Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21r-E/1.1

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1 General considerations top

Open reduction; K-wire fixation enlarge

K-wire fixation provides less stability than ESIN fixation. It needs additional cast or splint immobilization to prevent elbow movement during healing causing elbow stiffness. Other potential disadvantages include infection and cross-union.

Grossly displaced radial head enlarge

This treatment may be used for reduction and fixation of a radial head that is severely displaced or if an image intensifier is not available.

2 Instruments and implants top

Open reduction; K-wire fixation - Instruments and implants enlarge

The following equipment is needed:

  • K-wires of appropriate sizes
  • Drill or a T-handle for manual insertion
  • Wire cutting instruments
  • Standard orthopedic instrument set

3 Patient preparation top

Patient preparation enlarge

This procedure is normally performed with the patient in a supine position.

4 Approaches top

Open reduction; K-wire fixation - Approaches enlarge

A direct lateral or a posterolateral approach may be used. This is associated with a high risk of disruption of the remaining blood supply.

5 Reduction top

Protect the remaining periosteum throughout the reduction maneuvers.

Open reduction; K-wire fixation - Minimizing additional vascular damage enlarge

Pearl: Minimizing additional vascular damage to the radial head

To minimize the risk of additional vascular damage to the radial head the following procedure is recommended:

1. Attempt initial reduction of the fracture through the closed capsule.

2. If unsuccessful, perform a dorsolateral arthrotomy with irrigation of the joint. The displaced radial head can usually be seen, irrespective of the direction of displacement.

Open reduction; K-wire fixation - Manual reduction enlarge

3. Digitally reduce the head fragment.

Open reduction; K-wire fixation - Reduction with a hook enlarge

4. If the head is entrapped/displaced in an unusual direction use a dental hook or an identical shaped K-wire push/pull the radial head to an appropriate position.

6 Fixation top

Preliminary fixation

After anatomical reduction the head fragment, placed between the metaphysis of the radius and the capitellum, is usually stable. Preliminary fixation is therefore not necessary.

General K-wire principles

Use K-wires with a sharp tip.

Powered insertion of K-wires generates heat in the tissues. Insert wires with a slow-running drill or by hand.

If multiple attempts are made to insert any one K-wire the bone may be weakened or the physis may be damaged. In general, only two attempts of insertion of any K-wire are advisable.

See the additional material for further information on K-wire principles.

Open reduction; K-wire fixation - K-wire insertion enlarge

Insertion of K-wires

The K-wires must provide adequate spread at the fracture site on any view.

If the K-wire spread is inadequate, the fixation is likely to be rotationally unstable.

Pitfall: The K-wires should engage the far cortex but not protrude into the soft tissues.

Open reduction; K-wire fixation - Confirmation of K-wire position enlarge

Confirm the position of the K-wires on both AP and lateral views.

If the position is inadequate, adjust the K-wires.

Open reduction; K-wire fixation - Trimming of K-wires enlarge

Trimming of K-wires

Whether the K-wires are left outside the skin or cut and buried beneath the skin depends on the surgeon’s preference.

K-wires may be left protruding, but there is a risk of pin-track infection. The advantage is that the K-wires can be removed without anesthesia.

Open reduction; K-wire fixation - Wound closure enlarge

Wound closure

Close the wound in layers with resorbable sutures.

Final radiological documentation

Take standard x-rays in lateral and AP view.

7 Additional immobilization top

Open reduction; K-wire fixation - Additional immobilization enlarge

K-wire fixation alone confers minimal stability. Additional immobilization is required to reduce the risk of secondary displacement.

Immobilize the arm in 90° flexion of the elbow with a cast or a splint to prevent elbow movement.

v1.0 2019-08-28