Rockwood Children CH8

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SECTION TWO • Upper Extremity

D

Figure 8-50.  ( Continued ) D, E: Radiographs following open reduction and plate fixation of the radius fracture, sparing the distal radial physis. (Courtesy of Children’s Orthopaedic Surgery Foundation.)

E

Open reduction is reserved for irreducible Salter–Harris type I and II fractures, open fractures, fractures with associated acute carpal tunnel or forearm compartment syndrome, dis- placed (more than 1 mm) Salter–Harris type III or IV fractures, or triplane-equivalent fractures. For an irreducible Salter–Har- ris type I or II fracture, exposure is from the side of the torn periosteum. Because these fractures usually are displaced dor- sally, a volar exposure is used. Smooth pins are used for sta- bilization and are left in for 3 to 4 weeks. Open fractures are exposed through the open wound with proximal and distal extension for adequate debridement. All open debridements are performed in the operating room under general anesthe- sia. Acute compartment syndromes are treated with immediate release of the transverse carpal ligament or forearm fascia. The transverse carpal ligament is released in a Z-plasty fashion to lengthen the ligament and prevent volar bow-stringing and scarring of the median nerve against the palmar skin.

Intra-Articular Fractures

Displaced intra-articular fractures in the skeletally immature are best treated with arthroscopically assisted reduction and fixation. Distraction across the joint can be achieved with application of an external fixator or wrist arthroscopy trac- tion devices and finger traps. Standard dorsal portals (3/4 and 4/5) are used for viewing the intra-articular aspect of the fracture and alignment of the reduction. 66,76 In addition, direct observation through the arthroscope can aid in safe placement of the intraepiphyseal pins. 53,87,92 Fluoroscopy is used to evaluate the extra-articular aspects of the fracture (triplane-equivalent and type IV fractures), the reduction, and placement of fixation pins. In older patients near or at skeletal maturity with intra-articular comminution, volar locking plate fixation is performed, similar to adults.

A

Figure 8-51.  A: Ipsilateral distal radial physeal and supracondylar fractures. This 6 year old sustained both a dorsally displaced distal radial physeal fracture (closed arrow) and a type II displaced supra- condylar fracture of the humerus (open arrow). B: Similar case treated with percutaneous pinning of radial physeal fracture and supracondy- lar humeral fracture.

B