pediatric fractures of the forearm, wrist and hand
DESCRIPTION
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. Pediatric Forearm Fractures. Approximately 40% of children’s long-bone fractures - PowerPoint PPT PresentationTRANSCRIPT
Pediatric Fractures of the Forearm, Wrist and Hand
John A. Heflin, MD
Original Author: Amanda Marshall, MD; March 2004Revised:
Steven Frick, MD; August 2006John A. Heflin, MD; April 2011
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%)
Pediatric Forearm Fracture Locations
• Proximal– Least common (approx 4%) due to decreased
lever arm and increased soft tissue envelope• Mid-shaft
– Account for 18 - 20% of both bone fractures• Distal
– Account for >75% of radius and/or ulna fractures– Approx 14% in distal physis
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
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
Pediatric ForearmPrimary ossification centers at 8 weeks gestation in
both radius and ulnaDistal physis provide most (80%) of longitudinal
growthDistal epiphyses of radius appears at age 1Distal epiphyses of distal ulna appears at age 5Normal forearm rotation:
Approx 90 degrees pronationApprox 90 degrees supination
Plastic deformation
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. Biomechanics3:263,1970
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
Incomplete (Greenstick) Fracture
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
Complete Fracture
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
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
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
Excellent Reduction with Well Molded Cast
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
Acceptable Limits
• Angulation– < 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; 6:146-156
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 0.8 - 1 degree per
month, or ~10 degrees per year• Rotational deformities will not remodel
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
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
Forearm Fractures - Complications• Malunion
– Most common• Refracture
– 13-14% radial/ulnar shaft– 1.5-2.7% distal radius
• Compartment syndrome • Synostosis
– very rare• Neurologic injury
– uncommon (<1%)
If headed for malunion…
Do not hesitate to stabilize.
Davis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:172-184Tischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir 1982;107:138-48.
Rotational MalunionRemember, these will not remodel…
Cast Burns- can occur during cast removal if blade dull or improper
technique used
Indications for Internal Fixation• Open fractures• Compartment syndrome• Inability to maintain acceptable
reduction• Multi-trauma• Floating elbow• Neurologic/vascular compromise• Re-fracture with displacement
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
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
Intramedullary Fixation
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)
Inserting Radial Rod
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
IM Fixation Complications
• Infection• Delayed union• Non-union• Prominent hardware• Hardware migration• Loss of reduction• Compartment syndrome
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
Plate Fixation
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
Open Metadiaphyseal Fractures• Irrigation and debridement in the OR• Plate and screws or percutaneous
cross pinning• Antibiotics for 24 hours
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
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
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
Galeazzi Fracture
Galeazzi Equivalent
Distal ulnar epiphysis
Previous Injury Following Closed Reduction
Distal ulnar epiphysis
Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast
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
Distal Radius Fractures
• Metaphyseal • Physeal
– Salter II most common• Torus• Greenstick• Complete
– Volar angulation with dorsal displacement most common
Differences?• Metaphyseal
– Less compromise of carpal tunnel
– Less pain• Physeal
– More compromise of the structures in the carpal tunnel
– More pain– Sensory changes
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): 195-200.
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
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
Physeal Injury Reduction Maneuver
Use finger trap for traction
Gentle push to complete reduction
Majority of correction achieved with traction
“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.
Treatment Recommendations - Reduction Attempts?
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.
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
• Sagittal plane:– Apex volar remodels ~ 0.9 degrees per month
• Coronal Plane:– Radial deviation remodels ~ 0.8 degrees per month
• Thus, 30-350 of residual angulation needs around 5 years to completely remodel
Residual Angulation and Complete Remodeling
Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10: 705-712.
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
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
Growth Arrest following Distal Radius Fracture
Injury films Injured and uninjured wrists after premature physeal closure
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
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).
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
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
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
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 ?
Scaphoid Fractures
Not always obvious on plain films
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
Scaphoid Fixation• Compression screw fixation is treatment of
choice for displaced scaphoid fracture• Import to achieve anatomic reduction
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
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
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
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
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
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
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
Can use pencil in webspace or flex MP to 90 and push radially to reduce
Reduce and Fix Displaced Intra-articular Fractures
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
Metacarpal Fractures
• 10-39% of pediatric hand fractures• Most commonly in 13-16 y/o• Most can be treated non-operatively
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 30-40 degrees– Index 10-15 degrees
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.
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
Intramedullary Nails for Metacarpals
• 1 Elastic stable intramedullary nail• No immobilization required• Indications:
– Sagittal >45, Frontal >10, Shortening >2 mm, any rotational malalignment
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
Bibliography (Forearm)• Davis DR, Green DP: Forearm fractures in children: Pitfalls and
complications. Clin Orthop 1976;120:172-184• 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;107:138-48.• Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad
Orthop Surg 1998; 6:146-156• Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop
1990;10: 705-712.• Rang MC: Children's Fractures, 3rd ed. Philadelphia: JB Lippincott, 2005, pp
135-163• Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal
forearm fractures in children. J PediatR Orthop 1996; 16( 2): 195-200.• Reinhardt KR, et al: Comparison of Intramedullary Nailing to Plating for
Both-Bone Forearm Fractures in Older Children. JPO 2008; 28(4) 403-409
Bibliography (Hand)
• Light TR. Carpal Injuries in Children. Hand Clin 2000; 16(4): 513-522
• 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) 11-18.
• Kaiser MM et al: Intramedullary nailing for metacarpal 2-5 fractures. JPO-B 2009; 18(6): 296-301
• Yeh PC, Dodds SD: Pediatric Hand Fractures. Techniques in Orthopaedics 2009; 24(3): 150-162
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