Rockwood Children CH8

266

SECTION TWO • Upper Extremity

A

C

D

B

Figure 8-33  A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately, the patient lost reduction after a new fiberglass cast was applied. D: Out-of- cast radiographs show a healed malunion in a similar position to the prereduction radiographs.

during reduction. The reduction and stability of the fracture and DRUJ dislocation may then be checked on dynamic flu- oroscopy; if both are anatomically reduced and stable, a long- arm cast with the forearm in the appropriate rotatory position of stability (i.e., pronation or supination) is applied. Six weeks of long-arm casting is recommended to allow for sufficient bony and soft tissue healing. In patients with Galeazzi-equivalent injuries characterized by complete distal radius fractures associated with ulnar phy- seal fractures, both bones should be reduced. Usually, this can be accomplished with the same methods of reduction as when the radial fracture is incomplete. If there is sufficient growth remaining and the distal ulnar physis remains open, remodel- ing of a nonanatomic distal ulnar physeal reduction may occur. As long as the DRUJ is reduced, malalignment of less than 10 degrees can remodel in a young child. DRUJ congruity and sta- bility, however, are dependent on distal ulnar alignment, and

great care should be taken in assessment of the DRUJ when accepting a nonanatomic distal ulnar reduction. Furthermore, the risk of ulnar growth arrest after a Galeazzi equivalent has been reported to be as high as 55%. 81 If the fracture is severely malaligned, the DRUJ cannot be reduced, or the patient is older and remodeling is unlikely, open reduction and smooth pin fix- ation are indicated. 211 Distal Radial Physeal Stress Fracture Repair Treatment of distal physeal stress injuries first and foremost involves rest. This activity restriction may be challenging in the pediatric athlete, depending on the level of the sports participa- tion and the desires of the child, parents, and other stakehold- ers to continue athletic participation. Education regarding the long-term consequences of a growth arrest is important in these emotionally charged situations. Short-arm cast immobilization