General Editor: Chris Colton

Authors: Fergal Monsell, Dalia Sepulveda

Pediatric distal forearm 23r-E/2.1

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Glossary

1 Introduction top

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Open reduction is required for these fractures when closed reduction maneuvers fail. The fractures are usually posteriorly angulated (apex anterior). Impediments to reduction are interposed periosteum and pronator quadratus. Anteriorly angulated (apex posterior) fractures are less common. Impediments to reduction are the extensor tendons.

2 Open reduction top

Approach

As the majority of these fractures are postreiorly displaced, open reduction is most commonly required from the anterior aspect.

A posterior approach may occasionally necessary for irreducible anterior displacement.


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Removal of impediments

Soft tissue impediments to reduction are removed, eg, pronator quadratus in the illustration.

Once the soft tissue impediments have been removed, the fracture will be reduced under direct vision.


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Direct reduction using K-wire

A K-wire inserted into the fracture site and used as a lever can be used to facilitate reduction

3 K-wire fixation top

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General considerations

For fractures that are unstable after reduction, a single K-wire is usually sufficient to stabilize the fracture.


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In cases of a more lateral metaphyseal wedge, the K-wire is inserted more in the coronal plane than in the sagittal plane.


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Skin incision

A small, separate skin incision is required for the K-wire insertion.

Care should be taken to avoid the dorsal sensory branch of the radial nerve.

The incision is deepened to the bone using a blunt artery forceps and a protective sleeve inserted.


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K-wire insertion

Via the protective sleeve, a single smooth 1.6 mm K-wire is inserted through the dorsal metaphyseal fragment engaging the anterior cortex of the radial diaphysis.

The wire should be inserted with an oscillating drill and cooled with saline to prevent thermal injury. Alternatively, the wire can be inserted manually using a T-handle.

Care should be taken to avoid the dorsal sensory branch of the radial nerve.


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Ideally, wires are inserted using image intensification control, in order to check the trajectory of the wire and to ensure engagement of the far diaphyseal cortex without penetration of soft tissues.


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Each K-wire is left protruding through the skin, bent and cut. The skin is protected with sterile padding prior to the application of a cast.

The illustration demonstrates the use of a small section of plastic tubing over the cut end of the protruding wire. This adds further protection for the skin.

Note: Excessive pressure between dressing and skin should be avoided to prevent skin necrosis.

4 Short arm cast top

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General considerations

The purpose of the cast is protective and for pain relief, as stability is provided by the K-wire(s).

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.


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Splitting of the cast

If a complete cast is applied in the acute phase after injury, it should be split over the full length of the cast. The split of the cast must be full thickness and expose the underlying skin.

5 Long arm cast top

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In the event that a long arm cast is necessary (see above) it is applied and split according to standard procedure:

v1.0 2016-12-01