General Editor: Chris Colton

Authors: Fergal Monsell, Dalia Sepulveda

Pediatric distal forearm 23r-E/1.1

Closed reduction; Short or long arm cast

1. Introduction

These fractures are usually posteriorly angulated (apex anterior) and can generally be reduced closed, ideally under general anesthesia. Impediments to reduction include interposed periosteum and pronator quadratus

Most fractures are stable after reduction and do not require fixation.

Anteriorly angulated (apex posterior) fractures are less common and usually reduced closed. Impediments to reduction include the extensor tendons.

2. Patient preparation

This procedure is normally performed with the patient in a supine position .

3. Anatomy of the distal forearm

A thorough knowledge of the anatomy around the wrist is essential.

The additional material gives a short introduction.

4. Reduction

Indirect reduction of posteriorly angulated partially displaced fractures

The reduction maneuver for posteriorly angulated fractures, together with some posterior translation (common), is by traction with direct pressure over the epiphysis, followed by palmarflexion.

Ideally, the reduction is verified with image intensification and any residual malalignment is corrected with direct pressure.

Indirect reduction of anteriorly angulated partially displaced fractures

The reduction maneuver for anteriorly angulated fractures, together with some anterior translation (uncommon), is by traction with direct pressure over the epiphysis, followed by dorsiflexion.

Ideally, the reduction is verified with image intensification and any residual malalignment is corrected with direct pressure.

Pitfall

Repeated reduction maneuvers, or delayed reduction (after 5-7 days), can damage the growth plate and result in premature growth arrest.

In such instances, it is prefererable to accept the deformity in anticipation of modelling with subsequent growth.

In rare instances with fresh injuries, the gentle use of a "joystick" K-wire inserted into the distal fragment can be performed.

Indirect reduction of completely posteriorly displaced fractures

For completely posteriorly displaced fractures, direct pressure is applied to the epiphysis with the wrist in hyperdorsiflexion.

The fracture is then reduced by palmarflexion (while continuously applying direct pressure to the epiphysis).

Failure to achieve a stable reduction is a strong indication for internal fixation using K-wires and/or accepting some residual displacement, in anticipation of subsequent fracture modelling.

Ideally, the reduction should be confirmed using image intensification.

In case of persistent malreduction, direct pressure in an appropriate direction should produce an anatomical reduction.

The reduction is often straightforward, stable, and may not require fixation.

Direct reduction using a K-wire

For irreducible fractures, a K-wire can be inserted percutaneously (through a stab incision) into the fracture site and used as a lever to facilitate reduction.

An assistant is required to maintain the reduction throughout the cast application.

5. Short arm cast

General considerations

The purpose of the cast is to maintain the reduction.

There is reasonable evidence to support the use of a short arm cast to manage simple extraarticular distal radial epiphyseal fractures.

The short arm cast is applied according to standard procedure:

Note: In young, small, or noncompliant patients, it is safer to apply a long arm cast.

Splitting the cast

If a complete cast is applied in the acute phase after injury, it is safer to split the cast down to skin over its full length.

6. Long arm cast

General considerations

A long arm cast should always be used where it is necessary to control forearm rotation in order to prevent fracture displacement. In very young and in noncompliant children, a long arm cast is preferable even if a short cast would otherwise be appropriate

The long arm cast is applied according to standard procedure:

Splitting the cast

If a complete cast is applied in the acute phase after injury, it is safer to split the cast down to skin over its full length.

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v1.0 2016-12-01