Pediatric Forearm Fractures

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Pediatric Forearm Fractures

• J.J. Prosser

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Incidence

• 3.4 of all childrens fractures
• Bimodal peak with boys 9 and 13 years old
• Girls 5 years old

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0ssification

• Radial and ulnar shafts ossify during the eighth
  week of gestation
• Distal radial epiphysis age 1
• Distal ulnar epiphysis age 6
• Radial head age 5-7
• Olecranon age 9-10
• They all close between the ages of 16-18

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Anatomic Area

• Distal third 75
• Middle third 18
• Proximal third 7

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Osteology

• The periosteum is very strong and thick in a
  child
• It is generally disrupted on the convex side,
  while an intact hinge remains on the concave side
• This is an important point when considering
  closed reduction

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Biomechanics

• The radius shortens with pronation and lengthens
  with supination
• Malreduction of 10 degrees in the middle third
  limits rotation by 20-30 degrees
• Bayonet apposition does not reduce forearm
  rotation

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Deforming Muscle Forces

• Proximal third
• Biceps and supinator flexion and supination of
  proximal fragment
• Pronator teres and quadratus pronate distal
  fragment
• Middle third
• Supinator, biceps, and pronator teres proximal
  fragment is neutral
• Pronator quadratus pronates distal fragment
• Distal third
• Brachioradialis dorsiflex and radial deviate
  distal fragment

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Mechanism of injury

• Indirect fall onto an outstretched hand
• Direct blow from an object onto the radial and
  ulnar shaft
• Rotation
• Pronation flexion injury(posterior angulation)
• Supination extension injury(anterior angulation)

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Clinical evaluation

• History age, mechanism of injury, and other
  areas of pain
• Physical exam skin integrity, neurovascular
  status, and examination of elbow and wrist joints

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Radiographic evaluation

• AP and lateral of forearm, wrist, and elbow
• The bicipital tuberosity is the landmark for
  identifying rotation

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Description

• Location proximal, middle, distal
• Type
• Plastic deformation
• Incomplete(greenstick)
• Compression(torus or buckle)
• Complete

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Salter-Harris

• 75 in children 10-16 years old
• Uncommon in children lt 5 years old
• Type II most common Thurston-Holland fragment

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Monteggia

• Proximal ulna fracture with dislocation of the
  radial head
• 0.4 of all forearm fractures in children
• Peak incidence between 4 and 10 years old
• Ulna fracture usually at junction of
  proximal/middle thirds

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Galeazzi

• Middle to distal third radius fracture with
  disruption of the distal radioulnar joint
• Rare in children
• Peak incidence between 9 and 12 years old

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Initial management

• Correct gross deformity
• Perform closed reduction and application of a
  well molded long arm cast
• Forearm reduction after rotation
• Proximal third supination
• Middle third neutral
• Distal third pronation
• Split cast if concerned about swelling(uni-valve,
  bi-valve)

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Acceptable deformity

• Patients gt 10 years old, treat like adult no
  deformity accepted
• Patients lt 10 years old
• Angular deformities 1 degree/month
• - 10
  degrees/year
• Rotational deformities none
• Bayonet apposition 1cm

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Undisplaced fractures

• Long arm cast 4-6 weeks until nontender
• Elbow at 110-120 degrees of flexion

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Plastic deformation

• Children lt 4 years old or with deformities lt 20
  degrees, same as undisplaced

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Greenstick fractures

• Complete the fracture to decrease risk of angular
  deformity
• Carefully crack the intact cortex while
  preventing displacement
• Well molded long arm cast

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Complete displacement

• Attempt closed reduction and long arm cast with
  pancake molding
• If the fracture is irreducible, ORIF may be
  indicated

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Operative management

• IM fixation Enders nail, K-wires
• - limited exposure at fracture
  site may be required for reduction
• Plate fixation prime indication is one of
  refracture in which the intramedullary canal has
  a high risk of being obstructed

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Problems

• Malunion over 60 have rotational losses gt20
  degrees
• Refracture incidence of 12
• - refrain from sports 1 month
  after cast removal
• Nonunion rare in children
• - high energy, open, infection
• - ulnar gt radial
• Neurovascular injuries posterior interosseous
  nerve damage with Monteggia Type III

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Problems continued

• Compartment syndrome pain aggravated by passive
  motion
• - pressure
  gt 30mmHg
• -
  fasciotomy
• Infection - gt 6 hours before debridement(exponenti
  al growth)
• RSD rare in children
• - burning pain, hyperesthesia, and
  swelling
• - resolves 6-12 months after injury
• Overgrowth 6-8 months after injury
• - averages 6-7mm