Pediatric Fractures of the Forearm, Wrist and Hand

John A. Heflin, MD

Original Author: Amanda Marshall, MD; March 2004Revised:

Steven Frick, MD; August 2006John A. Heflin, MD; April 2011

Pediatric Forearm Fractures

• Approximately 40% of children’s long-bone fractures

• Most from fall to an outstretched hand• Ulna susceptible to direct blow

– “night-stick” fracture• Forearm fracture incidence increasing

– Increased sporting activity– Increased body weight

• Neurologic injury rare (<1%)

Pediatric Forearm Fracture Locations

• Proximal– Least common (approx 4%) due to decreased

lever arm and increased soft tissue envelope• Mid-shaft

– Account for 18 - 20% of both bone fractures• Distal

– Account for >75% of radius and/or ulna fractures– Approx 14% in distal physis

Pediatric Forearm Fracture Types

• Plastic Deformation– No cortical disruption– Stress higher than elastic limit of bone

• Incomplete “Greenstick” Fractures– One cortex intact– Include buckle or torus type fractures

• Complete Fractures– No cortex intact– Most unstable

Goals of Treatment

• Restore alignment and clinical appearance• Limit injury to local soft tissues• Prevention of further injury • Pain relief• Regain functional forearm rotation

– For ADL’s need 50 degrees supination, 50 degrees pronation

Pediatric ForearmPrimary ossification centers at 8 weeks gestation in

both radius and ulnaDistal physis provide most (80%) of longitudinal

growthDistal epiphyses of radius appears at age 1Distal epiphyses of distal ulna appears at age 5Normal forearm rotation:

Approx 90 degrees pronationApprox 90 degrees supination

Plastic deformation

Plastic Deformation of the Forearm

• Fixed deformation remains when bone stressed beyond elastic limit

• Most common in forearm– May be ulna and/or radius

• Periosteum remains intact– Usually no periosteal callus

• Deformation can limit pronation/supination

Chamay: Jour. Biomechanics3:263,1970

Plastic Deformation

• Remodeling not as reliable• Reduce when:

– Obvious clinical deformity– Greater than 20 degrees of angulation– Prevents reduction of a concomitant fracture– Prevents full pronation-supination in a child >4 years– Any child older than 8 years

• Requires considerable force, applied slowly • Place in well-molded long arm cast for 4 to 6

weeks

Incomplete (Greenstick) Fracture

Incomplete (Greenstick) Fractures• Minimally displaced fractures:

– Immobilized in a well-molded long arm cast • Unacceptable alignment:

– Apply pressure to apex of fracture to restore alignment and clinical appearance

– Slightly overcorrect (5-10 degrees)– Completing fracture decreases risk of recurrence of

deformity and may facilitate reduction– Apex dorsal deformity not well tolerated

Complete Fracture

Complete Fracture• Almost no intrinsic

stability to length, linear, or rotational alignment

• Muscle forces more of a deforming factor

• Typically has greater soft tissue injury

Cruess R:OCNA 4:969,1973

Closed Reduction Method• Conscious sedation/Bier

block/general anesthesia• Traction/counter-traction• Reproduce/exaggerate

deformity to unlock fragments

• Reduce/lock fragments using periosteal hinge

• Correct rotational deformity

Closed Reduction Method• Optimal forearm immobilization position in rotation:

– Apex volar: pronation– Apex dorsal: supination

• Maintain cast for 4 to 6 weeks or until radiographic evidence of union

• Conversion to a short arm cast at 3 to 4 weeks if healing adequate

• Malreduction of 10 degrees in the middle third can limit rotation by 20 to 30 degrees

Excellent Reduction with Well Molded Cast

How Much Angulation is too Much?

• Depends on fracture, location, age, stability• Closed reduction should be attempted for

any angulation greater than 20 degrees• Angulation encroaching on interosseous

space may limit rotation• Any angulation that is clinically apparent

Acceptable Limits

• Angulation– < 9 years: 15 degrees– ≥ 9 years: 10 degrees

• Malrotation– < 9 years: 45 degrees– ≥ 9 years: 30 degrees

• Shortening– Usually not a problem – includes bayonette apposition

Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad Orthop Surg 1998; 6:146-156

Remodeling Potential –Variables to Consider

• Age of child• Distance from fracture to physis

– Distal metaphyseal fractures most forgiving– Proximal forearm fractures: much less remodeling

• Angular deformities: – Physeal growth: correction of 0.8 - 1 degree per

month, or ~10 degrees per year• Rotational deformities will not remodel

After Closed Reduction and Casting

• Weekly radiographs for 3 weeks to confirm acceptable alignment and rotation

• Can re-manipulate up to 3 weeks after injury for shaft fractures

• Consider re-manipulation for angular deformity exceeding 10 degrees in children > 8 years

• Overriding (bayonette) apposition acceptable in children <8 years

Maintaining Reduction

• Appropriately molded cast most important– 3-point mold– Well formed ulnar border– Good interosseous mold

• However… it’s much easier to maintain a good reduction than a marginal one

Forearm Fractures - Complications• Malunion

– Most common• Refracture

– 13-14% radial/ulnar shaft– 1.5-2.7% distal radius

• Compartment syndrome • Synostosis

– very rare• Neurologic injury

– uncommon (<1%)

If headed for malunion…

Do not hesitate to stabilize.

Davis DR, Green DP: Forearm fractures in children: Pitfalls and complications. Clin Orthop 1976;120:172-184Tischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir 1982;107:138-48.

Rotational MalunionRemember, these will not remodel…

Cast Burns- can occur during cast removal if blade dull or improper

technique used

Indications for Internal Fixation• Open fractures• Compartment syndrome• Inability to maintain acceptable

reduction• Multi-trauma• Floating elbow• Neurologic/vascular compromise• Re-fracture with displacement

Implant Choice for Pediatric Diaphyseal Forearm Fractures

• IM nails or K-wire (2 mm typically) – Good stabilization – Minimal soft tissue dissection – Easy removal of implants– Augmented with short term above elbow cast

immobilization• Older children (10 years and above) may be

better treated as adults with plates and screws

Intramedullary Fixation

• Single bone fixation may be attempted for both bone fracture

• Stabilize second if still unstable• Either bone can be fixed first

– Start with the less comminuted and less displaced fracture

– Usually easier to begin from the ulna due to straight shape of the bone

Intramedullary Fixation

Intramedullary Fixation

• Ulna: insert rod in lateral surface of proximal ulna (olecranon)– Alternate entry point: tip of olecranon (not

recommended)• Radius: insert rod just proximal to the radial

styloid – Avoid injury to the superficial radial nerve– Alternate entry point: just proximal to Lister's

tubercle (not recommended)

Inserting Radial Rod

Intramedullary Fixation

• Pre-bend radial nail– To restore bow

• Mini - open reduction if necessary• Tap rod across fracture site

– Pushing and plunging may cause deep swelling• Leave 1cm nail flush against metaphysis

IM Fixation Complications

• Infection• Delayed union• Non-union• Prominent hardware• Hardware migration• Loss of reduction• Compartment syndrome

Plate Fixation• Provides absolute stability when there is bony apposition• Can be used to bridge comminution• More commonly used in older pediatric patients• Use if concern for compartment syndrome

– Releases the compartments thus decreasing the chance of a compartment syndrome

• Usually 3.5mm DCP type plate– At least 3 screws above and below fracture

Plate Fixation

Open Fractures

• Immediate operative stabilization of open fractures in both adults and children does not increase the infection rate

• Timing of antibiotics very important– Closer to time of injury = less risk of infection

Open Metadiaphyseal Fractures• Irrigation and debridement in the OR• Plate and screws or percutaneous

cross pinning• Antibiotics for 24 hours

Implant Removal

• In younger children, hardware usually removed (plates or IM fixation)

• Can consider removal of IM fixation at 3-6 months if solid healing on radiographs

• In older children (>10 years), plates and screws often not removed unless symptomatic– Can remove at 6 to 9 months if fracture completely

healed

Galeazzi Fracture- Radial Shaft Fracture with DRUJ Injury

• Usually at junction of middle and distal thirds

• Distal fragment typically angulated towards ulna

• Closed treatment for most

• Carefully assess DRUJ post reduction, clinically and radiographically

Galeazzi Equivalent

• Radial shaft fracture with distal ulnar physeal injury instead of DRUJ injury

• Distal ulnar physeal injuries have a high incidence of growth arrest

Galeazzi Fracture

Galeazzi Equivalent

Distal ulnar epiphysis

Previous Injury Following Closed Reduction

Distal ulnar epiphysis

Pin fixation ulnar epiphysis and ulna to radius pin with above elbow cast

Distal Radius Fractures• Most common fracture in children

– 28-30% of all fractures• Metaphyseal most frequent

– 62% of radius fractures• Distal radial physis second

– 14% of radius fractures• Simple falls most common mechanism• Rapid growth may predispose, with weaker area at

metaphysis

Distal Radius Fractures

• Metaphyseal • Physeal

– Salter II most common• Torus• Greenstick• Complete

– Volar angulation with dorsal displacement most common

Differences?• Metaphyseal

– Less compromise of carpal tunnel

– Less pain• Physeal

– More compromise of the structures in the carpal tunnel

– More pain– Sensory changes

Associated Injuries

• Distal ulnar metaphyseal fracture or ulnar styloid avulsion

• Distal ulnar physeal injury – High incidence of growth disturbance– Up to 50%

• Median or ulnar nerve injury – Rare

• Acute carpal tunnel syndrome – Also rare– More common in dorsal angulated physeal

injuries

Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal forearm fractures in children. J PediatR Orthop 1996; 16( 2): 195-200.

Nondisplaced Distal Radius Fractures - Treatment

• Below elbow immobilization

• 3 weeks• Torus fractures are

stable injuries – Still need to treat– Can treat with a

removable forearm splint

Displaced Distal Radius Physeal Fractures-Treatment

• Closed reduction usually not difficult– Traction with finger traps

(reduce shear)– Gentle dorsal push

• Immobilize – Well molded cast / splint

above or below elbow (surgeon preference)

• 3-4 weeks immobilization

Physeal Injury Reduction Maneuver

Use finger trap for traction

Gentle push to complete reduction

Majority of correction achieved with traction

“Repeated efforts at reduction do nothing more than grate the plate away.”

“These injuries unite quickly, so that attempts to correct malposition after a week are liable to do

more damage to the plate than good.”

Rang, Children’s Fractures 2005.

Treatment Recommendations - Reduction Attempts?

Treatment Recommendations

“For Salter-Harris type I and II injuries in children younger than 10 years of age, angulation of up

to 30° can be accepted. In children older than 10 years, up to 15° of

angulation is generally acceptable.”

Armstrong et al, Skeletal Trauma, 1998.

Remodeling Potential - 12 yo Male

Presented 10 days after fracture – no reduction, splinted in ED and now with early healing – no additional reduction

At 6 months – extensive remodeling of deformity noted

• Sagittal plane:– Apex volar remodels ~ 0.9 degrees per month

• Coronal Plane:– Radial deviation remodels ~ 0.8 degrees per month

• Thus, 30-350 of residual angulation needs around 5 years to completely remodel

Residual Angulation and Complete Remodeling

Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop 1990;10: 705-712.

Displaced Distal Radius Fractures – Care after Closed Reduction

• Radiograph within one week to check reduction• Do not re-manipulate physeal fractures after 5-7

days for fear of further injury to physis• Metaphyseal fractures may be re-manipulated for

2-3 weeks if alignment lost• Expect significant remodeling of any residual

deformity

Distal Radius Fractures – Potential Complications

• Growth arrest – Unusual after distal radius

physeal injury– Around 4-5%

• Malunion – Will typically remodel– Follow for one year prior to

any corrective osteotomy• Shortening

– Usually not a problem – Resolves with growth

Remodeling at 2 years

Growth Arrest following Distal Radius Fracture

Injury films Injured and uninjured wrists after premature physeal closure

Distal Radius Growth Arrest

• Relatively rare (approx 4%)

• Related To:– Severity of trauma– Amount of displacement– Repeated attempts at

reduction– Re-manipulation or late

manipulation

Distal Radius Conclusions• Most common physeal plate injury (39%)• Increased incidence of growth plate

abnormalities with 2 or more reductions• Distal radius growth arrest rate 4-5%• Acceptable alignment:

– 50% apposition– 30° angulation

• Accept malreduced fractures upon late presentation (over 7 days).

Distal Radius Fracture – Indications for Operative Treatment

• Inability to obtain acceptable reduction• Open fractures• Displaced intra-articular fractures• Associated soft tissue injuries• Soft tissue interposition• Associated fractures (SC humerus)• Associated acute carpal tunnel syndrome or

compartment syndrome

Distal Radius – Fixation Options

• Smooth K-wire fixation usually adequate– Avoid physis when possible

• Some fractures require plate fixation – Intra-articular fractures– Older pediatric/adolescent

patients• External fixation for severe

soft tissue injury

Carpal Injuries in Children

• Unusual / uncommon in children• Scaphoid fracture most common carpal fracture

– Still less than 1% of all upper extremity fractures• Capitate / Lunate / Hamate fractures can occur

(rare)• Carefully check carpal bones on every wrist film• Comparison films of uninjured wrist helpful

Acute Distal Radius Metaphyseal Fracture in a 13 year Skateboarder

• Patient gave history of a fall sustained one year ago with a “bad wrist sprain”

• Did you note the scaphoid nonunion ?

Scaphoid Fractures

Not always obvious on plain films

Scaphoid Fractures - Treatment• Tender snuff box

– Immobilize until tenderness resolves• If still tender at 1-2 weeks

– Repeat x-ray• Confirmed fracture

– If non-displaced, immobilize in above elbow cast for 6 weeks then short arm cast 4-6 weeks

• Displaced fracture – ORIF– > 1 mm displacement, 10 degrees angulation

Scaphoid Fixation• Compression screw fixation is treatment of

choice for displaced scaphoid fracture• Import to achieve anatomic reduction

Hand Fractures

• Metacarpal and phalangeal fractures – If displaced, attempt closed reduction

• Correct both angulation and rotation• Immobilize for 3-4 weeks• Indications for ORIF

– Open fractures– Displaced intra-articular fractures– Inability to obtain / maintain reduction

Phalangeal Fractures(Epidemiology)

• 43% proximal phalanx• Commonly physeal – 37% of all physeal

fractures– Usually SH II (54%)

• 30% affect small finger• 20% affect the thumb

Distal Phalangeal Fractures• Very common• Usually crush injuries • Address any associated

nail bed injuries• If open give appropriate

antibiotics, I&D • If distal end amputated:

– May heal by secondary intent

– Can attach amputated part as composite graft

Mallet Finger

• Salter Harris III injury of distal phalanx

• Extension splint for 6 weeks• ORIF or pinning for:

– Large articular fragments (>25%)

– DIP incongruity/volar subluxation

Open Physeal Fractures

• “Seymore’s fracture”• Associated with nail bed

lacerations– Germinal matrix can be

incarcerated in physis– Requires nail bed repair, I&D,

antibiotics– Commonly get infected– Often requires pinning

Phalangeal Neck Fractures

• Distal fragment rotated and extended

• Blocks IP joint flexion• Limited remodeling potential• Closed reduction and

percutaneous pinning• Malunion may require

osteotomy and pinning

Middle and Proximal Phalangeal Fractures

• Most are SH I or SH II injuries

• Majority treated with closed management

• Buddy taping and/or position of function cast

• ORIF for displaced intra-articular fractures (SH III) or instability

Can use pencil in webspace or flex MP to 90 and push radially to reduce

Reduce and Fix Displaced Intra-articular Fractures

MCP Joint Dislocations• Most common dislocation

in pediatric hand• Dorsal dislocations cause

hyperextended appearance– Metacarpal head palpable in

palm• Often require operative

reduction– Index finger most often

irreducible

Metacarpal Fractures

• 10-39% of pediatric hand fractures• Most commonly in 13-16 y/o• Most can be treated non-operatively

Metacarpal Neck Fractures

• Most common in small and ring fingers– “Boxer’s Fracture”

• Closed management for most

• Accept progressively less angulation from small finger to index– Small 30-40 degrees– Index 10-15 degrees

Metacarpal Fractures by Location• Base fractures

– 13-20%• CMC dislocations

– Rare, can occur with base fractures• Shaft fractures

– Rare, 10-14% • Neck fractures

– 56-70% (most common)• Physeal / epiphyseal fractures

– 18%Cornwall, R: Hand Clin

2006, 22, pp 1-10.

Metacarpal Shaft Fractures

• Rare, especially index• Spiral pattern – torsional mechanism

– High incidence of rotational deformity– Significant shortening can occur

• High energy injuries can have compartment syndrome

• Slower healing – 4-6 week immobilization

Intramedullary Nails for Metacarpals

• 1 Elastic stable intramedullary nail• No immobilization required• Indications:

– Sagittal >45, Frontal >10, Shortening >2 mm, any rotational malalignment

Metacarpal Base Fracture and CMC Dislocations

• Compartment syndrome can occur– Splints rather than casts initially

• Radiographs may be difficult to interpret– CT may be helpful

• Can be combined with CMC dislocation or isolated injury

Bibliography (Forearm)• Davis DR, Green DP: Forearm fractures in children: Pitfalls and

complications. Clin Orthop 1976;120:172-184• Fernandez FF et al: Failures and complications in intramedullary nailing of

children's forearm fractures. J Child Orthop 2010; 4(2):159-67• Fischer W. Forearm fractures in childhood (author's transl). Zentralbl Chir

1982;107:138-48.• Noonan JK et al: Forearm and Distal Radius Fractures in Children. J Am Acad

Orthop Surg 1998; 6:146-156• Price CT et al: Malunited forearm fractures in children. J Pediatr Orthop

1990;10: 705-712.• Rang MC: Children's Fractures, 3rd ed. Philadelphia: JB Lippincott, 2005, pp

135-163• Ray TD, Tessler RH, Dell PC. Traumatic ulnar physeal arrest after distal

forearm fractures in children. J PediatR Orthop 1996; 16( 2): 195-200.• Reinhardt KR, et al: Comparison of Intramedullary Nailing to Plating for

Both-Bone Forearm Fractures in Older Children. JPO 2008; 28(4) 403-409

Bibliography (Hand)

• Light TR. Carpal Injuries in Children. Hand Clin 2000; 16(4): 513-522

• Cornwall, R: Finger metacarpal fractures and dislocations in children. Hand Clin 2006; 22(1):1-10.

• Papadonikolakis K, et al: Fractures of the phalanges Hand Clinics 2006; 22(1) 11-18.

• Kaiser MM et al: Intramedullary nailing for metacarpal 2-5 fractures. JPO-B 2009; 18(6): 296-301

• Yeh PC, Dodds SD: Pediatric Hand Fractures. Techniques in Orthopaedics 2009; 24(3): 150-162

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