Rockwood Children CH8

293

CHAPTER 8 • Fractures of the Distal Radius and Ulna

A

B

C

D

Figure 8-58.  A, B: A 10-year-old boy sustained a closed Salter–Harris type I separation of the distal ulnar physis ( arrows ) combined with a fracture of the distal radial metaphysis. C: An excellent closed reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.

in rabbits’ forelimbs. The distal ulna loses its normal articula- tion in the sigmoid notch of the distal radius. The metaphyseal– diaphyseal region of the radius often becomes notched from its articulation with the distal ulna during forearm rotation. Fre- quently, these patients have pain and limitation of motion with pronation and supination. 16 Ideally, this problem is identified before the development of marked ulnar foreshortening and subsequent radial deformity. Because it is well known that distal ulnar physeal fractures have a high incidence of growth arrest, these patients should have serial radiographs at 6 to 12 months after fracture for early iden- tification. Unfortunately, in the distal ulnar physis, physeal bar resection generally is unsuccessful. Surgical arrest of the radial physis can prevent radial deformity. Usually, this occurs toward

the end of growth so that the forearm length discrepancy is not a problem. Rarely, patients present late with established deformity. Treat- ment involves rebalancing the length of the radius and ulna. The options include hemiphyseal arrest of the radius, corrective radial closing wedge osteotomy, and ulnar lengthening, 16,81,145 or a combination of these procedures. The painful impinge- ment of the radius and ulna with forearm rotation can be cor- rected with reconstitution of the DRUJ. If the radial physis has significant growth remaining, a complete radial physeal arrest should be done at the same time as the surgical rebalancing of the radius and ulna. Treatment is individualized depending on the age of the patient, degree of deformity, and level of pain and dysfunction.