Rockwood Children CH8

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SECTION TWO • Upper Extremity

considerations. Assessment of skeletal maturity and physeal sta- tus is important, particularly when considering use of implants which rigidly engage the distal radial epiphysis and when open reduction may potentially increase the risk of physeal distur- bance. Secondly, children are not small adults, and care should be made to evaluate the width of the distal radial metaphysis and epiphysis. Use of precontoured volar locking plates typ- ical of adult distal radius fractures may not be feasible, given size mismatch and/or presence of an open distal radial physis. With the numerous plate options available, it is quite feasible to match up sizes of plate and bone. Finally, care should be made to assess for articular extension of the fracture. Anatomic realignment of the distal radial joint surface is critical, even in the young child. Positioning Patients are positioned supine with the affected limb supported by a radiolucent hand table. Positioning of the fluoroscopic unit is similar to that in closed reduction and pinning techniques. Surgical Approach All open fractures, regardless of grade of soft tissue injury, should be irrigated and debrided in the operating room (Fig. 8-40). The open wound should be enlarged adequately to debride the contaminated and nonviable tissues and identify, protect, or if needed, repair the adjacent neurovascular struc- tures. Judicious extension of the traumatic wound will allow for extensile exposure, facilitate fracture reduction, and allow for implant placement.

A

B

appropriate fracture care (also see Controversies) regarding nonoperative management of open fractures. Irreducible metaphyseal or physeal fractures are rare and generally are secondary to interposed soft tissues. With dor- sally displaced fractures, the interposed structure usually is the volar periosteum or pronator quadratus 95 and rarely the flexor tendons or neurovascular structures. 95,112,216 In volarly displaced fractures, the periosteum or extensor tendons may be interposed. Closed reduction rarely fails if there is no interposed soft tissue. Occasionally, however, multiple attempts at reduction of a bayonet apposition fracture can lead to significant swelling that makes closed reduction impossible. If the patient is too old to remodel bayonet apposition, open reduction is appropriate. Plate fixation can be used in more skeletally mature ado- lescents. Low-profile, fragment-specific fixation methods and locking plates also are now commonly used for internal fixation of distal radial fractures in adults. The utility of these anatomi- cally contoured locking plates in children and skeletally imma- ture adolescents is unknown, as is the deleterious effect, if any, on growth potential. Furthermore, the advantage of these more rigid constructs in younger patients in whom adequate stabil- ity may be achieved with pins is unclear, particularly given the reports of late tendon rupture and other soft tissue complica- tions associated with fixed-angle volar plates. 167 Indications for skeletally mature adolescents are the same as for adults. Articu- lar malalignment and comminution are assessed by CT preop- eratively, and fracture-specific fixation is used as appropriate. These plates have proved to be quite useful in indicated cases. Preoperative planning for open reduction and fixation is similar to the approach cited above, with a few additional Figure 8-39.  Pin leverage. A: If a bayonet is irreducible, after sterile preparation, a chisel-point Steinmann pin can be inserted between the fracture fragments from a dorsal approach. Care must be taken not to penetrate too deeply past the dorsal cortex of the proximal fragment. B: Once the chisel is across the fracture site, it is levered into position and supplementary pressure is placed on the dorsum of the distal frag- ment ( arrow ) to slide it down the skid into place. This procedure is usually performed with an image intensifier.

Figure 8-40.  Open fractures. Radiograph ( A ) and clinical photo ( B ) of an open fracture of the distal radius. This patient needs formal irriga- tion and debridement in the operating room. A B