Rockwood Children CH8

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SECTION TWO • Upper Extremity

Bicortical Complete Radial Metaphyseal Injuries Nondisplaced bicortical metaphyseal fractures are treated with cast immobilization. A short-arm, well-molded cast is utilized. Radiographs are obtained for the first 2 to 3 weeks. Casts are discontinued at 6 weeks. Displaced fractures with unacceptable alignment are treated with closed reduction and long-arm cast immobili- zation. This fracture can be reduced in the emergency room. Portable fluoroscopy is used. Loss of reduction with cast immobilization is more likely if the fracture is not completely reduced. A long-arm cast is applied with the elbow flexed 90 degrees, the wrist in slight palmar flexion, and the fore- arm in the desired rotation for stability and alignment. Rota- tional positioning and short- versus long-arm casting varies with each fracture and each surgeon. A three-point mold is applied at the fracture site as the cast hardens. In addition, molds are applied to maintain a straight ulnar border, the interosseous space, and straight posterior humeral line. This creates a “box” long-arm cast that lessens displacement risk rather than the “banana” cast that allows displacement. Por- table fluoroscopy is used. The cast is split and spread anytime there are signs of neurovascular compromise or excessive swelling. The patient is instructed to maintain elevation for at least 48 to 72 hours after discharge and return immediately if

excessive swelling or neurovascular compromise occurs. We inform our patients and parents that the risk of return for wedging, repeat reduction, or pinning under anesthesia is up to 30% during the first 3 weeks. If there is loss of reduction, we individualize treatment depending on the patient’s age, degree of deformity, time since fracture, and remodeling potential. A percutaneous pin is often used for the second reduction (Fig. 8-49). Occa- sionally, in pure bending injuries, loss of reduction can be corrected with cast wedging. Cast immobilization usually is for 4 to 6 weeks. A pro- tective volar splint is often used and activities are restricted until the patient regains full motion and strength for 2 weeks after cast removal. Physical therapy rarely is indicated. In cases of loss of reduction exceeding the limits of fracture remodeling, repeat closed reduction and pin fixation is con- sidered. Percutaneous pinning is also performed in cases of excessive swelling or signs of neurologic injury. Similarly, con- current displaced supracondylar and distal radial fractures are treated with percutaneous fixation of both fractures to lessen the risk of neurovascular compromise. Older patients near the end of growth with bayonet apposition fractures also are treated with percutaneous pin fixation. Finally, open fractures usually are treated with pin fixation after I and D.

A

B

C

Figure 8-49.  Remanipulation. A, B: Two weeks after what initially appeared to be a nondisplaced green- stick fracture, a 14-year-old boy was found to have developed late angulation of 30 degrees in both the coronal and sagittal planes. C: Because this was beyond the limits of remodeling, a remanipulation was performed. To prevent reangulation, the fracture was secured with a pin placed percutaneously obliquely through the dorsal cortex.