Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21r-E/3 + 21r-E/4

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Glossary

General considerations

The treatment of epiphyseal and epimetaphyseal fractures (Salter-Harris III and IV) is identical.

The choice between nonoperative or operative treatment depends on the size and displacement of the fragment.

Removal of very small osteochondral fragments may produce a better outcome than reduction and fixation.

If open reduction and fixation is required, the approach, reduction and fixation is equivalent to the treatment of these fractures in the adult.

The conventional approach to articular fractures recommends that displacement over 2 mm should be reduced and stabilized.

If this fracture occurs with an elbow dislocation, restoration of proximal radial anatomy may be important in maintenance of postoperative elbow stability.

Associated fractures, eg, olecranon or coronoid, 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
Open reduction; screw fixation
Main indication Skill Equipment
Displaced or unstable fracture Highly experienced and skilled surgeon Simple surgical and imaging resources

Advantages

  • Anatomic reduction possible
  • Stable fixation possible with screws (often not possible with K-wires)

Disadvantages

  • Excessive surgical dissection risks damage to the blood supply of the radial head
  • Neurovascular injury, particularly posterior interosseous nerve
  • Risk of implant failure
  • Risk of damage of the adjacent articular cartilage surface by prominent screw heads
  • Risk of radial head overgrowth
  • Risk of infection
*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