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CHAPTER 8 • Fractures of the Distal Radius and Ulna

C

D Figure 8-5.  ( Continued ) C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.

nerve contusion sustained at the time of fracture displacement, persistent pressure or traction from an unreduced fracture, or an acute compartment syndrome (Fig. 8-7). 205 Ulnar neuropathy has been described with similar mechanisms, as well as entrap- ment or incarceration of the ulnar nerve within the fracture site. Wrist ligamentous and articular cartilage injuries have been described in association with distal radial and ulna fractures in adults and less commonly in children. 12,55 Concomitant scaphoid fractures have occurred (Fig. 8-8). 32,41,196 Associated wrist injuries need to be treated both in the acute setting and in the patient with persistent pain after fracture healing. More

than 50% of distal radial physeal fractures have an associated ulnar fracture. This usually is an ulnar styloid fracture, but can be a distal ulnar plastic deformation, greenstick, or complete fracture. 33,107,123,191 Some patients with distal radial and ulna fractures are multitrauma victims. Care of the distal forearm fracture in these situations must be provided within the context of concomitant systemic injuries. Isolated ulnar physeal fractures are rare injuries. 1,185 Most ulnar physeal fractures occur in association with radial metaphyseal or physeal fractures. Physeal separations are classified by the stan- dard Salter–Harris criteria. The rare pediatric Galeazzi injury

Physis

Metaphyseal fracture fragment

Epiphysis

1st metacarpal

Median nerve

Transverse carpal ligament

Hematoma

Figure 8-7.  Volar forearm anatomy outlining the potential compression of the median nerve between the metaphysis of the radius and dorsally displaced physeal fracture. The taut volar transverse carpal ligament and fracture hematoma also are contributing factors. (Redrawn with permission from Waters PM, Kolettis GJ, Schwend R. Acute median neuropathy following physeal fractures of the distal radius. J Pediatr Orthop. 1994;14(2):173–177.)

Figure 8-6.  Galeazzi fracture–dislocation variant. Interposed perios- teum can block reduction of the distal ulnar physis ( arrow ). This desta- bilizes the distal radial metaphyseal fracture. (Reprinted with permission from Lanfried MJ, Stenclik M, Susi JG. Variant of Galeazzi fracture– dislocation in children. J Pediatr Orthop. 1991;11(3):333–335.)