Courtesy: Amr ABdelgawad, Maimonaides Medical Centre, Brooklyn, NYC, USA

 

Pediatric Forearm and Hand Fractures

Distal Radius Fracture

Types

• Greenstick fracture with angulation and one cortex broken.
• Torus (buckle) fracture with compression and intact cortex.
• Complete fracture.
• Metaphyseal fracture.
• Physeal fracture (Salter Harris types).

Acceptable alignment

• Up to 20 degrees of dorsal angulation (apex volar).
• Acceptable in boys up to 14 years and girls up to 12 years.

Treatment

• Closed reduction with a well molded cast.
• Close follow up to detect displacement.

Remodeling potential

• Excellent because of the highly active distal radial physis.
• Even marked angulation may remodel in younger children.

Complication: Acute carpal tunnel syndrome

• Caused by median nerve compression.
• Reduce the fracture if symptoms occur before reduction.
• Split the cast if symptoms occur after reduction.
• Persistent symptoms require carpal tunnel release and fracture stabilization.
• This is not compartment syndrome and does not require fasciotomy.

Distal Radius Physeal Fracture

Key points

• Usually Salter Harris Type I or II.
• Heals faster than metaphyseal fractures.
• Very low risk of growth arrest.

Important rule

• Presentation after 4 to 5 days should not undergo forceful reduction.
• Treat with splint or cast to avoid physeal injury.

Distal Ulna Physeal Injury

Key points

• High risk of growth arrest (30 to 40 percent).
• May result in ulnar shortening.

Management of sequelae

• Ulnar lengthening is the preferred treatment.
• Distal radial epiphysiodesis is generally avoided.

Galeazzi Fracture

Definition

• Distal radius fracture associated with distal radioulnar joint dislocation.

Features

• Usually demonstrates volar angulation with apex dorsal.
• Radius and ulna fail to overlap on the lateral radiograph.

Treatment

• Closed reduction.
• Long arm cast in supination.
• Supination reduces the distal radioulnar joint.

Scaphoid Fracture

Features

• Most commonly involves the distal pole.
• Usually nondisplaced.

Treatment

• Cast immobilization for 4 to 6 weeks.
• Surgery is rarely required.

Phalanx Fractures

Important concept

• Remodeling decreases as the fracture is located farther from the physis.

Indications for surgery

• Rotational deformity.
• Significant displacement.

Treatment

• Closed reduction and pin fixation.

Late malunion

• Ostectomy may improve function.
• Corrective osteotomy is generally avoided.

Seymour Fracture

Definition

• Open physeal fracture of the distal phalanx with nail bed entrapment.

Clinical features

• May resemble a mallet finger.
• Should always be considered an open fracture.

Treatment

• Urgent debridement.
• Open reduction.
• Nail bed repositioning.
• Pin fixation.
• Antibiotic therapy.

Base of Proximal Phalanx of the Thumb

Injury

• Bony avulsion of the ulnar collateral ligament (Skier’s thumb equivalent).

Treatment

• Open reduction and screw fixation.
• Restores metacarpophalangeal joint stability.

Extra Octave Fracture

Definition

• Salter Harris Type II fracture involving the base of the proximal phalanx of the little finger.

Treatment

• Closed reduction and splint immobilization.

Exam Pearls

• Distal radius fractures have excellent remodeling potential.
• Distal ulna physeal injuries have a high risk of growth arrest.
• Avoid forceful reduction of physeal fractures presenting after 5 days.
• Rotational deformity of finger fractures requires surgical correction.
• Seymour fracture is an open fracture requiring urgent surgery.
• Galeazzi fracture is treated with reduction and long arm casting in supination.