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Pediatric Forearm Fractures

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Pediatric Forearm Fractures ... Thurston-Holland fragment Monteggia Proximal ulna fracture with dislocation of the radial head 0.4% of all forearm fractures in ... – PowerPoint PPT presentation

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Title: Pediatric Forearm Fractures


1
Pediatric Forearm Fractures
  • J.J. Prosser

2
Incidence
  • 3.4 of all childrens fractures
  • Bimodal peak with boys 9 and 13 years old
  • Girls 5 years old

3
0ssification
  • Radial and ulnar shafts ossify during the eighth
    week of gestation
  • Distal radial epiphysis age 1
  • Distal ulnar epiphysis age 6
  • Radial head age 5-7
  • Olecranon age 9-10
  • They all close between the ages of 16-18

4
Anatomic Area
  • Distal third 75
  • Middle third 18
  • Proximal third 7

5
Osteology
  • The periosteum is very strong and thick in a
    child
  • It is generally disrupted on the convex side,
    while an intact hinge remains on the concave side
  • This is an important point when considering
    closed reduction

6
Biomechanics
  • The radius shortens with pronation and lengthens
    with supination
  • Malreduction of 10 degrees in the middle third
    limits rotation by 20-30 degrees
  • Bayonet apposition does not reduce forearm
    rotation

7
Deforming Muscle Forces
  • Proximal third
  • Biceps and supinator flexion and supination of
    proximal fragment
  • Pronator teres and quadratus pronate distal
    fragment
  • Middle third
  • Supinator, biceps, and pronator teres proximal
    fragment is neutral
  • Pronator quadratus pronates distal fragment
  • Distal third
  • Brachioradialis dorsiflex and radial deviate
    distal fragment

8
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9
Mechanism of injury
  • Indirect fall onto an outstretched hand
  • Direct blow from an object onto the radial and
    ulnar shaft
  • Rotation
  • Pronation flexion injury(posterior angulation)
  • Supination extension injury(anterior angulation)

10
Clinical evaluation
  • History age, mechanism of injury, and other
    areas of pain
  • Physical exam skin integrity, neurovascular
    status, and examination of elbow and wrist joints

11
Radiographic evaluation
  • AP and lateral of forearm, wrist, and elbow
  • The bicipital tuberosity is the landmark for
    identifying rotation

12
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13
Description
  • Location proximal, middle, distal
  • Type
  • Plastic deformation
  • Incomplete(greenstick)
  • Compression(torus or buckle)
  • Complete

14
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15
Salter-Harris
  • 75 in children 10-16 years old
  • Uncommon in children lt 5 years old
  • Type II most common Thurston-Holland fragment

16
Monteggia
  • Proximal ulna fracture with dislocation of the
    radial head
  • 0.4 of all forearm fractures in children
  • Peak incidence between 4 and 10 years old
  • Ulna fracture usually at junction of
    proximal/middle thirds

17
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18
Galeazzi
  • Middle to distal third radius fracture with
    disruption of the distal radioulnar joint
  • Rare in children
  • Peak incidence between 9 and 12 years old

19
Initial management
  • Correct gross deformity
  • Perform closed reduction and application of a
    well molded long arm cast
  • Forearm reduction after rotation
  • Proximal third supination
  • Middle third neutral
  • Distal third pronation
  • Split cast if concerned about swelling(uni-valve,
    bi-valve)

20
Acceptable deformity
  • Patients gt 10 years old, treat like adult no
    deformity accepted
  • Patients lt 10 years old
  • Angular deformities 1 degree/month
  • - 10
    degrees/year
  • Rotational deformities none
  • Bayonet apposition 1cm

21
Undisplaced fractures
  • Long arm cast 4-6 weeks until nontender
  • Elbow at 110-120 degrees of flexion

22
Plastic deformation
  • Children lt 4 years old or with deformities lt 20
    degrees, same as undisplaced

23
Greenstick fractures
  • Complete the fracture to decrease risk of angular
    deformity
  • Carefully crack the intact cortex while
    preventing displacement
  • Well molded long arm cast

24
Complete displacement
  • Attempt closed reduction and long arm cast with
    pancake molding
  • If the fracture is irreducible, ORIF may be
    indicated

25
Operative management
  • IM fixation Enders nail, K-wires
  • - limited exposure at fracture
    site may be required for reduction
  • Plate fixation prime indication is one of
    refracture in which the intramedullary canal has
    a high risk of being obstructed

26
Problems
  • Malunion over 60 have rotational losses gt20
    degrees
  • Refracture incidence of 12
  • - refrain from sports 1 month
    after cast removal
  • Nonunion rare in children
  • - high energy, open, infection
  • - ulnar gt radial
  • Neurovascular injuries posterior interosseous
    nerve damage with Monteggia Type III

27
Problems continued
  • Compartment syndrome pain aggravated by passive
    motion
  • - pressure
    gt 30mmHg
  • -
    fasciotomy
  • Infection - gt 6 hours before debridement(exponenti
    al growth)
  • RSD rare in children
  • - burning pain, hyperesthesia, and
    swelling
  • - resolves 6-12 months after injury
  • Overgrowth 6-8 months after injury
  • - averages 6-7mm
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