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CHAPTER 8 • Fractures of the Distal Radius and Ulna

reduction, as forceful remanipulation may increase the risk of iatrogenic physeal arrest. 27,125,176 Fortunately, remodeling of an extension deformity with growth is common if the patient has more than 2 years of growth remaining and the deformity is less than 20 degrees. Even marked deformity can remodel if there is sufficient growth remaining and the deformity is in the plane of motion of the wrist. Galeazzi Fracture Repair Nonoperative management remains the first-line treatment for pediatric Galeazzi fractures, distinguishing these injuries from their adult counterparts. 56,171,200 Indeed, the adult Galeazzi frac- ture has been often called a “fracture of necessity,” given the near-universal need for surgical reduction and internal fixation to restore anatomic radial alignment and DRUJ congruity. In pediatric patients, however, the distal radial fracture often is a greenstick type that is stable after reduction; therefore, nonop- erative treatment with closed reduction and cast immobilization is often sufficient. 109,171 Surgical treatment may be considered for adolescents with complete fractures and displacement, as their injury pattern, skeletal maturity, remodeling potential, and DRUJ instability concerns are more similar to the adult Galeazzi. Incomplete fractures of the distal radius with either a true dislocation of the DRUJ or an ulnar physeal fracture are treated with closed reduction and long-arm cast immobilization. This can be done in the emergency room with conscious sedation or in the operating room with general anesthesia. Portable fluoros- copy is useful in these situations. If the radius fracture has apex volar angulation and dorsal displacement of the radius with associated volar dislocation of the ulnar head in relationship to the radius, pronation and volar-to-dorsal force on the radial fracture are used for reduction. Conversely, if the radius fracture is apex dorsal with volar displacement and dorsal dislocation of the distal ulna, supination and dorsal-to-volar force is utilized

Figure 8-31.  Lateral fluoroscopic projection of a distal radius fracture treated with dorsal cast wedging to correct loss of reduction. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

distal and too deep so as to obstruct the dorsal veins. Advocates of short-arm casting indicate at least equivalent results with proper casting techniques and more comfort during immobili- zation due to free elbow mobility. Instructions for elevation and close monitoring of swelling and the neurovascular status of the extremity are critical. The fracture also should be monitored closely with serial radiographs to be certain that there is no loss of anatomic alignment (Fig. 8-33). Generally, these fractures are stable after closed reduction and cast immobilization. If there is loss of reduction after 7 days, the surgeon should be wary of repeat

C

Figure 8-32.  A: Lateral radiograph of dorsally displaced Salter– Harris type II fracture. B: Lateral radiograph after closed reduction and cast application. C: Reduction of the volar displaced fracture. The forearm was in supination with three-point molding ante- rior over the distal epiphysis and proximal shaft ( white arrows ). The third point is placed dorsally over the distal metaphysis ( open arrow ). (The dorsal surface of the cast is oriented toward the bottom of this figure.) (Reprinted from Wilkins KE, ed. Operative Manage- ment of Upper Extremity Fractures in Children . Rosemont, IL: Ameri- can Academy of Orthopaedic Surgeons; 1994:17, with permission.)

A, B