Rockwood Children CH8

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CHAPTER 8 • Fractures of the Distal Radius and Ulna

of concerns about further physeal injury. In the rare displaced intra-articular Salter–Harris type III or IV fracture, internal fix- ation can be intraepiphyseal without violating the physis. If it is necessary to cross the physis, then smooth, small-diameter pins should be used to lessen the risk of iatrogenic physeal injury. Extra-articular external fixation also can be used to stabilize and align the fracture. Closed Reduction and Pin Fixation of Displaced Distal Radial Fractures Preoperative Planning ✔ ✔ Closed Reduction and Pin Fixation of Displaced Distal Radial Fractures: PREOPERATIVE PLANNING CHECKLIST

region of the radial styloid carries the risk of iatrogenic radial sensory nerve or extensor tendon injury. 137 For this reason, a small longitudinal incision over the radial styloid at the site of pin insertion may be utilized to identify and retract adjacent soft tissues, facilitating safe pin passage. Alternatively, smooth pins may be inserted using an oscillating technique.

Technique

✔ ✔ Closed Reduction and Pin Fixation of Distal Radius Fractures: KEY SURGICAL STEPS

❑❑ Closed reduction of distal radius fracture ❑❑ Confirm bony alignment with intraoperative fluoroscopy ❑❑ Small incision over radial styloid • Longitudinal spreading in subcutaneous tissues • Retraction/protection of radial sensory nerve and extensor tendons ❑❑ Place smooth wire from distal fracture fragment, across fracture site, engaging the ulnar cortex of the proximal fracture fragment • Fluoroscopic confirmation of pin trajectory and placement ❑❑ Assess fracture stability ❑❑ Place second wire if needed • Cross-pinning may be performed from dorsoulnar corner of distal radial epiphysis proximally and radially into proximal fracture fragment ❑❑ Assess stability ❑❑ Bend and cut pins outside of skin ❑❑ Sterile dressing and cast application ❑❑ Pin removal after adequate bony healing, typically in 4 weeks After appropriate anesthesia, closed reduction of the distal radius fracture into anatomic alignment is performed using the principles and techniques previously described. While maintaining fracture reduction, a skin incision is made over the radial styloid, long enough to ascertain there is no iatro- genic injury to the radial sensory nerve or extensor tendons (Fig. 8-35). Careful longitudinal spreading is performed in the subcutaneous tissues, and the radial sensory nerve and extensor tendons may be identified and carefully retracted. Pin fixation

❑❑ Standard; radiolucent hand table

OR table

❑❑ Supine with affected limb supported by radiolucent hand table or image intensifier of fluoroscopy unit

Position/positioning aids

❑❑ Variable, dependent on surgeon position

Fluoroscopy location

❑❑ Smooth Kirschner (K)-wires, typically 0.045 or 0.062 in in diameter

Equipment

❑❑ Nonsterile

Tourniquet

Preoperative planning begins with careful clinical and radio- graphic evaluation. Thorough neurovascular examination is performed to assess for signs and symptoms of nerve injury or impending compartment syndrome. Radiographs—both from the time of injury, after initial attempts at closed reduction, and any subsequent follow-up radiographs—are carefully evaluated to assess pattern of injury and direction of instability. Given the relative simplicity of closed reduction and per- cutaneous fixation techniques, minimal equipment is required. Intraoperative fluoroscopy and surgical instrumentation for pin placement are typically sufficient. Positioning After adequate induction of general anesthesia, patients are positioned supine on a standard operating table, with the affected limb abducted and supported on a radiolucent hand table. While a nonsterile tourniquet may be applied to the proximal brachium, this is typically not utilized. Fluoroscopy may be brought in from the head, foot, or side of the patient, depending on surgeon position and preference. For example, as most pinning is performed from distal to proximal, the right- hand–dominant surgeon may wish to sit in the axilla and have the fluoroscopy unit come in from the head of the patients when pinning a left distal radius. Surgical Approach While percutaneous pinning may be performed without need for skin incision, placement of smooth C- or K-wires into the

Figure 8-35.  Small incision noted with pins left out of skin for removal at 4 weeks. (Courtesy of Children’s Orthopaedic Surgery Foundation.)