دکتر اکبری اقدم استادیار دانشکده پزشکی اصفهان

 Common 12 to 16y  Most common site for refracture  Fx suspected >>child has not returned all normal arm function within 1 to 2 days of injury

 Practical classification 2 bones 3 levels 4fracture patterns (Bow,Greenstick,Compelet&Comminuted)

 Closed Reduction still remains the gold standard for closed isolated pediatric forearm fractures

 Non or minimally displace Long arm cast(except above 4 y with stable distal third fx) 1 and 2 week visit 6-8 week cast After that splint until union compelet

 Displaced fractures Manipolation with sedation Contorol with fluroscopy Sugar tong splint(7-10 layers 3inch plaster) Next week x-ray and change splint to cast 2 next weeks follow up 4 weeks after reduction can chang short cast Except under 4 y Return to sport now if…

 Distal third< 20 degree  Middle third< 15 degree  Upper third <10 degree  100% translation with <1cm shortening  Rotation< 45 degree.difficult to measure Bicipital tuberisity and radial styloid

 Open fracture  Fracture with unacceptibale reduction  Fx in assosiated supracodylar fx(to avoid risk of compartement syn)

 Interamedullary fixation is preferred If one bone fixation Fix ulna If both bone should be fix,radius first mm nail brace or cast 6-12 mo nail removal

 Redisplacement  Forearm stiffness  Refracture  Malunion  Nonunion  Cross union(synostosis)  Infection  …

 Type 1  Ant dis radial head associated with ulnar diaphyseal fx at any level(most common)

 Ant radial head dislocasion (include pulled elbow) No plastic deformity of ulna  Ant dis radial head with radial neck fx  Ant dis radial head with fx of radial diaphyseal fx proximal to ulnar fx  ….

 direct blow theory  Hyperpronation theory  Hyperextention theory

 Fusiform swelling elbow  Pain &limit ROM elbow

 Three steps:  Correcting the ulnar deformity  Stable reduction of radial head  Maintaining ulnar length and fx stability

 A bivalved long arm cast 4-6 w slight supination and elbow 90 to 110 flex  Radiography every 1 to 2 w  Hardware remove

 Congenital Posterior Bilateral Can be associated with various syndromes  Traumatic Isolated ant. Or ant lateral dislocation Unless congenital or systemic difference

 Posterior monteggia fx dx  Rare in children usully older patient  Mechanism Direct force,sudden rotation and supination Suddenly loaded in longitodinal direction elbow at 60 flex

 Incomplete fx ulna>>close reduction casting in extension  If doubt>>interamedullary fixation  Comminuted or very proximal ulnar fx>>open reduction plate screw

 Lat swelling,varus,significant limitation of ROM  Mechanism>>hyperextesion of elbow combined with pronation

 Incomplete or plastic deformation of ulna Close reduction >> Elbow in extension longitudinal traction valgus sterss test Long arm cast elbow 70 to 80 flex

 Ant dis with fx both radius and ulna Radial fx level same or distal too ulnar fx  Fx unstable fixation

Chronic Monteggia Injury Under 12 years old MRI Determine congruency radial head and capitellum

 Surgery Radial nerve identify Anconeous-extansor carpiulnaris interval Repair or reconsteraction of annular lig Radius head unreduceable >>ulnar osteotomy After radial head redauction>>anullar lig repi

 Fracture of the distal radius with DRUJ disruption  Mechanism >>axial load,forearm rotation  Signs &symptoms>>pain,limitation of forearm rotation,wrist flex ext

 Type 1 dorsal (apex volar)displacment  Type 2 volar(apex dorsal)displacment  Galeazzi equivalent Distal radius fx with distal ulnar physis disruption

 Volar apex Radius fx greenstick or incomplete Close reduction and long arm cast in supination Complete fx Open reduction and fix with plate

 Incompelet radius fx Close reduction  Compelet fx Open reduction