Short Stature

Paediatric forearm and wrist fracture

Paediatric forearm fracture patterns including Galeazzi injury and its management.

13 questions 2 source pages

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Q1Describe the X-ray and initial assessment of a paediatric forearm fracture.▸

Fracture of both radius and ulna at the shaft with shortening (bayonet) in a skeletally immature patient
Hx: age, mechanism of injury
r/o acute complications: compartment syndrome / neurovascular injury

Q2What are the aims of treatment in a paediatric forearm fracture?▸

Q3What factors determine acceptable alignment in paediatric forearm fractures?▸

Q4What are the acceptable alignment limits (Rockwood 2010)?▸

<10 years: angulation <15 degrees, shortening and bayonetting <1cm
>10 years: anatomical reduction (<10 degrees sagittal for 11-13 years; 0-5 for >13 years)
0 degrees coronal for >=11 years

Q5Describe the closed reduction and casting technique.▸

Point palm in direction of apex of deformity; traction + angulation + rotation in the direction of angulation
Bayonet deformity requires more traction to reduce; single bone may need more traction
Mould with 3-point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane)
Sagittal:coronal cast width ratio <0.8

Q6What are the principles of K-wire fixation?▸

K wire should occupy at least 2/3 of the diameter of the medullary isthmus
Prebend radial wire to 3x the diameter of the medullary canal, apex of bend at fracture level
Radial styloid entry between EC I and II; ulnar entry at olecranon; confirm correct rotation
Indication for plating: close to skeletal maturity, meta-diaphyseal junction (width mismatch)

Q7What are the deforming forces by fracture level and how is rotation assessed?▸

Proximal 1/3: proximal fragment flexed (biceps) and supinated (supinator), distal pronated (PT + PQ) -> align in supination
Middle 1/3: proximal balanced by supinator and PT, distal pronated by PQ -> align in neutral
Distal 1/3: proximal pronated by PT + PQ -> align in pronation
AP: radial styloid/ radial tuberosity 180deg; Lat: coronoid process/ ulnar styloid 180deg

Q8What are the complications of paediatric forearm fractures?▸

Q9What is the definition of a Galeazzi fracture?▸

Displaced fracture of the distal shaft of the radius
Associated greenstick fracture of the distal ulna and/or distal ulna physeal fracture
DRUJ dislocation

Q10What is the assessment and aim of management?▸

Age, mechanism of injury; r/o associated injury (X-ray whole UL, look at PRUJ)
Neurovascular injury, compartment syndrome
Aim: restore full rotation of the forearm
Anatomical reduction of radius and concentric reduction of DRUJ

Q11When is surgery indicated and what technique is used?▸

Indications: failed CR, SHII; SHIII/IV (unstable); triplane variant; Galeazzi
CR under GA; percutaneous K wire pinning (needs to cross the physis to be stable enough)
Long arm cast in supination
May need ORIF - volar approach to radius, fix with IMN/plating

Q12How do you check DRUJ stability and manage instability?▸

Method one: elbow 90 degrees, test dorsal/palmar displacement in neutral, pronation, supination and radial deviation
Method two: compress ulna against radius while passively moving through supination and pronation
Stable = free mobilisation; unstable in either pronation or supination = immobilise in stable position 4-6 weeks
Grossly unstable: check radius reduction, fix ulnar styloid if large fragment; open DRUJ, TFCC repair; transfix radius and ulna proximal to DRUJ if still unstable

Q13What is acceptable alignment in distal radius fractures?▸

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