1 Introduction topenlarge
These intraarticular fractures require adult principles of anatomical reduction and stable fixation.
Closed reduction can be attempted and it is sometimes possible to achieve an anatomical reduction. However, if the position is not perfect, then open reduction is required.
2 Reduction topenlarge
Reduction can be attempted using direct pressure, determined by the anatomy of the fracture.
Critical assessment of postreduction x-rays is essential. Any imperfection of position strongly indicates an open procedure.
Direct reduction using a bone clamp
Direct reduction can be achieved with a bone clamp taking care to avoid the dorsal sensory branch of the radial nerve.
Direct reduction using K-wire
For irreducible fractures, a single K-wire can be inserted (through a stab incision) into the epiphyseal fragment and used as a joystick to facilitate reduction.
Confirmation of reduction
Ideally, reduction should be confirmed using image intensification.
Pearl: An arthrogram of the wrist will give the most accurate confirmation of articular reduction.
3 K-wire fixation topenlarge
A small skin incision is made for the K-wire insertion.
This incision is deepened to the bone using a blunt artery forceps and a protective sleeve is inserted.
Care should be taken to avoid the dorsal sensory branch of the radial nerve and the dorsal sensory branch of the ulnar nerve.
Insertion of the intraepiphyseal K-wire
A smooth 1.25-1.6 mm K-wire is inserted through the radial epiphysis in a direction determined by the fracture pattern. The K-wire should ideally cross the fracture plane as near to 90° as the fracture anatomy permits.
The wire should be inserted with an oscillating drill and cooled with saline solution to prevent thermal injury.
The wire may also be inserted by hand using a T-handle.
Ideally, the K-wire is inserted using image intensifier control, in order to check the trajectory of the wire.
Alternative: Cannulated screw
In the child nearing skeletal maturity an intra epiphyseal lag screw can be inserted. Using the intraepiphyseal wire as a guide, a cannulated screw is inserted over the wire with the appropriate soft-tissue protection, provided the full instrumentation is available.
Insertion of a second K-wire
Occasionally a second wire is required to maintain the reduction.
This wire is inserted obliquely through the radial epiphysis, across the physis and engaging the medial cortex of the radial metaphysis.
Stabilization of the ulna
An oblique wire is used to stabilize the ulna using similar principles.
Ideally, reduction should be confirmed using image intensification, or arthrography.
The K-wires are left protruding through the skin, bent and cut. The skin is protected with sterile padding prior to application of a cast.
The illustration demonstrates the use of a small section of plastic tubing over the cut ends 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 topenlarge
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.
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.