Davos Courses

General Editor: Chris Colton

Authors: Fergal Monsell, Dalia Sepulveda

Pediatric distal forearm 23-M/3.1

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Glossary

General considerations

Complete radial and ulnar fractures tend to occur in children above 5 years of age.

The periosteum is either partially or totally disrupted and will influence the choice of treatment. In case of minor posterior angulation, the posterior periosteum will be intact whereas the anterior periosteum will be torn). The degree of angulation and the bone age of the child determine the tolerance for accepting residual malalignment.

Nonoperative management is the most frequent and the most successful treatment option, independent of displacement. Casting should respect the three point fixation principle.

If reduction fails to achieve an acceptable position operative treatment may be indicated. In the first instance this is likely to be closed reduction under general anesthesia and percutaneous fixation with K-wires. In open fractures, the use of an external fixator may be considered.

Open reduction might be necessary if the periosteum, or quadratus muscle, is interposed preventing a successful closed reduction. In patients near skeletal maturity, open reduction and plate fixation, as used in adults, is an option.

Long arm cast
Main indication Skill Equipment
Minimally displaced and stable fractures Basic surgical experience, no specialized skills Basic equipment only

In the majority of instances with potential instability in both bones of the forearm, control of forearm rotation is the treatment of choice.

Supporting indications

  • Undisplaced and stable fractures, independent of age
  • Posterior angulation of less than 15° in children below 10 years of age
  • Management of pain

Contraindications

  • Angulation of more than 15°, and children above 10 years of age
  • Open fractures

Advantages

  • Maintains the original fracture position using three-point molding

Disadvantages

  • Requires skilled practitioner
  • Need for more frequent monitoring
Closed reduction; Long arm cast
Main indication Skill Equipment
Angulation >15°, or complete displacement, certainly over the age of 10 years (Crawford) Some specialized surgical experience Basic equipment only

Advantages

  • Does not require surgical facilities

Disadvantages

  • Requires skilled practitioner
  • Risk of soft tissue compression if cast is not split
  • Need for more frequent monitoring

Crawford SN, Lee LS, Izuka BH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am. 2012 Feb 1;94(3):246-252.

Closed reduction; K-wire fixation
Main indication Skill Equipment
Instability after closed reduction Some specialized surgical experience Simple surgical and imaging resources

Advantages

  • Reduces the risk of secondary displacement

Disadvantages

  • Requires skilled practitioner and surgical facilities
  • Risk of soft tissue compression if cast is not split
  • Need for more frequent monitoring
  • Risk of pin-track problems and need for removal
Open reduction; K-wire fixation
Main indication Skill Equipment
Failure of closed reduction with residual angulation >15°, or complete displacement, certainly over the age of 10 years (Crawford) Some specialized surgical experience Simple surgical and imaging resources

Advantages

  • Allows removal of interposed tissues
  • Allows direct reduction of fractures

Disadvantages

  • Requires skilled practitioner and full surgical facilities
  • Risk of soft tissue compression if cast is not split
  • Risk of pin-track problems and need for removal

Crawford SN, Lee LS, Izuka BH. Closed treatment of overriding distal radial fractures without reduction in children. J Bone Joint Surg Am. 2012 Feb 1;94(3):246-252.

External fixation
Main indication Skill Equipment
Open fractures (Gustilo III) and/or polytrauma Some specialized surgical experience Simple surgical and imaging resources

Advantages

  • Rapid application in polytrauma
  • Allows definitive cast-free management of soft tissues, fractures and pain
  • Allows correction of secondary malalignment

Disadvantages

  • Requires skilled practitioner and full surgical facilities
  • Risk of pin-track problems and need for removal
Open reduction; Plate fixation
Main indication Skill Equipment
Displaced and unstable fractures in an adolescent Some specialized surgical experience Simple surgical and imaging resources

Contraindications

  • Skeletally immature patients (relative contraindication)
  • Local soft tissue compromise

Advantages

  • Allows removal of interposed tissues
  • Allows direct reduction of fractures

Disadvantages

  • Requires skilled practitioner and full surgical facilities
*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 2016-12-01