General Editor: Chris Colton

Authors: Fergal Monsell, Dalia Sepulveda

Pediatric distal forearm 23r-E/2.2

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Glossary

1 Introduction top

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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 Reduction top

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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.


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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.


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Indirect reduction of completely posteriorly displaced fractures

In the rare multifragmentary fractures, the standard reduction maneuvers are unlikely to be successful. Reduction relies largely on longitudinal distraction with direct manual pressure over the epiphyseal fragment.

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.


The reduction is often straightforward and may not require K-wire fixation, if it is stable. Relaxing the manual reduction pressure, will determine this, as an unstable reduction will redisplace.


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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.

3 Long arm cast top

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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:


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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.

v1.0 2016-12-01