Rockwood Children CH8

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CHAPTER 8 • Fractures of the Distal Radius and Ulna

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alignment of the physis and articular surface is not present, the risk of growth arrest, long-term deformity, or limited function is great (Fig. 8-42). Even minimal displacement (more than 2 mm) should not be accepted in this situation. Preoperatively, CT or MRI scans are invaluable in defining fracture pattern, assessing articular congruity, and planning definitive treatment (Fig. 8-43). Based on these images, appro- priate preoperative planning may be performed. There is great variation in fracture patterns, and treatment and fixation must be individualized to restore bony alignment and stability. In addition to traditional percutaneous and open techniques, arthroscopically assisted reduction may be helpful to align and stabilize these uncommon intra-articular fractures. 53 Although equipment-intensive, anatomic reduction and stabilization of the physis and articular surface can be achieved with arthros- copy, fluoroscopy, and combinations of external fixation or transphyseal fixation pins or screws (Fig. 8-44). Positioning Standard positioning is used, as described above. In cases where wrist arthroscopy is to be performed, use of a wrist traction tower with finger trap suspension applied to the index and long Figure 8-42.  A: A markedly displaced Salter–Harris type IV fracture of the distal radius in an 11-year-old boy who fell from a horse. B: Radio- graph taken 3 weeks after closed reduction demonstrates displacement of the comminuted fragments. C: Eighteen months after injury, there was 15 mm of radial shortening, and the patient had a pronounced radial deviation deformity of the wrist.

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fingers will stabilize the wrist and provide appropriate traction for arthroscopic visualization.

Surgical Approach The volar surgical approach remains the standard workhorse exposure for distal radius fractures requiring open reduction. Often, more distal subperiosteal elevation is needed to visual- ize intra-articular fracture lines. This is more common in older, skeletally mature adolescents. In many intra-articular fracture patterns, there are radial sty- loid and/or dorsal lunate facet fragments that necessitate expo- sure, reduction, and fixation. In these cases, supplemental dorsal approaches may need to be used. A longitudinal incision based over or ulnar to Lister’s tubercle is most commonly used and provides a utilitarian approach. Superficial dissection is per- formed to the extensor retinaculum, with preservation of the dorsal veins if possible. In dorsal lunate facet fractures, incision of the retinaculum over the third or fourth extensor compart- ment and subsequent retraction of the extensor pollicis longus or extensor digitorum communis tendons, respectively, will pro- vide access to the distal dorsal radius. Care is made to preserve the origins of the radiocarpal ligaments whenever possible.