a greater effect on supination, with the distal third affecting pronation to a greater degree.Malreduction of 10 degrees in the middle third limits rotation by 20 to 30 degrees.Bayonet apposition (overlapping) does not reduce forearm rotation
9Deforming Muscle Forces Proximal third fractures :Biceps and supinator: These function to flex and supinate the proximal fragment.Pronator teres and pronator quadratus: These pronate the distal fragment.Middle third fractures:Supinator, biceps, and pronator teres: The proximal fragment is in neutral.Pronator quadratus: Pronates the distal fragment.Distal third fractures:Brachioradialis: Dorsiflexes and radially deviates the distal segment.Pronator quadratus, wrist flexors and extensors, and thumb abductors: They also cause fracture deformity.
10Mechanism of injury Indirect: Pronation: Supination: The mechanism is a fall onto an outstretched hand. Forearm rotation determines the direction of angulationPronation:flexion injury (dorsal angulation)Supination:extension injury (volar angulation)Direct:Direct trauma to the radial or ulnar shaft.
11Clinical evaluationThe patient typically presents with pain, swelling, variable gross deformity, and a refusal to use the injured upper extremity.A careful neurovascular examination is essential. Injuries to the wrist may be accompanied by symptoms of carpal tunnel compression.The ipsilateral hand, wrist, forearm, and arm should be palpated, with examination of the ipsilateral elbow and shoulder to rule out associated fractures or dislocations.
12Clinical evaluationIn cases of dramatic swelling of the forearm, compartment syndrome should be ruled out on the basis of serial neurovascular examinations with compartment pressure monitoring if indicated. Pain on passive extension of the digits is most sensitive for recognition of a possible developing compartment syndrome; the presence of any of the classic signs of compartment syndrome (pain out of proportion to injury, pallor, paresthesias, pulselessness, paralysis) should be aggressively evaluated with possible forearm fasciotomy.Examination of skin integrity must be performed, with removal of all bandages and splints placed in the field.
13Radiographic evaluation Anteroposterior and lateral views of forearm, wrist, and elbow should be obtained. The forearm should not be rotated to obtain these views; instead, the beam should be rotated to obtain a cross-table view.The bicipital tuberosity is the landmark for identifying the rotational position of the proximal fragment :Ninety degrees of supination: It is directed medially.Neutral: It is directed posteriorly.Ninety degrees of pronation: This is directed laterally.In the normal, uninjured radius, the bicipital tuberosity is 180% to the radial styloid
14Remodeling Potential – Variables to Consider AgeDistance from fracture to physisProximal forearm fractures less forgivingAmount of deformityDirection of angulationRotational deformities will not remodel
15Goals of Treatment Regain full forearm rotation Restore alignment and clinical appearance50 degrees supination, 50 degrees pronation
16Nonoperative Treatment Gross deformity should be corrected on presentation to limit injury to soft tissues. The extremity should be splinted for pain relief and for prevention of further injury if closed reduction will be delayed.The extent and type of fracture and the child age are factors that determine whether reduction can be carried out with sedation, local anesthesia, or general anesthesia.
17Nonoperative Treatment Finger traps may be applied with weights to aid in reduction.Closed reduction and application of a well-molded (both three-point and interosseous molds) long arm cast or splint should be performed for most fractures, unless the fracture is open, unstable, irreducible, or associated with compartment syndrome.
18Nonoperative Treatment Exaggeration of the deformity (often >90 degrees) should be performed to disengage the fragments. The angulated distal fragment may then be apposed onto the end of the proximal fragment, with simultaneous correction of rotation.Reduction should be maintained with pressure on the side of the intact periosteum (concave side).
19Excellent Reduction with Well Molded Cast Nonoperative TreatmentExcellent Reduction with Well Molded Cast
20Nonoperative Treatment Because of deforming muscle forces, the level of the fracture determines forearm rotation of immobilization:Proximal third fractures: supinationMiddle third fractures: neutralDistal third fractures: pronationThe arm should be elevated The cast should be maintained for 4 to 6 weeks until radiographic evidence of union has occurred. Conversion to a short arm cast may be undertaken at 3 to 4 weeks if healing is adequate
21Acceptable deformity: Angular deformities: Correction of 1 degree per month, or 10 degrees per year results from physeal growth. Exponential correction occurs over time; therefore, increased correction occurs for greater deformities.Rotational deformities: These do not appreciably correct.
22Acceptable deformity: Bayonet apposition: A deformity 1 cm is acceptable and will remodel if the patient is <8 to 10 years old.In patients >10 years of age, no deformity should be accepted.
23Nonoperative Treatment Plastic deformation:Children <4 years or with deformities <20 degrees usually remodel and can be treated with a long arm cast for 4 to 6 weeks until the fracture site is nontender.Any plastic deformation should be corrected that :prevents reduction of a concomitant fracture,prevents full rotation in a child >4 years,exceeds 20 degrees
24Nonoperative Treatment Plastic deformation:General anesthesia is typically necessary, because forces of 20 to 30 kg are usually required for correctionThe apex of the bow should be placed over a well-padded wedge, with application of a constant force for 2 to 3 minutes followed by application of a well-molded long arm cast.The correction should have less than 10 to 20 degrees of angulation
25Nonoperative Treatment Greenstick fractures:Nondisplaced or minimally displaced fractures may be immobilized in a well-molded long arm cast. They should be slightly overcorrected to prevent recurrence of deformity.Completing the fracture decreases the risk of recurrence of the deformity; however, reduction of the displaced fracture may be more difficult. Therefore, it may be beneficial to carefully fracture the intact cortex while preventing displacement. A well-molded long arm cast should then be applied.
26After Closed Reduction and Casting Nonoperative TreatmentAfter Closed Reduction and CastingWeekly radiographs for 3 weeks to confirm acceptable alignment and rotationoverriding (bayonette) position OKCan remanipulate up to 3 weeks after injury for shaft fracturesAngular deformity exceeding 10 degrees in child older than 8 years- consider remanipulation
27Operative Indications Unstable/unacceptable fracture reduction after closed reductionOpen fracture/compartment syndromeFloating elbowRefracture with displacementSegmental fractureNeurologic/vascular compromiseAge (girls >14 years old, boys >15 years old)Surgical stabilization of pediatric forearm fractures is required in 1.5% to 31% of cases.
28Implant Choice for Pediatric Forearm Fractures IM nails (2 mm typically) allow for stabilization with minimal soft tissue dissection and easy removal of implantsIM fixation usually augmented with short term above elbow cast immobilizationOlder children (10 years and above) may be better treated as adults with plates and screws
29Operative TreatmentIntramedullary fixation: Percutaneous insertion of intramedullary rods or wires may be used for fracture stabilization. Typically, flexible rods are used or rods with inherent curvature to permit restoration of the radial bow.The radius is reduced first, with insertion of the rod just proximal to the radial styloid after visualization of the two branches of the superficial radial nerve.Alternate entry point just proximal to Lister's tubercle between second and third dorsal compartment
30Operative TreatmentThe ulna is then reduced, with insertion of the rod either antegrade through the olecranon or retrograde through the distal metaphysis, with protection of the ulnar nerve.
31Open Both Bone Forearm Fracture Operative TreatmentOpen Both Bone Forearm Fracture
3212 Year Old- Accept Less Angulation in Older Kids Operative Treatment12 Year Old- Accept Less Angulation in Older Kids
33Operative TreatmentPostoperatively, a volar splint is placed for 4 weeks. The hardware is left in place for 6 to 9 months, at which time removal may take place, provided solid callus is present across the fracture site and the fracture line is obliterated.
34Operative TreatmentPlate fixation: Severely comminuted fractures or those associated with segmental bone loss are ideal indications for plate fixation, because in these patterns rotational stability is needed. Plate fixation is also used in cases of forearm fractures in skeletally mature individuals.Ipsilateral supracondylar fractures: When associated with forearm fractures, a floating elbow results. These may be managed by conventional pinning of the supracondylar fracture followed by plaster immobilization of the forearm fracture.
35Metal RemovalIn younger children IM fixation usually removed at 3-6 months when solid healing noted on radiographsWhen plates and screws used then often implants not removed unless symptomatic
36Acceptable Angulations Case by case decisionsClosed reduction should be attempted for angulation greater than 20 degreesHow much to accept before proceeding with open reduction dependent on many factorsAngulation encroaching on interosseous space may be more likely to limit rotation
37Acceptable Angulations Accepted angulation is (provided the child has at least 2 years of growth remaining):20 degrees of angulation in distal-third shaft fractures of the radius and ulna15 degrees at the midshaft level10 degrees in the proximal thirdWe accept 100% translation if shortening is less than 1 cm. Although other authors recommend accepting up to 45 degrees of rotation
39Complication Refracture: This occurs in 5% of patients and is more common after greenstick fractures and after plate removal.Malunion:This is a possible complicationSynostosis:Rare complication in children. Risk factors include high-energy trauma, surgery, repeated manipulations, proximal fractures, and head injury.Compartment syndrome:One should always bivalve the cast after a reduction.Nerve injury:Median, ulnar and posterior interosseous nerve (PIN) nerve injuries have all been reported. There is an 8.5% incidence of iatrogenic injury in fractures that are surgically stabilized.
4016 Year old with Rotational Malunion Complication16 Year old with Rotational Malunionin older patients operative treatment preferred to maintain functional forearm rotation
41Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury relatively rare injuries in childrenUsually at junction of middle and distal thirdsDistal fragment typically angulated towards ulnaClosed treatment for mostCarefully assess DRUJ post reduction, clinically and radiographically
43Galeazzi EquivalentRadial shaft fracture with distal ulnar physeal injury instead of DRUJ injuryDistal ulnar physeal injuries have a high incidence for growth arrest
4412 Year Old Male Galeazzi Equivalent Distal ulnar epiphysis
45Distal Radius Fractures Most commonly fractured bone in childrenMetaphyseal most frequent, distal radial physeal secondSimple falls most common mechanismRapid growth may predispose, with weaker area at metaphysis
46Distal Radius Fractures MetaphysealPhyseal – Salter II most commonTorusGreenstickComplete - Volar angulation with dorsal displacement of the distal fragment most common
47Associated InjuriesFrequently distal ulnar metaphyseal fracture or ulnar styloid avulsionOccasionally distal ulnar physeal injury – high incidence of growth disturbanceMedian or ulnar nerve injury – rareAcute carpal tunnel syndrome can occur, also rare
48Nondisplaced distal radius fractures treatment Below elbow immobilization3 weeksTorus fractures are stable injuries and can be treated with a removable forearm splint
49Displaced distal radius fractures-treatment Closed reduction usually not difficultTraction (reduce shear), recreate deformity and reduce using intact periosteal hingeImmobilize – many different positions of wrist and forearm rotation recommendedWell molded cast / splint, above or below elbow surgeon preference3-4 weeks immobilization
50Treatment 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 1983.
51Treatment Recommendations - Reductions / Acceptable Alignment No correlation between reduction attempts and growth retardation.No correlation between post-reduction position and growth retardation.Noted a relationship between fracture type (S-H IV) and growth arrest.Aitken, JBJS 1935.
52Treatment Recommendations “An attempt should be made to reduce all displacements… however, repeated manipulations or osteotomy are not warranted.”“Displacement of the epiphysis does not persist. All displacements are reduced well within a year.”“The one case of deformity in the series is attributed to crushing of the physis.”Aitken, JBJS 1935.
53Treatment 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.
54Displaced Distal Radius Fractures – Care after Closed Reduction Radiograph within one week to check reductionDo not remanipulate physeal fractures after 5-7 days for fear of further injuring physisMetaphyseal fractures may be remanipulated for 2-3 weeks if alignment lostExpect significant remodeling of any residual deformity
55Remodeling Potential- 12 years Male Presented 10 days after fracture – no reduction, splinted in ED and now with early healingAt 6 months – extensive remodeling of deformity noted
57Distal Radius Fractures - Complications Growth arrest unusual after distal radius physeal injuryMalunion will typically remodel – follow for one year prior to any corrective osteotomyShortening usually not a problem – resolves with growthRemodeling in 8 months
58Distal Radius Fracture – Indications for Operative Treatment Inability to obtain acceptable reductionOpen fracturesDisplaced intraarticular fxsAssociated soft tissue injuriesAssociated fractures (SC humerus)Associated acute carpal tunnel syndrome or compartment syndrome
59Distal Radius – Fixation Options Smooth K wire fixation usually adequateEx fix for severe soft tissue injurySome fxs amenable to plate fixation
62Distal Radius Growth Arrest ComplicationsDistal Radius Growth ArrestRelatively rare (< 1 – 7%)Severity of traumaAmount of displacementRepeated attempts at reductionRemanipulation or late manipulation
63Conclusions Most common physeal plate injury (46%) Increased incidence of growth plate abnormalities with 2 or more reductionsAcceptable alignment: 50% apposition30° angulationAccept malreduced fractures upon late presentation (over 7 days).Growth arrest rate up to 7%
64Carpal Injuries in Children Unusual / Uncommon in childrenScaphoid most commonly fractured carpal boneCapitate / Lunate / Hamate fractures also can occurMake a habit of carefully checking carpal bones on every wrist film
65Carpal Injuries in Children The age at the time of appearance of the ossific nucleus of the carpal bones and distal radius and ulna.The ossific nucleus of the pisiform (not shown) appears at about 6 to 8 years of age
66Carpal Injuries in Children Scaphoid nonunionPatient gave history of a fall sustained one year ago with a “bad wrist sprain”9 years old1.5 years afterAfter 2 months of casting, early fracture union is present
67Distal Radius and Scaphoid Fractures Carpal Injuries in ChildrenDistal Radius and Scaphoid Fractures
68Scaphoid Fractures - Treatment Tender snuff box – immobilize until tenderness resolvesIf still tender at 1-2 weeks – repeat xrayConfirmed fracture – if nondisplaced immobilize in above elbow cast for 6 – 8 weeksDisplaced fracture ORIF
69Hand FracturesMetacarpal and phalangeal fractures – if displaced closed reductionCorrect angulation and rotationImmobilize in intrinsic plus position 3-4 weeksIndications for ORIF – open fractures, displaced intraarticular fractures, inability to obtain or maintain reduction
70Hand FracturesThe long axes of the metacarpal and proximal phalanx should align, as they do in this normal hand.If there is a fracture in the proximal phalanx, as in this patient's opposite or injured hand, the axes will not be colinear
71Distal Phalangeal Fractures Crush injuriesAddress any associated nail bed injuriesIf open give appropriate antibiotics, I&D
72Distal Phalangeal Fractures Mallet finger injuriesClosed or open management
73Distal Phalangeal Fractures Physeal injuryClinically resemble a mallet fingerS-H I or II fracture
74Middle and Proximal Phalangeal Fractures Physeal fractures of the proximal phalanx may be the most common pediatric hand fractureExtraarticular S-H II fractures are most prevalentClosed management for majorityORIF for displaced intraarticular fracturesRestore rotational alignment
75Middle and Proximal Phalangeal Fractures Can use pencil in webspace trick or flex MP to 90 and push radially to reduce “extra-octave” fractures
76Middle and Proximal Phalangeal Fractures Phalangeal Neck FracturesClosed treatment of fractures of the phalangeal neck is difficult because these fractures often are unstable and displaced
77Reduce and Fix Displaced Intraarticular Fractures Middle and Proximal Phalangeal FracturesReduce and Fix Displaced Intraarticular Fractures
78Metacarpal Fractures Closed management for most Accept less angulation in index than small fingerThe metacarpal neck is the most frequent site of metacarpal fractures in children. (10 to 30 degrees of angulation is acceptable)more common in the small and ring fingers
82OsteologyThe radius is a curved bone, cylindric in the proximal third, triangular in the middle third, and flat distally with an apex lateral bow.The ulna has a triangular shape throughout, with an apex posterior bow in the proximal third.The proximal radioulnar joint is most stable in supination where the broadest part of the radial head contacts the radial notch of the ulna and the interosseous membrane is most taut. The annular ligament is its major soft tissue stabilizer.The distal radioulnar joint (DRUJ) is stabilized by the ulnar collateral ligament, the anterior and posterior radioulnar ligaments, and the pronator quadratus muscle. Three percent of distal radius fractures have concomitant DRUJ disruption.The triangular fibrocartilage complex (TFCC) has an articular disc joined by volar and dorsal radiocarpal ligaments and by ulnar collateral ligament fibers. It attaches to the distal radius at its ulnar margin, with its apex attached to the base of the ulna styloid, extending distally to the base of the fifth metacarpal.The periosteum is very strong and thick in the child. It is generally disrupted on the convex fracture side, whereas an intact hinge remains on the concave side. This is an important consideration when attempting closed reduction.
86Cast Burns- can occur during cast removal if blade dull or improper technique used
87Pediatric Forearm Fractures CompleteGreenstick fracturesBuckle or torus fracturesPlastic deformationProximal, middle or distalFxs at same levelFxs at different levelAlmost always a rotational component
88Forearm Rotation Position in Cast – Supinate, Pronate or Midposition? Depends on location of fracture and position of distal fragment in relation to proximalMatch distal fragment to proximal – can use bicipital tuberosity as a guide, and compare diameter of bones at fx
89Maintaining Reduction Appropriately molded cast very importantEasier to maintain an initial excellent reduction than a marginal oneAbove elbow or below elbow immobilization – surgeon preference for distal 1/3 fractures
90Indications for Open Reduction Open fracturesInability to maintain acceptable reductionMultiple traumaFloating elbowNeurologic/vascular compromiseRefractureIM fixation- little soft tissue disruption required to insert
91Forearm Fractures - Complications Malunion-most commonRefracture – 5% within 6 monthsCompartment syndrome – observe closely, diagnosis and treatment similar to adultsSynostosis rareNeurologic injury uncommon
92Plastic Deformation of the Forearm Fixed bending remains when bone deformed past elastic limitMost commonly in forearm, may be ulna or radiusPeriosteum intact and thus usually no periosteal callusCan limit rotation
93Plastic Deformation Remodeling not as reliable Significant curvature that produces clinical deformity should be correctedGreater than 20 degrees, older than 8 years – reduce deformityGeneral anesthesiaConsiderable force, slowly applied over a padded fulcrum
94ORIF Distal UlnaUlnar epiphysisExposed end of metaphysis
95Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast
96MoKazem.comهذه المحاضرة هي من سلسلة محاضرات تم إعدادها و تقديمها من قبل الأطباء المقيمين في شعبة الجراحة العظمية في مشفى دمشق, تحت إشراف د. بشار ميرعلي.الموقع غير مسؤول عن الأخطاء الواردة في هذه المحاضرة.This lecture is one of a series of lectures were prepared and presented by residents in the department of orthopedics in Damascus hospital, under the supervision of Dr. Bashar Mirali.This site is not responsible of any mistake may exist in this lecture.Dr. Muayad Kadhimد. مؤيد كاظم