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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
د. رائد كساب

2 Pediatric Forearm Fractures- Radial and Ulnar Shafts
Approximately 4% of children’s fractures Middle and proximal radius more protected by musculature than distal Ulna subcutaneous and susceptible to trauma when raised for self protection Most fractures are from fall on an outstretched arm

3 EPIDEMIOLOGY These 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

4 Forearm Developmental Anatomy
Primary ossification centers at 8 weeks gestation in both radius and ulna Distal physes provide most of longitudinal growth Distal epiphyses of radius appears radiographically at age 1, of distal ulna at age 5 Proximal and middle radius connected to ulna by intraosseous membrane

5 Forearm 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.

6 Osteology The 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..

7 Osteology 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 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.

8 Biomechanics The 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

9 Deforming 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.

10 Mechanism of injury Indirect: Pronation: Supination:
The mechanism is a fall onto an outstretched hand. Forearm rotation determines the direction of angulation Pronation: flexion injury (dorsal angulation) Supination: extension injury (volar angulation) Direct: Direct trauma to the radial or ulnar shaft.

11 Clinical evaluation The 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.

12 Clinical evaluation In 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.

13 Radiographic 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

14 Remodeling Potential – Variables to Consider
Age Distance from fracture to physis Proximal forearm fractures less forgiving Amount of deformity Direction of angulation Rotational deformities will not remodel

15 Goals of Treatment Regain full forearm rotation
Restore alignment and clinical appearance 50 degrees supination, 50 degrees pronation

16 Nonoperative 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.

17 Nonoperative 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.

18 Nonoperative 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).

19 Excellent Reduction with Well Molded Cast
Nonoperative Treatment Excellent Reduction with Well Molded Cast

20 Nonoperative Treatment
Because of deforming muscle forces, the level of the fracture determines forearm rotation of immobilization: Proximal third fractures: supination Middle third fractures: neutral Distal third fractures: pronation The 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

21 Acceptable 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.

22 Acceptable 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.

23 Nonoperative 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

24 Nonoperative Treatment
Plastic deformation: General anesthesia is typically necessary, because forces of 20 to 30 kg are usually required for correction The 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

25 Nonoperative 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.

26 After Closed Reduction and Casting
Nonoperative Treatment After Closed Reduction and Casting Weekly radiographs for 3 weeks to confirm acceptable alignment and rotation overriding (bayonette) position OK Can remanipulate up to 3 weeks after injury for shaft fractures Angular deformity exceeding 10 degrees in child older than 8 years- consider remanipulation

27 Operative Indications
Unstable/unacceptable fracture reduction after closed reduction Open fracture/compartment syndrome Floating elbow Refracture with displacement Segmental fracture Neurologic/vascular compromise Age (girls >14 years old, boys >15 years old) Surgical stabilization of pediatric forearm fractures is required in 1.5% to 31% of cases.

28 Implant Choice for Pediatric Forearm Fractures
IM nails (2 mm typically) allow for stabilization with minimal soft tissue dissection and easy removal of implants IM fixation usually augmented with short term above elbow cast immobilization Older children (10 years and above) may be better treated as adults with plates and screws

29 Operative Treatment Intramedullary 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

30 Operative Treatment The 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.

31 Open Both Bone Forearm Fracture
Operative Treatment Open Both Bone Forearm Fracture

32 12 Year Old- Accept Less Angulation in Older Kids
Operative Treatment 12 Year Old- Accept Less Angulation in Older Kids

33 Operative Treatment Postoperatively, 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.

34 Operative Treatment Plate 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.

35 Metal Removal In younger children IM fixation usually removed at 3-6 months when solid healing noted on radiographs When plates and screws used then often implants not removed unless symptomatic

36 Acceptable Angulations
Case by case decisions Closed reduction should be attempted for angulation greater than 20 degrees How much to accept before proceeding with open reduction dependent on many factors Angulation encroaching on interosseous space may be more likely to limit rotation

37 Acceptable 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 ulna 15 degrees at the midshaft level 10 degrees in the proximal third We accept 100% translation if shortening is less than 1 cm. Although other authors recommend accepting up to 45 degrees of rotation

38 Acceptable Angulations

39 Complication Refracture:
This occurs in 5% of patients and is more common after greenstick fractures and after plate removal. Malunion: This is a possible complication Synostosis: 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.

40 16 Year old with Rotational Malunion
Complication 16 Year old with Rotational Malunion in older patients operative treatment preferred to maintain functional forearm rotation

41 Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury
relatively rare injuries in children 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

42 Galeazzi Fracture Closed Reduction

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

44 12 Year Old Male Galeazzi Equivalent
Distal ulnar epiphysis

45 Distal Radius Fractures
Most commonly fractured bone in children Metaphyseal most frequent, distal radial physeal second Simple falls most common mechanism Rapid growth may predispose, with weaker area at metaphysis

46 Distal Radius Fractures
Metaphyseal Physeal – Salter II most common Torus Greenstick Complete - Volar angulation with dorsal displacement of the distal fragment most common

47 Associated Injuries Frequently distal ulnar metaphyseal fracture or ulnar styloid avulsion Occasionally distal ulnar physeal injury – high incidence of growth disturbance Median or ulnar nerve injury – rare Acute carpal tunnel syndrome can occur, also rare

48 Nondisplaced distal radius fractures treatment
Below elbow immobilization 3 weeks Torus fractures are stable injuries and can be treated with a removable forearm splint

49 Displaced distal radius fractures-treatment
Closed reduction usually not difficult Traction (reduce shear), recreate deformity and reduce using intact periosteal hinge Immobilize – many different positions of wrist and forearm rotation recommended Well molded cast / splint, above or below elbow surgeon preference 3-4 weeks immobilization

50 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 1983.

51 Treatment 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.

52 Treatment 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.

53 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.

54 Displaced Distal Radius Fractures – Care after Closed Reduction
Radiograph within one week to check reduction Do not remanipulate physeal fractures after 5-7 days for fear of further injuring physis Metaphyseal fractures may be remanipulated for 2-3 weeks if alignment lost Expect significant remodeling of any residual deformity

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

56 Remodeling Potential

57 Distal Radius Fractures - Complications
Growth arrest unusual after distal radius physeal injury Malunion will typically remodel – follow for one year prior to any corrective osteotomy Shortening usually not a problem – resolves with growth Remodeling in 8 months

58 Distal Radius Fracture – Indications for Operative Treatment
Inability to obtain acceptable reduction Open fractures Displaced intraarticular fxs Associated soft tissue injuries Associated fractures (SC humerus) Associated acute carpal tunnel syndrome or compartment syndrome

59 Distal Radius – Fixation Options
Smooth K wire fixation usually adequate Ex fix for severe soft tissue injury Some fxs amenable to plate fixation

60 Open Metadiaphyseal Fractures- I&D, Pinning

61 Complications Premature Physeal Closure / Growth Arrest
1.25% (Aitken, 1935) 3% (Bragdon, 1965) 7% (Lee, 1984) Nerve Injury 8% Ulnar Styloid Nonunions 27% (Aitken, 1935)

62 Distal Radius Growth Arrest
Complications Distal Radius Growth Arrest Relatively rare (< 1 – 7%) Severity of trauma Amount of displacement Repeated attempts at reduction Remanipulation or late manipulation

63 Conclusions Most common physeal plate injury (46%)
Increased incidence of growth plate abnormalities with 2 or more reductions Acceptable alignment: 50% apposition 30° angulation Accept malreduced fractures upon late presentation (over 7 days). Growth arrest rate up to 7%

64 Carpal Injuries in Children
Unusual / Uncommon in children Scaphoid most commonly fractured carpal bone Capitate / Lunate / Hamate fractures also can occur Make a habit of carefully checking carpal bones on every wrist film

65 Carpal 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

66 Carpal Injuries in Children
Scaphoid nonunion Patient gave history of a fall sustained one year ago with a “bad wrist sprain” 9 years old 1.5 years after After 2 months of casting, early fracture union is present

67 Distal Radius and Scaphoid Fractures
Carpal Injuries in Children Distal Radius and Scaphoid Fractures

68 Scaphoid Fractures - Treatment
Tender snuff box – immobilize until tenderness resolves If still tender at 1-2 weeks – repeat xray Confirmed fracture – if nondisplaced immobilize in above elbow cast for 6 – 8 weeks Displaced fracture ORIF

69 Hand Fractures Metacarpal and phalangeal fractures – if displaced closed reduction Correct angulation and rotation Immobilize in intrinsic plus position 3-4 weeks Indications for ORIF – open fractures, displaced intraarticular fractures, inability to obtain or maintain reduction

70 Hand Fractures The 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

71 Distal Phalangeal Fractures
Crush injuries Address any associated nail bed injuries If open give appropriate antibiotics, I&D

72 Distal Phalangeal Fractures
Mallet finger injuries Closed or open management

73 Distal Phalangeal Fractures
Physeal injury Clinically resemble a mallet finger S-H I or II fracture

74 Middle and Proximal Phalangeal Fractures
Physeal fractures of the proximal phalanx may be the most common pediatric hand fracture Extraarticular S-H II fractures are most prevalent Closed management for majority ORIF for displaced intraarticular fractures Restore rotational alignment

75 Middle and Proximal Phalangeal Fractures
Can use pencil in webspace trick or flex MP to 90 and push radially to reduce “extra-octave” fractures

76 Middle and Proximal Phalangeal Fractures
Phalangeal Neck Fractures Closed treatment of fractures of the phalangeal neck is difficult because these fractures often are unstable and displaced

77 Reduce and Fix Displaced Intraarticular Fractures
Middle and Proximal Phalangeal Fractures Reduce and Fix Displaced Intraarticular Fractures

78 Metacarpal Fractures Closed management for most
Accept less angulation in index than small finger The 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

79 Metacarpal Fractures Metacarpal Neck Fractures

80 Metacarpal Fractures Metacarpal Base Fractures
Closed reduction and percutaneous pinning usually are sufficient

81 Open Crush Injury to Hand

82 Osteology The 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.

83 S/P Closed Reduction Distal ulnar epiphysis

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

85 Closed Reduction Methods
Adequate analgesia / anesthesia Traction – countertraction Increase deformity Reduce / lock on fragments Correct rotational deformity

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

87 Pediatric Forearm Fractures
Complete Greenstick fractures Buckle or torus fractures Plastic deformation Proximal, middle or distal Fxs at same level Fxs at different level Almost always a rotational component

88 Forearm Rotation Position in Cast – Supinate, Pronate or Midposition?
Depends on location of fracture and position of distal fragment in relation to proximal Match distal fragment to proximal – can use bicipital tuberosity as a guide, and compare diameter of bones at fx

89 Maintaining Reduction
Appropriately molded cast very important Easier to maintain an initial excellent reduction than a marginal one Above elbow or below elbow immobilization – surgeon preference for distal 1/3 fractures

90 Indications for Open Reduction
Open fractures Inability to maintain acceptable reduction Multiple trauma Floating elbow Neurologic/vascular compromise Refracture IM fixation- little soft tissue disruption required to insert

91 Forearm Fractures - Complications
Malunion-most common Refracture – 5% within 6 months Compartment syndrome – observe closely, diagnosis and treatment similar to adults Synostosis rare Neurologic injury uncommon

92 Plastic Deformation of the Forearm
Fixed bending remains when bone deformed past elastic limit Most commonly in forearm, may be ulna or radius Periosteum intact and thus usually no periosteal callus Can limit rotation

93 Plastic Deformation Remodeling not as reliable
Significant curvature that produces clinical deformity should be corrected Greater than 20 degrees, older than 8 years – reduce deformity General anesthesia Considerable force, slowly applied over a padded fulcrum

94 ORIF Distal Ulna Ulnar epiphysis Exposed end of metaphysis

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

96 هذه 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 Kadhim د. مؤيد كاظم

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