Rockwood Children CH8

270

SECTION TWO • Upper Extremity

A

B

Figure 8-36.  A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.

can be either single or double, though often a single pin will suffice (Fig. 8-36). A smooth pin is then inserted into the dis- tal fracture fragment and passed obliquely in a proximal and ulnar fashion, crossing the fracture site and engaging the far ulnar cortex proximal to the fracture line. Fluoroscopy is used to guide proper fracture reduction and pin placement. Pin(s) may be placed within the distal radial epiphysis and passed across the physis before engaging the more proximal metaphyseal fracture fragment. Alternatively, smooth pins may be placed just proximal to the distal radial physis; while theo- retically decreasing the risk of physeal disturbance, this has not been well demonstrated in the published literature. Stability of the fracture should be evaluated with flexion and extension and rotatory stress under fluoroscopy. Often, in children and adolescents, a single pin and the reduced perios- teum provide sufficient stability to prevent redisplacement of the fracture (Fig. 8-37). If fracture stability is questionable with a single pin, a second pin should be placed. The second pin can either parallel the first pin or, to create cross-pin stability, can be placed distally from the dorsal ulnar corner of the radial epiphy- sis between the fourth and fifth dorsal compartments and passed obliquely to the proximal radial portion of the metaphysis (Fig. 8-38). Again, the skin incisions for pin placement should be sufficient to avoid iatrogenic injury to the extensor tendons. The pins are bent, left out of the skin, and covered with petroleum gauze and sterile dressing. Splint or cast immobiliza- tion is used but does not need to be tight, as fracture stability is conferred by the pins. The pins are left in until there is adequate fracture healing (usually 4 weeks). The pins can be removed in the office without sedation or anesthesia. One of the arguments against pin fixation is the risk of additional injury to the physis by a pin. 23 The risk of physeal arrest is more from the displaced fracture than from a short- term, smooth pin. As a precaution, smooth, small-diameter pins should be used, insertion should be as atraumatic as possible,

and removal should be done as soon as there is sufficient frac- ture healing for fracture stability in a cast or splint alone. Another pinning technique involves intrafocal placement of multiple pins into the fracture site to lever the distal fragment into anatomic reduction (Fig. 8-39). The pins are then passed through the opposing cortex for stability. 129,194 A supplemental, loose-fitting cast is applied. Open Reduction and Fixation of Distal Radius Fractures Preoperative Planning ✔ ✔ Open Reduction and Fixation of Distal Radius Fractures: PREOPERATIVE PLANNING CHECKLIST

❑❑ Standard, radiolucent hand table

OR table

❑❑ Supine

Position/positioning aids

❑❑ Variable depending on surgeon preference

Fluoroscopy location

❑❑ Smooth wires (0.0625-in diameter), small fragment 3.5-mm plates and screws, precontoured volar locking plates in older patients or intra- articular fractures

Equipment

❑❑ Nonsterile tourniquet placed on ipsilateral proximal brachium

Tourniquet

Open reduction is indicated for open or irreducible fractures. Open fractures constitute approximately 1% of all distal radial metaphyseal fractures. Although treatment approaches to open fractures continue to evolve, at present the standard of care remains surgical irrigation and debridement, followed by