Rockwood Children CH8

260

SECTION TWO • Upper Extremity

A, B

C

Figure 8-26.  A, B: Anteroposterior (AP) and lateral radiographs of a distal radial metaphyseal frac- ture. This injury was initially assumed to be stable and was treated with cast immobilization with suboptimal mold. C, D: Subsequent radiographs taken 3 weeks after injury demonstrate loss of alignment and early bony healing. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

D

Simple immobilization without reduction may also be considered in minimally displaced fractures within accept- able alignment, based on patient age and remodeling poten- tial. Hove and Brudvik 98 evaluated a cohort of 88 patients treated nonoperatively for distal radius fractures. Though eight patients had early loss of reduction with greater than 15 to 20 degrees angulation, all demonstrated complete remodeling and restoration of normal function later. Al-Ansari et al. similarly evaluated 124 patients with “minimally angulated” distal radius fractures. Even patients who healed with 30 to 35 degrees angulation went on to complete fracture remodeling and nor- mal function. 5 Finally, in a prior randomized clinical trial, 96 patients between 5 and 12 years of age with distal radius fractures with less than 15 degrees of sagittal plane angulation were treated with either cast or splint immobilization. 21 No dif- ference was seen in fracture alignment at 6 weeks in the two

treatment groups, and functional outcomes did not differ, as measured by the Activity Scale for Kids. Though the risk of late displacement and issues of compliance and comfort exist, this investigation supports the concept that splint immobilization may be considered in younger patients (age < 10 years) with minimal displacement. The high potential for remodeling of a distal radial metaphyseal malunion has led some clinicians to recommend immobilization alone. 50 Cast immobilization alone without fracture manipulation may even be effective in young patients with complete dorsal displacement and bayonet appo- sition with acceptable sagittal and coronal plane alignments. Crawford et al. prospectively evaluated 51 children under the age of 10 years treated with cast immobilization for shortened and bayoneted fractures of the distal radial metaphysis. 38,50 All patients went on to complete radiographic remodeling and full return of wrist motion.