د. رائد كساب. pediatric forearm fractures- radial and ulnar shafts approximately 4% of...

$: د. رائد كساب. Pediatric Forearm Fractures- Radial and Ulnar Shafts Approximately 4% of children’s fractures Middle and proximal radius more protected$
كساب. رائد د

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

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

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

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.

Forearm Developmental Anatomy

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..

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.

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

Deforming Muscle Forces

Brachioradialis: Dorsiflexes and radially deviates the distal segment.

Pronator quadratus, wrist flexors and extensors, and thumb abductors: They also cause fracture deformity.

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:

Mechanism of injury

Direct trauma to the radial or ulnar shaft.

Indirect: 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:

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.

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.

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.

In the normal, uninjured radius, the bicipital tuberosity is 180% to the radial styloid

Ninety degrees of supination: It is directed medially.

Neutral: It is directed posteriorly. Ninety degrees of pronation: This is

directed laterally.

The bicipital tuberosity is the landmark for identifying the rotational position of the proximal fragment :

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

Goals of Treatment

Regain full forearm rotation

Restore alignment and clinical appearance

50 degrees supination, 50 degrees pronation

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.


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.

Finger traps may be applied

with weights to aid in

reduction.

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).

Excellent Reduction with Well Molded Cast



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

Because of deforming muscle forces, the level of the fracture determines forearm rotation of immobilization:Proximal third fractures:

supinationMiddle third fractures: neutralDistal third fractures: pronation

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.

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.


Any plastic deformation should be corrected that :

prevents reduction of a concomitant fracture,

prevents full rotation in a child >4 years,

exceeds 20 degrees

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.


The correction should have less than 10 to 20 degrees of angulation

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.

Plastic deformation:


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.

Greenstick fractures:

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


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.

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

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

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.

Open Both Bone Forearm Fracture

Operative Treatment

12 Year Old- Accept Less Angulation in Older Kids

Operative Treatment

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.

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.

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

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


We accept 100% translation if shortening is less than 1 cm. Although other authors recommend accepting up to 45 degrees of rotation

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

ComplicationRefracture: 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.

16 Year old with Rotational Malunion

in older patients operative treatment preferred to maintain functional forearm rotation

Complication

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

Closed Reduction

Galeazzi Fracture

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

12 Year Old Male Galeazzi Equivalent

Distal ulnar epiphysis

Galeazzi Equivalent

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

Distal Radius Fractures

Metaphyseal

Physeal – Salter II most common

Torus

Greenstick

Complete - Volar angulation with

dorsal displacement of the distal

fragment most common

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

Nondisplaced distal radius fractures treatment

Below elbow immobilization

3 weeks

Torus fractures are stable

injuries and can be treated

with a removable forearm

splint

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

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.

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.

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.

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.

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

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

Remodeling Potential

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

Distal Radius Fracture – Indications for Operative TreatmentInability 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

Distal Radius – Fixation Options

Smooth K wire

fixation usually

adequate

Ex fix for severe soft

tissue injury

Some fxs amenable to

plate fixation

Open Metadiaphyseal Fractures- I&D, Pinning

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)

Distal Radius Growth Arrest

Relatively rare (< 1 –

7%)

Severity of trauma

Amount of displacement

Repeated attempts at

reduction

Remanipulation or late

manipulation

Complications

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%

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

•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


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

Distal Radius and Scaphoid Fractures


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

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

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

Distal Phalangeal Fractures

Address any associated

nail bed injuries

If open give appropriate

antibiotics, I&D

Crush injuries


Mallet finger injuries

Closed or open management


Physeal injury

• Clinically resemble a mallet finger

• S-H I or II fracture

Middle and Proximal Phalangeal Fractures

Closed management for

majority

ORIF for displaced

intraarticular fractures

Restore rotational alignment

Physeal fractures of the proximal

phalanx may be the most common

pediatric hand fracture

Extraarticular S-H II fractures are

most prevalent

Can use pencil in

webspace trick or flex

MP to 90 and push

radially to reduce

“extra-octave”

fractures



Phalangeal Neck Fractures

Closed treatment of fractures

of the phalangeal neck is

difficult because these

fractures often are unstable

and displaced

Reduce and Fix Displaced Intraarticular Fractures


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


Metacarpal Neck Fractures

Metacarpal Base Fractures


Closed reduction and percutaneous pinning usually are sufficient

Open Crush Injury to Hand

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.

S/P Closed Reduction

Distal ulnar epiphysis

Growth Arrest following Distal Radius Fracture

Injury films Injured and uninjured wrists after premature physeal closure

Complications

Closed Reduction MethodsAdequate analgesia

/ anesthesiaTraction –

countertractionIncrease deformityReduce / lock on

fragmentsCorrect rotational

deformity

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

Pediatric Forearm FracturesCompleteGreenstick fracturesBuckle or torus fracturesPlastic deformationProximal, middle or distalFxs at same levelFxs at different levelAlmost always a rotational component

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

Maintaining ReductionAppropriately molded

cast very importantEasier to maintain an

initial excellent reduction than a marginal one

Above elbow or below elbow immobilization – surgeon preference for distal 1/3 fractures

Indications for Open ReductionOpen fracturesInability to maintain

acceptable reductionMultiple traumaFloating elbowNeurologic/vascular

compromiseRefracture

IM fixation- little soft tissue disruption required to insert

Forearm Fractures - ComplicationsMalunion-most

commonRefracture – 5%

within 6 monthsCompartment

syndrome – observe closely, diagnosis and treatment similar to adults

Synostosis rareNeurologic injury

uncommon

Plastic Deformation of the ForearmFixed 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

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 anesthesiaConsiderable force,

slowly applied over a padded fulcrum

ORIF Distal Ulna

Exposed end of metaphysis

Ulnar epiphysis

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

MoKazem.com

من • تقديمها و إعدادها تم محاضرات سلسلة من هي المحاضرة هذه , دمشق مشفى في العظمية الجراحة شعبة في المقيمين األطباء قبل

. . ميرعلي بشار د إشراف تحت• . المحاضرة هذه في الواردة األخطاء عن مسؤول غير الموقع

•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.

كاظم. مؤيد Dr. Muayad Kadhimد

د. رائد كساب. pediatric forearm fractures- radial and ulnar shafts approximately 4% of...

Documents