Rockwood Children CH8

268

SECTION TWO • Upper Extremity

injuries. Operative stabilization serves both to maintain adequate bony alignment and more importantly, minimize the risk of compartment syndrome due to excessive swelling and circumferential immobilization. Perhaps the best indication is a displaced radial physeal fracture with median neuropathy and significant volar soft tissue swelling (Fig. 8-34). 204 These patients are at risk for development of an acute carpal tun- nel syndrome or forearm compartment syndrome with closed reduction and well-molded cast immobilization. 15,44,204 The torn

periosteum volarly allows the fracture bleeding to dissect into the volar forearm compartments and carpal tunnel. If a tight cast is applied with a volar mold over that area, compartment pressures can increase dangerously. Percutaneous pin fixation allows the application of a loose dressing, splint, or cast without the risk of loss of fracture reduction. Internal fixation usually is with smooth, small-diameter pins to lessen the risk of growth arrest. Plates and screws rarely are used unless the patient is near skeletal maturity because

A, B

C

D

E

Figure 8-34.  A: Clinical photograph of patient with a displaced Salter–Harris type II fracture of the distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C: Lateral radiograph following closed reduction and cast application. Excessive flexion has been utilized to maintain fracture reduction, resulting in persistent median neuropathy and increasing pain. D: Radiographs following urgent closed reduction and percutaneous pinning. E: Follow-up radiograph depicting distal radial physeal arrest and increased ulnar variance. (Courtesy of Children’s Orthopaedic Surgery Foundation.)