Chapter 11: Fractures of the Distal Radius and Ulna

Jonathan G. Schoenecker, Donald S. Bae

Chapter Outline

Introduction to Fractures of the Distal Radius and Ulna

Forearm fractures are the most common long bone fractures in children, occurring with an annual incidence of approximately 1.5 per 100 children per year33 and comprising up to 40% of all pediatric fractures.13,30,33,107,122 Among all forearm fractures, the distal radius and ulna are most commonly affected.30,122,212 Peak incidence of distal radius and ulnar fractures occurs during the preadolescent growth spurt.13,30,122,212 The nondominant arm in males is most commonly affected. Several recent studies suggest that the frequency of pediatric distal radius fractures is rising, likely due to epidemiologic trends toward diminished bone density, increased body mass indices, higher-risk activities, and younger age at the time of initial sports participation.82,83,116,179 
In children younger than 15 years of age, the frequency with which these fractures occur demonstrates considerable seasonal variation.200 In a prior longitudinal study of 5,013 children over 1 year in Wales, the incidence of wrist and forearm fractures was roughly half (5.9/1,000 per year) in the three winter months compared with the rest of the year (10.7/1,000 per year). In addition, the nonwinter fractures were more severe in terms of requiring reduction and hospitalization. 
Due to the greater forces borne and imparted to the radius, as well as the increased porosity of the distal radial metaphysis, distal radial fractures are far more common than distal ulnar fractures and so, isolated distal radius fractures do occur regularly. However, fractures of the distal ulna most often occur in association with fractures of the distal radius.122,155 The metaphysis of the distal radius is the most common site of forearm fracture in children and adolescents.13,116,122 The pediatric Galeazzi injury usually involves a distal radial metaphyseal fracture and a distal ulnar physeal fracture that result in a displaced distal radioulnar joint (DRUJ). Galeazzi fracture-dislocations are relatively rare injuries in children with a cited occurrence of 3% of pediatric distal radial fractures.198 
Given the frequency with which these injuries occur, the evaluation and management of distal radius and ulna fractures in children remains a fundamental element of pediatric orthopedics. Despite established treatment principles, however, care of these injuries remain challenging due to the spectrum of injury patterns, issues of skeletal growth and remodeling, diversity of nonoperative and surgical techniques, evolving patient/family expectations, and increasing emphasis on cost-effective care. 

Assessment of Fractures of the Distal Radius and Ulna

Fractures of the Distal Radius and Ulna Injury Mechanisms

Distal Radius and Ulna Fractures

The mechanism of injury is generally a fall on an outstretched hand. Typically, the extended position of the wrist at the time of loading leads to tensile failure on the volar side of the distal forearm. (Fig. 11-1). Conversely, axial loading on the flexed wrist will produce a volarly displaced fracture with apex dorsal angulation (Fig. 11-2). Occasionally, a direct blow sustained to the distal forearm may result in fracture and displacement. In addition to the angular deformity caused by axial and bending loads applied to the distal forearm, rotational displacement may also occur, based upon the position of the forearm and torsional forces sustained at the time of injury. 
Figure 11-1
 
A: Tension failure greenstick fracture. The dorsal cortex is plastically deformed (white arrow), and the volar cortex is complete and separated (black arrows). B: Dorsal bayonet.
A: Tension failure greenstick fracture. The dorsal cortex is plastically deformed (white arrow), and the volar cortex is complete and separated (black arrows). B: Dorsal bayonet.
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Figure 11-1
A: Tension failure greenstick fracture. The dorsal cortex is plastically deformed (white arrow), and the volar cortex is complete and separated (black arrows). B: Dorsal bayonet.
A: Tension failure greenstick fracture. The dorsal cortex is plastically deformed (white arrow), and the volar cortex is complete and separated (black arrows). B: Dorsal bayonet.
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Figure 11-2
Reverse bayonet.
 
A: Typical volar bayonet fracture. Often the distal end of the proximal fragment is buttonholed through the extensor tendons (arrows). (Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.) B: Intact volar periosteum and disrupted dorsal periosteum (arrows). The extensor tendons are displaced to either side of the proximal fragment.
A: Typical volar bayonet fracture. Often the distal end of the proximal fragment is buttonholed through the extensor tendons (arrows). (Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.) B: Intact volar periosteum and disrupted dorsal periosteum (arrows). The extensor tendons are displaced to either side of the proximal fragment.
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Figure 11-2
Reverse bayonet.
A: Typical volar bayonet fracture. Often the distal end of the proximal fragment is buttonholed through the extensor tendons (arrows). (Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.) B: Intact volar periosteum and disrupted dorsal periosteum (arrows). The extensor tendons are displaced to either side of the proximal fragment.
A: Typical volar bayonet fracture. Often the distal end of the proximal fragment is buttonholed through the extensor tendons (arrows). (Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.) B: Intact volar periosteum and disrupted dorsal periosteum (arrows). The extensor tendons are displaced to either side of the proximal fragment.
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Fracture type and degree of displacement is also dependent on the height and velocity of the fall or injury mechanism.212 Indeed, the spectrum of injury may range from nondisplaced torus (or “buckle”) injuries (common in younger children with a minimal fall) or dorsally displaced fractures with apex volar angulation (more common in older children with higher-velocity injuries (Fig. 11-1). Displacement may be severe enough to cause foreshortening and bayonet apposition. Rarely, a mechanism such as a fall from a height can cause a distal radial fracture associated with a more proximal fracture of the forearm or elbow (Fig. 11-3).12,171 These “floating elbow” situations connote higher-energy trauma and as a result are associated with risks of neurovascular compromise and compartment syndrome.12,171 
Figure 11-3
A 10-year-old girl with an innocuous-appearing distal radial fracture associated with an ipsilateral angulated radial neck fracture (arrows.)
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Fractures of the distal forearm in children typically occur when the radius and/or ulna are more susceptible to fracture secondary to biomechanical changes during skeletal development. Recent work based upon load-to-strength ratio and other measures of bone quality have identified specific times during skeletal development where the biologic properties of the distal upper extremity produce relatively weaker bone, making a child more susceptible to fracture.65,109,118,145 In these studies, prepubescent boys and girls were found to have lower estimates of bone strength compared to same sex postpubertal peers. From these studies, it can be concluded that children are uniquely susceptible for fracture when longitudinal growth outpaces mineral accrual during rapid growth.13 As 90% of the radius growth is from the distal physis and accounts for 70% of the loading across the wrist, the radius is more prone to fracture than the ulna during rapid growth.200 Fractures occur at the biomechanically weakest anatomic location of bone, which also varies over time. As the metaphyseal cortex of the radius is relatively thin and porous fractures in this region are most common, followed by physeal.138,190 
Usually, fractures occur during sports-related activities. Indeed, the recent trend toward increased sports participation in children has led to a substantial increase in the incidence of distal radius and/or ulna fractures.102,211 Certain sports, such as skiing/snowboarding, basketball, soccer, football, rollerblading/skating, and hockey have been associated with an increased risk of distal radial fracture, though a fall or injury of sufficient severity may occur in any recreational activity.188 Protective wrist guards have been shown to decrease the injury rate in snowboarders, especially beginners and persons with rental equipment.173 
As cited above, there is seasonal variation, with an increase in both incidence and severity of fractures in summer.201 Children who are overweight, have poor postural balance, ligamentous laxity, or less bone mineralization are at increased risk for distal radial fractures.83,117,123,165,180,212 Although bone quality measures predict that boys had lower risk of fracture than girls at every stage except during early puberty,145 these fractures have been reported to be three times more common in boys. However, the increased participation in athletics by girls at a young age may be changing this ratio. 

Radial Physeal Stress Fractures

Repetitive axial loading of the wrist may lead to physeal stress injuries, almost always involving the radius (Fig. 11-4). These physeal stress injuries are most commonly seen in competitive gymnasts.29,47,52,191,192 Factors that predispose to this injury include excessive training, poor techniques, and attempts to advance too quickly in competitive level and have been also observed in other sports including wresting, break dancing, and cheerleading.76 
Figure 11-4
Radiographic images of the gymnast's wrist.
 
A: AP radiograph of the left wrist in a 12-year-old female demonstrates physeal widening, cystic changes, and metaphyseal sclerosis. B: AP radiograph of the same wrist after 3 months of rest from gymnastics, demonstrating incomplete resolution of the physeal changes.
A: AP radiograph of the left wrist in a 12-year-old female demonstrates physeal widening, cystic changes, and metaphyseal sclerosis. B: AP radiograph of the same wrist after 3 months of rest from gymnastics, demonstrating incomplete resolution of the physeal changes.
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Figure 11-4
Radiographic images of the gymnast's wrist.
A: AP radiograph of the left wrist in a 12-year-old female demonstrates physeal widening, cystic changes, and metaphyseal sclerosis. B: AP radiograph of the same wrist after 3 months of rest from gymnastics, demonstrating incomplete resolution of the physeal changes.
A: AP radiograph of the left wrist in a 12-year-old female demonstrates physeal widening, cystic changes, and metaphyseal sclerosis. B: AP radiograph of the same wrist after 3 months of rest from gymnastics, demonstrating incomplete resolution of the physeal changes.
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Galeazzi Fracture

Axial loading of the wrist in combination with extremes of forearm rotation (Fig. 11-5) may result in distal radius fractures with associated disruption of the DRUJ, the so-called “pediatric Galeazzi fracture.”26,40,72,122,127,135,199 In adults, the mechanism of injury usually is an axially loading fall with hyperpronation. This results in a distal radial fracture with DRUJ ligament disruption and dorsal dislocation of the ulna. However, in children, both supination (apex volar) and pronation (apex dorsal) deforming forces have been described.126,198 The mechanism of injury is most obvious when the radial fracture is incomplete. With an apex volar (supination) radial fracture, the distal ulna is displaced volarly, whereas with an apex dorsal (pronation) radial fracture, the distal ulna is displaced dorsally. This is evident both on clinical and radiographic examinations. In addition, the radius is foreshortened in a complete fracture, causing more radial deviation of the hand and wrist. In children, this injury may involve either disruption of the DRUJ ligaments or, more commonly, a distal ulnar physeal fracture (Fig. 11-6).1,170 
Figure 11-5
Supination-type Galeazzi fracture.
 
A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
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A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
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Figure 11-5
Supination-type Galeazzi fracture.
A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
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A: View of the entire forearm of an 11-year-old boy with a Galeazzi fracture-dislocation. B: Close-up of the distal forearm shows that there has been disruption of the distal radioulnar joint (arrows). The distal radial fragment is dorsally displaced (apex volar), making this a supination type of mechanism. Note that the distal ulna is volar to the distal radius. C, D: The fracture was reduced by pronating the distal fragment. Because the distal radius was partially intact by its greenstick nature, the length was easily maintained, reestablishing the congruity of the distal radioulnar joint. The patient was immobilized in supination for 6 weeks, after which full forearm rotation and function returned.
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Figure 11-6
Galeazzi fracture-dislocation variant.
 
Interposed periosteum can block reduction of the distal ulnar physis (arrow). This destabilizes the distal radial metaphyseal fracture.
 
(Reprinted from Lanfried MJ, Stenclik M, Susi JG. Variant of Galeazzi fracture–dislocation in children. J Pediatr Orthop. 1991; 11:333, with permission.)
Interposed periosteum can block reduction of the distal ulnar physis (arrow). This destabilizes the distal radial metaphyseal fracture.
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Figure 11-6
Galeazzi fracture-dislocation variant.
Interposed periosteum can block reduction of the distal ulnar physis (arrow). This destabilizes the distal radial metaphyseal fracture.
(Reprinted from Lanfried MJ, Stenclik M, Susi JG. Variant of Galeazzi fracture–dislocation in children. J Pediatr Orthop. 1991; 11:333, with permission.)
Interposed periosteum can block reduction of the distal ulnar physis (arrow). This destabilizes the distal radial metaphyseal fracture.
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Injuries Associated with Fractures of the Distal Radius and Ulna

The risk of associated injuries is significantly less in the skeletally immature as compared to skeletally mature patients.58 The entire ipsilateral extremity should be carefully examined for fractures of the carpus, forearm, or elbow.12,32,91,120,171,182,193 Indeed, 3% to 13% of distal radial fractures have associated ipsilateral extremity fractures.182 Associated fractures of the hand and elbow regions need to be assessed because their presence implies more severe trauma. For example, the incidence of a compartment syndrome is higher with a “floating elbow” combination of radial, ulnar, and elbow fractures.171 
With marked radial or ulnar fracture displacement, neurovascular compromise can occur.15,44,203 Median neuropathy may be seen in severely displaced distal radius fractures, due to direct nerve contusion sustained at the time of fracture displacement, persistent pressure or traction from an unreduced fracture, or an acute compartment syndrome (Fig. 11-7).203 Ulnar neuropathy has been described with similar mechanisms, as well as entrapment or incarceration of the ulnar nerve within the fracture site. 
Figure 11-7
Volar forearm anatomy outlining the potential compression of the median nerve between the metaphysis of the radius and dorsally displaced physeal fracture.
 
The taut volar transverse carpal ligament and fracture hematoma also are contributing factors.
 
(Redrawn from Waters PM, Kolettis GJ, Schwend R. Acute median neuropathy following physeal fractures of the distal radius. J Pediatr Orthop. 1994; 14:173–177, with permission.)
The taut volar transverse carpal ligament and fracture hematoma also are contributing factors.
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Figure 11-7
Volar forearm anatomy outlining the potential compression of the median nerve between the metaphysis of the radius and dorsally displaced physeal fracture.
The taut volar transverse carpal ligament and fracture hematoma also are contributing factors.
(Redrawn from Waters PM, Kolettis GJ, Schwend R. Acute median neuropathy following physeal fractures of the distal radius. J Pediatr Orthop. 1994; 14:173–177, with permission.)
The taut volar transverse carpal ligament and fracture hematoma also are contributing factors.
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Wrist ligamentous and articular cartilage injuries have been described in association with distal radial and ulnar fractures in adults and less commonly in children.12,55 Concomitant scaphoid fractures have occurred (Fig. 11-8).32,41,194 Associated wrist injuries need to be treated both in the acute setting and in the patient with persistent pain after fracture healing. Some patients with distal radial and ulnar fractures are multitrauma victims. Care of the distal forearm fracture in these situations must be provided within the context of concomitant systemic injuries. More than 50% of distal radial physeal fractures have an associated ulnar fracture. This usually is an ulnar styloid fracture, but can be a distal ulnar plastic deformation, greenstick, or complete fracture.33,107,123,190 
Figure 11-8
Coronal computed tomography (CT) image of an adolescent with ipsilateral distal radius and scaphoid fractures.
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Isolated ulnar physeal fractures are rare injuries.1,183 Most ulnar physeal fractures occur in association with radial metaphyseal or physeal fractures. Physeal separations are classified by the standard Salter–Harris criteria. The rare pediatric Galeazzi injury usually involves an ulnar physeal fracture rather than a soft tissue disruption of the DRUJ. Another ulnar physeal fracture is an avulsion fracture off the distal aspect of the ulnar styloid.1 Although an ulnar styloid injury is an epiphyseal avulsion, it can be associated with soft tissue injuries of the TFCC and ulnocarpal joint, though does not typically cause growth-related complications. 

Signs and Symptoms of Fractures of the Distal Radius and Ulna

Fractures of the Distal Radius and Ulna

Children with distal radial and/or ulnar fractures present with pain, swelling, and deformity of the distal forearm (Fig. 11-9). The clinical signs depend on the degree of fracture displacement. With a nondisplaced torus fracture in a young child, medical attention may not be sought until several days after injury; the intact periosteum and biomechanical stability is protective in these injuries, resulting in minimal pain and guarding. Similarly, many of the physeal injuries are nondisplaced and present only with pain and tenderness at the physis.142,154 With displaced fractures, the typical dorsal displacement and apex volar angulation create an extension deformity that is usually clinically apparent. Careful inspection of the forearm is critical to evaluate for possible skin lacerations, wounds, and open fractures. 
Figure 11-9
Dorsal bayonet deformity.
 
A: Typical distal metaphyseal fracture with dorsal bayonet showing a dorsal angulation of the distal forearm. B: Usually, the periosteum is intact on the dorsal side and disrupted on the volar side.
A: Typical distal metaphyseal fracture with dorsal bayonet showing a dorsal angulation of the distal forearm. B: Usually, the periosteum is intact on the dorsal side and disrupted on the volar side.
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Figure 11-9
Dorsal bayonet deformity.
A: Typical distal metaphyseal fracture with dorsal bayonet showing a dorsal angulation of the distal forearm. B: Usually, the periosteum is intact on the dorsal side and disrupted on the volar side.
A: Typical distal metaphyseal fracture with dorsal bayonet showing a dorsal angulation of the distal forearm. B: Usually, the periosteum is intact on the dorsal side and disrupted on the volar side.
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With greater displacement, physical examination is often limited by the patient's pain and anxiety, but it is imperative to obtain an accurate examination of the motor and sensory components of the radial, median, and ulnar nerves before treatment is initiated. Neurovascular compromise is uncommon but can occur.203 A prior prospective study indicated an 8% incidence of nerve injury in children with distal radial fractures.204 Median nerve irritability or dysfunction is most common, caused by direct trauma to the nerve at the time of injury or ongoing ischemic compression from the displaced fracture. Median nerve motor function is evaluated by testing the abductor pollicis brevis (intrinsic) and flexor pollicis longus (extrinsic) muscles. Ulnar nerve motor evaluation includes testing the first dorsal interosseous (intrinsic), abductor digit quinti (intrinsic), and flexor digitorum profundus to the small finger (extrinsic) muscles. Radial nerve evaluation involves testing the common digital extensors for metacarpophalangeal joint extension as well as extensor pollicis longus. Sensibility to light touch and two-point discrimination should be tested. Normal two-point discrimination is less than 5 mm but may not be reliably tested in children younger than 5 to 7 years of age. Pin-prick sensibility testing will only hurt and scare the already anxious child and should be avoided. 

Radial Physeal Stress Fracture

In contrast to the child with an acute, traumatic distal radius fracture, patients with distal radial physeal stress injuries typically report recurring, activity-related wrist pain. Characteristically, this pain is described as diffuse “aching” and “soreness” in the region of the distal radial metaphysis and physis. Pain may be reproduced in the extremes of wrist extension and flexion, and usually there is local tenderness over the dorsal, distal radial physis. Resistive strength testing of the wrist extensors will also reproduce the pain. There may be fusiform swelling about the wrist if there is reactive bone formation. The differential diagnosis includes physeal stress injury, ganglion, ligamentous or TFCC injury, tendinosis or musculotendinous strain, carpal fracture, and osteonecrosis of the scaphoid (Preiser disease) or lunate (Kienbock disease). Diagnosis is made radiographically in the context of the clinical presentation. 

Galeazzi Fracture

Children with Galeazzi injuries present with pain, limited forearm rotation, and limited wrist flexion and extension. Neurovascular impairment is rare. The radial deformity usually is clinically evident. Prominence of the ulnar head is seen with DRUJ disruption. Ligamentous disruption is often subtle and may be evident only by local tenderness and instability to testing of the DRUJ. 

Imaging and Other Diagnostic Studies Fractures of the Distal Radius and Ulna

Plain radiographs are diagnostic of the fracture type and degree of displacement. Standard anteroposterior (AP) and lateral radiographs usually are sufficient. Complete wrist, forearm, and elbow views are recommended in cases of high-energy injuries or when there is clinical suspicion for an ipsilateral fracture of the hand, wrist, or elbow. More extensive radiographic evaluation (e.g., computed tomography [CT], magnetic resonance imaging [MRI]) is typically reserved for evaluation of suspected or known intra-articular fractures or associated carpal injuries (e.g., scaphoid fractures, hook of hamate fractures, perilunate instability); these situations are most commonly encountered in older adolescents. 
There has been increasing enthusiasm for the use of ultrasound in the diagnostic evaluation of distal radius and ulna fractures.28,60,99,142,154,162 Two independent studies have demonstrated the feasibility and accuracy of bedside ultrasound for diagnosing nondisplaced fractures28,162 Ultrasonography is most useful in cases of suspected fractures in the absence of plain radiographic abnormalities, or in very young children in whom the skeletal structures are incompletely ossified. 
Radiographic evaluation should be performed not only to confirm the diagnosis but also to quantify the degree of displacement, angulation, malrotation, and comminution (Fig. 11-10). Understanding of the normal radiographic parameters is essential in quantifying displacement. In adults, the normal distal radial inclination averages 22 degrees on the AP view and 11 degrees of volar tilt on the lateral projection.73,137,148,181,220 Radial inclination is a goniometric measurement of the angle between the distal radial articular surface and a line perpendicular to the radial shaft on the AP radiograph. Volar tilt is measured by a line across the distal articular surface and a line perpendicular to the radial shaft on the lateral view. Pediatric values for radial inclination and volar tilt may vary from adult normative values, depending on the degree of skeletal maturity and the ossification of the epiphysis. Indeed, radial inclination is often less than 22 degrees in younger children, though volar tilt tends to be more consistent regardless of patient age. 
Figure 11-10
Angulation of the x-ray beam tangential to the articular surface, providing the optimal lateral view of the distal radius.
 
The wrist is positioned as for the standard lateral radiograph, but the x-ray beam is directed 15 degrees cephalad.
 
(Redrawn from Johnson PG, Szabo RM. Angle measurements of the distal radius: A cadaver study. Skel Radiol. 1993; 22:243, with permission.)
The wrist is positioned as for the standard lateral radiograph, but the x-ray beam is directed 15 degrees cephalad.
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Figure 11-10
Angulation of the x-ray beam tangential to the articular surface, providing the optimal lateral view of the distal radius.
The wrist is positioned as for the standard lateral radiograph, but the x-ray beam is directed 15 degrees cephalad.
(Redrawn from Johnson PG, Szabo RM. Angle measurements of the distal radius: A cadaver study. Skel Radiol. 1993; 22:243, with permission.)
The wrist is positioned as for the standard lateral radiograph, but the x-ray beam is directed 15 degrees cephalad.
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As noted above, advanced imaging may be helpful in cases of intra-articular extension to characterize fracture pattern and joint congruity. This may be done by AP and lateral tomograms, CT scans, or MRI. Dynamic motion studies with fluoroscopy can provide important information on fracture stability and the success of various treatment options. Dynamic fluoroscopy requires adequate pain relief and has been used more often in adult patients with distal radial fractures. 
Radiographs are also diagnostic in cases of suspected distal radial physeal stress injuries. Physeal widening, cystic and sclerotic changes in the metaphyseal aspect of the distal radial physis, beaking of the distal radial epiphysis, and reactive bone formation are highly suggestive of chronic physeal stress fracture. In advanced cases, premature physeal closure or physeal bar formation may be seen, indicating long-standing stress.29,47,52,174,192,213 In these situations, continued ulnar growth leads to an ulnar positive variance with resulting pain from ulnocarpal impaction and/or TFCC tear.12,174,213 Plain radiographs may not reveal early physeal stress fracture. If the diagnosis is suggested clinically, additional studies may be indicated. Technicium bone scanning is sensitive but nonspecific. MRI is usually diagnostic, demonstrating the characteristic “double line” on coronal T1 and gradient echo sequences.128 
In Galeazzi fractures, the radial fracture is readily apparent on plain radiographs. Careful systematic evaluation of the radiographs will reveal concurrent injuries to the ulna and/or DRUJ (Fig. 11-11). A true lateral radiograph is essential to identify the direction of displacement and thus to determine the method of reduction. Rarely are advanced imaging studies, such as CT or MRI scan, are necessary. 
Careful inspection reveals a distal ulnar physeal fracture.
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Figure 11-11
Lateral radiograph depicting volar subluxation of the distal ulna in relation to the distal radius, a pediatric Galeazzi equivalent.
Careful inspection reveals a distal ulnar physeal fracture.
Careful inspection reveals a distal ulnar physeal fracture.
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Classification Fractures of the Distal Radius and Ulna

Distal Radius and Ulna Fractures

Distal radius and ulna fractures are classified according to fracture pattern, type of associated ulnar fracture, and direction of displacement, angulation, and rotation. Most distal radial metaphyseal fractures are displaced dorsally with apex volar angulation.190 Volar displacement with apex dorsal angulation occurs less commonly with volar flexion mechanisms. 
Distal radial and ulnar fractures are then defined by their anatomic relationship to the physis. Physeal fractures are classified by the widely accepted Salter–Harris system (see below).27,175 Metaphyseal injuries are often different from their adult equivalents, due to the thick periosteum surrounding the relatively thin metaphyseal cortex. Metaphyseal fractures are generally classified according to fracture pattern and may be torus fractures, greenstick or incomplete fractures, or complete bicortical injuries. Pediatric equivalents of adult Galeazzi fracture-dislocations involve a distal radial fracture and either a soft tissue disruption of the DRUJ or a physeal fracture of the distal ulna (Table 11-1). 
 
Table 11-1
Distal Forearm Fractures: General Classification
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Table 11-1
Distal Forearm Fractures: General Classification
Physeal fractures
  •  
    Distal radius
  •  
    Distal ulna
Distal metaphyseal (radius or ulna)
  •  
    Torus
  •  
    Greenstick
  •  
    Complete fractures
Galeazzi fracture-dislocations
  •  
    Dorsal displaced
  •  
    Volar displaced
X

Physeal Injuries

The Salter–Harris system is the basis for classification of physeal fractures.174 Most are Salter–Harris type II fractures.27 In the more common apex volar injuries, dorsal displacement of the distal epiphysis and the dorsal Thurston–Holland metaphyseal fragment is evident on the lateral view (Fig. 11-12). Salter–Harris type I fractures also usually displace dorsally. Volar displacement of either a Salter–Harris type I or II fracture is less common (Fig. 11-13). Nondisplaced Salter–Harris type I fractures may be indicated only by a displaced pronator fat pad sign (Fig. 11-14),175,218 ultrasound,28,99,153 or tenderness over the involved physis.141,153 A scaphoid fat pad sign may indicate a scaphoid fracture (Fig. 11-15).94 
Figure 11-12
Dorsally displaced physeal fracture (type A).
 
The distal epiphysis with a small metaphyseal fragment is displaced dorsally (curved arrow) in relation to the proximal metaphyseal fragment.
The distal epiphysis with a small metaphyseal fragment is displaced dorsally (curved arrow) in relation to the proximal metaphyseal fragment.
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Figure 11-12
Dorsally displaced physeal fracture (type A).
The distal epiphysis with a small metaphyseal fragment is displaced dorsally (curved arrow) in relation to the proximal metaphyseal fragment.
The distal epiphysis with a small metaphyseal fragment is displaced dorsally (curved arrow) in relation to the proximal metaphyseal fragment.
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Figure 11-13
Volarly displaced physeal fracture (type B).
 
Distal epiphysis with a large volar metaphyseal fragment is displaced in a volar direction (curved arrow).
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:21, with permission.)
Distal epiphysis with a large volar metaphyseal fragment is displaced in a volar direction (curved arrow).
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Figure 11-13
Volarly displaced physeal fracture (type B).
Distal epiphysis with a large volar metaphyseal fragment is displaced in a volar direction (curved arrow).
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:21, with permission.)
Distal epiphysis with a large volar metaphyseal fragment is displaced in a volar direction (curved arrow).
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Figure 11-14
 
A: Subperiosteal hemorrhage from an occult fracture of the distal radius causes an anterior displacement of the normal pronator quadratus fat pad (arrows). B: A 13-year-old girl with tenderness over the distal radius after a fall. The only radiographic finding is an anterior displacement of the normal pronator quadratus fat pad (arrow). C: The opposite normal side (arrow indicates normal fat pad). D: Two weeks later, there is a small area of periosteal new bone formation (arrow) anteriorly, substantiating that bony injury has occurred.
A: Subperiosteal hemorrhage from an occult fracture of the distal radius causes an anterior displacement of the normal pronator quadratus fat pad (arrows). B: A 13-year-old girl with tenderness over the distal radius after a fall. The only radiographic finding is an anterior displacement of the normal pronator quadratus fat pad (arrow). C: The opposite normal side (arrow indicates normal fat pad). D: Two weeks later, there is a small area of periosteal new bone formation (arrow) anteriorly, substantiating that bony injury has occurred.
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Figure 11-14
A: Subperiosteal hemorrhage from an occult fracture of the distal radius causes an anterior displacement of the normal pronator quadratus fat pad (arrows). B: A 13-year-old girl with tenderness over the distal radius after a fall. The only radiographic finding is an anterior displacement of the normal pronator quadratus fat pad (arrow). C: The opposite normal side (arrow indicates normal fat pad). D: Two weeks later, there is a small area of periosteal new bone formation (arrow) anteriorly, substantiating that bony injury has occurred.
A: Subperiosteal hemorrhage from an occult fracture of the distal radius causes an anterior displacement of the normal pronator quadratus fat pad (arrows). B: A 13-year-old girl with tenderness over the distal radius after a fall. The only radiographic finding is an anterior displacement of the normal pronator quadratus fat pad (arrow). C: The opposite normal side (arrow indicates normal fat pad). D: Two weeks later, there is a small area of periosteal new bone formation (arrow) anteriorly, substantiating that bony injury has occurred.
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Figure 11-15
Anatomic relationships of the navicular fat stripe (NFS).
 
The NFS, shaded black, is located between the combined tendons of the abductor pollicis longus and extensor pollicis brevis, and the lateral surface of the carpal navicular.
 
(Adapted from Terry DW, Ramen JE. The navicular fat stripe. Ham J Roent Rad Ther Nucl Med. 1975; 124: 25, with permission.)
The NFS, shaded black, is located between the combined tendons of the abductor pollicis longus and extensor pollicis brevis, and the lateral surface of the carpal navicular.
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Figure 11-15
Anatomic relationships of the navicular fat stripe (NFS).
The NFS, shaded black, is located between the combined tendons of the abductor pollicis longus and extensor pollicis brevis, and the lateral surface of the carpal navicular.
(Adapted from Terry DW, Ramen JE. The navicular fat stripe. Ham J Roent Rad Ther Nucl Med. 1975; 124: 25, with permission.)
The NFS, shaded black, is located between the combined tendons of the abductor pollicis longus and extensor pollicis brevis, and the lateral surface of the carpal navicular.
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Salter–Harris type III fractures are rare and may be caused by a compression, shear, or avulsion of the radial origin of the volar radiocarpal ligaments (Fig. 11-16).9,125 Triplane equivalent fractures,157 a combination of Salter–Harris type II and III fractures in different planes, have similarly been reported but are rare. CT scans may be necessary to define the fracture pattern and degree of intra-articular displacement. 
Figure 11-16
AP radiograph of Salter–Harris type III fracture of the distal radius.
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Metaphyseal Injuries

Metaphyseal fracture patterns are classified as torus, incomplete or greenstick, and complete fractures (Fig. 11-17). This system of classification has been shown to have good agreement between experienced observers.167 Torus fractures are axial compression injuries. The site of cortical failure is the transition from metaphysis to diaphysis.128 As the mode of failure is compression, these injuries are inherently stable and are further stabilized by the intact surrounding periosteum. Rarely, they may extend into the physis, putting them at risk for growth impairment.155,156,158 
Figure 11-17
Metaphyseal biomechanical patterns.
 
A: Torus fracture. Simple bulging of the thin cortex (arrow). B: Compression greenstick fracture. Angulation of the dorsal cortex (large curved arrow). The volar cortex is intact but slightly plastically deformed (small white arrows). C: Complete length maintained. Both cortices are completely fractured, but the length of the radius has been maintained.
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:24, with permission.)
A: Torus fracture. Simple bulging of the thin cortex (arrow). B: Compression greenstick fracture. Angulation of the dorsal cortex (large curved arrow). The volar cortex is intact but slightly plastically deformed (small white arrows). C: Complete length maintained. Both cortices are completely fractured, but the length of the radius has been maintained.
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Figure 11-17
Metaphyseal biomechanical patterns.
A: Torus fracture. Simple bulging of the thin cortex (arrow). B: Compression greenstick fracture. Angulation of the dorsal cortex (large curved arrow). The volar cortex is intact but slightly plastically deformed (small white arrows). C: Complete length maintained. Both cortices are completely fractured, but the length of the radius has been maintained.
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:24, with permission.)
A: Torus fracture. Simple bulging of the thin cortex (arrow). B: Compression greenstick fracture. Angulation of the dorsal cortex (large curved arrow). The volar cortex is intact but slightly plastically deformed (small white arrows). C: Complete length maintained. Both cortices are completely fractured, but the length of the radius has been maintained.
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Incomplete or greenstick fractures occur with a combination of compressive, tensile, and rotatory forces, resulting in complete failure of one cortex and plastic deformation of the other cortex. Most commonly, the combined extension and supination forces lead to tensile failure of the volar cortex and dorsal compression injury. The degree of force determines the amount of plastic deformation, dorsal comminution, and fracture angulation and rotation. 
With greater applied loads, complete fracture occurs with disruption of both the volar and dorsal cortices. Length may be maintained with apposition of the proximal and distal fragments. Frequently, the distal fragment lies proximal and dorsal to the proximal fragment in bayonet apposition (Table 11-2). 
 
Table 11-2
Classification: Distal Metaphyseal Fractures
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Table 11-2
Classification: Distal Metaphyseal Fractures
Directional displacement
Fracture combinations
  •  
    Isolated radius
  •  
    Radius with ulna
  •  
    Ulnar styloid
  •  
    Ulnar physis
  •  
    Ulnar metaphysis, incomplete
  •  
    Ulnar metaphysis, complete
Biomechanical patterns
  •  
    Torus
  •  
    Greenstick
  •  
    One cortex
  •  
    Two cortices
  •  
    Complete fracture
  •  
    Length maintained
  •  
    Bayonet apposition
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Ulnar fractures often associated with radial metaphyseal injuries may occur in the metaphysis, physis, or through the ulnar styloid. Similar to radial metaphyseal fractures, the ulnar fracture can be complete or incomplete. These injuries are also characterized according to fracture pattern and displacement. 
Distal radial fractures also can occur in conjunction with more proximal forearm fractures,19,203 Monteggia fracture-dislocations,18 supracondylar distal humeral fractures,170,181 or carpal fractures.32,41,91,119 The combination of a displaced supracondylar distal humeral fracture and a displaced distal radial metaphyseal fracture has been called the pediatric floating elbow. This injury combination is unstable and has an increased risk for malunion and neurovascular compromise. 

Distal Ulna Fractures

Isolated ulnar physeal fractures are rare, as most ulnar physeal injuries occur in association with radial metaphyseal or physeal fractures.1,182 Physeal injuries are classified according to the Salter–Harris classification.155 Ulnar physeal fractures may also be seen with the pediatric Galeazzi injuries,169 which usually involve an ulnar physeal fracture rather than a soft tissue disruption of the DRUJ. 
Avulsion fractures of the ulnar styloid also represent epiphyseal avulsion injuries. Most commonly associated with distal radial fractures,1,182 these styloid fractures typically represent soft tissue avulsions of the ulnar insertion of the TFCC or ulnocarpal ligaments12 and are rarely associated with growth-related complications. 

Galeazzi Fracture

Galeazzi fracture-dislocations are most commonly described by direction of displacement of either the distal ulnar dislocation or the radial fracture.126 Letts preferred to describe the direction of the ulna: volar or dorsal.77,198 Others classified pediatric Galeazzi injuries by the direction of displacement of the distal radial fracture. Dorsally displaced (apex volar) fractures were more common than volarly displaced (apex dorsal) injuries in their series. Wilkins and O'Brien209 modified the Walsh and McLaren method by classifying radial fractures as incomplete and complete fractures and ulnar injuries as true dislocations versus physeal fractures (Table 11-3). DRUJ dislocations are called true Galeazzi lesions and distal ulnar physeal fractures are called pediatric Galeazzi equivalents.109,121,126 
 
Table 11-3
Classification: Galeazzi Fractures in Children
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Table 11-3
Classification: Galeazzi Fractures in Children
Type I: Dorsal (apex volar) displacement of distal radius
  •  
    Radius fracture pattern
  •  
    Greenstick
  •  
    Complete
  •  
    Distal ulna physis
  •  
    Intact
  •  
    Disrupted (equivalent)
Type II: Volar (apex dorsal) displacement of distal radius
  •  
    Radius fracture pattern
  •  
    Greenstick
  •  
    Complete
  •  
    Distal ulna physis
  •  
    Intact
  •  
    Disrupted
 

Data from Walsh HPJ, McLaren CAN, Owen R. Galeazzi fractures in children. J Bone Joint Surg Br. 1987; 69B:730–733.

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Pathoanatomy and Applied Anatomy Relating to Fractures of the Distal Radius and Ulna

The distal radial epiphysis normally appears between 0.5 and 2.3 years in boys and 0.4 and 1.7 years in girls.73,147,136 Initially transverse in appearance, it rapidly becomes more adultlike with its triangular shape. The contour of the radial styloid progressively elongates with advancing skeletal maturity. The secondary center of ossification for the distal ulna appears at about age.147 Similar to the radius, the ulnar styloid appears with the adolescent growth spurt. It also becomes more elongated and adultlike until physeal closure. On average, the ulnar physis closes at age 16 in girls and age 17 in boys, whereas the radial physis closes on average 6 months later than the ulnar physis.172,220 The distal radial and ulnar physes contribute approximately 75% to 80% of the growth of the forearm and 40% of the growth of the upper extremity (Fig. 11-18).148 
Figure 11-18
Ossification of the distal radius.
 
A: Preossification distal radius with transverse ossification in a 15-month-year-old boy. B: The triangular secondary ossification center of the distal radius in a 2-year-old girl. C: The initial ossification center of the styloid in this 7-year-old girl progresses radially (arrow). D: Extension of the ulnar ossification center into the styloid process of an 11-year-old. E: The styloid is fully ossified and the epiphyses have capped their relative metaphyses in this 13-year-old boy.
A: Preossification distal radius with transverse ossification in a 15-month-year-old boy. B: The triangular secondary ossification center of the distal radius in a 2-year-old girl. C: The initial ossification center of the styloid in this 7-year-old girl progresses radially (arrow). D: Extension of the ulnar ossification center into the styloid process of an 11-year-old. E: The styloid is fully ossified and the epiphyses have capped their relative metaphyses in this 13-year-old boy.
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Figure 11-18
Ossification of the distal radius.
A: Preossification distal radius with transverse ossification in a 15-month-year-old boy. B: The triangular secondary ossification center of the distal radius in a 2-year-old girl. C: The initial ossification center of the styloid in this 7-year-old girl progresses radially (arrow). D: Extension of the ulnar ossification center into the styloid process of an 11-year-old. E: The styloid is fully ossified and the epiphyses have capped their relative metaphyses in this 13-year-old boy.
A: Preossification distal radius with transverse ossification in a 15-month-year-old boy. B: The triangular secondary ossification center of the distal radius in a 2-year-old girl. C: The initial ossification center of the styloid in this 7-year-old girl progresses radially (arrow). D: Extension of the ulnar ossification center into the styloid process of an 11-year-old. E: The styloid is fully ossified and the epiphyses have capped their relative metaphyses in this 13-year-old boy.
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The distal radius articulates with the distal ulna at the DRUJ.177 Both the radius and ulna articulate with the carpus, serving as the platform for the carpus and hand. The radial joint surface has three concavities for its articulations: the scaphoid and lunate fossa for the carpus and the sigmoid notch for the ulnar head. These joints are stabilized by a complex series of volar and dorsal radiocarpal, ulnocarpal, and radioulnar ligaments. The volar ligaments are the major stabilizers. Starting radially at the radial styloid, the radial collateral, radioscaphocapitate, radiolunotriquetral (long radiolunate), and radioscapholunate (short radiolunate) ligaments volarly stabilize the radiocarpal joint. The dorsal radioscaphoid and radial triquetral ligaments are less important stabilizers. The complex structure of ligaments stabilize the radius, ulna, and carpus through the normal wrist motion of 120 degrees of flexion and extension, 50 degrees of radial and ulnar deviation, and 150 degrees of forearm rotation.150 
The triangular fibrocartilage complex (TFCC) is the primary stabilizer of the ulnocarpal and radioulnar articulations.150 It extends from the sigmoid notch of the radius across the DRUJ and inserts into the base of the ulnar styloid. It also extends distally as the ulnolunate, ulnotriquetral, and ulnar collateral ligaments and inserts into the ulnar carpus and base of the fifth metacarpal.150 The volar ulnocarpal ligaments (V ligament) from the ulna to the lunate and triquetrum are important ulnocarpal stabilizers.22,178 The central portion of the TFCC is the articular disk (Fig. 11-19). The interaction between the bony articulation and the soft tissue attachments accounts for stability of the DRUJ during pronation and supination.151 At the extremes of rotation, the joint is most stable. The compression loads between the radius and ulna are aided by the tensile loads of the TFCC to maintain stability throughout rotation. 
Figure 11-19
Diagrammatic drawing of the TFCC and the prestyloid recess.
 
The meniscal reflection runs from the dorsoulnar radius to the ulnovolar carpus. The arrow denotes access under the reflection to the tip of the styloid the so-called prestyloid recess.
 
(Redrawn from Bowers WH. Green's Operative Hand Surgery. New York, NY: Churchill-Livingstone, 1993.)
The meniscal reflection runs from the dorsoulnar radius to the ulnovolar carpus. The arrow denotes access under the reflection to the tip of the styloid the so-called prestyloid recess.
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Figure 11-19
Diagrammatic drawing of the TFCC and the prestyloid recess.
The meniscal reflection runs from the dorsoulnar radius to the ulnovolar carpus. The arrow denotes access under the reflection to the tip of the styloid the so-called prestyloid recess.
(Redrawn from Bowers WH. Green's Operative Hand Surgery. New York, NY: Churchill-Livingstone, 1993.)
The meniscal reflection runs from the dorsoulnar radius to the ulnovolar carpus. The arrow denotes access under the reflection to the tip of the styloid the so-called prestyloid recess.
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The interosseous ligament of the forearm (Fig. 11-20) helps stabilize the radius and ulna more proximally in the diaphysis of the forearm. The ulna remains relatively immobile as the radius rotates around it. Throughout the midforearm, the interosseous ligament connects the radius to the ulna. It passes obliquely from the proximal radius to the distal ulna. However, the interosseous ligament is not present in the distal radius. Moore et al.140 found that injuries to the TFCC and interosseous ligament were responsible for progressive shortening of the radius with fracture in a cadaveric study. The soft tissue component to the injury is a major factor in the deformity and instability in a Galeazzi fracture-dislocation. 
Figure 11-20
The attachment and the fibers of the interosseous membrane are such that there is no attachment to the distal radius.
 
(Redrawn from Kraus B, Horne G. Galeazzi fractures. J Trauma. 1985; 25:1094, with permission.)
(Redrawn from 


Kraus B,

Horne G
.
Galeazzi fractures.
J Trauma.
1985; 25:1094, with permission.)
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Figure 11-20
The attachment and the fibers of the interosseous membrane are such that there is no attachment to the distal radius.
(Redrawn from Kraus B, Horne G. Galeazzi fractures. J Trauma. 1985; 25:1094, with permission.)
(Redrawn from 


Kraus B,

Horne G
.
Galeazzi fractures.
J Trauma.
1985; 25:1094, with permission.)
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The length relationship between the distal radius and ulna at the wrist is defined as ulnar variance. In adults, this is measured by the relationship of the radial corner of the distal ulnar articular surface to the ulnar corner of the radial articular surface.100 However, measurement of ulnar variance in children requires modifications of this technique. Hafner89 described measuring from the ulnar metaphysis to the radial metaphysis to lessen the measurement inaccuracies related to epiphyseal size and shape, a technique recently validated by Goldfarb (Fig. 11-21).80 If the ulna and radius are of equal lengths, there is a neutral variance. If the ulna is longer, there is a positive variance. If the ulna is shorter, there is a negative variance. Variance measurement is usually made in millimeters. 
Figure 11-21
Hafner's technique to measure ulnar variance.
 
A: The distance from the most proximal point of the ulnar metaphysis to the most proximal point of the radial metaphysis. B: The distance from the most distal point of the ulnar metaphysis to the most distal point of the radial metaphysis.
 
(Adapted from Hafner R, Poznanski AK, Donovan JM. Ulnar variance in children. Standard measurements for evaluation of ulnar shortening in juvenile rheumatoid arthritis, hereditary multiple exostosis and other bone or joint disorders in childhood. Skel Radiol. 1989; 18:514, with permission.)
A: The distance from the most proximal point of the ulnar metaphysis to the most proximal point of the radial metaphysis. B: The distance from the most distal point of the ulnar metaphysis to the most distal point of the radial metaphysis.
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Figure 11-21
Hafner's technique to measure ulnar variance.
A: The distance from the most proximal point of the ulnar metaphysis to the most proximal point of the radial metaphysis. B: The distance from the most distal point of the ulnar metaphysis to the most distal point of the radial metaphysis.
(Adapted from Hafner R, Poznanski AK, Donovan JM. Ulnar variance in children. Standard measurements for evaluation of ulnar shortening in juvenile rheumatoid arthritis, hereditary multiple exostosis and other bone or joint disorders in childhood. Skel Radiol. 1989; 18:514, with permission.)
A: The distance from the most proximal point of the ulnar metaphysis to the most proximal point of the radial metaphysis. B: The distance from the most distal point of the ulnar metaphysis to the most distal point of the radial metaphysis.
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Although not dependent on the length of the ulnar styloid,22 the measurement of ulnar variance is dependent on forearm position and radiographic technique.61 Radiographs of the wrist to determine ulnar variance should be standardized with the hand and wrist placed on the cassette, with the shoulder abducted 90 degrees, elbow flexed 90 degrees, and forearm in neutral rotation (Fig. 11-22). The importance of ulnar variance relates to the force transmission across the wrist with axial loading. Normally, the radiocarpal joint bears approximately 80% of the axial load across the wrist, and the ulnocarpal joint bears 20%. Changes in the length relationship of the radius and ulna alter respective load bearing. Indeed, 2.5 mm of ulnar positive variance has been demonstrated to double the forces borne across the ulnocarpal articulation in adult biomechanical analyses.105,151 Biomechanical and clinical studies have shown that this load distribution is important in fractures, TFCC tears (positive ulnar variance), and Kienbock disease (negative ulnar variance).4,75 
Figure 11-22
Technique for neutral rotation radiograph with wrist neutral, forearm pronated, elbow flexed 90 degrees, and shoulder abducted 90 degrees.
Flynn-ch011-image022.png
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The distal radius normally rotates around the relatively stationary ulna. The two bones of the forearm articulate at the proximal radioulnar joints and DRUJs. In addition, proximally the radius and ulna articulate with the distal humerus and distally with the carpus. These articulations are necessary for forearm pronation and supination. At the DRUJ, the concave sigmoid notch of the radius incompletely matches the convex, asymmetric, semicylindrical shape of the distal ulnar head.22,151 This allows some translation at the DRUJ with rotatory movements. The ligamentous structures are critical in stabilizing the radius as it rotates about the ulna (Fig. 11-23). 
Figure 11-23
 
Distal radioulnar joint stability in pronation (left) is dependent on (A) tension developed in the volar margin of the triangular fibrocartilage (TFCC, small arrows) and (B) compression between the contact areas of the radius and ulna (volar surface of ulnar articular head and dorsal margin of the sigmoid notch, large arrows). Disruption of the volar TFCC would therefore allow dorsal displacement of the ulna in pronation. The reverse is true in supination, where disruption of the dorsal margin of the TFCC would allow volar displacement of the ulna relative to the radius as this rotational extreme is reached. The dark area of the TFCC emphasizes the portion of the TFCC that is not supported by the ulnar dome. The dotted circle is the arc of load transmission (lunate to TFCC) in that position.
 
(Redrawn from Bowers WH. Green's Operative Hand Surgery. New York, NY: Churchill-Livingstone, 1993.)
Distal radioulnar joint stability in pronation (left) is dependent on (A) tension developed in the volar margin of the triangular fibrocartilage (TFCC, small arrows) and (B) compression between the contact areas of the radius and ulna (volar surface of ulnar articular head and dorsal margin of the sigmoid notch, large arrows). Disruption of the volar TFCC would therefore allow dorsal displacement of the ulna in pronation. The reverse is true in supination, where disruption of the dorsal margin of the TFCC would allow volar displacement of the ulna relative to the radius as this rotational extreme is reached. The dark area of the TFCC emphasizes the portion of the TFCC that is not supported by the ulnar dome. The dotted circle is the arc of load transmission (lunate to TFCC) in that position.
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Figure 11-23
Distal radioulnar joint stability in pronation (left) is dependent on (A) tension developed in the volar margin of the triangular fibrocartilage (TFCC, small arrows) and (B) compression between the contact areas of the radius and ulna (volar surface of ulnar articular head and dorsal margin of the sigmoid notch, large arrows). Disruption of the volar TFCC would therefore allow dorsal displacement of the ulna in pronation. The reverse is true in supination, where disruption of the dorsal margin of the TFCC would allow volar displacement of the ulna relative to the radius as this rotational extreme is reached. The dark area of the TFCC emphasizes the portion of the TFCC that is not supported by the ulnar dome. The dotted circle is the arc of load transmission (lunate to TFCC) in that position.
(Redrawn from Bowers WH. Green's Operative Hand Surgery. New York, NY: Churchill-Livingstone, 1993.)
Distal radioulnar joint stability in pronation (left) is dependent on (A) tension developed in the volar margin of the triangular fibrocartilage (TFCC, small arrows) and (B) compression between the contact areas of the radius and ulna (volar surface of ulnar articular head and dorsal margin of the sigmoid notch, large arrows). Disruption of the volar TFCC would therefore allow dorsal displacement of the ulna in pronation. The reverse is true in supination, where disruption of the dorsal margin of the TFCC would allow volar displacement of the ulna relative to the radius as this rotational extreme is reached. The dark area of the TFCC emphasizes the portion of the TFCC that is not supported by the ulnar dome. The dotted circle is the arc of load transmission (lunate to TFCC) in that position.
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Treatment Options for Fractures of the Distal Radius and Ulna

Nonoperative Treatment of Fractures of the Distal Radius and Ulna

The goal of pediatric distal radius fracture care is to achieve bony union within acceptable radiographic parameters to optimize long-term function and avoid late complications. Management is influenced tremendously by the remodeling potential of the distal radius in growing children (Fig. 11-24). In general, remodeling potential is dependent upon the amount of skeletal growth remaining, proximity of the injury to the physis, and relationship of the deformity to plane of adjacent joint motion. Fractures in very young children, close to the distal radial physis, with predominantly sagittal plane angulation have the greatest remodeling capacity. Acceptable sagittal plane angulation of acute distal radial metaphyseal fractures has been reported to be from 10 to 35 degrees in patients under 5 years of age.63,108,114,147,161,169,209 Similarly, in patients under 10 years of age, the degree of acceptable angulation has ranged from 10 to 25 degrees.63,108,114,147,161,169,209 For children over 10 years of age, acceptable alignment has ranged from 5 to 20 degrees depending on the skeletal maturity of the patient (Table 11-4). 
Figure 11-24
 
A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
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A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
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Figure 11-24
A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
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A: AP and lateral views of displaced radial physeal fracture. B: Healed malunion 1 month after radial physeal fracture. C: Significant remodeling at 5 months after fracture. D: Anatomic remodeling with no physeal arrest.
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Table 11-4
Angular Corrections in Degrees
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Table 11-4
Angular Corrections in Degrees
Sagittal Plane
Age (yrs) Boys Girls Frontal Plane
4–9 20 15 15
9–11 15 10 5
11–13 10 10 0
>13 5 0 0
 

Acceptable residual angulation is that which will result in total radiographic and functional correction. (Courtesy of B. De Courtivron, MD. Centre Hospitalie Universitaire de Tours. Tours, France.)

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Criteria for what constitutes acceptable frontal plane deformity have been more uniform. The fracture tends to displace radially with an apex ulnar angulation. This deformity also has remodeling potential,152,221 but less so than sagittal plane deformity. Most authorities agree that 10 degrees or less of acute malalignment in the frontal plane should be accepted. Greater magnitudes of coronal plane malalignment may not remodel and may result in limitations of forearm rotation (Table 11-4).42,44,54,62,208 
In general, 20 to 30 degrees of sagittal plane angulation, 10 to 15 degrees of radioulnar deviation, and complete bayonet apposition with reliably remodel in younger children with growth remaining.50,70,97,221 

Indications/Contraindications

For the reasons cited above, the vast majority of pediatric distal radius fractures may be successfully treated with nonoperative means. General indications for nonoperative treatment include torus fractures, displaced physeal or metaphyseal fractures within acceptable parameters of expected skeletal remodeling, displaced fractures with unacceptable alignment amenable to closed reduction and immobilization, and late presenting displaced physeal injuries. 
Contraindications to nonoperative care include open fractures, fractures with excessive soft tissue injury or neurovascular compromise precluding circumferential cast immobilization, irreducible fractures in unacceptable alignment, unstable fractures failing initial nonoperative care, and fractures with displacement that will not remodel (Table 11-5). 
 
Table 11-5
Distal Radius Fractures
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Table 11-5
Distal Radius Fractures
Nonoperative Treatment
Indications Relative Contraindications
Torus fractures Open fractures
Nondisplaced fractures Neurovascular compromise or excessive swelling precluding circumferential cast immobilization
Displaced fractures within acceptable radiographic alignment Irreducible fracture in unacceptable alignment
Displaced fractures amenable to closed reduction and immobilization Unstable fractures failing initial reduction and cast immobilization
Late presenting physeal fractures
Distal radial physeal stress fractures
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Techniques: Splint Immobilization of Torus Fractures

By definition, torus fractures are compression fractures of the distal radial metaphysis and are therefore inherently stable (Fig. 11-25). There is typically minimal cortical disruption or displacement. As a result, treatment should consist of protected immobilization to prevent further injury and relieve pain. Multiple studies have compared the effectiveness and cost of casting, splinting, and simple soft bandage application in the treatment of torus fractures. As expected, there is little difference in outcome of the various immobilization techniques.2,21,102,145,161,171,180,205 
Figure 11-25
 
Anteroposterior (A) and lateral (B) radiographs of a distal radius torus fracture.
Anteroposterior (A) and lateral (B) radiographs of a distal radius torus fracture.
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Figure 11-25
Anteroposterior (A) and lateral (B) radiographs of a distal radius torus fracture.
Anteroposterior (A) and lateral (B) radiographs of a distal radius torus fracture.
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Davidson et al.43 randomized 201 children with torus fractures to plaster cast or removable wrist splint immobilization for 3 weeks. All patients went on to successful healing without complications or need for follow-up clinical visits or radiographs. Similarly, Plint et al.159 reported the results of a prospective randomized clinical trial in which 87 children were treated with either short-arm casts or removable splints for 3 weeks. Not only were there no differences in healing or pain, but also early wrist function was considerably better in the splinted patients. West et al.207 even challenged the need for splinting in their clinical study randomizing 39 patients to either plaster casts or soft bandages. Again, fracture healing was universal and uneventful, and patients treated with soft bandages had better early wrist motion. 
Given the reliable healing seen with torus fracture healing, Symons et al.184 performed a randomized trial of 87 patients treated with plaster splints to either hospital follow-up or home removal. No difference was seen in clinical results, and patient/families preferred home splint removal. A similar study by Khan et al.115 confirmed these findings. No differences in outcomes were seen in 117 patients treated with either rigid cast removal in fracture clinic versus soft cast removal at home, and families preferred home removal of their immobilization. 
A recent meta-analysis of torus and minimally displaced fractures treated by removable splints instead of circumferential casts was found to have improved secondary outcomes for the patient and family and with equal position at healing.11 Therefore, simple splinting is sufficient, and once the patient is comfortable, range-of-motion exercises and nontraumatic activities may begin. Fracture healing usually occurs in 3 to 4 weeks.2,10 Simple torus fractures heal without long-term sequelae or complications. 

Techniques: Cast Immobilization of Nondisplaced or Minimally Displaced Distal Radial Metaphyseal and Physeal Fractures

Nondisplaced fractures are treated with cast immobilization until appropriate bony healing and pain resolution have been achieved.47,52,173 Although these fractures are radiographically well aligned at the time of presentation, fracture stability is difficult to assess and a risk of late displacement exists (Fig. 11-26). Serial radiographs are obtained in the first 2 to 3 weeks to confirm maintenance of acceptable radiographic alignment. In general, most fractures will heal within 4 to 6 weeks. 
Figure 11-26
 
A, B: Anteroposterior (AP) and lateral radiographs of a distal radial metaphyseal fracture. This injury was initially assumed to be stable and was treated with cast immobilization with suboptimal mold. C, D: Subsequent radiographs taken 3 weeks after injury demonstrate loss of alignment and early bony healing.
A, B: Anteroposterior (AP) and lateral radiographs of a distal radial metaphyseal fracture. This injury was initially assumed to be stable and was treated with cast immobilization with suboptimal mold. C, D: Subsequent radiographs taken 3 weeks after injury demonstrate loss of alignment and early bony healing.
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Figure 11-26
A, B: Anteroposterior (AP) and lateral radiographs of a distal radial metaphyseal fracture. This injury was initially assumed to be stable and was treated with cast immobilization with suboptimal mold. C, D: Subsequent radiographs taken 3 weeks after injury demonstrate loss of alignment and early bony healing.
A, B: Anteroposterior (AP) and lateral radiographs of a distal radial metaphyseal fracture. This injury was initially assumed to be stable and was treated with cast immobilization with suboptimal mold. C, D: Subsequent radiographs taken 3 weeks after injury demonstrate loss of alignment and early bony healing.
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Simple immobilization without reduction may also be considered in minimally displaced fractures within acceptable alignment, based upon patient age and remodeling potential. Hove and Brudvik98 evaluated a cohort of 88 patients treated nonoperatively for distal radius fractures. Though eight patients had early loss of reduction with greater than 15 to 20 degrees angulation, all demonstrated complete remodeling and restoration of normal function. Al-Ansari et al. similarly evaluated 124 patients with “minimally angulated” distal radius fractures. Even patients who healed with 30 to 35 degrees angulation went on to complete fracture remodeling and normal function.5 Finally, in a prior randomized clinical trial, 96 patients between 5 and 12 years of age with distal radius fractures with less than 15 degrees of sagittal plane angulation were treated with either cast or splint immobilization.21 No difference were seen in fracture alignment at 6 weeks in the two treatment groups, and functional outcomes did not differ, as measured by the Activity Scale for Kids. Though the risk of late displacement and issues of compliance and comfort exist, this investigation supports the concept that splint immobilization may be considered in younger patients with minimal displacement. 
Furthermore, cast immobilization alone without fracture manipulation may be effective in young patients with complete dorsal displacement and bayonet apposition with acceptable sagittal and coronal plane alignments. Recently, Crawford et al. prospectively evaluated 51 children under the age of 10 years treated with cast immobilization for shortened and bayonetted fractures of the distal radial metaphysis.38,50 All patients went on to complete radiographic remodeling and full return of wrist motion. 

Techniques: Reduction and Immobilization of Incomplete Fractures of the Distal Radius and Ulna

Treatment of incomplete distal radial and ulnar fractures is similarly dependent upon patient age and remodeling potential, magnitude, and direction of fracture displacement and angulation, and the biases of the care provider and patient/family regarding fracture remodeling and deformity. In cases of incomplete or greenstick distal radius fractures—with or without ulnar involvement—with unacceptable deformity, closed reduction and cast immobilization are recommended. 
The method of reduction for greenstick fractures depends on the pattern of displacement. With apex volar angulated fractures of the radius, the rotatory deformity is supination. Pronating the radius and applying a dorsal-to-volar reduction force is utilized to restore bony alignment. Conversely, fractures with apex dorsal angulation result from pronation mechanisms of injury. Supinating the distal forearm and applying a volar-to-dorsal force should reduce the incomplete fracture of the radius.135 Though these fractures are incomplete and patients often present with minimal pain, adequate analgesia will facilitate bony reduction and quality of cast application. Typically this is done with the assistance of conscious sedation.64,79,114 
Following reduction, portable fluoroscopy may be used to evaluate fracture alignment. Once acceptable alignment is achieved, a long-arm cast is applied with appropriate rotation and three-point molds, based upon the initial pattern of injury. Long-arm casting is typically used for the first 4 weeks, and bony healing is achieved in 6 weeks in the majority of patients. 
The high potential for remodeling of a distal radial metaphyseal malunion has led some clinicians to recommend immobilization alone.50 As in the case of torus fractures,195 a recent study suggests that soft bandages can be applied to treat incomplete green stick forearm fractures;120 however, as the greenstick fracture is substantially more unstable than the torus fracture166 the authors do not advocate soft bandage treatment of greenstick fractures. 

Techniques: Closed Reduction and Cast Immobilization of Displaced Distal Radial Metaphyseal Fractures

Closed reduction and cast immobilization remains the standard of care for children with displaced distal radial metaphyseal fractures presenting with unacceptable alignment. Again, fracture reduction maneuvers are dependent upon injury mechanism and fracture pattern. In patients with typical dorsal displacement of the distal epiphyseal fracture fragment with apex volar angulation, closed reduction is performed with appropriate analgesia, typically conscious sedation or general anesthesia. Finger traps applied to the ipsilateral digits may facilitate limb positioning and stabilization during fracture reduction but application of weights may hinder reduction by increasing dorsal periosteal tension. Recently, the lower extremity-aided fracture reduction maneuver (LEAFR) has been proposed as a simple, effective, reproducible, and mechanically advantageous technique of effectuating closed reductions in children with bayoneted distal radius fractures.59 Given the stout, intact dorsal periosteum in these injuries, pure longitudinal traction is often insufficient to restore bony alignment, particularly in cases of bayonet apposition. Fracture reduction is performed first by hyperextension and exaggeration of the deformity, which relaxes the dorsal periosteal sleeve (Fig. 11-27). Longitudinal traction is then applied to restore adequate length. Finally, the distal fracture fragment is flexed to correct the translational and angular displacement, with rotational correction imparted as well. If available, fluoroscopy may be utilized to confirm adequacy of reduction, and a well-molded cast is applied. 
Figure 11-27
 
A, B: Use of the thumb to push the distal fragment hyperdorsiflexed 90 degrees (solid arrow) until length is reestablished. Countertraction is applied in the opposite direction (open arrows). C, D: Once length has been reestablished, the distal fragment is flexed into the correct position. Alignment is checked by determining the position of the fragments with the thumb and forefingers of each hand.
A, B: Use of the thumb to push the distal fragment hyperdorsiflexed 90 degrees (solid arrow) until length is reestablished. Countertraction is applied in the opposite direction (open arrows). C, D: Once length has been reestablished, the distal fragment is flexed into the correct position. Alignment is checked by determining the position of the fragments with the thumb and forefingers of each hand.
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Figure 11-27
A, B: Use of the thumb to push the distal fragment hyperdorsiflexed 90 degrees (solid arrow) until length is reestablished. Countertraction is applied in the opposite direction (open arrows). C, D: Once length has been reestablished, the distal fragment is flexed into the correct position. Alignment is checked by determining the position of the fragments with the thumb and forefingers of each hand.
A, B: Use of the thumb to push the distal fragment hyperdorsiflexed 90 degrees (solid arrow) until length is reestablished. Countertraction is applied in the opposite direction (open arrows). C, D: Once length has been reestablished, the distal fragment is flexed into the correct position. Alignment is checked by determining the position of the fragments with the thumb and forefingers of each hand.
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The optimal type of cast immobilization remains controversial. Both long- and short-arm casts have been proposed following distal radial fracture reduction.31,88,93,205 Long-arm casts have the advantage of restricting forearm rotation and theoretically reducing the deforming forces imparted to the distal radius. However, above elbow immobilization is more inconvenient and has been associated with greater need for assistance with activities of daily living, as well as more days of school missed.205 Prior randomized controlled trials have demonstrated that short-arm casts are as effective at maintaining reduction as long-arm casts, provided that acceptable alignment is achieved and an appropriate cast mold is applied.20,205 A recent meta-analysis pooling the results of over 300 study subjects have further supported these findings.93 
Perhaps more important than the length of the cast applied is the cast mold applied at the level of the fracture (Fig. 11-28). Appropriate use of three-point molds will assist in maintenance of alignment in bending injuries. Similarly, application of interosseous mold will help to maintain interosseous space between the radius and ulna as well as coronal plane alignment. A host of radiographic indices have been proposed to quantify and characterize the quality of the cast mold, including the cast index, three-point index, gap index, padding index, Canterbury index, and second metacarpal/distal radius angle (Fig. 11-29).10,57,90,162 Although the cast index is easily calculated and perhaps most widely utilized, some authorities tout the three-point index as the preferred index for this assessment and prediction of redisplacement.48 
Figure 11-28
Three-point molding.
 
Top: Three-point molding for dorsally angulated (apex volar) fractures, with the proximal and distal points on the dorsal aspect of the cast and the middle point on the volar aspect just proximal to the fracture site. Bottom: For volar angulated fractures, where the periosteum is intact volarly and disrupted on the dorsal surface, three-point molding is performed with the proximal and distal points on the volar surface of the cast and the middle point just proximal to the fracture site on the dorsal aspect of the cast.
Top: Three-point molding for dorsally angulated (apex volar) fractures, with the proximal and distal points on the dorsal aspect of the cast and the middle point on the volar aspect just proximal to the fracture site. Bottom: For volar angulated fractures, where the periosteum is intact volarly and disrupted on the dorsal surface, three-point molding is performed with the proximal and distal points on the volar surface of the cast and the middle point just proximal to the fracture site on the dorsal aspect of the cast.
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Figure 11-28
Three-point molding.
Top: Three-point molding for dorsally angulated (apex volar) fractures, with the proximal and distal points on the dorsal aspect of the cast and the middle point on the volar aspect just proximal to the fracture site. Bottom: For volar angulated fractures, where the periosteum is intact volarly and disrupted on the dorsal surface, three-point molding is performed with the proximal and distal points on the volar surface of the cast and the middle point just proximal to the fracture site on the dorsal aspect of the cast.
Top: Three-point molding for dorsally angulated (apex volar) fractures, with the proximal and distal points on the dorsal aspect of the cast and the middle point on the volar aspect just proximal to the fracture site. Bottom: For volar angulated fractures, where the periosteum is intact volarly and disrupted on the dorsal surface, three-point molding is performed with the proximal and distal points on the volar surface of the cast and the middle point just proximal to the fracture site on the dorsal aspect of the cast.
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Figure 11-29
Radiographic evaluation of cast mold.
 
A: Cast index (x/y) is the ratio of the inner cast diameter at the level of the fracture on the lateral projection (x) to the inner cast diameter at the level of the fracture as seen on the anteroposterior (AP) view (y). B: The three point index ([(a + b + c)/x] + [(d + e + f)/y]) is the sum of the three critical gaps divided by the contact area of the fracture fragments as assess on both the AP and lateral views.
A: Cast index (x/y) is the ratio of the inner cast diameter at the level of the fracture on the lateral projection (x) to the inner cast diameter at the level of the fracture as seen on the anteroposterior (AP) view (y). B: The three point index ([(a + b + c)/x] + [(d + e + f)/y]) is the sum of the three critical gaps divided by the contact area of the fracture fragments as assess on both the AP and lateral views.
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Figure 11-29
Radiographic evaluation of cast mold.
A: Cast index (x/y) is the ratio of the inner cast diameter at the level of the fracture on the lateral projection (x) to the inner cast diameter at the level of the fracture as seen on the anteroposterior (AP) view (y). B: The three point index ([(a + b + c)/x] + [(d + e + f)/y]) is the sum of the three critical gaps divided by the contact area of the fracture fragments as assess on both the AP and lateral views.
A: Cast index (x/y) is the ratio of the inner cast diameter at the level of the fracture on the lateral projection (x) to the inner cast diameter at the level of the fracture as seen on the anteroposterior (AP) view (y). B: The three point index ([(a + b + c)/x] + [(d + e + f)/y]) is the sum of the three critical gaps divided by the contact area of the fracture fragments as assess on both the AP and lateral views.
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Complete fractures of the distal radius have a higher rate of loss of reduction after closed treatment than do incomplete fractures (Fig. 11-30).246 Indeed, prior investigations have demonstrated that 20% to 30% of patients will have radiographic loss of reduction following closed reduction and casting of displaced distal radius fractures. Risk factors for loss of reduction include greater initial fracture displacement and/or comminution, suboptimal reduction, suboptimal cast mold, associated distal ulnar fractures.7,10,48,57,90,139,162 
Figure 11-30
 
(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
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(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
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Figure 11-30
(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
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(A) Serial radiographs at 3 days and 10 days (B) revealing slow loss of reduction that is common after closed reduction of distal radial metaphyseal fractures.
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Given the risk of radiographic loss of reduction, serial radiographs are recommended in the early postinjury period. Weekly radiographs are obtained in the first 2 to 3 weeks following reduction to confirm adequacy of alignment. Failure to identify and correct malalignment in the early postinjury period may lead to malunion and subsequent clinical loss of motion and upper limb function. 
Malalignment of fractures during the development of soft tissue callus before bridging ossification (injury to 2 to 3 weeks after reduction) often can be realigned using cast wedging (Fig. 11-31).14,17,36,85,101,190,206 Recently, this technique has been utilized less frequently given the advances in surgical management of fractures. Authors have advocated opening wedges, closing wedges, as well as a combination of each of these approaches. Most commonly we use open wedge techniques as closing wedges have the potential for pinching of the skin and causing accumulation of cast padding at the wedge site which may cause skin breakdown.85,101 In addition, closing wedges also may shorten and reduce the volume of the cast thus decreasing fracture stability. There have been multiple techniques proposed for predicting the size of a wedge. Bebbington et al.14 suggested a technique that involves tracing the angle of displacement onto the cast itself thus representing the fracture fragments. Wedges are then inserted until the malalignment is reduced as the traced line becomes straight. Wells et al. recently described a technique in which the wedge position and opening angle are determined from the radiographic displacement and center of rotational alignment. Utilizing these methods on saw bones, they were able to reduce malalignment within 5 degrees with 90% success.206 Regardless of the method, if utilized appropriately, cast wedging reduces the risk of additional anesthesia and potential surgery. 
Figure 11-31
Lateral fluoroscopic projection of a distal radius fracture treated with dorsal cast wedging to correct loss of reduction.
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Techniques: Displaced Distal Radial Physeal Fractures

Most displaced Salter–Harris I and II fractures are treated with closed reduction and cast stabilization. Closed manipulation of the displaced fracture is similarly performed with appropriate conscious sedation, analgesia, or, rarely, anesthesia to achieve pain relief and an atraumatic reduction.64,79,114 Most of these fractures involve dorsal and proximal displacement of the epiphysis with an apex volar extension deformity. Manipulative reduction is by gentle distraction and flexion of the distal epiphysis, carpus, and hand over the proximal metaphysis (Fig. 11-32). The intact dorsal periosteum is used as a tension band to aid in reduction and stabilization of the fracture. Unlike similar fractures in adults, finger trap distraction with pulley weights is often counterproductive. However, finger traps can help stabilize the hand, wrist, and arm for manipulative reduction and casting by applying a few pounds of weight for balance. Otherwise, an assistant is helpful to support the extremity in the proper position for casting. 
Figure 11-32
 
A: Lateral radiograph of dorsally displaced Salter–Harris type II fracture. B: Lateral radiograph after closed reduction and cast application. C: Reduction of the volar displaced fracture. The forearm was in supination with three-point molding anterior over the distal epiphysis and proximal shaft (white arrows). The third point is placed dorsally over the distal metaphysis (open arrow). (The dorsal surface of the cast is oriented toward the bottom of this figure.)
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994: 17, with permission.)
A: Lateral radiograph of dorsally displaced Salter–Harris type II fracture. B: Lateral radiograph after closed reduction and cast application. C: Reduction of the volar displaced fracture. The forearm was in supination with three-point molding anterior over the distal epiphysis and proximal shaft (white arrows). The third point is placed dorsally over the distal metaphysis (open arrow). (The dorsal surface of the cast is oriented toward the bottom of this figure.)
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Figure 11-32
A: Lateral radiograph of dorsally displaced Salter–Harris type II fracture. B: Lateral radiograph after closed reduction and cast application. C: Reduction of the volar displaced fracture. The forearm was in supination with three-point molding anterior over the distal epiphysis and proximal shaft (white arrows). The third point is placed dorsally over the distal metaphysis (open arrow). (The dorsal surface of the cast is oriented toward the bottom of this figure.)
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994: 17, with permission.)
A: Lateral radiograph of dorsally displaced Salter–Harris type II fracture. B: Lateral radiograph after closed reduction and cast application. C: Reduction of the volar displaced fracture. The forearm was in supination with three-point molding anterior over the distal epiphysis and proximal shaft (white arrows). The third point is placed dorsally over the distal metaphysis (open arrow). (The dorsal surface of the cast is oriented toward the bottom of this figure.)
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If portable fluoroscopy is available, immediate radiographic assessment of the reduction is obtained. Otherwise, a well-molded cast is applied and AP and lateral radiographs are obtained to assess the reduction. The cast should provide three-point molding over the distal radius to lessen the risk of fracture displacement and should follow the contour of the normal forearm. The distal dorsal mold should not impair venous outflow from the hand, which can occur if the mold is placed too distal and too deep so as to obstruct the dorsal veins. Advocates of short-arm casting indicate at least equivalent results with proper casting techniques and more comfort during immobilization due to free elbow mobility. Instructions for elevation and close monitoring of swelling and the neurovascular status of the extremity are critical. 
The fracture also should be monitored closely with serial radiographs to be certain that there is no loss of anatomic alignment (Fig. 11-33). Generally, these fractures are stable after closed reduction and cast immobilization. If there is loss of reduction after 7 days, the surgeon should be wary of repeat reduction, as forceful remanipulation may increase the risk of iatrogenic physeal arrest.27,125,174 Fortunately, remodeling of an extension deformity with growth is common if the patient has more than 2 years of growth remaining and the deformity is less than 20 degrees. Even marked deformity can remodel if there is sufficient growth remaining and the deformity is in the plane of motion of the wrist. 
Figure 11-33
 
A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
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A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
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Figure 11-33
A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
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A: AP and lateral radiographs of severely displaced Salter–Harris type II fracture of the distal radius. B: Closed reduction shows marked improvement but not anatomic reduction. The case had to be bivalved due to excess swelling. C: Unfortunately the patient lost reduction after a new fiberglass cast was applied. D: Out-of-cast radiographs show a healed malunion in a similar position to the prereduction radiographs.
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Techniques: Galeazzi Fractures

Nonoperative management remains the first-line treatment for pediatric Galeazzi fractures, distinguishing these injuries from their adult counterparts.56,169,198 Indeed, the adult Galeazzi fracture has been often called a “fracture of necessity,” given the near universal need for surgical reduction and internal fixation to restore anatomic radial alignment and DRUJ congruity. In pediatric patients, however, the distal radial fracture often is a greenstick type that is stable after reduction; therefore, nonoperative treatment with closed reduction and cast immobilization is sufficient.109,169 Surgical treatment may be considered for adolescents with complete fractures and displacement, as their injury pattern, skeletal maturity, and remodeling potential is more similar to the adult Galeazzi. 
Incomplete fractures of the distal radius with either a true dislocation of the DRUJ or an ulnar physeal fracture are treated with closed reduction and long-arm cast immobilization. This can be done in the emergency room with conscious sedation or in the operating room with general anesthesia. Portable fluoroscopy is useful in these situations. If the radius fracture has apex volar angulation and dorsal displacement of the radius—and associated volar dislocation of the ulnar head in relationship to the radius, pronation and volar-to-dorsal force on the radial fracture is used for reduction. Conversely, if the radius fracture is apex dorsal with volar displacement and dorsal dislocation of the distal ulna, supination and dorsal-to-volar force is utilized during reduction. The reduction and stability of the fracture and DRUJ dislocation may then be checked on dynamic fluoroscopy; if both are anatomically reduced and stable, a long-arm cast with the forearm in the appropriate rotatory position (i.e., pronation or supination) is applied. Six weeks of long-arm casting is recommended to allow for sufficient bony and soft tissue healing. 
In patients with Galeazzi equivalent injuries characterized by complete distal radius fractures associated with ulnar physeal fractures, both bones should be reduced. Usually, this can be accomplished with the same methods of reduction as when the radial fracture is incomplete. If there is sufficient growth remaining and the distal ulnar physis remains open, remodeling of a nonanatomic distal ulnar physeal reduction may occur. As long as the DRUJ is reduced, malalignment of less than 10 degrees can remodel in a young child. DRUJ congruity and stability, however, are dependent upon distal ulnar alignment, and great care should be taken in assessment of the DRUJ when accepting a nonanatomic distal ulnar reduction. Furthermore, the risk of ulnar growth arrest after a Galeazzi equivalent has been reported to be as high as 55%.81 If the fracture is severely malaligned, the DRUJ cannot be reduced, or the patient is older and remodeling is unlikely, open reduction and smooth pin fixation are indicated.209 

Techniques: Distal Radial Physeal Stress Fractures

Treatment of distal physeal stress injuries first and foremost involves rest. This activity restriction may be challenging in the pediatric athlete, depending on the level of the sports participation and the desires of the child, parents, and other stakeholders to continue athletic participation. Education regarding the long-term consequences of a growth arrest is important in these emotionally charged situations. Short-arm cast immobilization for several weeks may be the only way to restrict stress to the distal radial physis in some patients. Splint protection is appropriate in cooperative patients. Protection should continue until there is resolution of tenderness and pain with activity. The young athlete can maintain cardiovascular fitness, strength, and flexibility while protecting the injured wrist. Once the acute physeal injury has healed, return to weight-bearing and open-chain activities should be gradual. The process of return to sports should be gradual, often 3 to 6 months, and adjustment of techniques and training methods is necessary to prevent recurrence. The major concern is development of a radial growth arrest in a skeletally immature patient, and consideration should be given to serial clinical and radiographic follow-up in high-risk patients to confirm maintenance of growth. 

Techniques: Distal Ulna Physeal Fractures

Treatment options are similar to those for radial physeal fractures: immobilization alone, closed reduction and cast immobilization, closed reduction and percutaneous pinning, and open reduction. Often, these fractures are minimally displaced or nondisplaced. Immobilization until fracture healing at 3 to 6 weeks is standard treatment. Closed reduction is indicated for displaced fractures with more than 50% translation or 20 degrees of angulation. Most ulnar physeal fractures reduce to a near anatomic alignment with reduction of the concomitant radius fracture due to the attachments of the DRUJ ligaments and TFCC. Failure to obtain a reduction of the ulnar fracture may indicate that there is soft tissue interposed in the fracture site, necessitating open reduction and fixation. 

Outcomes

Most of the published literature provide information on the short-term clinical and radiographic results of treatment for pediatric distal radius fractures indicates a positive outcome. With adherence to the principles and techniques described above, radiographic realignment, successful bony healing, and avoidance of complications are achieved in the majority of cases. Given the high healing capacity and remodeling potential of these injuries, there is less concern regarding long-term outcomes of nonoperative treatment compared with adult patients. In general, concerns regarding long-term outcomes have focused on patients who sustain distal radial physeal fractures and thus are at risk for subsequent growth disturbance and skeletal imbalance of the distal forearm. 
The risk of growth disturbance following distal radial physeal fractures is approximately 4%. Cannata et al.27 previously reported the long-term outcomes of 163 distal radial physeal fractures in 157 patients. Displaced fractures were treated with closed reduction and cast immobilization for 6 weeks. Mean follow-up was 25.5 years. Posttraumatic growth disturbance resulting in 1cm or greater of length discrepancy was seen in 4.4% of distal radial and 50% of distal ulnar physeal fractures. In a similar prospective analysis of 290 children with distal radial physeal fractures, Bae and Waters12 noted that 4% of patients went on to demonstrate clinical or radiographic distal radial growth disturbance. Consideration should be given for follow-up radiographic evaluation following distal radial physeal fractures to assess for possible physeal arrest. In symptomatic patients with posttraumatic growth disturbance and growth remaining, surgical interventions including distal ulnar epiphysiodeses, corrective osteotomies of the radius, ulnar shortening osteotomies, and associated soft tissue reconstructions have been demonstrated to improve clinical function and radiographic alignment.201 

Operative Treatment of Fractures of the Distal Radius and Ulna

Indications/Contraindications

Although surgical indications and techniques continue to evolve, in general surgical indications for pediatric distal radius and ulna fractures include open fractures, irreducible fractures, unstable fractures, floating elbow injuries, and fractures with soft tissue or neurovascular compromise precluding circumferential cast immobilization. Surgical reduction and fixation is also indicated in cases of joint incongruity associated with intra-articular Salter–Harris III, IV, or “triplane” fractures. 
Distal radial fracture stability has been more clearly defined in adults204 than in children. At present, an unstable fracture in a child is often defined as one in which closed reduction cannot be maintained. Pediatric classification systems have yet to more precisely define fracture stability, but this issue is critical in determining proper treatment management. As noted above, distal radial metaphyseal fractures have been shown to have a high degree of recurrent displacement and, therefore, inherent instability7,10,48,57,90,138,162,204 For these reasons, pediatric distal radial metaphyseal fractures are not classified in the same manner as adults in regard to stability. Instead, unstable fractures have been predominately defined by the failure to maintain a successful closed reduction. Irreducible fractures usually are due to an entrapped periosteum or pronator quadratus. 
Surgical treatment is similarly recommended in patients with neurovascular compromised and severely displaced injuries. Operative stabilization serves both to maintain adequate bony alignment and more importantly, minimize the risk of compartment syndrome due to excessive swelling and circumferential immobilization. Perhaps the best indication is a displaced radial physeal fracture with median neuropathy and significant volar soft tissue swelling (Fig. 11-34).202 These patients are at risk for development of an acute carpal tunnel syndrome or forearm compartment syndrome with closed reduction and well-molded cast immobilization.15,44,202 The torn periosteum volarly allows the fracture bleeding to dissect into the volar forearm compartments and carpal tunnel. If a tight cast is applied with a volar mold over that area, compartment pressures can increase dangerously. Percutaneous pin fixation allows the application of a loose dressing, splint, or cast without the risk of loss of fracture reduction. 
Figure 11-34
 
A: Clinical photograph of patient with a displaced Salter–Harris type II fracture of the distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C: Lateral radiograph following closed reduction and cast application. Excessive flexion has been utilized to maintain fracture reduction, resulting in persistent median neuropathy and increasing pain. D: Radiographs following urgent closed reduction and percutaneous pinning. E: Follow-up radiograph depicting distal radial physeal arrest and increased ulnar variance.
A: Clinical photograph of patient with a displaced Salter–Harris type II fracture of the distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C: Lateral radiograph following closed reduction and cast application. Excessive flexion has been utilized to maintain fracture reduction, resulting in persistent median neuropathy and increasing pain. D: Radiographs following urgent closed reduction and percutaneous pinning. E: Follow-up radiograph depicting distal radial physeal arrest and increased ulnar variance.
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Figure 11-34
A: Clinical photograph of patient with a displaced Salter–Harris type II fracture of the distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C: Lateral radiograph following closed reduction and cast application. Excessive flexion has been utilized to maintain fracture reduction, resulting in persistent median neuropathy and increasing pain. D: Radiographs following urgent closed reduction and percutaneous pinning. E: Follow-up radiograph depicting distal radial physeal arrest and increased ulnar variance.
A: Clinical photograph of patient with a displaced Salter–Harris type II fracture of the distal radius. The patient has marked swelling volarly with hematoma and fracture displacement. The patient had a median neuropathy upon presentation. B: Lateral radiograph of the displaced fracture. C: Lateral radiograph following closed reduction and cast application. Excessive flexion has been utilized to maintain fracture reduction, resulting in persistent median neuropathy and increasing pain. D: Radiographs following urgent closed reduction and percutaneous pinning. E: Follow-up radiograph depicting distal radial physeal arrest and increased ulnar variance.
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Internal fixation usually is with smooth, small-diameter pins to lessen the risk of growth arrest. Plates and screws rarely are used unless the patient is near skeletal maturity because of concerns about further physeal injury. In the rare displaced intra-articular Salter–Harris type III or IV fracture, internal fixation can be intraepiphyseal without violating the physis. If it is necessary to cross the physis, then smooth, small-diameter pins should be used to lessen the risk of iatrogenic physeal injury. Extra-articular external fixation also can be used to stabilize and align the fracture. 

Surgical Procedure: Closed Reduction and Pin Fixation of Displaced Distal Radial Fractures

Preoperative Planning
Preoperative planning begins with careful clinical and radiographic evaluation. Thorough neurovascular examination is performed to assess for signs and symptoms of nerve injury or impending compartment syndrome. Radiographs—both from the time of injury, after initial attempts at closed reduction, and any subsequent follow-up radiographs—are carefully evaluated to assess pattern of injury and direction of instability. 
Given the relative simplicity of closed reduction and percutaneous fixation techniques, minimal equipment is required. Intraoperative fluoroscopy and surgical instrumentation for pin placement are typically sufficient (Table 11-6). 
Table 11-6
Closed Reduction and Pin Fixation of Distal Radius Fractures
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Supine position with affected limb supported by radiolucent hand table or image intensifier of fluoroscopy unit
  •  
    Fluoroscopy location: Variable, dependent upon surgeon position
  •  
    Equipment: Smooth Kirschner (K)-wires, typically 0.045” or 0.062” in diameter
  •  
    Tourniquet (sterile/nonsterile): nonsterile tourniquet
X
Positioning
After adequate induction of general anesthesia, patients are positioned supine on a standard operating table, with the affected limb abducted and supported on a radiolucent hand table. While a nonsterile tourniquet may be applied to the proximal brachium, this is typically not utilized. Fluoroscopy may be brought in from the head, foot, or side of the patient, depending on surgeon position and preference. For example, as most pinning is performed from distal to proximal, the right-hand dominant surgeon may wish to sit in the axilla and have the fluoroscopy unit come in from the head of the patients when pinning a left distal radius. 
Surgical Approach(es)
While percutaneous pinning may be performed without need for skin incision, placement of K-wires into the region of the radial styloid carries the risk of iatrogenic radial sensory nerve or extensor tendon injury.135 For this reason, a small longitudinal incision over the radial styloid at the site of pin insertion may be utilized to identify and retract adjacent soft tissues, facilitating safe pin passage. Alternatively, smooth pins may be inserted using an oscillating technique. 
Pin Fixation
After appropriate anesthesia, closed reduction of the distal radius fracture into anatomic alignment is performed, using the principles and techniques previously described. While maintaining fracture reduction, a skin incision is made over the radial styloid, long enough to ascertain there is no iatrogenic injury to the radial sensory nerve or extensor tendons (Fig. 11-35). Careful longitudinal spreading is performed in the subcutaneous tissues, and the radial sensory nerve and extensor tendons may be identified and carefully retracted. Pin fixation can be either single or double, though often a single pin will suffice (Fig. 11-36). A smooth pin is then inserted into the distal fracture fragment and passed obliquely in a proximal and ulnar fashion, crossing the fracture site and engaging the far ulnar cortex proximal to the fracture line. Fluoroscopy is used to guide proper fracture reduction and pin placement. 
Figure 11-35
Small incision noted with pins left out of skin for removal at 4 weeks.
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Figure 11-36
 
A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
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A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
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Figure 11-36
A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
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A: AP and lateral radiographs of displaced Salter–Harris type II fracture pinned with a single pin. B: After reduction and pinning with parallel pins.
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Pin(s) may be placed within the distal radial epiphysis and passed across the physis before engaging the more proximal metaphyseal fracture fragment. Alternatively, smooth pins may be placed just proximal to the distal radial physis; while theoretically decreasing the risk of physeal disturbance, this has not been well demonstrated in the published literature.252 
Stability of the fracture should be evaluated with flexion and extension and rotatory stress under fluoroscopy. Often in children and adolescents, a single pin and the reduced periosteum provide sufficient stability to prevent redisplacement of the fracture (Fig. 11-37). If fracture stability is questionable with a single pin, a second pin should be placed. The second pin can either parallel the first pin or, to create cross-pin stability, can be placed distally from the dorsal ulnar corner of the radial epiphysis between the fourth and fifth dorsal compartments and passed obliquely to the proximal radial portion of the metaphysis (Fig. 11-38). Again, the skin incisions for pin placement should be sufficient to avoid iatrogenic injury to the extensor tendons. 
Figure 11-37
Severe swelling.
 
A, B: Complete displacement and bayonet apposition of a distal radial fracture associated severe swelling from a high-energy injury. C: Once reduced, the fragment was secured with an oblique percutaneous pin across the fracture site, sparing the distal radial physis.
A, B: Complete displacement and bayonet apposition of a distal radial fracture associated severe swelling from a high-energy injury. C: Once reduced, the fragment was secured with an oblique percutaneous pin across the fracture site, sparing the distal radial physis.
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Figure 11-37
Severe swelling.
A, B: Complete displacement and bayonet apposition of a distal radial fracture associated severe swelling from a high-energy injury. C: Once reduced, the fragment was secured with an oblique percutaneous pin across the fracture site, sparing the distal radial physis.
A, B: Complete displacement and bayonet apposition of a distal radial fracture associated severe swelling from a high-energy injury. C: Once reduced, the fragment was secured with an oblique percutaneous pin across the fracture site, sparing the distal radial physis.
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Figure 11-38
Crossed-pin technique for stabilization of distal radial metaphyseal fracture in a skeletally immature patient.
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The pins are bent, left out of the skin, and covered with petroleum guaze and sterile dressing. Splint or cast immobilization is used but does not need to be tight, as fracture stability is conferred by the pins. The pins are left in until there is adequate fracture healing (usually 4 weeks). The pins can be removed in the office without sedation or anesthesia. 
One of the arguments against pin fixation is the risk of additional injury to the physis by a pin.23 The risk of physeal arrest is more from the displaced fracture than from a short-term, smooth pin. As a precaution, smooth, small-diameter pins should be used, insertion should be as atraumatic as possible, and removal should be done as soon as there is sufficient fracture healing for fracture stability in a cast or splint alone. 
Another pinning technique involves intrafocal placement of multiple pins into the fracture site to lever the distal fragment into anatomic reduction (Fig. 11-39). The pins are then passed through the opposing cortex for stability.129,192 A supplemental, loose-fitting cast is applied (Table 11-7). 
Figure 11-39
Pin leverage.
 
A: If a bayonet is irreducible, after sterile preparation, a chisel-point Steinmann pin can be inserted between the fracture fragments from a dorsal approach. Care must be taken not to penetrate too deeply past the dorsal cortex of the proximal fragment. B: Once the chisel is across the fracture site, it is levered into position and supplementary pressure is placed on the dorsum of the distal fragment (arrow) to slide it down the skid into place. This procedure is usually performed with an image intensifier.
A: If a bayonet is irreducible, after sterile preparation, a chisel-point Steinmann pin can be inserted between the fracture fragments from a dorsal approach. Care must be taken not to penetrate too deeply past the dorsal cortex of the proximal fragment. B: Once the chisel is across the fracture site, it is levered into position and supplementary pressure is placed on the dorsum of the distal fragment (arrow) to slide it down the skid into place. This procedure is usually performed with an image intensifier.
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Figure 11-39
Pin leverage.
A: If a bayonet is irreducible, after sterile preparation, a chisel-point Steinmann pin can be inserted between the fracture fragments from a dorsal approach. Care must be taken not to penetrate too deeply past the dorsal cortex of the proximal fragment. B: Once the chisel is across the fracture site, it is levered into position and supplementary pressure is placed on the dorsum of the distal fragment (arrow) to slide it down the skid into place. This procedure is usually performed with an image intensifier.
A: If a bayonet is irreducible, after sterile preparation, a chisel-point Steinmann pin can be inserted between the fracture fragments from a dorsal approach. Care must be taken not to penetrate too deeply past the dorsal cortex of the proximal fragment. B: Once the chisel is across the fracture site, it is levered into position and supplementary pressure is placed on the dorsum of the distal fragment (arrow) to slide it down the skid into place. This procedure is usually performed with an image intensifier.
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Table 11-7
Closed Reduction and Pin Fixation of Distal Radius Fractures
Surgical Steps
  •  
    Closed reduction of distal radius fracture
  •  
    Confirm bony alignment with intraoperative fluoroscopy
  •  
    Small incision over radial styloid
    •  
      Longitudinal spreading in subcutaneous tissues
    •  
      Retraction/protection of radial sensory nerve and extensor tendons
  •  
    Place smooth K-wire from distal fracture fragment, across fracture site, engaging the ulnar cortex of the proximal fracture fragment
    •  
      Fluoroscopic confirmation of pin trajectory and placement
  •  
    Assess fracture stability
  •  
    Place second K-wire if needed
    •  
      Cross-pinning may be performed from dorsoulnar corner of distal radial epiphysis proximally and radially into proximal fracture fragment
  •  
    Assess stability
  •  
    Bend and cut pins outside of skin
  •  
    Sterile dressing and cast application
  •  
    Pin removal after adequate bony healing, typically in 4 wks
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Surgical Procedure: Open Reduction and Fixation

Preoperative Planning
Open reduction is indicated for open or irreducible fractures. Open fractures constitute approximately 1% of all distal radial metaphyseal fractures. Although treatment approaches to open fractures continue to evolve, at present the standard of care remains surgical irrigation and debridement, followed by appropriate fracture care (also see controversies regarding nonoperative management of open fractures). 
Irreducible metaphyseal or physeal fractures are rare and generally are secondary to interposed soft tissues. With dorsally displaced fractures, the interposed structure usually is the volar periosteum or pronator quadratus95 and rarely the flexor tendons or neurovascular structures.95,112,214 In volarly displaced fractures, the periosteum or extensor tendons may be interposed. 
Closed reduction rarely fails if there is no interposed soft tissue. Occasionally, however, multiple attempts at reduction of a bayonet apposition fracture can lead to significant swelling that makes closed reduction impossible. If the patient is too old to remodel bayonet apposition, open reduction is appropriate. 
Plate fixation can be used in more skeletally mature adolescents. Low-profile, fragment-specific fixation methods and locking plates also are now commonly used for internal fixation of distal radial fractures in adults. The utility of these anatomically contoured locking plates in children and skeletally immature adolescents is unknown, as is the deleterious effect, if any, on growth potential. Furthermore, the advantage of these more rigid constructs in younger patients in whom adequate stability may be achieved with pins is unclear, particularly given the reports of late tendon rupture and other soft tissue complications associated with fixed-angle volar plates,165 Indications for skeletally mature adolescents are the same as for adults. Articular malalignment and comminution are assessed by CT preoperatively, and fracture-specific fixation is used as appropriate. 
Preoperative planning for open reduction and fixation is similar to the approach cited above, with a few additional considerations. Assessment of skeletal maturity and physeal status is important, particularly when considering use of implants which rigidly engage the distal radial epiphysis and when open reduction may potentially increase the risk of physeal disturbance. Secondly, children are not small adults, and care should be made to evaluate the width of the distal radial metaphysis and epiphysis. Use of precontoured volar locking plates typical of adult distal radius fractures may not be feasible, given size mismatch and/or presence of an open distal radial physis. Finally, care should be made to assess for articular extension of the fracture. Anatomic realignment of the distal radial joint surface is critical, even in the young child (Table 11-8). 
 
Table 11-8
Open Reduction and Fixation of Distal Radius Fractures
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Table 11-8
Open Reduction and Fixation of Distal Radius Fractures
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Radiolucent hand table
  •  
    Fluoroscopy location: Variable depending upon surgeon preference
  •  
    Equipment: Smooth K-wires (0.0625” diameter), small fragment 3.5-mm plates and screws, precontoured volar locking plates in older patients or intra-articular fractures
  •  
    Tourniquet (sterile/nonsterile): Nonsterile tourniquet placed on ipsilateral proximal brachium
X
Positioning
Patients are positioned supine with the affected limb supported by a radiolucent hand table. Positioning of the fluoroscopic unit is similar to that in closed reduction and pinning techniques. 
Surgical Approach(es)
All open fractures, regardless of grade of soft tissue injury, should be irrigated and debrided in the operating room (Fig. 11-40). The open wound should be enlarged adequately to debride the contaminated and nonviable tissues and protect the adjacent neurovascular structures. Judicious extension of the traumatic wound will allow for extensile exposure, facilitate fracture reduction, and allow for implant placement. 
Figure 11-40
Open fractures.
 
Radiograph (A) and clinical photo (B) of an open fracture of the distal radius. This patient needs formal irrigation and debridement in the operating room.
Radiograph (A) and clinical photo (B) of an open fracture of the distal radius. This patient needs formal irrigation and debridement in the operating room.
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Figure 11-40
Open fractures.
Radiograph (A) and clinical photo (B) of an open fracture of the distal radius. This patient needs formal irrigation and debridement in the operating room.
Radiograph (A) and clinical photo (B) of an open fracture of the distal radius. This patient needs formal irrigation and debridement in the operating room.
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Open reduction for closed unstable or irreducible fractures is typically performed through a volar approach to the distal radius. A longitudinal incision overlying the flexor carpi radialis (FCR) tendon is created, centered on the fracture site with awareness of the location of the distal radial physis. Classically, superficial dissection is carried out in the interval between the radial artery and the FCR. In distal radius fractures, dissection may also be performed directly through the FCR sheath by incising the roof of the FCR sheath and retracting the tendon ulnarly; the intact radial FCR sheath, when retracted, will serve to protect the adjacent radial artery. Deep to the FCR, a fat plane will be encountered overlying the pronator quadratus. The pronator quadratus is incised along its radial border, leaving a small cuff of tissue for subsequent repair, and elevated in a subperiosteal fashion from radial to ulnar. Although this muscle can be interposed in the fracture site, the volar periosteum is more commonly interposed. This is evident only after elevation of the pronator quadratus. The periosteum is extracted from the physis with care to minimize further injury to the physis. Upon completion of pronator quadratus elevation, the fracture may be easily visualized. 
Technique
After adequate fracture exposure is obtained, bony reduction is performed easily using similar maneuvers as during closed manipulations. Once anatomic fracture alignment is achieved, percutaneous smooth K-wires may be used for stabilization of the reduction. The method of pin insertion is the same as after closed reduction; use of a small incision during K-wire insertion will minimize risk to the radial sensory nerve and extensor tendons. 
Similarly for open fracture care, fracture reduction and fixation is performed, usually with two smooth K-wires, after thorough irrigation and debridement. In the uncommon open physeal fractures, care is taken with mechanical debridement to avoid injury to the physeal cartilage. If the soft tissue injury is severe, supplemental external fixation allows observation and treatment of the wound without jeopardizing the fracture reduction. The original open wound should not be closed primarily. Appropriate prophylactic antibiotics should be used depending on the severity of the open fracture. 
Plate fixation may also be used for stabilization following open reduction. While the indications for plate fixation evolve and remain patient- and surgeon-dependent, plate fixation is more strongly considered in multitrauma patients, comminuted fractures, older patients nearing or at skeletal maturity, refractures, and fractures at the metaphyseal–diaphyseal junction in whom percutaneous pinning techniques are more challenging. 
Following standard surgical exposure and fracture reduction, neutralization or dynamic compression plates are applied to radius using techniques similar to adult fracture care, with a few caveats. Standard 3.5-mm implants may be too bulky for younger or smaller pediatric patients. In these situations, double-stacked one-third tubular plates, 2.7-mm plates, or 2.4-mm plates may be used. In addition, given the rapid bony healing, stout periosteum, and postoperative cast immobilization characteristic of pediatric fracture care, two cortices of fixation may be sufficient distal to the fracture site. Finally, in patients with skeletal growth remaining, implants should be placed sparing the distal physis. 
In older adolescents at skeletal maturity or those with intra-articular injuries, volar locking plates may be used for internal fixation. Although a host of commercially available plates are available, the principles are constant: meticulous exposure, anatomic fracture reduction, and stable fixation proximal and distal to the fracture site. Care should be made in anatomically contoured volar locking plates to avoid penetration of obliquely angled distal locking screws into the radiocarpal joint, as well as excessive dorsal prominence of screws, which may lead to late extensor tendon irritation or rupture (Fig. 11-41). 
Figure 11-41
ORIF of distal radius with T plate and supplemental pin fixation.
 
A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
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A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
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Figure 11-41
ORIF of distal radius with T plate and supplemental pin fixation.
A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
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A: Injury CT scan revealing intra-articular displacement. B: ORIF with T buttress plate and supplemental styloid pin 1-month postoperative. C: One year after ORIF with anatomic alignment and asymptomatic hardware.
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Following fixation, the pronator quadratus, FCR sheath, and subcutaneous tissues are closed in layers, followed by skin closure. In cases of plate fixation, short-arm cast immobilization is sufficient postoperatively (Table 11-9). 
 
Table 11-9
Open Reduction and Fixation of Distal Radius Fractures
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Table 11-9
Open Reduction and Fixation of Distal Radius Fractures
Surgical Steps
  •  
    Expose distal radius
    •  
      Volar approach most common
  •  
    Superficial dissection through FCR sheath or in FCR-radial artery interval
  •  
    Incise radial margin of pronator quadratus with radial-to-ulnar subperiosteal elevation
  •  
    Fracture exposure and reduction
    •  
      Careful extraction of interposed periosteum or soft tissue
  •  
    Stable fixation with either K-wires or plate-and-screw constructs
  •  
    Meticulous layered wound closure
  •  
    Postoperative cast immobilization
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Surgical Procedure: Fixation of Intra-Articular fractures

Preoperative Planning
The rare Salter–Harris type III or IV fracture or “triplane” fracture158 may require open reduction if the joint or physis cannot be anatomically reduced via closed means. If anatomic alignment of the physis and articular surface is not present, the risk of growth arrest, long-term deformity, or limited function is great (Fig. 11-42). Even minimal displacement (more than 1 mm) should not be accepted in this situation. 
Figure 11-42
 
A: A markedly displaced Salter–Harris type IV fracture of the distal radius in an 11-year-old boy who fell from a horse. B: Radiograph taken 3 weeks after closed reduction demonstrates displacement of the comminuted fragments. C: Eighteen months after injury, there was 15 mm of radial shortening, and the patient had a pronounced radial deviation deformity of the wrist.
A: A markedly displaced Salter–Harris type IV fracture of the distal radius in an 11-year-old boy who fell from a horse. B: Radiograph taken 3 weeks after closed reduction demonstrates displacement of the comminuted fragments. C: Eighteen months after injury, there was 15 mm of radial shortening, and the patient had a pronounced radial deviation deformity of the wrist.
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Figure 11-42
A: A markedly displaced Salter–Harris type IV fracture of the distal radius in an 11-year-old boy who fell from a horse. B: Radiograph taken 3 weeks after closed reduction demonstrates displacement of the comminuted fragments. C: Eighteen months after injury, there was 15 mm of radial shortening, and the patient had a pronounced radial deviation deformity of the wrist.
A: A markedly displaced Salter–Harris type IV fracture of the distal radius in an 11-year-old boy who fell from a horse. B: Radiograph taken 3 weeks after closed reduction demonstrates displacement of the comminuted fragments. C: Eighteen months after injury, there was 15 mm of radial shortening, and the patient had a pronounced radial deviation deformity of the wrist.
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Preoperatively, CT or MRI scans are invaluable in defining fracture pattern, assessing articular congruity, and planning definitive treatment (Fig. 11-43). Based upon these images, appropriate preoperative planning may be performed. There is great variation in fracture patterns, and treatment and fixation must be individualized to restore bony alignment and stability. In addition to traditional percutaneous and open techniques, arthroscopically assisted reduction may be helpful to align and stabilize these uncommon intra-articular fractures.53 Although it is an equipment intensive operation with arthroscopy, external fixation, transphyseal and transepiphyseal pin or screw fixation, and fluoroscopy, anatomic reduction, and stabilization of the physis and articular surface can be achieved (Fig. 11-44, Table 11-10). 
Figure 11-43
 
A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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Figure 11-43
A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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A: Displaced distal radius metaphyseal and intra-articular fracture. B: Emergency department postreduction radiographs in cast. C: Representative postreduction CT scan images revealing joint displacement. D: Clinical appearance after decreased swelling over 5 days preoperatively. E: Planned plate for fracture fragment-specific volar fixation. F: Volar approach via FCR tendon sheath. G: Exposed fracture site with reduction. H: Plate fixation of fracture anatomically. I: Radiographs of ORIF with volar plating system.
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Figure 11-44
 
A: CT scan of displaced Salter–Harris type IV fracture. B: Surgical correction included external fixation distraction, arthroscopically assisted reduction, and smooth pin fixation.
A: CT scan of displaced Salter–Harris type IV fracture. B: Surgical correction included external fixation distraction, arthroscopically assisted reduction, and smooth pin fixation.
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Figure 11-44
A: CT scan of displaced Salter–Harris type IV fracture. B: Surgical correction included external fixation distraction, arthroscopically assisted reduction, and smooth pin fixation.
A: CT scan of displaced Salter–Harris type IV fracture. B: Surgical correction included external fixation distraction, arthroscopically assisted reduction, and smooth pin fixation.
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Table 11-10
Fixation of Intra-Articular Fractures
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Table 11-10
Fixation of Intra-Articular Fractures
Preoperative Planning Checklist
  •  
    OR Table: Standard
  •  
    Position/positioning aids: Radiolucent hand table
  •  
    Fluoroscopy location: Variable according to surgeon preference
  •  
    Equipment: K-wires, small fragment plating systems, anatomically precontoured volar locking plates, small joint arthroscope
  •  
    Tourniquet (sterile/nonsterile): nonsterile tourniquet on proximal brachium
  •  
    Adequate preoperative imaging, including CT or MRI
X
Positioning
Standard positioning is utilized, as described above. In cases where wrist arthroscopy is to be performed, use of a wrist traction tower with finger trap suspension applied to the index and long fingers will stabilize the wrist and provide appropriate traction for arthroscopic visualization. 
Surgical Approach(es)
The volar surgical approach remains the standard workhorse exposure for distal radius fractures requiring open reduction. Often, more distal subperiosteal elevation is needed to visualize intra-articular fracture lines. This is more common in older, skeletally mature adolescents. 
In many intra-articular fracture patterns, there are radial styloid and/or dorsal lunate facet fragments that necessitate exposure, reduction, and fixation. In these cases, supplemental dorsal approaches may need to be utilized. A longitudinal incision based over or ulnar to Lister's tubercle is most commonly utilized and provides a utilitarian approach. Superficial dissection is performed to the extensor retinaculum, with preservation of the dorsal veins if possible. In dorsal lunate facet fractures, incision of the retinaculum over the third or fourth extensor compartment and subsequent retraction of the extensor pollicis longus or extensor digitorum communis tendons, respectively, will provide access to the distal dorsal radius. Care is made to preserve the origins of the radiocarpal ligaments whenever possible. 
Technique
Given the spectrum of intra-articular distal radius fracture patterns, a sequential description of surgical steps is difficult; each patient must be treated in an individualized fashion according to fracture pattern, size of bony fragments, severity of displacement, and skeletal maturity. Universal surgical principles of adequate fracture reduction, anatomic realignment, and stable fixation will provide for optimal results. A few additional considerations are important. 
Attempts should be made to achieve closed or minimally invasive reduction whenever possible. With adequate anesthesia, muscle relaxation, and traction, displaced articular fragments may often be anatomically realigned, facilitating percutaneous fixation or implant placement without violating the radiocarpal joint or physis. Furthermore, K-wires may be used to joystick displaced fracture fragments or in an intrafocal fashion192 to further assist in fracture reduction. Intraoperative fluoroscopy is invaluable in these cases. 
Wrist arthroscopy may be a helpful adjunct for articular visualization.35,53 With approximately 10 to 12 pounds of distraction placed via finger traps to the index and long fingers, a small joint arthroscope (2.4 to 2.9 mm in diameter) may be inserted into the standard 3 to 4 wrist arthroscopy portal; this portal lies between the third and fourth extensor compartments and is typically 1 to 2 cm distal to Lister's tubercle. Care should be taken to avoid excessive extravasation of arthroscopy fluid into the zone of injury during arthroscopy; expeditious arthroscopy and use of low-pressure and flow rates are helpful in these situations. 
Finally, a wide spectrum of internal fixation options are available. Percutaneous K-wires are effective when properly positioned, particularly in younger patients with open physes in whom efforts are made to minimize the risk of iatrogenic growth disturbance. Wires passed obliquely from distal to proximal are effective for radial styloid and dorsal lunate facet fracture fragments; similarly, transverse epiphyseal pins may impart stability to articular fracture fragments. In older patients nearing or at skeletal maturity, adultlike locking plate constructs may be utilized (Table 11-11). 
 
Table 11-11
Fixation of Intra-Articular Fractures
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Table 11-11
Fixation of Intra-Articular Fractures
Surgical Principles
  •  
    Careful preoperative evaluation of fracture pattern, comminution, and displacement
  •  
    Fracture-specific surgical approaches
  •  
    Articular realignment
    •  
      Use of traction, wrist arthroscopy, fluoroscopy, or arthrotomy to aid in visualization
  •  
    Stabilization of the articular surface to the proximal radius
  •  
    Fixation using K-wires, interfragmentary screws, or plate-and-screw constructs for maintenance of alignment
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Surgical Procedure: Reduction and Fixation of Distal Ulnar Fractures

Open reduction is performed in cases where acceptable alignment is not achieved following radial reduction and attempted closed manipulation. This is an indication for open reduction. 
Preoperative Planning
Preoperative planning and patient positioning are similar to that of displaced distal radius fractures. 
Surgical Approach(es)
Incisions for surgical exposure of the ulna are typically ulnar or dorsoulnar, though ideally surgical exposure approaches the ulna from the side of periosteal disruption. In physeal fractures, the periosteum is typically torn opposite the Thurston–Holland fragment; in metaphyseal injuries, periosteal injury is opposite the direction of displacement. Deep dissection is most commonly made in the extensor carpi ulnaris—flexor carpi ulnaris interval ulnarly or the extensor digiti quinti—extensor carpi ulnaris intervals dorsally. Careful subperiosteal elevation may be performed in the zone of injury, which is typically already traumatized from the fracture. Interposed soft tissue (periosteum, extensor tendons, abductor digiti quinti, or flexor tendons) may then be identified and must be extracted from the fracture site.1,81,182 
Technique
Following exposure, soft tissue extraction, and bony reduction, if fracture instability persists, internal fixation is performed. Often, a single small-diameter smooth K-wire can be used to maintain alignment. This K-wire may be passed obliquely from distal to proximal, crossing the fracture site. In older patients with larger bones and greater instability, two parallel K-wires may be used, and this may be further supplemented by tension band fixation (Fig. 11-45). A small drill hole made proximal to the fracture site is created, and a nonabsorbable braided suture or small caliber stainless steel wire is passed through the drill hole and around the previously placed K-wires in a figure-of-eight fashion. Pins are typically removed after 4 weeks following radiographic confirmation of bony healing. Plate and screw fixation may also be performed in distal metaphyseal fractures and/or older, skeletally mature patients. Use of smaller implants, distal locking screws, or mini-fragment blade plates will assist in obtaining adequate fixation in the often small distal ulnar fracture fragment. Further injury to the physis should be avoided during operative exposure and reduction because of the high risk of growth arrest (Table 11-12).81 
Figure 11-45
 
A: Plain radiographs depicting displaced distal radial metaphyseal and ulnar styloid fractures. Given the fracture and distal radioulnar joint instability, the injury was treated with closed reduction and percutaneous pinning of the distal radius as well as open reduction and tension band fixation of the ulnar styloid. B: Follow-up radiograph following reduction and fixation demonstrate anatomic alignment. The prior radial pins have been removed, and the parallel smooth wires used for tension band fixation of the ulnar styloid are seen.
A: Plain radiographs depicting displaced distal radial metaphyseal and ulnar styloid fractures. Given the fracture and distal radioulnar joint instability, the injury was treated with closed reduction and percutaneous pinning of the distal radius as well as open reduction and tension band fixation of the ulnar styloid. B: Follow-up radiograph following reduction and fixation demonstrate anatomic alignment. The prior radial pins have been removed, and the parallel smooth wires used for tension band fixation of the ulnar styloid are seen.
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Figure 11-45
A: Plain radiographs depicting displaced distal radial metaphyseal and ulnar styloid fractures. Given the fracture and distal radioulnar joint instability, the injury was treated with closed reduction and percutaneous pinning of the distal radius as well as open reduction and tension band fixation of the ulnar styloid. B: Follow-up radiograph following reduction and fixation demonstrate anatomic alignment. The prior radial pins have been removed, and the parallel smooth wires used for tension band fixation of the ulnar styloid are seen.
A: Plain radiographs depicting displaced distal radial metaphyseal and ulnar styloid fractures. Given the fracture and distal radioulnar joint instability, the injury was treated with closed reduction and percutaneous pinning of the distal radius as well as open reduction and tension band fixation of the ulnar styloid. B: Follow-up radiograph following reduction and fixation demonstrate anatomic alignment. The prior radial pins have been removed, and the parallel smooth wires used for tension band fixation of the ulnar styloid are seen.
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Table 11-12
Fixation of Displaced Distal Ulnar Fractures
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Table 11-12
Fixation of Displaced Distal Ulnar Fractures
Surgical Steps
  •  
    Expose distal ulna
    •  
      Preserve distal ulnar physis, capsular attachments of DRUJ and ulnocarpal joint, and ulnar wrist ligaments whenever possible
  •  
    Anatomic reduction of ulnar fracture
  •  
    Stable fixation based upon fracture pattern and patient age
    •  
      K-wire fixation
    •  
      K-wire with tension band construct
    •  
      Plate-and-screw fixation
  •  
    Assess DRUJ alignment and stability intraoperatively
  •  
    Postoperative cast immobilization
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Surgical Procedure: Galeazzi Fractures

Open reduction of the radius is indicated in Galeazzi fractures or fracture equivalents in cases of failure to obtain or maintain fracture and DRUJ reduction. This most often occurs with unstable complete fractures in older adolescents. 
Preoperative Planning
Preoperative planning and patient positioning are similar as described above. Unlike adult Galeazzi fracture dislocations, advanced imaging (e.g., CT or MRI) is rarely needed in pediatric patients. 
Surgical Approach(es)
Open reduction and internal fixation of complete radius fractures is performed through a standard volar approach, as described above. In the majority of acute injuries, with anatomic reduction of the radius, restoration of radial length and alignment will allow for spontaneous reduction of the DRUJ. Occasionally, however, the DRUJ dislocation cannot be reduced via closed means (Fig. 11-46). In these situations, the first intra-operative step is to reassess the quality of radial fracture reduction and fixation. Following this, open reduction of the DRUJ may be performed to remove any interposed soft tissues blocking reduction (periosteum, extensor carpi ulnaris tendon, extensor digiti quinti tendon, other ligamentous structures).56,86,110,126,149,170,199 
Figure 11-46
An adolescent girl presented 4 weeks after injury with a painful, stiff wrist.
 
A: By examination, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general anesthesia. B: At the time of surgery, the distal ulna was found to have buttonholed out of the capsule, and there was entrapped triangular fibrocartilage and periosteum in the join.
A: By examination, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general anesthesia. B: At the time of surgery, the distal ulna was found to have buttonholed out of the capsule, and there was entrapped triangular fibrocartilage and periosteum in the join.
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Figure 11-46
An adolescent girl presented 4 weeks after injury with a painful, stiff wrist.
A: By examination, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general anesthesia. B: At the time of surgery, the distal ulna was found to have buttonholed out of the capsule, and there was entrapped triangular fibrocartilage and periosteum in the join.
A: By examination, she was noted to have a volar distal radioulnar dislocation that was irreducible even under general anesthesia. B: At the time of surgery, the distal ulna was found to have buttonholed out of the capsule, and there was entrapped triangular fibrocartilage and periosteum in the join.
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The easiest approach for open reduction of the DRUJ is an extended ulnar approach. Care should be taken to avoid injury to the ulnar sensory nerve branches, which typically pass obliquely from proximal volar to distal dorsal in the region of the ulnar styloid. This approach allows exposure both volarly and dorsally to extract the interposed soft tissues and repair the torn structures. Alternatively, a Bowers approach to the DRUJ may be used (Fig. 11-47). A curvilinear incision is made over the DRUJ. The fifth dorsal extensor compartment is incised and the extensor digiti quinti is retracted. The DRUJ lies immediately deep to this interval, and the joint may be opened and inspected, facilitating reduction. 
Figure 11-47
 
A: Clinical photograph depicting the dorsoulnar curvilinear incision used to approach the distal radioulnar joint in a patient with an irreducible Galleazi fracture. B: Intraoperative photograph depicting the sigmoid notch of the distal radius. The ECU and EDQ tendons are seen retracted volarly and radially. The volarly displaced distal ulna remains dislocated.
A: Clinical photograph depicting the dorsoulnar curvilinear incision used to approach the distal radioulnar joint in a patient with an irreducible Galleazi fracture. B: Intraoperative photograph depicting the sigmoid notch of the distal radius. The ECU and EDQ tendons are seen retracted volarly and radially. The volarly displaced distal ulna remains dislocated.
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Figure 11-47
A: Clinical photograph depicting the dorsoulnar curvilinear incision used to approach the distal radioulnar joint in a patient with an irreducible Galleazi fracture. B: Intraoperative photograph depicting the sigmoid notch of the distal radius. The ECU and EDQ tendons are seen retracted volarly and radially. The volarly displaced distal ulna remains dislocated.
A: Clinical photograph depicting the dorsoulnar curvilinear incision used to approach the distal radioulnar joint in a patient with an irreducible Galleazi fracture. B: Intraoperative photograph depicting the sigmoid notch of the distal radius. The ECU and EDQ tendons are seen retracted volarly and radially. The volarly displaced distal ulna remains dislocated.
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Technique
Open reduction and internal fixation of the radius are done through an anterior approach. Standard compression plating is preferred to intramedullary or cross-pinning techniques (Fig. 11-48). Stable, anatomic reduction of the radius almost always leads to stable reduction of the DRUJ dislocation. A long-arm cast is used for 6 weeks to allow fracture and soft tissue healing. 
Figure 11-48
 
A: The patient with a pronation injury had a closed reduction and attempted fixation with pins placed percutaneously across the fracture site. However, this was inadequate in maintaining the alignment and length of the fracture of the distal radius. B: The length of the radius and the distal radioulnar relationship were best reestablished after internal fixation of the distal radius with a plate placed on the volar surface. The true amount of shortening present on the original injury film is not really appreciated until the fracture of the distal radius is fully reduced.
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:34, with permission.)
A: The patient with a pronation injury had a closed reduction and attempted fixation with pins placed percutaneously across the fracture site. However, this was inadequate in maintaining the alignment and length of the fracture of the distal radius. B: The length of the radius and the distal radioulnar relationship were best reestablished after internal fixation of the distal radius with a plate placed on the volar surface. The true amount of shortening present on the original injury film is not really appreciated until the fracture of the distal radius is fully reduced.
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Figure 11-48
A: The patient with a pronation injury had a closed reduction and attempted fixation with pins placed percutaneously across the fracture site. However, this was inadequate in maintaining the alignment and length of the fracture of the distal radius. B: The length of the radius and the distal radioulnar relationship were best reestablished after internal fixation of the distal radius with a plate placed on the volar surface. The true amount of shortening present on the original injury film is not really appreciated until the fracture of the distal radius is fully reduced.
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:34, with permission.)
A: The patient with a pronation injury had a closed reduction and attempted fixation with pins placed percutaneously across the fracture site. However, this was inadequate in maintaining the alignment and length of the fracture of the distal radius. B: The length of the radius and the distal radioulnar relationship were best reestablished after internal fixation of the distal radius with a plate placed on the volar surface. The true amount of shortening present on the original injury film is not really appreciated until the fracture of the distal radius is fully reduced.
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If the DRUJ dislocation cannot be reduced, it is exposed as described above. Typically after anatomic alignment of the radius and extraction of any soft tissues blocking DRUJ reduction, the joint is stable and no additional fixation is required. In cases of extreme instability and/or soft tissue compromise, smooth K-wire fixation of the DRUJ can be used to maintain reduction and allow application of a loose-fitting cast. The K-wire(s) are placed with the forearm in supination and passed transversely across from the reduced DRUJ from the ulna to the radius, and the pin(s) left exposed out of the skin. Pin removal is in the office at 4 weeks with continuation of the cast for 6 weeks. 
Ulnar physeal fractures may also be irreducible in Galeazzi equivalent injuries. This also has been reported to be secondary to interposed periosteum, extensor tendons, or joint capsule.56,86,122,127,149,170,199 Open reduction must be executed with care to avoid further violating the physis (Table 11-13). 
 
Table 11-13
Galeazzi Fractures
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Table 11-13
Galeazzi Fractures
Surgical Steps
  •  
    Expose distal radius fracture
  •  
    Anatomic reduction and stabilization of radius
    •  
      Plate fixation preferred
  •  
    Careful intraoperative assessment of forearm rotation and DRUJ stability
    •  
      Intraoperative fluoroscopy to confirm DRUJ alignment
  •  
    If DRUJ not reducible, open reduction via ulnar or Bowers approach
  •  
    If DRUJ not reducible in setting of distal ulnar physeal fracture, open reduction and stabilization of ulnar fracture performed
  •  
    Radioulnar pinning in cases of reducible but unstable DRUJ reduction
  •  
    Long-arm cast immobilization for 6 wks
    •  
      If utilized, radioulnar pin removal 4–6 wks postoperatively
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Surgical Procedure: External Fixation

External fixation rarely is indicated for fractures in skeletally immature patients. Though a viable treatment option,178 the success rates of both closed reduction and percutaneous pinning techniques make external fixation unnecessary for uncomplicated distal radial fractures in children. Presently, indications for external fixation include distal radius fractures with severe associated soft tissue injuries. Severe crush injuries, open fractures, or replantations after amputation requiring additional soft tissue coverage are all indications for external fixation. Supplemental external fixation also may be necessary for severely comminuted fractures to maintain length and provide additional stability to pin or plate constructs. Standard application of the specific fixator chosen is done with care to avoid injury to the adjacent sensory nerves and extensor tendons. 
Preoperative Planning
Preoperative planning and patient positioning are similar to as described above. A host of commercially available external fixators may be utilized, with selection of pin diameter based upon fracture location and patient size. 
Surgical Approach(es)
In general, external fixation for distal radius fractures in children spans the radiocarpal articulation. Although nonbridging (or wrist joint sparing) constructs may be utilized, the small size of the distal radial epiphysis in young children often precludes the ability to obtain adequate purchase with external fixator pins. For this reason, typical constructs involve fixator pin placement through the index metacarpal and more proximal radial diaphysis. 
Distally, a dorsoradial incision is made over the mid-diaphyseal region of the index metacarpal. Dissection is performed through the subcutaneous tissues. The periosteum may be incised via an open approach, and careful limited subperiosteal elevation will allow for the first dorsal interosseous and adductor pollicis muscles to retract safely. Percutaneous techniques may also be utilized, with care taken to avoid inadvertent injury to the radial sensory nerve, extensor tendons, or intrinsic muscles. 
Proximally, a dorsoradial approach in the region of the distal radial metadiaphysis is made. Again identification and retraction of the radial sensory nerve is performed. Deep dissection will allow visualization of the characteristic “bare area” between the musculotendinous units of the first and second extensor compartments. A longitudinal periosteal incision is created, facilitating safe and direct placement of external fixator pins. 
Technique
Exposure and pin placement are described as above. Following placement of two terminally threaded pins distal and proximal to the fracture, appropriate traction and reduction may be performed. Use of double-stacked radiolucent bars will increase construct rigidity and facilitate radiographic evaluation. 
After fluoroscopic confirmation of pin placement and acceptable fracture alignment, prior surgical incisions may be closed primarily and sterile bandages and/or petroleum gauze may be applied to the pin sites. 

Authors' Preferred Method of Treatment for Fractures of the Distal Radius and Ulna

Torus fractures

Torus fractures may be safely and effectively treated with removable splint immobilization for 3 weeks. Immobilization provides comfort from pain during healing and protects against displacement with secondary injury. After 3 weeks, splints may be removed at home without need for formal clinical evaluation. Gradual resumption of activities is allowed once wrist motion and strength return. 

Incomplete Greenstick Fractures

Displaced greenstick fractures are at risk for progressive malalignment and subsequent loss of forearm rotation. For this reason, closed reduction and long-arm cast immobilization is performed for displaced greenstick fractures with greater than 10 degrees of angulation. Generally, these fractures have apex volar angulation and dorsal displacement. Conscious sedation is used with portable fluoroscopy in the emergency care setting. The distal fragment and hand are distracted and then reduced volarly. With isolated distal radial fractures, it is imperative to reduce the DRUJ with appropriate forearm rotation. For apex volar fractures, this usually is with pronation. If the fracture is apex dorsal with volar displacement, the reduction forces are the opposite. A long-arm cast with three-point molding is used for 3 to 4 weeks. Radiographs are obtained every 7 to 10 days until there is sufficient callus formation. A short-arm cast or volar wrist splint is used until full healing, generally at 4 to 6 weeks after fracture reduction. The patient is then restricted from contact sports until full motion and strength are regained, which may take up to several weeks after cast removal. Formal therapy rarely is required. The patient and parents are counseled regarding the risk of redisplacement of the fracture during cast immobilization, as well as the risk of refracture following cast removal. 

Bicortical Complete Radial Metaphyseal Injuries

Nondisplaced bicortical metaphyseal fractures are treated with cast immobilization. Our preference at present is to begin with short-arm cast immobilization, with achieving appropriate fracture mold. Given the risk of late displacement, serial radiographs are obtained for the first 2 to 3 weeks. By 3 to 4 weeks after injury, there is sufficient healing to transition to short-arm cast immobilization. Casts are discontinued at 6 weeks, with gradual resumption of activities with return of wrist motion and strength. 
Displaced fractures with unacceptable alignment are treated with closed reduction and long-arm cast immobilization. At our institutions, we reduce this fracture in the emergency room with conscious sedation and supplemental local hematoma block or in the operating room with general anesthesia. In either situation, portable fluoroscopy is used. The fracture usually is reduced in the emergency room in young patients with minimal swelling and no neurovascular compromise and in whom cast treatment will be sufficient. Reduction with general anesthesia is preferred for older patients and for those with marked displacement, swelling, or associated neurovascular compromise in whom percutaneous pin treatment is considered. 
The reduction maneuver is the same regardless of anesthesia type or stabilization method. As opposed to a Colles fracture in an adult, traction alone will not reduce the fracture because the dorsal periosteum acts as a tension band that does not respond to increasing linear traction with weights. Finger traps with minimal weight (less than 10 lb) can be used to balance the hand and help with rotational alignment (Fig. 11-49). However, applying progressive weight will only distract the carpus and will not alter the fracture alignment. 
Figure 11-49
Acceptable method of closed reduction of distal physeal fractures of the radius.
 
A: Position of the fracture fragments as finger trap traction with countertraction is applied (arrows). B: With traction alone, the fracture will often reduce without external pressure (arrows). C: If the reduction is incomplete, simply applying direct pressure over the fracture site in a distal and volar direction with the thumb often completes the reduction while maintaining traction. This technique theoretically decreases the shear forces across the physis during the reduction process.
A: Position of the fracture fragments as finger trap traction with countertraction is applied (arrows). B: With traction alone, the fracture will often reduce without external pressure (arrows). C: If the reduction is incomplete, simply applying direct pressure over the fracture site in a distal and volar direction with the thumb often completes the reduction while maintaining traction. This technique theoretically decreases the shear forces across the physis during the reduction process.
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Figure 11-49
Acceptable method of closed reduction of distal physeal fractures of the radius.
A: Position of the fracture fragments as finger trap traction with countertraction is applied (arrows). B: With traction alone, the fracture will often reduce without external pressure (arrows). C: If the reduction is incomplete, simply applying direct pressure over the fracture site in a distal and volar direction with the thumb often completes the reduction while maintaining traction. This technique theoretically decreases the shear forces across the physis during the reduction process.
A: Position of the fracture fragments as finger trap traction with countertraction is applied (arrows). B: With traction alone, the fracture will often reduce without external pressure (arrows). C: If the reduction is incomplete, simply applying direct pressure over the fracture site in a distal and volar direction with the thumb often completes the reduction while maintaining traction. This technique theoretically decreases the shear forces across the physis during the reduction process.
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After applying preliminary traction with either lightweight finger traps or hand traction, a hyperdorsiflexion maneuver is performed. The initial deformity is accentuated and the distal fragment is brought into marked dorsiflexion. The dorsum of the hand should be brought more than 90 degrees and at times parallel to the dorsum of the forearm to lessen the tension on the dorsal periosteum. Thumb pressure is used on the distal fragment while still in this deformed position to restore length by bringing the distal fragment beyond the proximal fragment. Reduction is then obtained by flexing the distal fragment while maintaining length. Often, this initial reduction maneuver restores length and alignment, but translational reduction is incomplete. The fracture should be completely reduced by toggling the distal fragment volarly by repetitive slight dorsiflexion positioning of the distal fragment followed by volar pressure with the thumbs. It is important to anatomically reduce the fracture. Loss of reduction with cast immobilization is more likely if the fracture remains translated or malaligned. 
A long-arm cast is applied with the elbow flexed 90 degrees, the wrist in slight palmar flexion, and the forearm in the desired rotation for stability and alignment. Rotational positioning and short- versus long-arm casting varies with each fracture and each surgeon. Our preference is neutral forearm rotation unless the fracture dictates differently. This allows excellent molding against the volar aspect of the distal radius at the fracture site. 
One of the most important elements in a successful casting for a forearm fracture is the application of the cast padding (Webril, Kendall, Mansfield, MA). Cast padding should be applied in a continuous roll with overlap of one-third to one-half its width. Extra padding is applied over the olecranon when a long-arm cast is used, along the volar and dorsal forearm where the cast may have to be split, and at the ends of the cast to prevent irritation from fraying. 
A three-point mold is applied at the fracture site as the cast hardens. In addition, molds are applied to maintain a straight ulnar border, the interosseous space, and straight posterior humeral line. This creates the classic “box” long-arm cast rather than the all too frequent “banana” cast that allows displacement. Final radiographs are obtained, and if the reduction is anatomic, the cast is overwrapped. 
Patients are either discharged or admitted to the hospital depending on the degree of concern regarding risk of excessive swelling, neurovascular compromise, and patient and parental reliability. If there is any doubt, the patient is admitted for observation. The cast is split anytime there are signs of neurovascular compromise or excessive swelling. The patient is instructed to maintain elevation for at least 48 to 72 hours after discharge and return immediately if excessive swelling or neurovascular compromise occurs. The patient and family are warned of the risk of loss of reduction and the need for close follow-up. We inform our patients and parents that the risk of return to the day surgery unit for repeat reduction or pinning is approximately 20% to 30% during the first 3 weeks. 
Follow-up examinations and radiographs are obtained weekly for 2 to 3 weeks. If there is loss of reduction, we individualize treatment depending on the patient's age, degree of deformity, time since fracture, and remodeling potential. If restoration of alignment with growth occurs, we reassure the family that the child should achieve anatomic alignment over time with growth. If the child is older, there is risk of further displacement, or the deformity is marked, repeat reduction is done in the day surgery unit with fluoroscopy. Most often, a percutaneous pin is used for the second reduction (Fig. 11-50). Occasionally, in pure bending injuries, loss of reduction can be corrected with cast wedging. 
Figure 11-50
Remanipulation.
 
A, B: Two weeks after what initially appeared to be an nondisplaced greenstick fracture, a 14-year-old boy was found to have developed late angulation of 30 degrees in both the coronal and sagittal planes. C: Because this was beyond the limits of remodeling, a remanipulation was performed. To prevent reangulation, the fracture was secured with a pin placed percutaneously obliquely through the dorsal cortex.
A, B: Two weeks after what initially appeared to be an nondisplaced greenstick fracture, a 14-year-old boy was found to have developed late angulation of 30 degrees in both the coronal and sagittal planes. C: Because this was beyond the limits of remodeling, a remanipulation was performed. To prevent reangulation, the fracture was secured with a pin placed percutaneously obliquely through the dorsal cortex.
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Figure 11-50
Remanipulation.
A, B: Two weeks after what initially appeared to be an nondisplaced greenstick fracture, a 14-year-old boy was found to have developed late angulation of 30 degrees in both the coronal and sagittal planes. C: Because this was beyond the limits of remodeling, a remanipulation was performed. To prevent reangulation, the fracture was secured with a pin placed percutaneously obliquely through the dorsal cortex.
A, B: Two weeks after what initially appeared to be an nondisplaced greenstick fracture, a 14-year-old boy was found to have developed late angulation of 30 degrees in both the coronal and sagittal planes. C: Because this was beyond the limits of remodeling, a remanipulation was performed. To prevent reangulation, the fracture was secured with a pin placed percutaneously obliquely through the dorsal cortex.
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Cast immobilization usually is for 4 to 6 weeks. Patients are typically transitioned from a long-arm cast to a short-arm cast at 4 weeks postinjury. With clinical and radiograph healing, a protective volar splint is used and activities are restricted until the patient regains full motion and strength, usually in 1 to 3 weeks after cast removal. As with other distal radial fractures, formal physical therapy rarely is required. 
In cases of loss of reduction exceeding the limits of fracture remodeling, repeat closed reduction and pin fixation is considered. Percutaneous pinning is also performed in cases of excessive swelling or signs of neurologic injury. In these situations, the patient is at risk for development of a forearm or carpal tunnel compartment syndrome with a well-molded, tight-fitting cast. Similarly, concurrent displaced supracondylar and distal radial fractures are treated with percutaneous fixation of both fractures to lessen the risk of neurovascular compromise. Older patients near the end of growth with bayonet apposition fractures also are treated with percutaneous pin fixation because they have less ability to remodel and their fractures are very unstable with a high risk of displacement. Finally, open fractures usually are treated with pin fixation. 
The pinning technique for the radius is either a single radial-sided pin or crossed radial- and ulnar-sided pins. Fixation of the ulna rarely is necessary. Stability with a single pin is checked with fluoroscopy, and if further fixation is needed, a second pin is added. The physis is avoided if possible. Intrafocal pins are used if reduction is not possible without levering the distal fragment into a reduced position. A small incision is made for the insertion of each pin to protect the radial sensory nerve and adjacent extensor tendons. Smooth pins are used and are removed in the office as soon as there is sufficient healing to make the fracture stable in a cast or splint (usually at 4 weeks). Rehabilitation is similar to that for cast-treated fractures. 
Open reduction is typically reserved for open or irreducible fractures in which an adequate closed reduction cannot be achieved. All open fractures are irrigated and debrided in the operating room. The initial open wound is extended adequately to inspect and cleanse the open fracture site. After thorough irrigation and debridement, the fracture is reduced and stabilized. A cast rarely is applied in this situation because of concern about fracture stability, soft tissue care, and excessive swelling. Crossed-pin fixation often is used with Gustilo grade 1 or 2 open fractures. More severe soft tissue injuries usually require external fixation with a unilateral frame, with care taken to avoid soft tissue impingement during pin placement. If flap coverage is necessary for the soft tissue wounds, the fixator pins should be placed in consultation with the microvascular surgeon planning the soft tissue coverage. In addition, open reduction internal fixation with volar plating is performed for unstable fractures in the skeletally mature adolescent. 
Irreducible fractures usually are secondary to soft tissue entrapment. With dorsal displacement, this is most often either the volar periosteum or pronator quadratus, and open reduction through a volar approach is necessary to extract the interposed soft tissues and reduce the fracture. Percutaneous pin fixation usually is used to stabilize the fracture in patients with open physes. If plate fixation is used, it should avoid violation of the physis (Fig. 11-51). Displaced intra-articular injuries in skeletally immature adolescents are adultlike and require standard treatment, such as open reduction and internal fixation (Fig. 11-52). Lower-profile and locking plates have been used more recently (Fig. 11-53). 
Figure 11-51
 
A: Radiograph of an open humeral diaphyseal fracture in the setting of a “floating elbow injury.” B: Radiograph depicting a displaced distal radial metaphyseal fracture. C: Plate fixation following irrigation and debridement of the humerus fracture. D, E: Radiographs following open reduction and plate fixation of the radius fracture, sparing the distal radial physis.
A: Radiograph of an open humeral diaphyseal fracture in the setting of a “floating elbow injury.” B: Radiograph depicting a displaced distal radial metaphyseal fracture. C: Plate fixation following irrigation and debridement of the humerus fracture. D, E: Radiographs following open reduction and plate fixation of the radius fracture, sparing the distal radial physis.
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Figure 11-51
A: Radiograph of an open humeral diaphyseal fracture in the setting of a “floating elbow injury.” B: Radiograph depicting a displaced distal radial metaphyseal fracture. C: Plate fixation following irrigation and debridement of the humerus fracture. D, E: Radiographs following open reduction and plate fixation of the radius fracture, sparing the distal radial physis.
A: Radiograph of an open humeral diaphyseal fracture in the setting of a “floating elbow injury.” B: Radiograph depicting a displaced distal radial metaphyseal fracture. C: Plate fixation following irrigation and debridement of the humerus fracture. D, E: Radiographs following open reduction and plate fixation of the radius fracture, sparing the distal radial physis.
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Figure 11-52
 
A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
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A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
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Figure 11-52
A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
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A, B: AP and lateral radiographs of a 14-year-old skeletally mature female with a displaced extra-articular fracture. C, D: This fracture was treated with a fixed-angle volar locking plate, with distal screws crossing the physis. The long-term effects of this type of fixation are unknown.
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Figure 11-53
 
A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
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A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
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Figure 11-53
A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
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A: CT scan of a displaced intra-articular fracture of a nearly skeletally mature adolescent. B: Dorsal plating with a low-profile system to achieve anatomic reduction and stable fixation.
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Physeal Injuries

Most Salter–Harris type I and II fractures are reduced closed under conscious sedation with the assistance of portable fluoroscopy. A long-arm cast with appropriate three-point molding is applied. This is changed to a short-arm cast when there is sufficient healing for fracture stability, usually after 3 to 4 weeks. Cast immobilization is discontinued when there is clinical and radiographic evidence of fracture healing, generally 4 to 6 weeks after fracture. Range-of-motion and strengthening exercises are begun with a home program. When the child achieves full motion and strength, he or she can return to full activity, including competitive sports. As the risk of posttraumatic physeal disturbance is approximately 4% to 5%, follow-up radiographs are obtained at 6 to 12 months after fracture to be certain there is no growth arrest.12,27 
Patients with distal radial physeal fractures with late displacement present treatment challenges. In younger patients with more than 2 years of growth remaining, remanipulation of physeal fractures is not performed after 7 to 10 postinjury, given concerns of iatrogenic growth arrest. In these situations, patients and families are counseled about remodeling potential and potential need for future interventions in the event that incomplete remodeling occurs (e.g., late corrective osteotomy). Serial radiographs are obtained 6 to 12 months after fracture healing to confirm appropriate skeletal remodeling and rule out growth disturbance. 
A patient with a displaced Salter–Harris type I or II physeal fracture associated with significant volar soft tissue swelling, median neuropathy, or ipsilateral elbow and radial fractures (floating elbow') is treated with closed reduction and percutaneous pinning (Fig. 11-54). This avoids the increased risk of compartment syndrome in the carpal canal or volar forearm that is present if a well-molded, tight cast is applied. In addition, acute percutaneous pinning of the fracture prevents increased swelling, cast splitting, loss of reduction, and concerns about malunion or growth arrest with repeat reduction. The risk of growth arrest from a narrow-diameter, smooth pin left in place for 3 to 4 weeks is exceedingly small.217 
Figure 11-54
 
A: Ipsilateral distal radial physeal and supracondylar fractures. This 6-year-old sustained both a dorsally displaced distal radial physeal fracture (closed arrow) and a type II displaced supracondylar fracture of the humerus (open arrows.) B: Similar case treated with percutaneous pinning of radial physeal fracture and supracondylar humeral fracture.
A: Ipsilateral distal radial physeal and supracondylar fractures. This 6-year-old sustained both a dorsally displaced distal radial physeal fracture (closed arrow) and a type II displaced supracondylar fracture of the humerus (open arrows.) B: Similar case treated with percutaneous pinning of radial physeal fracture and supracondylar humeral fracture.
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Figure 11-54
A: Ipsilateral distal radial physeal and supracondylar fractures. This 6-year-old sustained both a dorsally displaced distal radial physeal fracture (closed arrow) and a type II displaced supracondylar fracture of the humerus (open arrows.) B: Similar case treated with percutaneous pinning of radial physeal fracture and supracondylar humeral fracture.
A: Ipsilateral distal radial physeal and supracondylar fractures. This 6-year-old sustained both a dorsally displaced distal radial physeal fracture (closed arrow) and a type II displaced supracondylar fracture of the humerus (open arrows.) B: Similar case treated with percutaneous pinning of radial physeal fracture and supracondylar humeral fracture.
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Open reduction is reserved for irreducible Salter–Harris type I and II fractures, open fractures, fractures with associated acute carpal tunnel or forearm compartment syndrome, displaced (more than 1 mm) Salter–Harris type III or IV fractures, or triplane equivalent fractures. For an irreducible Salter–Harris type I or II fracture, exposure is from the side of the torn periosteum. Because these fractures usually are displaced dorsally, a volar exposure is used. Smooth pins are used for stabilization and are left in for 3 to 4 weeks. Open fractures are exposed through the open wound with proximal and distal extension for adequate debridement. All open debridements are performed in the operating room under general anesthesia. Acute compartment syndromes are treated with immediate release of the transverse carpal ligament or forearm fascia. The transverse carpal ligament is released in a Z-plasty fashion to lengthen the ligament and prevent volar bow-stringing and scarring of the median nerve against the palmar skin. 

Intra-Articular Fractures

Displaced intra-articular fractures in the skeletally immature are best treated with arthroscopically assisted reduction and fixation. Distraction across the joint can be achieved with application of an external fixator or wrist arthroscopy traction devices and finger traps. Standard dorsal portals (3/4 and 4/5) are used for viewing the intra-articular aspect of the fracture and alignment of the reduction. 66,76 In addition, direct observation through the arthroscope can aid in safe placement of the intraepiphyseal pins.53,87,92 Fluoroscopy is used to evaluate the extra-articular aspects of the fracture (triplane equivalent and type IV fractures), the reduction, and placement of fixation pins. 
In older patients near or at skeletal maturity with intra-articular comminution, volar locking plate fixation is performed, similar to adults (Figs. 11-55, 11-56). 
Figure 11-55
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Figure 11-55
Algorithm
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Figure 11-56
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Figure 11-56
Algorithm
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Potential Pitfalls and Preventative Measures
Potential pitfalls and preventative measures are described in the preceding sections and summarized in Table 11-14
 
Table 11-14
Distal Radius Fractures
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Table 11-14
Distal Radius Fractures
Potential Pitfalls and Preventions
Pitfall Preventions
Loss of reduction Correct diagnosis of bicortical disruption
Optimal fracture reduction
Well-molded cast application
Serial radiographic evaluation
Posttraumatic growth arrest Avoidance of repeated forceful reduction maneuvers acutely
Avoidance of late manipulation for loss of reduction in children with considerable remaining growth
Compartment syndrome Thorough neurovascular evaluation at time of initial presentation
Avoidance of excessive forceful manipulation during reduction maneuvers
Immediate pin fixation in patients with excessive soft tissue swelling or neurovascular compromise
Bivalve circumferential casts to avoid excessive external compression
Timely surgical stabilization with fasciotomies or carpal tunnel release in patients with impending compartment syndrome
Radial sensory nerve injury Use of small incisions for nerve identification and retraction during pinning procedures
Pin placement using oscillating technique
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Management of Expected Adverse Outcomes and Unexpected Complications in Fractures of the Distal Radius and Ulna

Loss of Reduction

Loss of reduction is a common occurrence after closed reduction and cast immobilization of displaced distal radius fractures (Fig. 11-57). Multiple studies demonstrate an incidence of loss of reduction of 20% to 30%.6,7,10,48,57,90,103,131,134,139,163,164,198,205,216,219 From these studies, factors that have been identified as increasing the risk of loss of reduction with closed manipulation and casting include poor casting, bayonet apposition, age greater than 10, translation of more than 50% the diameter of the radius, apex volar angulation of more than 30 degrees, isolated radial fractures, and radial and ulnar metaphyseal fractures at the same level. More specifically, Mani et al.131 concluded that initial displacement of the radial shaft of over 50% was the single most reliable predictor of failure of reduction. Proctor et al.164 found that complete initial displacement resulted in a 52% incidence of redisplacement of distal radial fractures in children and described remanipulation rates of 23%. Pretell et. al.163 found that post reduction translation of the radius greater than 10% in the sagittal plane resulted 2.7 times more likely loss of reduction. Alemdarólu et al.6,7 suggest that radial fractures with greater than 30 degrees of obliquity have 11.7 times more likelihood to redisplace than a straight transverse fracture. 
Figure 11-57
Results of angulation.
 
A: Significant apex volar angulation of the distal fragment. B: The appearance was not as apparent cosmetically as in another patient with less angulation that was directed apex dorsally.
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.)
 
C: Radial deviation constricts the interosseous space, which may decrease forearm rotation.
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:28, with permission.)
A: Significant apex volar angulation of the distal fragment. B: The appearance was not as apparent cosmetically as in another patient with less angulation that was directed apex dorsally.
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Figure 11-57
Results of angulation.
A: Significant apex volar angulation of the distal fragment. B: The appearance was not as apparent cosmetically as in another patient with less angulation that was directed apex dorsally.
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:27, with permission.)
C: Radial deviation constricts the interosseous space, which may decrease forearm rotation.
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:28, with permission.)
A: Significant apex volar angulation of the distal fragment. B: The appearance was not as apparent cosmetically as in another patient with less angulation that was directed apex dorsally.
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In addition to the initial and postreduction angulation, a poor casting technique is often implicated as a cause of loss of reduction. Recently, it has become evident that casting alone is likely not sufficient to prevent loss of reduction for fractures at high risk of loss of reduction. Miller et al.136 reported that despite these optimal conditions, 30% of high-risk patients treated with cast immobilization alone sustained a loss of reduction that required remanipulation. These findings have generated enthusiasm for percutaneous pinning and casting for as a preferable method to avoid loss of reduction.78,217 Although the authors of these studies, and others,217 conclude that pinning is a safe, effective means of treating distal radial metaphyseal fractures (see Controversies); the results of casting and pinning were equivalent after 2 years postfracture.38,133 
In general loss of reduction has been tolerated because of the remodeling potential of the distal radius.70,153,221 However, given that remodeling can be incomplete leading to malunion (see Malunion section) with functional deficits, high rates of loss of reduction has led to considerable controversies regarding acceptable displacement, casting techniques, remanipulation, and need for initial percutaneous pinning. We prefer to reduce forearm fractures as near to perfect alignment as possible. No element of malrotation is accepted in the reduction. As indicated in the treatment sections, fractures at high risk of loss of reduction and malunion are treated with anatomic reduction and pin or, rarely, plate fixation. Fractures treated in a cast are followed closely and rereduced for any loss of alignment of more than 10 degrees. Although loss of forearm rotation can occur with anatomic healing,144,190 it is less likely than with a malunion. 

Malunion

While complications from metaphyseal and physeal fractures of the radius are relatively rare, malunions do occur.11,31,39,37,38,44,50,198 De Courtivron45 reported that of 602 distal radial fractures, 14% had an initial malunion of more than 5 degrees. In addition, as noted above, the rate of loss of reduction for distal radius fractures ranges from 20% to 30%, and although many of these fractures will be rereduced, inevitably surgeons will encounter malunion of the distal radius most often to avoid injury to the physis from remanipulation beyond 7 days of injury or a patient may miss a follow-up appointment. Fortunately, with significant growth remaining, many angular malunions of the distal radius will remodel,45,50,70,108,153,221 probably because of asymmetric physeal growth (Fig. 11-24).112,125 The younger the patient, the less the deformity, and the closer the fracture is to the physis, the greater the potential for remodeling. Distal radial fractures are most often juxtaphyseal, the malunion typically is in the plane of motion of the wrist joint (dorsal displacement with apex volar angulation), and the distal radius accounts for 60% to 80% of the growth of the radius. All these factors favor remodeling of a malunion. 
The malunited fracture should be monitored over the next 6 to 12 months for remodeling. If the fracture does not remodel, persistent extension deformity of the distal radial articular surface puts the patient at risk for developing midcarpal instability185,186 or degenerative arthritis of the wrist, though a recent report has raised the question of whether imperfect final radiographic alignment necessarily leads to symptomatic arthrosis.69 For malunion correction, an opening-wedge (dorsal or volar) osteotomy is made, iliac crest bone of appropriate trapezoidal shape to correct the deformity is inserted, and either a plate or external fixator is used to maintain correction until healing.68 
As there are controversies as to what degree of deformity is either less likely to remodel, or cause a functional loss (see Controversies) the degree and plane of loss of motion, as well as the individual affected, determine if this is functionally significant.215 In cadaver studies, malangulation of more than 20 degrees of the radius or ulna caused loss of forearm rotation,132,187 whereas less than 10 degrees of malangulation did not alter forearm rotation significantly. Distal third malunion affected rotation less than middle or proximal third malunion. Radioulnar malunion affected forearm rotation more than volar–dorsal malunion. Excessive angulation may lead to a loss of rotation at a 1:2 degree ratio, whereas malrotation may lead to rotational loss at only a 1:1 degree loss.169 The functional loss associated with rotational motion loss is difficult to predict. This has led some clinicians to recommend no treatment,42,44 arguing that most of these fractures will remodel, and those that do not remodel will not cause a functional problem.106 However, a significant functional problem is present if shoulder motion cannot compensate for loss of supination. 
Intra-articular malunion is potentially devastating complication, due to the risk of degenerative arthritis if the articular stepoff is more than 2 mm.119 MRI or CT scans can be useful in preoperative evaluations. Arthroscopy allows direct examination of the deformity and areas of impingement or potential degeneration. Intra-articular osteotomy with bone grafting in the metaphysis to support the reconstructed articular surface is controversial and risky; however, it has the potential to restore anatomic alignment to the joint and prevent serious long-term complications. This problem fortunately is uncommon in children because of the rarity of the injury and this type of malunion. 
In Galeazzi fractures, malunion of the radius can lead to subluxation of the DRUJ, limited forearm rotation, and pain, usually secondary to persistent shortening and malrotation of the radial fracture. Most often, this occurs when complete fractures are treated with closed reduction and there is failure to either obtain or maintain reduction of the radial fracture. The ulna remains subluxed and heals with an incongruent joint. Treatment of this requires proper recognition and corrective osteotomy. If physical examination is not definitive for diagnosis, then a CT scan in pronation, neutral rotation, or supination may be helpful. MRI or wrist arthroscopy will aid in the diagnosis and management of associated ligamentous, chondral, or TFCC injuries that will benefit from debridement or repair. It is important to understand that if the DRUJ subluxation is caused by a radial malunion, a soft tissue reconstruction of the DRUJ alone will fail. In the true soft tissue disruption, repair of the TFCC will often stabilize the DRUJ. If there is no TFCC tear, soft tissue reconstruction of the DRUJ ligaments with extensor retinaculum or local tendon is appropriate. 

Nonunion

Nonunion of a closed radial or ulnar fracture is rare. In children, nonunion has been universally related to a pathologic condition of the bone or vascularity.27,84 Congenital pseudarthrosis or neurofibromatosis (Fig. 11-58) should be suspected in a patient with a nonunion after a benign fracture.111 This occurs most often after an isolated ulnar fracture.81,183 The distal bone is often narrowed, sclerotic, and plastically deformed. These fractures rarely heal with immobilization. Vascularized fibular bone grafting usually is necessary for healing of a nonunion associated with neurofibromatosis or congenital pseudarthrosis. If the patient is very young, this may include a vascularized epiphyseal transfer to restore distal growth. 
Figure 11-58
This 3-year-old presented to the emergency room with pain after an acute fall on his arm.
 
The ulna is clearly pathologic with thinning and deformity before this injury. This represents neurofibromatosis.
The ulna is clearly pathologic with thinning and deformity before this injury. This represents neurofibromatosis.
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Figure 11-58
This 3-year-old presented to the emergency room with pain after an acute fall on his arm.
The ulna is clearly pathologic with thinning and deformity before this injury. This represents neurofibromatosis.
The ulna is clearly pathologic with thinning and deformity before this injury. This represents neurofibromatosis.
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Vascular impairment also can lead to nonunion. Distal radial nonunion has been reported in a child with an ipsilateral supracondylar fracture with brachial artery occlusion. Revascularization of the limb led to eventual union of the fracture. Nonunion also can occur with osteomyelitis and bone loss.25 Debridement of the necrotic bone and either traditional bone grafting, osteoclasis lengthening, vascularized bone grafting, or creation of a single-bone forearm are surgical options. The choice depends on the individual patient. 

Cross-Union

Cross-union, or posttraumatic radioulnar synostosis, is a rare complication of pediatric distal radial and ulnar fractures. It has been described after high-energy trauma and internal fixation.196,197 A single-pin crossing both bones increases the risk of cross-union.197 Synostosis take-down can be performed, but the results usually are less than full restoration of motion. It is important to determine if there is an element of rotational malunion with the cross-union because this will affect the surgical outcome. 
Soft tissue contraction across both bones also has been described.66 Contracture release resulted in restoration of forearm motion. 

Refracture

Fortunately, refractures after distal radial fractures are rare and much less common than after diaphyseal level radial and ulnar fractures and fractures in adults. This is likely due to the unique biology in children where, as opposed to adults, remineralization after forearm fractures in children occurs rapidly with a transient elevation in bone mineral density.71 Most commonly, refracture occurs with premature discontinuation of immobilization or early return to potentially traumatic activities. It is advisable to protectively immobilize the wrist until full radiograph and clinical healing (usually 6 weeks) and to restrict activities until full motion and strength are regained (usually an additional 1 to 6 weeks). Individuals involved in high-risk activities, such as downhill ski racing, snowboarding, or skateboarding, should be protected with a splint during those activities for much longer. 

Physeal Arrest of the Distal Radius

Distal radial physeal arrest can occur from either the trauma of the original injury (Fig. 11-59)3,8,96 or late reduction of a displaced fracture. The incidence of radial growth arrest has been shown to be 4% to 5% of all displaced radial physeal fractures.12,27,126 The trauma to the physeal cartilage from displacement and compression is a significant risk factor for growth arrest. However, a correlation between the risk of growth arrest and the degree of displacement, type of fracture, or type of reduction has yet to be defined. Similarly, the risk of further compromising the physis with late reduction at various time intervals is still unclear. The current recommendation is for an atraumatic reduction of a displaced physeal fracture less than 7 days after injury. 
Figure 11-59
 
A: AP radiograph of growth arrest with open ulnar physis. B: MRI scan of large area of growth arrest that was not deemed respectable by mapping. Note is made of impaction of the distal ulna against the triquetrum and a secondary peripheral TFCC tear. C: Radiograph after ulnar shortening osteotomy, restoring neutral ulnar variance.
A: AP radiograph of growth arrest with open ulnar physis. B: MRI scan of large area of growth arrest that was not deemed respectable by mapping. Note is made of impaction of the distal ulna against the triquetrum and a secondary peripheral TFCC tear. C: Radiograph after ulnar shortening osteotomy, restoring neutral ulnar variance.
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Figure 11-59
A: AP radiograph of growth arrest with open ulnar physis. B: MRI scan of large area of growth arrest that was not deemed respectable by mapping. Note is made of impaction of the distal ulna against the triquetrum and a secondary peripheral TFCC tear. C: Radiograph after ulnar shortening osteotomy, restoring neutral ulnar variance.
A: AP radiograph of growth arrest with open ulnar physis. B: MRI scan of large area of growth arrest that was not deemed respectable by mapping. Note is made of impaction of the distal ulna against the triquetrum and a secondary peripheral TFCC tear. C: Radiograph after ulnar shortening osteotomy, restoring neutral ulnar variance.
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When a growth arrest develops, the consequences depend on the severity of the arrest and the amount of growth remaining. A complete arrest of the distal radial physis in a skeletally immature patient can be a serious problem. The continued growth of the ulna with cessation of radial growth can lead to incongruity of the DRUJ, ulnocarpal impaction, and development of a TFCC tear (Fig. 11-60).12,202 The radial deviation deformity at the wrist can be severe enough to cause limitation of wrist and forearm motion. Pain and clicking can develop at the ulnocarpal or radioulnar joints, indicative of ulnocarpal impaction or a TFCC tear. The deformity will progress until the end of growth. Pain and limited motion and function will be present until forearm length is rebalanced, until the radiocarpal, ulnocarpal, and radioulnar joints are restored, and until the TFCC tear and areas of chondromalacia are repaired or debrided.12,150,189 
Figure 11-60
 
A: AP radiograph of radial growth arrest and ulnar overgrowth after physeal fracture. Patient complained of ulnar-sided wrist pain and clicking. B: Clinical photograph of ulnar overgrowth and radial deviation deformity.
A: AP radiograph of radial growth arrest and ulnar overgrowth after physeal fracture. Patient complained of ulnar-sided wrist pain and clicking. B: Clinical photograph of ulnar overgrowth and radial deviation deformity.
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Figure 11-60
A: AP radiograph of radial growth arrest and ulnar overgrowth after physeal fracture. Patient complained of ulnar-sided wrist pain and clicking. B: Clinical photograph of ulnar overgrowth and radial deviation deformity.
A: AP radiograph of radial growth arrest and ulnar overgrowth after physeal fracture. Patient complained of ulnar-sided wrist pain and clicking. B: Clinical photograph of ulnar overgrowth and radial deviation deformity.
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Ideally, physeal arrest of the distal radius will be discovered early before the consequences of unbalanced growth develop. Radiographic screening 6 to 12 months after injury can identify the early arrest. A small area of growth arrest in a patient near skeletal maturity may be clinically inconsequential. However, a large area of arrest in a patient with marked growth remaining can lead to ulnocarpal impaction and forearm deformity if intervention is delayed. MRI can map the area of arrest.155 If it is less than 45% of the physis, a bar resection with fat interposition can be attempted.124 This may restore radial growth and prevent future problems (Fig. 11-61). If the bar is larger than 45% of the physis, bar resection is unlikely to be successful. An early ulnar epiphysiodesis will prevent growth imbalance of the forearm.202 The growth discrepancy between forearms in most patients is minor and does not require treatment. However, this is not the case for a patient with an arrest at a very young age, for whom complicated decisions regarding forearm lengthening need to occur. 
Figure 11-61
Osseous bridge resection.
 
A: This 10-year-old had sustained a distal radial physeal injury 3 years previously and now complained of prominence of the distal ulna with decreased supination and pronation. B: Polytomes revealed a well-defined central osseous bridge involving about 25% of the total diameter of the physis. C: The bridge was resected, and autogenous fat was inserted into the defect. Growth resumed with resumption of the normal ulnar variance. Epiphysiodesis of the distal ulna was postponed for 6 months. D: Unfortunately, the radius slowed its growth, and a symptomatic positive ulnar variance developed. E: This was treated with an epiphysiodesis (open arrow). and surgical shortening of the ulna. The clinical appearance and range of motion of the forearm returned to essentially normal.
A: This 10-year-old had sustained a distal radial physeal injury 3 years previously and now complained of prominence of the distal ulna with decreased supination and pronation. B: Polytomes revealed a well-defined central osseous bridge involving about 25% of the total diameter of the physis. C: The bridge was resected, and autogenous fat was inserted into the defect. Growth resumed with resumption of the normal ulnar variance. Epiphysiodesis of the distal ulna was postponed for 6 months. D: Unfortunately, the radius slowed its growth, and a symptomatic positive ulnar variance developed. E: This was treated with an epiphysiodesis (open arrow). and surgical shortening of the ulna. The clinical appearance and range of motion of the forearm returned to essentially normal.
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Figure 11-61
Osseous bridge resection.
A: This 10-year-old had sustained a distal radial physeal injury 3 years previously and now complained of prominence of the distal ulna with decreased supination and pronation. B: Polytomes revealed a well-defined central osseous bridge involving about 25% of the total diameter of the physis. C: The bridge was resected, and autogenous fat was inserted into the defect. Growth resumed with resumption of the normal ulnar variance. Epiphysiodesis of the distal ulna was postponed for 6 months. D: Unfortunately, the radius slowed its growth, and a symptomatic positive ulnar variance developed. E: This was treated with an epiphysiodesis (open arrow). and surgical shortening of the ulna. The clinical appearance and range of motion of the forearm returned to essentially normal.
A: This 10-year-old had sustained a distal radial physeal injury 3 years previously and now complained of prominence of the distal ulna with decreased supination and pronation. B: Polytomes revealed a well-defined central osseous bridge involving about 25% of the total diameter of the physis. C: The bridge was resected, and autogenous fat was inserted into the defect. Growth resumed with resumption of the normal ulnar variance. Epiphysiodesis of the distal ulna was postponed for 6 months. D: Unfortunately, the radius slowed its growth, and a symptomatic positive ulnar variance developed. E: This was treated with an epiphysiodesis (open arrow). and surgical shortening of the ulna. The clinical appearance and range of motion of the forearm returned to essentially normal.
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If a radial growth arrest occurs associated with a radial physeal stress fracture, treatment depends on the degree of deformity and the patient's symptoms. Physeal bar resection often is not possible because the arrest is usually too diffuse in stress injuries. If there is no significant ulnar overgrowth, a distal ulnar epiphysiodesis will prevent the development of an ulnocarpal impaction syndrome. For ulnar overgrowth and ulnocarpal pain, an ulnar shortening osteotomy is indicated. Techniques include transverse, oblique, and Z-shortening osteotomies. Transverse osteotomy has a higher risk of nonunion than either oblique or Z-shortening and should be avoided. Even when oblique or Z-shortenings are used, making the osteotomy more distally in the metaphyseal region will lessen the risk of nonunion, owing to the more robust vascularity of the distal ulna. The status of the TFCC also should be evaluated by MRI or wrist arthroscopy. If there is an associated TFCC tear, it should be repaired as appropriate. 
Growth arrest of the distal radius after metaphyseal fracture is extremely rare with only five cases reported in the literature. Wilkins and O'Brien209 proposed that these arrests may be in fractures that extend from the metaphysis to the physis. This coincides with a Peterson type I fracture (Fig. 11-62)156 and in essence is a physeal fracture. These fractures should be monitored for growth arrest. 
Figure 11-62
Physeal arrest in a Peterson type I fracture.
 
A: Injury film showing what appears to be a benign metaphyseal fracture. Fracture line extends into the physis (arrows). B: Two years postinjury, a central arrest (open arrow) has developed, with resultant shortening of the radius.
 
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:21, with permission.)
A: Injury film showing what appears to be a benign metaphyseal fracture. Fracture line extends into the physis (arrows). B: Two years postinjury, a central arrest (open arrow) has developed, with resultant shortening of the radius.
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Figure 11-62
Physeal arrest in a Peterson type I fracture.
A: Injury film showing what appears to be a benign metaphyseal fracture. Fracture line extends into the physis (arrows). B: Two years postinjury, a central arrest (open arrow) has developed, with resultant shortening of the radius.
(Reprinted from Wilkins KE, ed. Operative Management of Upper Extremity Fractures in Children. Rosemont, IL: American Academy of Orthopaedic Surgeons, 1994:21, with permission.)
A: Injury film showing what appears to be a benign metaphyseal fracture. Fracture line extends into the physis (arrows). B: Two years postinjury, a central arrest (open arrow) has developed, with resultant shortening of the radius.
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Both undergrowth and overgrowth of the distal radius after fracture were described by de Pablos.46 The average difference in growth was 3 mm, with a range of −5 to +10 mm of growth disturbance compared with the contralateral radius. Maximal overgrowth occurred in the 9- to 12-year-old age group. As long as the patient is asymptomatic, under- or overgrowth is not a problem. If ulnocarpal impaction or DRUJ disruption occurs, then surgical rebalancing of the radius and ulna may be necessary 

Physeal Arrest Distal Ulna

Physeal growth arrest is frequent with distal ulnar physeal fractures (Fig. 11-63), occurring in 10% to 55% of patients.81 It is unclear why the distal ulna has a higher incidence of growth arrest after fracture than does the radius. Ulnar growth arrest in a young child leads to relative radial overgrowth and bowing. The most common complication of distal ulnar physeal fractures is growth arrest. Golz81 described 18 such fractures, with growth arrest in 10%. If the patient is young enough, continued growth of the radius will lead to deformity and dysfunction. The distal ulnar aspect of the radial physis and epiphysis appears to be tethered by the foreshortened ulna (Fig. 11-64). The radial articular surface develops increased inclination toward the foreshortened ulna. This is similar to the deformity Peinado152 created experimentally with arrest of the distal ulna in rabbits' forelimbs. The distal ulna loses its normal articulation in the sigmoid notch of the distal radius. The metaphyseal–diaphyseal region of the radius often becomes notched from its articulation with the distal ulna during forearm rotation. Frequently, these patients have pain and limitation of motion with pronation and supination.16 
Figure 11-63
 
A, B: A 10-year-old boy sustained a closed Salter–Harris type I separation of the distal ulnar physis (arrows) combined with a fracture of the distal radial metaphysis. C: An excellent closed reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.
A, B: A 10-year-old boy sustained a closed Salter–Harris type I separation of the distal ulnar physis (arrows) combined with a fracture of the distal radial metaphysis. C: An excellent closed reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.
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Figure 11-63
A, B: A 10-year-old boy sustained a closed Salter–Harris type I separation of the distal ulnar physis (arrows) combined with a fracture of the distal radial metaphysis. C: An excellent closed reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.
A, B: A 10-year-old boy sustained a closed Salter–Harris type I separation of the distal ulnar physis (arrows) combined with a fracture of the distal radial metaphysis. C: An excellent closed reduction was achieved atraumatically. D: Long-term growth arrest of the distal ulna occurred.
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Figure 11-64
 
A: The appearance of the distal ulna in the patient seen in Figure 11-44, 3 years after injury, demonstrating premature fusion of the distal ulnar physis with 3.2 cm of shortening. The distal radius is secondarily deformed, with tilting and translocation toward the ulna. B: In the patient in Figure 11-44 with distal ulnar physeal arrest, a lengthening of the distal ulna was performed using a small unipolar distracting device. The ulna was slightly overlengthened to compensate for some subsequent growth of the distal radius. C: Six months after the lengthening osteotomy, there is some deformity of the distal ulna, but good restoration of length has been achieved. The distal radial epiphyseal tilt has corrected somewhat, and the patient has asymptomatic supination and pronation to 75 degrees. D: Similar case to Figure 11-66AC, but with more progressive distal radial deformity treated with corrective osteotomy and epiphysiodesis of the distal radius.
A: The appearance of the distal ulna in the patient seen in Figure 11-44, 3 years after injury, demonstrating premature fusion of the distal ulnar physis with 3.2 cm of shortening. The distal radius is secondarily deformed, with tilting and translocation toward the ulna. B: In the patient in Figure 11-44 with distal ulnar physeal arrest, a lengthening of the distal ulna was performed using a small unipolar distracting device. The ulna was slightly overlengthened to compensate for some subsequent growth of the distal radius. C: Six months after the lengthening osteotomy, there is some deformity of the distal ulna, but good restoration of length has been achieved. The distal radial epiphyseal tilt has corrected somewhat, and the patient has asymptomatic supination and pronation to 75 degrees. D: Similar case to Figure 11-66A–C, but with more progressive distal radial deformity treated with corrective osteotomy and epiphysiodesis of the distal radius.
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Figure 11-64
A: The appearance of the distal ulna in the patient seen in Figure 11-44, 3 years after injury, demonstrating premature fusion of the distal ulnar physis with 3.2 cm of shortening. The distal radius is secondarily deformed, with tilting and translocation toward the ulna. B: In the patient in Figure 11-44 with distal ulnar physeal arrest, a lengthening of the distal ulna was performed using a small unipolar distracting device. The ulna was slightly overlengthened to compensate for some subsequent growth of the distal radius. C: Six months after the lengthening osteotomy, there is some deformity of the distal ulna, but good restoration of length has been achieved. The distal radial epiphyseal tilt has corrected somewhat, and the patient has asymptomatic supination and pronation to 75 degrees. D: Similar case to Figure 11-66AC, but with more progressive distal radial deformity treated with corrective osteotomy and epiphysiodesis of the distal radius.
A: The appearance of the distal ulna in the patient seen in Figure 11-44, 3 years after injury, demonstrating premature fusion of the distal ulnar physis with 3.2 cm of shortening. The distal radius is secondarily deformed, with tilting and translocation toward the ulna. B: In the patient in Figure 11-44 with distal ulnar physeal arrest, a lengthening of the distal ulna was performed using a small unipolar distracting device. The ulna was slightly overlengthened to compensate for some subsequent growth of the distal radius. C: Six months after the lengthening osteotomy, there is some deformity of the distal ulna, but good restoration of length has been achieved. The distal radial epiphyseal tilt has corrected somewhat, and the patient has asymptomatic supination and pronation to 75 degrees. D: Similar case to Figure 11-66A–C, but with more progressive distal radial deformity treated with corrective osteotomy and epiphysiodesis of the distal radius.
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Ideally, this problem is identified before the development of marked ulnar foreshortening and subsequent radial deformity. Because it is well known that distal ulnar physeal fractures have a high incidence of growth arrest, these patients should have serial radiographs at 6 to 12 months after fracture for early identification. Unfortunately, in the distal ulnar physis, physeal bar resection generally is unsuccessful. Surgical arrest of the radial physis can prevent radial deformity. Usually, this occurs toward the end of growth so that the forearm length discrepancy is not a problem. 
Rarely, patients present late with established deformity. Treatment involves rebalancing the length of the radius and ulna. The options include hemiphyseal arrest of the radius, corrective radial closing wedge osteotomy, and ulnar lengthening,16,81,143 or a combination of these procedures. The painful impingement of the radius and ulna with forearm rotation can be corrected with reconstitution of the DRUJ. If the radial physis has significant growth remaining, a radial physeal arrest should be done at the same time as the surgical rebalancing of the radius and ulna. Treatment is individualized depending on the age of the patient, degree of deformity, and level of pain and dysfunction. 
Golz et al.81 cited ulnar physeal arrest in 55% of Galeazzi equivalent fractures. If the patient is young enough, this ulnar growth arrest in the presence of ongoing radial growth will lead to deformity. Initially, there will be ulnar shortening. Over time, the foreshortened ulna can act as a tether, causing asymmetric growth of the radius. There will be increased radial articular inclination on the AP radiograph and subluxation of the DRUJ. Operative choices include ulnar lengthening, radial closing wedge osteotomy, radial epiphysiodesis, and a combination of the above procedures that is appropriate for the individual patient's age, deformity, and disability. 

Ulnocarpal Impaction Syndrome

The growth discrepancy between the radius and ulna can lead to relative radial shortening and ulnar overgrowth. The distal ulna can impinge on the lunate and triquetrum and cause pain with ulnar deviation, extension, and compression activities.16 This is particularly true in repetitive wrist loading sports such as field hockey, lacrosse, and gymnastics.49 Physical examination loading the ulnocarpal joint in ulnar deviation and compression will recreate the pain. Radiographs show the radial arrest, ulnar overgrowth, and distal ulnocarpal impingement. The ulnocarpal impaction also may be caused by a hypertrophic ulnar styloid fracture union or an ulnar styloid nonunion.25 MRI may reveal chondromalacia of the lunate or triquetrum, a tear of the TFCC, and the extent of the distal radial physeal arrest. 
Treatment should correct all components of the problem. The ulnar overgrowth is corrected by either an ulnar shortening or radial lengthening osteotomy. Most often, a marked degree of positive ulnar variance requires ulnar shortening to neutral or negative variance (Fig. 11-65). If the ulnar physis is still open, a simultaneous arrest should be done to prevent recurrent deformity. If the degree of radial deformity is marked, this should be corrected by a realignment or lengthening osteotomy. Criteria for radial correction is debatable, but we have used radial inclination of less than 11 degrees on the AP radiograph as an indication for correction.202 In the rare case of complete arrest in a very young patient, radial lengthening is preferable to ulnar shortening to rebalance the forearm. 
Figure 11-65
 
A: AP radiograph of distal radial growth arrest, ulnar overgrowth, and an ulnar styloid nonunion. Wrist arthroscopy revealed an intact triangular fibrocartilage complex. B: AP and lateral radiographs after ulnar shortening osteotomy.
A: AP radiograph of distal radial growth arrest, ulnar overgrowth, and an ulnar styloid nonunion. Wrist arthroscopy revealed an intact triangular fibrocartilage complex. B: AP and lateral radiographs after ulnar shortening osteotomy.
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Figure 11-65
A: AP radiograph of distal radial growth arrest, ulnar overgrowth, and an ulnar styloid nonunion. Wrist arthroscopy revealed an intact triangular fibrocartilage complex. B: AP and lateral radiographs after ulnar shortening osteotomy.
A: AP radiograph of distal radial growth arrest, ulnar overgrowth, and an ulnar styloid nonunion. Wrist arthroscopy revealed an intact triangular fibrocartilage complex. B: AP and lateral radiographs after ulnar shortening osteotomy.
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Triangular Fibrocartilage Complex Tears

Peripheral traumatic TFCC tears should be repaired. The presence of an ulnar styloid nonunion at the base often is indicative of an associated peripheral tear of the TFCC.1,12,150,189 The symptomatic ulnar styloid nonunion is excised25 and any TFCC tear is repaired. If physical examination or preoperative MRI indicates a TFCC tear in the absence of an ulnar styloid nonunion, an initial arthroscopic examination can define the lesion and appropriate treatment. Peripheral tears are the most common TFCC tears in children and adolescents and can be repaired arthroscopically by an outside-in suture technique. Tears off the sigmoid notch are the next most common in adolescents and can be repaired with arthroscopic-assisted, transradial sutures. Central tears are rare in children and, as opposed to adults with degenerative central tears, arthroscopic debridement usually does not result in pain relief in children. Distal volar tears also are rare and are repaired open, at times with ligament reconstruction.189 
Some ulnar styloid fractures result in nonunion or hypertrophic union.1,12,25,150,189 Nonunion may be associated with TFCC tears or ulnocarpal impaction. The hypertrophic healing represents a pseudoulnar positive variance with resultant ulnocarpal impaction. Both cause ulnar-sided wrist pain. Compression of the lunate or triquetrum on the distal ulna reproduces the pain. Clicking with ulnocarpal compression or forearm rotation represents either a TFCC tear or chondromalacia of the lunate or triquetrum. Surgical excision of the nonunion or hypertrophic union with repair of the TFCC to the base of the styloid is the treatment of choice. Postoperative immobilization for 4 weeks in a long-arm cast followed by 2 weeks in a short-arm cast protects the TFCC repair. 

Neuropathy

Median neuropathy can occur from direct trauma from the initial displacement of the fracture, traction ischemia from a persistently displaced fracture, or the development of a compartment syndrome in the carpal canal or volar forearm (Fig. 11-7).15,203 Median neuropathy and marked volar soft tissue swelling are indications for percutaneous pin stabilization of the fracture to lessen the risk of compartment syndrome in a cast. Median neuropathy caused by direct trauma or traction ischemia generally resolves after fracture reduction. The degree of neural injury determines the length of time to recovery. Recovery can be monitored with an advancing Tinel sign along the median nerve. Motor-sensory testing can define progressive return of neural function. 
Median neuropathy caused by a carpal tunnel syndrome will not recover until the carpal tunnel is decompressed. After anatomic fracture reduction and pin stabilization, volar forearm and carpal tunnel pressures are measured. Gelberman74 recommended waiting 20 minutes or more to allow for pressure–volume equilibration before measuring pressures. If the pressures are elevated beyond 40 mm Hg or the difference between the diastolic pressure and the compartment pressure is less than 30 mm Hg,107 an immediate release of the affected compartments should be performed. The carpal tunnel is released through a palmar incision in line with the fourth ray, with care to avoid injuring the palmar vascular arch and the ulnar nerves exiting the Guyon canal. The transverse carpal ligament is released with a Z-plasty closure of the ligament to prevent late bow-stringing of the nerve against the palmar skin. The volar forearm fascia is released in the standard fashion. 
Both the median and ulnar34,195 nerves are less commonly injured in metaphyseal fractures than in physeal fractures. The mechanisms of neural injury in a metaphyseal fracture include direct contusion from the displaced fragment, traction ischemia from tenting of the nerve over the proximal fragment,153 entrapment of the nerve in the fracture site,210 rare laceration of the nerve, and the development of an acute compartment syndrome. If signs or symptoms of neuropathy are present, a prompt closed reduction should be performed. Extreme positions of immobilization should be avoided because this can lead to persistent traction or compression ischemia and increase the risk of compartment syndrome. If there is marked swelling, it is better to percutaneously pin the fracture than to apply a constrictive cast. If there is concern about compartment syndrome, the forearm, and carpal canal pressures should be measured immediately. If pressures are markedly elevated, appropriate fasciotomies and compartment releases should be performed immediately. Finally, if the nerve was intact before reduction and is out after reduction, neural entrapment should be considered, and surgical exploration and decompression may be required. Fortunately, most median and ulnar nerve injuries recover after anatomic reduction of the fracture. 
Injuries to the ulnar nerve and anterior interosseous nerve have been described with Galeazzi fracture-dislocations.56,135,170,199 These reported injuries have had spontaneous recovery. Moore et al.141 described an 8% rate of injury to the radial nerve with operative exposure of the radius for internal fixation in their series. Careful surgical exposure, dissection, and retraction can decrease this risk. 

Infection

Infection after distal radial fractures is rare and is associated with open fractures or surgical intervention (also see Controversies). Fee et al.67 described the development of gas gangrene in four children after minor puncture wounds or lacerations associated with distal radial fractures. Treatment involved only local cleansing of the wound in all four and wound closure in one. All four developed life-threatening clostridial infections. Three of the four required upper limb amputations, and the fourth underwent multiple soft tissue and bony procedures for coverage and treatment of osteomyelitis. 
Infections related to surgical intervention also are rare. Superficial pin-site infections can occur and should be treated with pin removal and antibiotics. Deep-space infection from percutaneous pinning of the radius has not been described (Table 11-15). 
 
Table 11-15
Distal Radial and Ulnar Fractures
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Table 11-15
Distal Radial and Ulnar Fractures
Common Adverse Outcomes and Complications
Loss of reduction
Malunion
Nonunion
Growth disturbance (radius or ulna)
Ulnocarpal impaction
TFCC tears
Synostosis
Neuropathy
Infection
X

Summary, Controversies, and Future Directions in Fractures of the Distal Radius and Ulna

Controversies

Acceptable Deformity

There is considerable controversy about what constitutes an acceptable reduction.11,37,38,39,42,45,50,69 This is clearly age dependent; the younger the patient, the greater the potential for remodeling. Volar–dorsal malalignment has the greatest potential for remodeling because this is in the plane of predominant motion of the joint. A recent prospective study found excellent long-term clinical and radiographic results with reduced cost with nonsedated cast molding in patients with displaced fractures in preteen children.38 Marked radioulnar malalignment is less likely to remodel. Malrotation will not remodel. The ranges for acceptable reduction according to age are given in the immobilization section on incomplete fractures and apply to complete fractures as well. 

Greenstick Fractures

Controversy exists regarding completion of greenstick fractures.44,168,176 Although some researchers advocate completion of the fracture to reduce the risk of subsequent loss of reduction from the intact periosteum and concave deformity acting as a tension band to redisplace the fracture, completing the fracture increases the risk of instability and malunion.168,203,209 

Immobilization

The position and type of immobilization after reduction also have been controversial. Recommendations for the position of postreduction immobilization include supination, neutral, and pronation. The rationale for immobilization in pronation is that reduction of the more common apex volar fractures requires correction of the supination deformity.63 Following this rationale, apex dorsal fractures should be reduced and immobilized in supination. Pollen160 believed that the brachioradialis was a deforming force in pronation and was relaxed in supination (Fig. 11-66) and advocated immobilization in supination for all displaced distal radial fractures. Kasser113 recommended immobilization in slight supination to allow better molding of the volar distal radius. Some researchers advocate immobilization in a neutral position, believing this is best at maintaining the interosseous space and has the least risk of disabling loss of forearm rotation in the long term. Davis and Green44 and Ogden146 advocated that each fracture seek its own preferred position of stability. Gupta and Danielsson88 randomized immobilization of distal radial metaphyseal greenstick fractures in neutral, supination, or pronation to try to determine the best position of immobilization. Their study showed a statistical improvement in final healing with immobilization in supination. More recently, Boyer et al.24 prospectively randomized 109 distal third forearm fractures into long-arm casts with the forearm in neutral rotation, supination, or pronation following closed reduction. No significant differences in final radiographic position were noted among the differing positions of forearm rotation. 
Figure 11-66
The brachioradialis is relaxed in supination but may become a deforming force in pronation.
 
(Reprint from Pollen AG. Fractures and Dislocations in Children. Churchill Livingstone, MD: Williams & Wilkins, 1973, with permission.)
(Reprint from 


Pollen AG
. Fractures and Dislocations in Children. Churchill Livingstone, MD: Williams & Wilkins, 1973, with permission.)
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Figure 11-66
The brachioradialis is relaxed in supination but may become a deforming force in pronation.
(Reprint from Pollen AG. Fractures and Dislocations in Children. Churchill Livingstone, MD: Williams & Wilkins, 1973, with permission.)
(Reprint from 


Pollen AG
. Fractures and Dislocations in Children. Churchill Livingstone, MD: Williams & Wilkins, 1973, with permission.)
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Another area of controversy is whether long- or short-arm cast immobilization is better. Historically, most publications on pediatric distal radial fracture treatment advocated long-arm cast treatment for the first 3 to 4 weeks of healing.20,93,146,160 The rationale is that elbow flexion reduces the muscle forces acting to displace the fracture. In addition, a long-arm cast may further restrict the child's activity and therefore decrease the risk of displacement. However, Chess et al.31 reported redisplacement and reduction rates with well-molded short-arm casts similar to those with long-arm casts. They used a cast index (sagittal diameter divided by coronal diameter at the fracture site) of 0.7 or less to indicate a well-molded cast. In addition, two prospective studies have recapitulated these findings. The short-arm cast offers the advantage of elbow mobility and better patient acceptance of casting. Two recent randomized prospective clinical trials and a meta-analysis review compared the efficacy of short- and long-arm cast immobilization following closed reduction for pediatric distal radial fractures.20,93 Bohm et al.20 randomized 102 patients over the age of 4 years to either short- or long-arm casts following closed reduction of displaced distal radial metaphyseal fractures. No statistically significant difference was seen in loss of reduction rate between the two treatment groups. Webb et al.205 similarly randomized 103 patients to short- or long-arm casts after reduction of distal radial fractures. No significant difference in rate of lost reduction was seen between the two cohorts. Patients in short-arm casts, however, missed fewer days of school and required less assistance with activities of daily living than those with long-arm casts. In both of these studies, quality of fracture reduction and cast mold were influential factors in loss of reduction rates. These studies have challenged the traditional teaching regarding the need for elbow immobilization to control distal radial fracture alignment. 

Immediate Pinning of Displaced Distal Radius Fractures

In the past decade or two, closed reduction and percutaneous pinning have become more common as the primary treatment of distal radial metaphyseal fractures in children and adolescents.95,78,129,183,192,217 Despite this practice change, a meta-analysis review of the data comparing cast immobilization versus immediate pinning reveals equivalent long-term outcomes, despite more loss of reduction in the cast groups and more pin complications in the pin groups11 The indications cited include fracture instability and high risk of loss of reduction increasing the likelihood of the need for remanipulation,6,48,57,90,103,130,133,138,162,163,219 excessive local swelling that increases the risk of neurovascular compromise,15,44,202 and ipsilateral fractures of the distal radius and elbow region (floating elbow) that increase the risk of compartment syndrome.19,170,181 In addition, surgeon's preference for pinning in a busy office practice has been considered an acceptable indication because of similar complication rates and long-term outcomes with pinning and casting132,135 and the avoidance of remanipulation because alignment is secure. 

Open Fractures

There have been multiple studies51,104 demonstrating that the infection rate (2.5% to 4%) following nonoperative treatment of Gustillo grade 1 open fractures results in infection rates comparable to reported rates for operative84 treatment (2.5%). However, these were retrospective studies and likely will not change the standard of care of these fractures until an appropriate prospective randomized study has been conducted. 

Conclusions

Fractures of the distal forearm are common in the pediatric population. Given their proximity to the distal physes of the radius and ulna, these fractures have tremendous remodeling capacity and as a result, the majority may be effectively treated with appropriate nonoperative means. The future direction for management of these fractures is primarily focused upon prognosticating which fractures would be better served through surgical reduction and fixation, considering the relatively high rate of loss of reduction of these fractures. 

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