Rockwood Children CH8

264

SECTION TWO • Upper Extremity

A

Figure 8-30.  A: Serial radiographs at 3 days and 10 days ( B ) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.

B

fractures involve dorsal and proximal displacement of the epiphysis with an apex volar extension deformity. Manipula- tive reduction is by gentle distraction and flexion of the dis- tal epiphysis, carpus, and hand over the proximal metaphysis (Fig. 8-32). The intact dorsal periosteum is used as a tension band to aid in reduction and stabilization of the fracture. Unlike similar fractures in adults, finger trap distraction with pulley weights is often counterproductive. However, finger traps can help stabilize the hand, wrist, and arm for manipulative reduc- tion and casting by applying a few pounds of weight for balance.

Otherwise, an assistant is helpful to support the extremity in the proper position for casting. If portable fluoroscopy is available, immediate radiographic assessment of the reduction is obtained. Otherwise, a well- molded cast is applied and AP and lateral radiographs are obtained to assess the reduction. The cast should provide three- point molding over the distal radius to lessen the risk of frac- ture displacement and should follow the contour of the normal forearm. The distal dorsal mold should not impair venous out- flow from the hand, which can occur if the mold is placed too