General Editor: Chris Colton

Authors: Fergal Monsell, Dalia Sepulveda

Pediatric distal forearm 23-M/3.1

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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.

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

Most of these fractures are stable after reduction and do not require fixation, particularly in younger children. In children approaching skeletal maturity instability after reduction becomes more likely.

2 Reduction top

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Indirect reduction of partially displaced, posteriorly angulated fractures

The reduction maneuver for posteriorly angulated fractures, together with some posterior translation (common) is by traction and 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 partially displaced, anteriorly angulated fractures

The reduction maneuver for anteriorly angulated fractures, together with some anterior translation (uncommon) is by traction and 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.


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Indirect reduction of completely posteriorly displaced fractures

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


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Following this, the fracture is reduced by palmarflexion (whilst continuously applying direct pressure to the epiphysis).


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Once the radius has been reduced the ulna will also usually reduce.

Ideally, this should be confirmed using image intensification.

In case of persistent malreduction of the ulna, direct pressure on either the posterior…


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…or anterior surface should produce an anatomical reduction.


Reduction is often more straightforward than single bone fractures, and may not require K-wire fixation, if stable. Relaxing the manual reduction pressure, will determine whether it is stable, as an unstable reduction will redisplace.

See:

  • Zamzam MM, Khoshhal KI. Displaced fracture of the distal radius in children: factors responsible for redisplacement after closed reduction. J Bone Joint Surg Br. 2005 Jun;87(6):841-843.

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Direct reduction using K-wire

For irreducible fractures, a percutaneous K-wire can be inserted (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. The presence of the assistant will, however, not be shown in all of the following illustrations.

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 of 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