Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21r-E/2

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Glossary

General considerations

Conservative treatment (immobilization without reduction or fixation) is only recommended for minimally displaced, stable factures (type I). The amount of angulation that can be accepted depends on the modeling capacity and therefore the age of the child. The modeling capacity in the proximal radius is much less than in the distal radius.

If there is radiological evidence of displacement or delayed union, an operative approach is recommended (see type-II fractures).

Displaced fractures (type II and III) can be reduced closed and fixed with ESIN technique. There is good clinical evidence of improved functional results following ESIN. If elastic nails are not available, long K-wires can be used for the ESIN technique.

K-wire fixation is not recommended because of the risks of infection, stiffness, cross-union, subsequent displacement.

If closed reduction is not possible or an image intensifier is not available, an initial small open approach may be necessary to reduce the fracture. Take care that the surgical approach does not disrupt the blood supply in the periosteum.

If this fracture occurs with an elbow dislocation, restoration of proximal radial anatomy is important in maintaining elbow stability.

Associated fractures of the olecranon or coronoid process or a Monteggia equivalent lesion should be excluded.

Sling immobilization
Main indication Skill Equipment
Minimally displaced, stable fracture, compliant patient Basic surgical experience, no specialized skills Basic equipment only

Advantages

  • Comfortable
  • Good radiological access
  • Avoidance of joint stiffness
  • Early functional treatment

Disadvantages

  • Risk of displacement
Cast immobilization
Main indication Skill Equipment
Minimally displaced, stable fracture, uncompliant patient Basic surgical experience, no specialized skills Basic equipment only

Contraindications

  • Severe swelling
  • Severe pain
  • Skin lesions

Advantages

  • Cannot be removed by patient/parent

Disadvantages

  • Loss of x-ray definition
  • Joint stiffness
  • Risk of displacement
Splint immobilization
Main indication Skill Equipment
Minimally displaced, stable fracture, uncompliant patient Basic surgical experience, no specialized skills Basic equipment only

Supporting indications

  • Swelling and pain
  • Skin lesions

Advantages

  • Removable for skin care
  • Removable if pain or neurovascular problems develop

Disadvantages

  • Risk of displacement
ESIN
Main indication Skill Equipment
Any unstable or displaced fracture Some specialized surgical experience Simple surgical and imaging resources

If elastic nails are not available, the ESIN method can be performed with long stainless-steel K-wires.

If closed reduction is not possible, open reduction may be necessary.

This treatment can be performed under direct vision if image intensifier is not available to confirm initial redial head and ESIN insertion.

Advantages

  • Minimally invasive treatment
  • Preserves remaining blood supply to the radial head
  • Minimizes the risk of radial head necrosis
  • Cast-free rehabilitation
  • Low risk of malunion
  • High rate of uncomplicated healing

Disadvantages

  • Image intensifier recommended
  • Risk of nerve or tendon injury at entry point
  • Risk of infection
  • Higher risk of nonunion due to disturbance of the fracture hematoma following open reduction
  • General anesthesia required
  • Second anesthetic required for implant removal
Open reduction; K-wire fixation
Main indication Skill Equipment
Displaced fracture, closed reduction impossible or image intensifier not available, implants for ESIN technique not available Highly experienced and skilled surgeon Simple surgical and imaging resources

Disadvantages

  • Risk of infection
  • Risk of cross-union
  • Requires plaster cast immobilization
  • Delayed postoperative mobilization
  • Risk of residual malunion
  • Risk of loss of joint function
  • Less comfortable for patient
  • General anesthesia required
  • Second anesthetic required for implant removal
*Skill
Basic surgical experience, no specialized skills Basic surgical experience, no specialized skills
Some specialized surgical experience Some specialized surgical experience
Highly experienced and skilled surgeon Highly experienced and skilled surgeon
*Equipment
Basic equipment only Basic equipment only
Simple surgical and imaging resources Simple surgical and imaging resources
Full specialized surgical and imaging resources Full specialized surgical and imaging resources

v1.0 2019-08-28