1 Introduction topenlarge
These fractures are usually posteriorly angulated (apex anterior) and whilst they can generally be reduced closed, occasionally impediments to reduction include periosteum, pronator quadratus and, rarely, the median nerve.
Anteriorly angulated (apex posterior) fractures are less common and are also generally reduced closed, but the extensor tendons occasionally impede reduction.
If closed reduction is unsuccessful, open reduction is required.
2 Open reduction top
As the majority of these fractures are posteriorly angulated, open reduction is most commonly performed from the anterior aspect.
A posterior approach may occasionally be necessary for irreducible anterior displacement.
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.
In multifragmentary fractures, direct K-wire leverage is not appropriate. In these fractures, direct open reduction via an anterior approach is undertaken prior to K-wire fixation.
Traction on the distal fragment via a hook assisted by a K-wire joystick in the intermediate fragment will usually facilitate anatomical reduction.
3 K-wire fixation topenlarge
Following stable reduction, single, or crossed, K-wires are usually sufficient to stabilize the fracture.
Small skin incisions are made, as required for K-wire insertion.
The 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.
For a posteriomedially inserted additional radial wire, a mini-open approach and a guide are required to protect the posterior soft tissues, particularly the extensor tendons.
A single or two crossed smooth 1.6 mm K-wires are inserted through the radial metaphysis, avoiding the growth plate and the pericondrial ring.
The lateral wire is inserted first.
The wires should be inserted with an oscillating drill and cooled with saline solution to prevent thermal injury.
The wires may also be inserted by hand using a T-handle.
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.
Pearl: For more distal fractures, it is occasionally necessary to insert antegrade wires engaging the distal radial metaphyseal flare.
The insertion incisions should be deepened to bone by spreading the tissues using a blunt artery forceps and the wires passed through protective guides.
Care should be taken that the wires do not damage the perichondrial ring of the physis.
An alternative in more distal radial fractures is to insert the wire through the radial styloid and across the radial physis. If this is undertaken, it is especially important to avoid thermal injury.
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 wires. 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 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.