Rockwood Children CH8

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CHAPTER 8 • Fractures of the Distal Radius and Ulna

for several weeks may be the only way to restrict stress to the distal radial physis in some patients. Splint protection is appro- priate in cooperative patients. Protection should continue until there is resolution of tenderness and pain with activity. The young athlete can maintain cardiovascular fitness, strength, and flexibility while protecting the injured wrist. Once the acute physeal injury has healed, return to weight-bearing and open-chain activities should be gradual. The process of return to sports should be protective, often 3 to 6 months, and adjust- ment of techniques and training methods is necessary to pre- vent recurrence. The major concern is development of a radial growth arrest in a skeletally immature patient, and consideration should be given to serial clinical and radiographic follow-up in high-risk patients to confirm maintenance of growth. A radial growth arrest will result in ulnar carpal impaction and risk of TFCC injury due to ulnar overgrowth. Distal Ulna Physeal Fracture Repair Treatment options are similar to those for radial physeal frac- tures: immobilization alone, closed reduction and cast immo- bilization, closed reduction and percutaneous pinning, and open reduction. Often, these fractures are minimally displaced or nondisplaced. Immobilization until fracture healing at 3 to 6 weeks is standard treatment. Closed reduction is indicated for displaced fractures with more than 50% translation or 20 degrees of angulation. Most ulnar physeal fractures reduce to a near-anatomic alignment with reduction of the concomitant radius fracture due to the attachments of the DRUJ ligaments and TFCC. Failure to obtain a reduction of the ulnar fracture may indicate that there is soft tissue interposed in the fracture site, necessitating open reduction and fixation. Outcomes Most of the published literature providing information on the short-term clinical and radiographic results of treatment for pediatric distal radius fractures indicates a positive outcome. With adherence to the principles and techniques described above, radiographic realignment, successful bony healing, and avoidance of complications are achieved in the majority of cases. Given the high healing capacity and remodeling poten- tial of these injuries, there is less concern regarding long-term outcomes of nonoperative treatment compared with adult patients. In general, concerns regarding long-term outcomes have focused on patients who sustain distal radial physeal frac- tures and thus are at risk for subsequent growth disturbance and skeletal imbalance of the distal forearm. The risk of growth disturbance following distal radial phy- seal fractures is approximately 4%. Cannata et al. 27 previously reported the long-term outcomes of 163 distal radial physeal fractures in 157 patients. Displaced fractures were treated with closed reduction and cast immobilization for 6 weeks. Mean follow-up was 25.5 years. Posttraumatic growth disturbance resulting in 1 cm or greater of length discrepancy was seen in 4.4% of distal radial and 50% of distal ulnar physeal fractures. In a similar prospective analysis of 290 children with distal radial physeal fractures, Bae and Waters 12 noted that 4% of patients went on to demonstrate clinical or radiographic distal

radial growth disturbance. Consideration should be given for follow-up radiographic evaluation following distal radial phy- seal fractures to assess for possible physeal arrest. In symptom- atic patients with posttraumatic growth disturbance and growth remaining, surgical interventions including distal ulnar epiph- ysiodeses, corrective osteotomies of the radius, ulnar shorten- ing osteotomies, and associated soft tissue reconstructions have been demonstrated to improve clinical function and radio- graphic alignment. 203 OPERATIVE TREATMENT OF FRACTURES OF THE DISTAL RADIUS AND ULNA Indications/Contraindications

Operative Treatment of Fractures of the Distal Radius and Ulna: INDICATIONS AND CONTRAINDICATIONS

Indications Open fracture Irreducible fracture Floating elbow injury Displaced, intra-articular fracture

Skeletally maturing adolescent patient with < 2 years of growth remaining with an irreducible fracture or a fracture that lost initial acceptable reduction Distal radius fractures with median neuropathy Adolescent patients with a complete Galeazzi fracture Contraindications Young child with > 2 years of growth remaining, extra-articular fracture, displaced < 20 degrees in the plane of motion Physeal fracture > 5 days after initial reduction that has lost reduction Although surgical indications and techniques continue to evolve, in general surgical indications for pediatric distal radius and ulna fractures include open fractures, irreducible fractures, unstable fractures, floating elbow injuries, and fractures with soft tissue or neurovascular compromise precluding circum- ferential cast immobilization. Surgical reduction and fixation is also indicated in cases of joint incongruity associated with intra-articular Salter–Harris III, IV, or “triplane” fractures. Distal radial fracture stability has been more clearly defined in adults 206 than in children. At present, an unstable fracture in a child is often defined as one in which closed reduction can- not be maintained. Pediatric classification systems have yet to more precisely define fracture stability, but this issue is critical in determining proper treatment management. As noted above, distal radial metaphyseal fractures have been shown to have a high degree of recurrent displacement and, therefore, inherent instability. 6,10,48,57,90,140,164,206 For these reasons, pediatric distal radial metaphyseal fractures are not classified in the same man- ner as adults in regard to stability. Instead, unstable fractures have been predominantly defined by the failure to maintain a successful closed reduction. Irreducible fractures usually are due to an entrapped periosteum or pronator quadratus. Surgical treatment is similarly recommended in patients with neurovascular compromised and severely displaced