- Fractures of the distal radius are common
- These fractures are often accompanied by injury to the ulna, the ulnar styloid, distal radioulnar joint (Galeazzi) and increasingly recognized injuries to the TFCC.
- Closed management is suitable for the vast majority of fractures secondary to the remodeling potential of the distal radial physis.
- There is increasing evidence supporting use of prefabricated splints over casting for many pediatric distal radius fractures.
- Although rare, growth arrest is possible with fractures involving or near the physis
Description:Fractures of the distal radius are common and represent 31% of fractures occurring in children (Randsborg, 2013). Their peak incidence is 11-12 years in girls and 13-14 years in boys with the incidence being 1.5 times greater in males than females. The physis is involved in one-third of pediatric distal radius fractures (Mann, 1990).
Clinical Findings:Fractures of the distal radius frequently present with pain, swelling, and tenderness localized to the wrist. There is often pain with passive and active range of motion of the forearm, wrist, and hand. In nonverbal children, sometimes the only sign of injury is decreased spontaneous movement of the extremity.
Imaging Studies:AP and lateral radiographs of the wrist will identify subtle and displaced fractures. Advanced imaging is rarely required, however, a CT scan may be helpful to characterize the rare pediatric intraarticular fracture of the distal radius.
Buckle/Torus FracturesA buckle or torus fracture is inherently stable and recognized by a characteristic unicortical indent in the distal radius. There is excellent evidence confirming the efficacy of simple treatment in the form of a prefabricated splint for 3 weeks, which can be removed at home at the end of treatment and obviate the need for a return visit to the clinic. This can decrease health care costs and ease family burden. Not only does simplified treatment perform just as well, patients seem to recover function and return to sports earlier (Plint, 2006; Bae, 2013).
Greenstick FracturesGreenstick fractures represent a combination of total cortical disruption and plastic deformation at the fracture site. These fractures typically have a rotational component causing the fractures of the radius and ulna to appear at different levels. When they result from a more pure bending force, the radius and ulna fracture appear at the same level. When at the same level, a simple uniplanar reduction maneuver should suffice. When at different levels, apex volar fractures are usually caused by hypersupination and are reduced in pronation, while apex dorsal fractures are caused by hyperpronation and are reduced in supination. (Pannu, 2014). A debate exists as to whether these are more easily treated by completing the fracture, with benefits being greater freedom to proper align and potentially more exuberant callous formation but drawbacks being less fracture stability.
Metaphyseal FracturesFractures of the distal radial metaphysis can commonly also involve the ulna and may present with significant clinical and radiographic deformity. Fortunately, studies show significant remodeling potential in these injuries even with bayonet apposition and in patients age younger than 10 years, where no reduction has been attempted (Do, 2003; Crawford, 2012; Blount 1967). (Figure 1)
When casting fractures in this region, attentive reduction and molding allows the majority of these fractures to maintain excellent alignment in a short arm cast following the principles of the cast index (Chess, 1994). There is good evidence that minimally displaced fractures may even be treated with a simple splint similar to the buckle fractures mentioned above (Boutis, 2010). Fractures falling outside of what is considered acceptable alignment should undergo an initial formal closed reduction. The complication rates for initial management with pin fixation appear to mirror those related to any potential loss of reduction by not pinning, and no change to long-term outcome. Overall, the evidence is mounting for increasingly simplified treatment of distal radius fractures (Bae, 2012).
Physeal FracturesFamiliarity with the periphyseal growth and development of the distal radius and ulna can be helpful in treating injuries in this area with early detection of growth discrepancy. The distal radial physis account for about 90% of radial growth, which accounts the significant remodeling potential of displaced fractures (Pritchett 1991). The physis is involved in one-third of pediatric distal radius fractures. The Salter-Harris classification serves as the mainstay for approaching these injuries, with the large majority being type II fractures and the most common of the remainder are type I.
Non-displaced type I fractures are often diagnosed on clinical grounds in the face of relatively normal radiographs with tenderness directly over the distal radial physis. With radiographically proven injuries, approximately one half are isolated radial physeal fractures while the others are associated with the ulnar styloid or metaphyseal fractures. Pure distal ulnar physeal injuries are much less common and are most often associated with a metaphyseal fracture of the distal radius. Isolated distal ulnar physeal lesions are rare (Cannatta, 2003).
Non-displaced physeal fractures can be treated in a below elbow splint or cast for 4 weeks before mobilization as tolerated. Displaced physeal fractures should undergo early attempts at closed reduction in order to reduce the risk of physeal arrest by avoiding repeated, forceful, and late attempts at reduction. Physeal arrest may still occur if there has been enough compressive force with the injury (Lee, 1984). These fractures, in the absence of an induced growth disruption, have the greatest potential in the forearm for remodeling into satisfactory alignment (Cannatta, 2003). Age at the time of fracture has significant impact on outcome. Given sufficient remaining growth, residual displacement after an imperfect reduction can remodel adequately. However, if the injury results in a growth arrest this may lead to a severe deformity in a younger child .
Apposition of 50% is acceptable with greater than 2 years remodeling potential remaining (Lee, 1984). Even residual angulation greater than 20 degrees will normalize substantially but not always completely (Friberg, 1979). Recommendations for reduction of ulnar fractures are similarly considered 50% apposition and 20 degrees of angulation (Bae, 2008). A triplane fracture of the distal radius is rare and can be treated with anatomic reduction of the joint surface and a orthogonal screw construct similar to the distal tibial triplane injury (Mingo-Robinet, 2014). Closure of the distal radius growth plate occurs over a very short time period (< 1 year), which may play a part in why transitional fractures in this area are rare (Kraus, 2011).
Complete physeal remodeling occurs in the vast majority of Salter-Harris II distal radius fractures with the greatest remodeling potential in children up to 10 years of age. Remodeling in multiple planes is possible. Functional deficits are rare if radial or ulnar shortening is less than 1cm (Cannatta, 2003; Houshian, 2004; Perona, 1990).
Following physeal injury, surveillance with plain radiography has been suggested as often as every 3 months, until parallel Park-Harris lines have been observed (Abzug, 2014). The post-traumatic physeal arrest rate is estimated to be 1-7% (Lee, 1984; Waters, 2002). When distal radial growth arrest does occur, it can occur with a metaphyseal or torus fracture in the region, not only a with crush injury (Salter-Harris V) to the physis (Tang, 2002; Abram, 1987; Valverde, 1996). When fractured, ulnar physeal growth arrest occurs at a much higher rate than its radial counterpart, potentially resulting in a cosmetic deformity but rarely functional limitations (Tang, 2002; Collado-Torres, 1995; Golz, 1991). Chronic distal radial physeal injury resulting in positive ulnar variance is known to develop in young gymnasts due to repetitive full weight bearing on the skeletally immature upper extremity (DiFiori, 2006).
Galeazzi FracturesAnother example of force traversing the ulnar side of the distal forearm is the less common Galeazzi injury. This is defined as a fracture of the distal radius associated with a dislocation of the distal radioulnar joint. These lesions are frequently missed on initial assessment, but fortunately still have good outcomes with closed treatment even when recognized late (Eberl, 2008). When the radial fracture is accurately reduced and the forearm held in full supination, reduction of the torn articular disc and ligaments should allow healing in their approximate position (Rodriguez-Merchan, 2005). (Figure 2)
The presence of the triangular fibrocartilage complex (TFCC) throughout development results in a concomitancy of ulnar styloid avulsion fractures with distal radial epiphyseal injuries. When this injury occurs prior to ulnar styloid ossification, it may appear as non-union of the styloid when the ossification eventually occurs. Patients with ongoing ulnar sided wrist pain after fracture of the distal radius should be worked up for a possible TFCC tear (Ogden, 1981; Bae, 2006).
Complications:With closed management of distal radius fractures, potential complications include skin breakdown, loss of reduction, malunion, growth arrest, tendon rupture or entrapment, acute carpal tunnel syndrome, and compartment syndrome. Operative treatment of distal radius fractures introduces the additional risks of infection, scarring, and iatrogenic nerve injury.
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