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CHAPTER 8 • Fractures of the Distal Radius and Ulna

A small incision is made for the insertion of the pin to protect the radial sensory nerve and adjacent extensor ten- dons. Smooth pins are used and are removed in the office as soon as there is sufficient healing to make the fracture stable in a cast or splint (usually at 4 weeks). Open reduction is typically reserved for open or irre- ducible fractures. Open fractures are irrigated and debrided in the operating room. The initial open wound is extended adequately to inspect and cleanse the open fracture site. After thorough irrigation and debridement, the fracture is reduced and stabilized. A cast rarely is applied in this situ- ation because of concern about fracture stability, soft tissue care, and excessive swelling. Pin fixation often is used with Gustilo grade 1 or 2 open fractures. More severe soft tissue injuries may require external fixation. If flap coverage is nec- essary for the soft tissue wounds, the fixator pins should be placed in consultation with the microvascular surgeon plan- ning the soft tissue coverage. In addition, open reduction internal fixation with volar plating is performed for unstable fractures in the skeletally mature adolescent.

Percutaneous pin fixation usually is used to stabilize the fracture in patients with open physes. If plate fixation is used, it should void violation of the physis (Fig. 8-50). Displaced intra-articular injuries in skeletally immature adolescents are adult-like and require open reduction and internal fixation. Physeal Injuries A patient with a displaced Salter–Harris type I or II physeal fracture associated with significant volar soft tissue swelling, median neuropathy, or ipsilateral elbow and radial fractures (floating elbow) is treated with closed reduction and percu- taneous pinning 12,27 (Fig. 8-51). This avoids the increased risk of compartment syndrome in the carpal canal or volar forearm that is present if a well-molded, tight cast is applied. In addition, acute percutaneous pinning of the fracture pre- vents increased swelling, cast splitting, loss of reduction, and concerns about malunion or growth arrest with repeat reduction. The risk of growth arrest from a narrow-diameter, smooth pin left in place for 3 to 4 weeks is exceedingly small. 219

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Figure 8-50.  A: Radiograph of an open humeral diaphyseal fracture in the set- ting of a “floating elbow injury.” B: Radiograph depicting a displaced distal radial metaphyseal fracture. C: Plate fixation following irrigation and debridement of the humerus fracture. ( continues )

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