Rockwood Children CH8

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SECTION TWO • Upper Extremity

capacity and as a result, the majority may be effectively treated with appropriate nonoperative means. The future direction for management of these fractures is primarily focused on prognos- ticating which fractures would be better served through surgical reduction and fixation, considering the relatively high rate of loss of reduction of these fractures.

CONCLUSIONS

Fractures of the distal forearm are common in the pediatric population. Given their proximity to the distal physes of the radius and ulna, these fractures have tremendous remodeling

Annotated References Reference

Annotation

Chess DG, Hyman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fracture. J Pediatr Orthop . 1994;14:211–213.

A forearm cast should be flat not round to maintain reduction. The “cast index”—the ratio of the cast diameter on the lateral compared to the AP radiograph—of less than or equal to 0.7 is a key cast-molding technique for successful maintenance of reduction of distal forearm fractures. A simple, effective, cost- and time-efficient method of treatment for displaced distal radius fractures in children which should eliminate the need to transfer 8 year olds with displaced distal radius fractures 3 hours in the middle of the night to children’s hospitals from community hospitals. A study ahead of its time that pre-dates the Michael Porter Value revolution—Porter ME. What is value in health care? NEJM . 2010;363:2477–2481. An older study that tempers the enthusiasm for the Iobst et al. revolution for treating grade 1 open forearm fractures without a formal I and D in the operating room A prospective, controlled trial evaluating the advantages and disadvantages of two commonly used methods of conscious sedation in children for fracture reduction. Completely displaced distal radius fractures and an ipsilateral ulna fracture that cannot be anatomically reduced is the best predictor for redisplacement. Forty-five consecutive patients treated with wound cleansing in the ED, closed reduction under conscious sedation in the ED, IV antibiotics, and no formal I and D in the operating room resulted in uncomplicated fracture healing and no infections. Using SCAMPs in the management of pediatric buckle fractures resulted in decreased practice variability, resource utilization, and cost of care with no change in outcomes. Initial displacement of > 50% and inability to achieve an anatomic reduction are the major risk factors for redisplacement. The cast index is the most useful method to grade cast molding. Removable splinting was superior to casting for function and bathing with equal outcomes noted for pain, healing, and reinjury. The value revolution gone wild. Michael Porter would be proud.

Crawford SN, Lee LS, Izuka BH. Closed reduction of overriding distal radius fractures without reduction in children. J Bone Joint Surg . 2012A;94:246–252.

Do TT, Strub WM, Foad SL, et al. Reduction versus remodeling in pediatric distal forearm fractures: a preliminary cost analysis. J Pediatr Orthop B . 2003;12:109–115. Fee NF, Dobranski A, Bisia RS. Gas gangrene complicating open forearm fractures. Report of five cases. J Bone Joint Surg . 1977A:59:135–138. Godambe SA, Elliot V, Matheny D, et al. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopaedic procedural sedation in the emergency department. Pediatrics . 2003;112:116–123. Hang JR, Hutchinson AF, Hau RC. Risk factors associated with loss of position after closed reduction of distal radial fractures in children. J Pediatr Orthop . 2011;31:501–506. Iobst CA, Spurdel C, Baitner AC, et al. A protocol for the management of pediatric type 1 open fractures. J Child Orthop . 2014;8:71–76. Khan S, Sawyer J, Pershad J. Closed reduction of distal forearm fractures by pediatric emergency room physicians. Acad Emerg Med . 2010;17:1169–1174. Luther G, Miller PE, Mahan ST, et al. Decreasing utilization using standardized clinical assessment and management plans (SCAMPs). J Pediatr Orthop . 2016 Sept 15. [Epub ahead of print] McQuinn AG, Jaarsma RL. Risk factors for redisplacement of pediatric distal forearm and distal radius fractures. J Pediatr Orthop . 2012;32:687– 692. Plint AC, Perry JJ, Correll R, et al. A randomized, controlled trial of removable splinting versus casting for wrist buckle fractures in children. Pediatrics . 2006;117:691–697. Samora JB, Klingele KE, Beebe AC, et al. Is there still a place for cast wedging in pediatric forearm fractures? J Pediatr Orthop . 2014;34:246–252. Voto SJ, Weiner DS, Leighley B. Redisplacement after closed reduction of forearm fractures in children. J Pediatr Orthop . 1990;10:79–84. Waters PM, Bae DS, Montgomery KD. Surgical management of post- traumatic distal radial growth arrest in adolescents. J Pediatr Orthop . 2002;22:717–724.

An update on the technique of cast wedging of the distal radius and ulna for the millennial generation.

Redisplacement occurs in about 7% of cases and can usually be successfully treated with a second closed reduction and casting.

Growth arrest occurs in about 4% of fractures. Surgical options and outcomes are nicely outlined in this paper.