Pediatric Fractures of the Forearm, Wrist and Hand,John A. Heflin, MDOriginal Author: Amanda Marshall, MD; March 2004 Revised: Steven Frick, MD; August 2006 John A. Heflin, MD; April 2011,Pediatric Forearm Fractures,Approximately 40% of childrens 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 (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 ADLs need 50 degrees supination, 50 degrees pronation,Pediatric Forearm,Primary ossification centers at 8 weeks gestation in both radius and ulna Distal physis provide most (80%) of longitudinal growth Distal epiphyses of radius appears at age 1 Distal epiphyses of distal ulna appears at age 5 Normal forearm rotation: Approx 90 degrees pronation Approx 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. Biomechanics 3:263,1970,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 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 its 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%),