Fractures of the Distal Radius and Ulna

Most displaced Salter-Harris I and II fractures are
treated with closed reduction and cast stabilization. Closed
manipulation of the displaced fracture is performed with appropriate
conscious

sedation, analgesia, or, rarely, anesthesia to achieve pain relief and an atraumatic reduction.⁸,¹⁰⁸,¹⁹¹
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 (Figs. 9-14 and 9-15).
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.

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 casting²⁸,²⁹
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 for the first 3 weeks to be certain that there is no
loss of anatomic alignment (Fig. 9-16).
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 because of the risk of physeal
arrest.⁸,¹⁹⁴
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.

The indications for percutaneous pinning of distal
radial physeal fractures are still controversial. The best indication
is a displaced radial physeal fracture with median neuropathy and
significant volar soft tissue swelling (Fig. 9-17).²³⁹
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.³⁴,⁹¹,¹⁹⁵,²³⁹
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.

Pin fixation can be either single or double (Fig. 9-18).
Fluoroscopy is used to guide proper fracture reduction and pin
placement. Anesthesia is used for adequate pain relief and to lessen
the risk of further physeal injury. The fracture is manipulated into
anatomic alignment and the initial, and often only, pin

is
placed from the distal epiphysis of the radial styloid obliquely across
the physis into the more proximal ulnar aspect of the radial metaphysis
(Fig. 9-19).
Alternatively, smooth pins may be placed such that they avoid crossing
the distal radial physis, theoretically decreasing the risk of physeal
disturbance, though this has not been well demonstrated in the
published literature.²⁵² A
sufficient skin incision should be made with pin placement to be
certain there is no iatrogenic injury to the radial sensory nerve or
extensor tendons. 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.
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 ulnar
corner of the radial epiphysis between the fourth and fifth dorsal
compartments and passed obliquely to the proximal radial portion of the
metaphysis. Again, the skin incisions for pin placement should be
sufficient to avoid iatrogenic injury to the extensor tendons.

The pins are bent, left out of the skin, and covered
with a sterile dressing. Splint or cast immobilization is used but does
not need to be tight because fracture stability is provided 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.²⁰
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.

The main indication for open reduction of a displaced
distal radial Salter-Harris type II physeal fracture is irreducibility.
Most often this is caused by interposed periosteum or, less likely,
pronator quadratus.¹⁰⁷,¹³⁷,²⁵⁰
Open reduction is done through a volar approach to the distal radial
physis. The interval between the radial artery and the flexor carpi
radialis is used. This dissection also can proceed directly through the
flexor carpi radialis sheath to protect the artery. The pronator
quadratus is isolated and elevated 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. The fracture can then be
easily reduced. Usually, a percutaneous smooth pin is used for
stabilization of the reduction. The method of pin insertion is the same
as after closed reduction.

Open physeal fractures are rare but require irrigation
and débridement. Care should be taken with mechanical débridement of
the physeal cartilage to avoid further risk of growth arrest. Cultures
should be taken at the time of operative débridement, and appropriate
antibiotics are used to lessen the risk of deep space infection.

The rare Salter-Harris type III or IV fracture or triplane fracture¹⁷¹
may require open reduction if the joint or physis cannot be
anatomically reduced closed. The articular and physeal alignment can be
evaluated by radiographic tomograms (trispiral or

CT),
MRI scans, or wrist arthroscopy. 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. 9-20).
Even minimal displacement (more than 1 mm) should not be accepted in
this situation. Arthroscopically assisted reduction is helpful to align
and stabilize these rare physeal fractures.⁴⁸,⁷⁶
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. 9-21).

Malunion. Complications from physeal fractures are relatively rare. The most frequent problem is malunion. Fortunately, these

fractures often occur in children with significant growth remaining.
The deformity from a Salter-Harris type I or II fracture is in the
plane of motion of the wrist joint and, therefore, will remodel with
ensuing growth (Fig. 9-23).⁸,¹⁰⁸,¹⁸¹
Repeat reduction should not be done more than 7 days after fracture
because of the risk of growth arrest. 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
instability²¹⁷ 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.⁶⁴ For
malunion correction, an opening-wedge dorsal 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.⁶²

Intra-articular malunion is more worrisome because of
the risk of development of degenerative arthritis if the articular
stepoff is more than 2 mm.¹¹³ 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.

Physeal Arrest. Distal radial physeal arrest can occur from either the trauma of the original injury (Fig. 9-24)⁹⁵,¹²⁴,²²⁷
or late (more than 7 days) 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.⁹,²⁴,¹²⁴
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.

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. 9-25).⁹,²³⁶
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 débrided.¹⁶¹,²²¹,²³⁶

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.¹⁶⁸ If it is less than 45% of the physis, a bar resection with fat interposition can be attempted.¹²⁰,¹²¹ This may restore radial growth and prevent future problems (Fig. 9-26). 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.²³⁶
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.

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.¹² This is particularly true in repetitive wrist loading sports such as field hockey, lacrosse, and gymnastics.⁴⁵
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

(Fig. 9-27) or an ulnar styloid nonunion.²²,¹³³
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
osteotomy or radial lengthening. Most often, a marked degree of
positive ulnar variance requires ulnar shortening to neutral or
negative variance (Fig. 9-28). 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 (Fig. 9-29).²³⁶
In the rare case of complete arrest in a very young patient, radial
lengthening is preferable to ulnar shortening to rebalance the forearm.

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.¹,¹⁶¹,²²¹,²³⁶ The symptomatic ulnar styloid nonunion is excised²²,¹³³,¹⁵⁹
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 débridement usually does not result in pain relief in
children. Distal volar tears also are rare and are repaired open, at
times with ligament reconstruction.²²¹

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 forear (Fig. 9-30).²³⁹ All patients with displaced distal radial fracturesm

should undergo a careful motor-sensory examination upon presentation to
an acute care facility. The flexor pollicis longus, index flexor
digitorum profundus, and abductor pollicis brevis muscles should be
tested. Light-touch and two-point discrimination sensibility of the
thumb and index finger should be tested in any child over 5 years of
age with a displaced Salter-Harris type I or II fracture. 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.

Carpal Tunnel Syndrome. 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. Gelberman⁷⁷
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,¹⁰⁸
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.

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. 9-32).
The radial articular surface develops increased inclination toward the
foreshortened ulna. This is similar to the deformity Peinado¹⁶⁴
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.¹²

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 (Fig. 9-32),¹²,⁸¹,¹⁵²
or a combination of these procedures. The painful impingement of the
radius and ulna with forearm rotation can be corrected with
reconstitution of the distal radioulnar joint. 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.¹⁵⁴ Treatment is individualized depending on the age of the patient, degree of deformity, and level of pain and dysfunction.

Torus fractures are compression injuries with minimal
cortical disruption. As failure occurs in compression, by definition
these are inherently stable injuries. Treatment should consist of
protected immobilization to prevent further injury and relieve pain.³⁹,¹⁰⁹,¹⁵⁶,¹⁷³,²⁰⁸,²¹⁵,²⁴³
Once the patient is comfortable, range-of-motion exercises and
nontraumatic activities can begin. Fracture healing usually occurs in 2
to 4 weeks.⁸,¹²³,¹³³,¹⁵⁷ Simple torus fractures usually heal without long-term sequelae.

Bicortical disruption on both the AP and lateral views
indicates a more severe injury than a stable torus fracture. Splint or
limited immobilization in this situation puts the child at risk for
displacement. More prolonged, long-arm cast protection in a young
patient who can wiggle out of a short-arm cast and closer follow-up
generally are recommended to lessen the risk of malunion. These
fractures generally heal in 3 to 6 weeks.

Immobilization Alone. Treatment of incomplete distal
radial and ulnar fractures depends on the age of the patient, the
degree and direction of fracture displacement and angulation, the
surgeon’s biases regarding remodeling, and the surgeon’s and
community’s biases regarding deformity. In younger patients, the
remodeling potential of an acute distal radial malunion is extremely
high. Acceptable sagittal plane angulation of an acute distal radial
metaphyseal fracture has been reported to be from 10 to 35 degrees in
patients under 5 years of age.¹⁶,³²,¹³²,¹⁵⁷,¹⁷⁵,²⁰²,²⁴⁶ Similarly, in patients under 10 years of age, the degree of acceptable angulation has ranged from 10 to 25 degrees.¹⁶,³²,¹³²,¹⁵⁷,¹⁷⁵,²⁰²,²⁴⁶
In patients over 10 years of age, acceptable alignment has ranged from
5 to 20 degrees depending on the skeletal maturity of the patient (Table 9-3).¹⁶,³²,⁴¹,¹³²,¹⁵⁷,¹⁷⁵,²⁰²,²⁴⁴,²⁴⁶

The high potential for remodeling of a distal radial
metaphyseal malunion has led some clinicians to recommend
immobilization alone.⁴⁶ As mentioned, the range of accepted sagittal malalignment has been broad and is age and clinician dependent (Figs. 9-39 and 9-40).

Acceptable frontal plane deformity has been more
uniform. The fracture tends to displace radially with an apex ulnar
angulation. This does have the potential to remodel,¹⁶⁵
but less so than sagittal plane deformity. Most researchers agree that
only 10 degrees or less of acute malalignment in the frontal plane
should be accepted. More malalignment than this may not remodel and may
result in loss of forearm rotation because of the loss of interosseous
space between the radius and ulna (see Table 9-3).²⁴⁵

Closed Reduction. Most displaced and malaligned
incomplete fractures should be reduced closed. The areas of controversy
are the degree of acceptable deformity, whether the intact cortex
should be fractured, and the position and type of immobilization.

Controversies about acceptable angulation of the
fracture after closed reduction involve the same differences discussed
in the immobilization section. As mentioned, more malalignment can be
accepted in younger patients, in those with sagittal plane deformity,
and in those without marked cosmetic deformity. Malaligned apex volar
incomplete fractures are less obvious than the less common apex dorsal
fractures.

As Evans⁵⁶ and Rang¹⁸¹
emphasized, incomplete forearm fractures have a rotatory component to
their malalignment. The more common apex volar fractures represent a
supination deformity, whereas the less common apex dorsal fractures are
malrotated in pronation. Correction of the malrotation is necessary to
achieve anatomic alignment. Controversy exists regarding completion of
greenstick fractures.⁴⁰,⁶¹,¹⁰²,¹⁸¹,¹⁹⁹
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 band²¹⁴,²⁴⁶ to redisplace the fracture, completing the fracture increases the risk of instability and malunion.

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.⁵⁶ Following this rationale, apex dorsal fractures should be reduced and immobilized in supination. Pollen¹⁷⁵ believed that the brachioradialis was a deforming force in pronation and was relaxed in supination (Fig. 9-41) and advocated immobilization in supination for all displaced distal radial fractures. Kasser¹⁰⁸
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.⁴⁴,¹³²,²¹⁶ Davis and Green⁴⁰ and Ogden¹⁵⁷ advocated that each fracture seek its own preferred position of stability. Gupta and Danielsson⁸⁹
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.²¹
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.

Another area of controversy is whether long-arm 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.⁸,¹⁶,¹⁰⁸,¹²³,¹⁵⁷,²¹⁶
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.²⁸,²⁹
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. Wilkins²⁴⁶
achieved similar results with short-arm cast treatment. The short-arm
cast offers the advantage of elbow mobility and better patient
acceptance of casting. Despite these data, historically most centers
continue to use long-arm cast immobilization.⁸,¹⁶,¹⁰⁸,¹²³,²¹⁶

Two recent randomized prospective clinical trials
compared the efficacy of short- and long-arm cast immobilization
following closed reduction for pediatric distal radial fractures.¹⁷,²⁴⁰ Bohm et al.¹⁷
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.²⁴⁰
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.

In addition to the cast index,²⁸,²⁹,²⁴⁰
a number of other radiographic parameters have been proposed to
quantify the quality of reduction and cast molding. These include the
gap index, the three-point index, and axis deviation.⁶,¹³⁴,²⁵¹ Three-point index was the most sensitive, specific, and predictive in a study by Ameldaroglu et al.⁶

As discussed earlier, there is controversy regarding short-arm or long-arm cast immobilization.²⁸,²⁹,²⁴⁶ However, regardless of the length of the cast, it is imperative to have a well-molded cast over the fracture site (Fig. 9-45).
After reduction of a dorsally displaced fracture, three-point fixation
is used with dorsal pressure proximal and distal to the fracture site
and volar pressure over the reduced fracture (Fig. 9-46). The cast should be molded to the normal contour of the forearm. An extension

long-arm cast can be used in younger children to better maintain
reduction of the ulnar bow. A thumb spica component with felt over the
dorsum of the thumb and wrist prevents distal migration of cast and
skin irritation. Excessive swelling should be monitored due to
dependency of the hand. If there is any concern regarding impending
compartment syndrome, the cast and Webril (Kendall, Mansfield, MA)
should be immediately bivalved and the patient’s clinical status
monitored closely. In general, closed reduction and well-molded casting
will result in successful healing of the fracture in desired alignment (Fig. 9-47).

The primary problem with closed reduction and cast immobilization is loss of reduction (Fig. 9-48). There are many studies that indicate an incidence of loss of reduction in the 20% to 30% range.¹³⁶,¹⁷⁷,²¹⁶ Mani et al.¹³⁶ and Proctor et al.¹⁷⁷ described remanipulation rates of 21% and 23%, respectively. Mani et al.¹³⁶
concluded that initial displacement of the radial shaft of over 50% was
the single most reliable predictor of failure of reduction. Proctor et
al.¹⁷⁷ found that complete initial
displacement resulted in a 52% incidence of redisplacement of distal
radial fractures in children. Gibbons et al.⁸⁰
noted that completely displaced distal radial fractures with intact
ulnas had a remanipulation rate of 91% after closed reduction and cast
immobilization alone compared to a 0% rate of remanipulation when the
same fractures were treated with closed reduction, Kirschner wire
fixation, and cast immobilization. All three studies strongly advocated
percutaneous pinning of distal radial fractures at risk of
redisplacement. Two prospective studies confirmed the risk of loss of
reduction with cast immobilization. Miller et al.¹⁴⁴
reported a study of distal radial metaphyseal fractures treated by
either closed reduction and cast immobilization or closed reduction and
percutaneous pinning. Selection criteria were a closed metaphyseal
fracture angulated more than 30 degrees in a skeletally immature
patient over 10 years of age. To maximize the outcome of the cast
immobilization group, these patients were treated by a member of the
Pediatric Orthopedic Society of North America with expertise in trauma

care.
General anesthesia, fluoroscopic control, and well-molded cast
immobilization were used. Despite these optimal conditions, 30% of the
patients in the cast immobilization group lost reduction and required
remanipulation. These findings were similar to the prospective study of
pinning and cast treatment of distal radial metaphyseal fractures.¹⁴⁰
Again, closed reduction and cast immobilization had a loss of reduction
rate of 21%, whereas pinning maintained reduction. The authors of these
prospective, randomized studies concluded that pinning is a safe,
effective means of treating distal radial metaphyseal fractures;
however, in both prospective studies, results of casting and pinning
were equivalent after 2 years postfracture.¹⁴⁰,¹⁴⁴

The results of all of these studies indicate that distal
radial metaphyseal fractures with initial displacement of more than 30
degrees are inherently unstable. Loss of reduction is common, with the
risk in the 20%-to-60% range. Incomplete reduction¹³⁶,¹⁷⁷ and poor casting techniques²⁸,²⁹,²⁴⁶
increase the risk of loss of reduction. In addition, the risk of loss
of reduction increases with the age of the patient and the degree of
initial displacement. Bayonet apposition in a child older than 10 years
is the highest risk.

Loss of reduction requires repeat manipulation to avoid
a malunion. Although the rate of malunion is frequent after these
fractures,⁸,²⁸,²⁹,³⁴,³⁵,⁴⁰,⁹¹,¹⁰⁸,¹²⁵,¹⁹⁵,²³² because of the potential for remodeling in skeletally immature patients it has not been considered a serious problem (Fig. 9-49).³,⁴,¹⁶,⁶⁷,⁶⁸,⁷¹,⁹⁸
Distal radial fractures are juxtaphyseal, the malunion often 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.

However, De Courtivron et al.⁴¹
reported that of 602 distal radial fractures, 14% had an initial
malunion of more than 5 degrees. Of these, 78% corrected the frontal
plane deformity, and only 53% remodeled completely in the sagittal
plane. In addition, 37% had loss of forearm rotation. Do et al.⁴⁶
came to similar conclusions in their analysis of 34 pediatric distal
radial metaphyseal fractures that lost reduction and healed with
angulation and/or shortening. Alemdaroglu et al.⁶
determined that initial complete displacement and initial fracture
obliquity of more than 30 degrees were the greatest risk factors for
redisplacement after closed reduction.

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.⁸⁸,¹³⁶,¹⁷⁷,²³⁸,²⁴⁴ The indications cited include fracture instability and high risk of loss of reduction,⁸⁸,¹³⁶,¹⁷⁷ excessive local swelling that increases the risk of neurovascular compromise,²³⁸,²³⁹,²⁴⁶ ipsilateral fractures of the distal radius and elbow region (floating elbow) that increase the risk of compartment syndrome,²¹⁰,²⁴⁵ and the likelihood that remanipulation will be required.²⁴⁴,²⁴⁶
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 casting¹⁴⁰,¹⁴⁴ and the avoidance of remanipulation because alignment is secure.

Pinning usually is done from distal to proximal under
fluoroscopic guidance. When possible, the physis is avoided. Adequate
exposure through a small incision over the radial styloid should be
obtained to avoid radial sensory nerve or extensor tendon injury.
Smooth Kirschner or C-wires are used. In younger patients, a single pin
with supplemental cast immobilization may be adequate fixation (Fig 9-50). Crossed pins are more stable provided they do not cross at the fracture site (Fig. 9-51).
The first pin, or single pin, enters from the radial side distal to the
fracture and passes obliquely to the ulnar aspect of the radius
proximal to the fracture. The second pin enters the radius distal to
the fracture between the fourth and fifth compartments and passes
obliquely across the fracture into the proximal radial side of the
radius. The pins are left out through

the
skin to allow easy removal. Another technique of pinning is intrafocal
placement of multiple pins into the fracture site to lever the distal
fragment into anatomic reduction (Kapandji technique, Fig. 9-52). The pins are then passed through the opposing cortex for stability.¹³⁰,²²⁴
A supplemental, loose-fitting cast is applied. The advantage of pin
fixation is that a tight, well-molded cast is not necessary to maintain
reduction. This lessens the risk of neurovascular compromise with
associated excessive swelling or ipsilateral fractures. Obviously, pin
fixation avoids the risk of loss of reduction in an unstable fracture.
Pinning does have the risk of infection and concerns regarding growth
injury.

Unlike distal radial fractures in adults, external
fixation rarely is indicated for similar fractures in skeletally
immature patients. Although it can be used successfully,²⁰¹,²³²
the success rates of both closed reduction and percutaneous pinning
techniques make it unnecessary for uncomplicated distal radial
fractures in children. The best indication is severe associated soft
tissue injuries. A severe crush injury, open fracture, or replantation
after amputation that requires extensive soft tissue care and surgery
are all indications for the use of external fixation. Supplemental
external fixation also may be necessary for severely comminuted
fractures to maintain length and provide additional stability to pin
fixation. Standard application of the specific fixator chosen is done
with care to avoid injury to the adjacent sensory nerves and extensor
tendons.

Open reduction is indicated for open or irreducible
fractures. Open fractures constitute approximately 1% of all distal
radial metaphyseal fractures. All open fractures, regardless of grade
of soft tissue injury, should be irrigated and débrided in the
operating room (Fig. 9-53). The open wound
should be enlarged adequately to débride the contaminated and nonviable
tissues and protect the adjacent neurovascular structures. After
thorough irrigation and débridement, the fracture should be
anatomically reduced and stabilized, usually with two smooth pins. 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.

Irreducible fractures are rare (Fig. 9-54) and generally are secondary to interposed soft tissues. With dorsally displaced

fractures, the interposed structure usually is the volar periosteum or pronator quadratus⁹³
and rarely the flexor tendons or neurovascular structures. In volarly
displaced fractures, the periosteum or extensor tendons may be
interposed. The fracture should be approached in a standard fashion
opposite the side of displacement (i.e., volar approach for an
irreducible dorsal fracture). The adjacent neurovascular and tendinous
structures are protected and the offending soft tissue is extracted
from the fracture site. Pin stabilization is recommended to prevent
problems with postoperative swelling or loss of reduction in cast.

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. Pin fixation without
violating the physis is recommended.

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,³⁶,¹¹²,¹⁸⁰
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.

Loss of reduction is a common complication of distal radial metaphyseal fractures treated with cast immobilization. Because

this complication occurs in at least 30% of bayonet apposition fractures,⁸⁰,¹³⁶,¹⁷⁷,²³⁴,²⁴⁴
many surgeons treat this fracture primarily with pin fixation to avoid
the problems that can occur with malunion. Otherwise, it is clear that
patients treated with cast immobilization need to be monitored closely.²⁵¹

Fortunately, many angular malunions of the distal radius will remodel,^* probably because of asymmetric physeal growth.¹⁰⁶,¹²² True growth arrest associated with a distal radial metaphyseal fracture is very rare.²¹⁸
The younger the patient, the less the deformity, and the closer the
fracture is to the physis, the greater the potential for remodeling. It
is unclear whether there is any capacity for rotational malunion
remodeling.⁷¹,¹⁹³
Angular and rotational malunion that does not remodel can lead to loss
of motion. The degree and plane of loss of motion, as well as the
individual affected, determine if this is functionally significant.²⁵¹ In cadaver studies, malangulation of more than 20 degrees of the radius or ulna caused loss of forearm rotation,¹³⁹,²¹⁶,²¹⁹
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.¹⁸¹
The functional loss associated with rotational motion loss is difficult
to predict. This has led some clinicians to recommend no treatment,³⁸,⁴⁰ arguing that most of these fractures will remodel, and those that do not remodel will not cause a functional problem.¹⁰¹ However, a significant functional problem is present if shoulder motion cannot compensate for loss of supination.

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,¹⁵³,²²²,²⁴⁶ it is less likely than with malunions.

Unfortunately, not all fractures heal anatomically or remodel to anatomic alignment. Long-term malunion is a concern for

midcarpal instability²¹⁷
and long-term arthrosis. A distal radial malunion in a skeletally
mature adolescent should be treated with an opening wedge osteotomy,
bone graft, and internal fixation (Fig. 9-61).⁶²,¹⁴²,¹⁷⁸

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.²⁴⁶ Congenital pseudarthrosis or neurofibromatosis (Fig. 9-62) should be suspected in a patient with a nonunion after a benign fracture.¹⁰⁵
This occurs most often after an isolated ulnar fracture. 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.

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.²² Débridement 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 is a rare complication of pediatric distal
radial and ulnar fractures. It has been described after high-energy
trauma and internal fixation.²³⁰ A single-pin crossing both bones increases the risk of cross-union.²³⁰
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.⁵⁷ Contracture release resulted in restoration of forearm motion.

Fortunately, refractures after metaphyseal radial
fractures are rare and much less common than after diaphyseal level
radial and ulnar fractures. 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.

Growth arrest of the distal radius after metaphyseal fracture is rare. Abram, Thompson, and Connolly et al.²,³¹a
each reported one patient with physeal arrest after nondisplaced torus
fractures. Two additional patients were reported in a series of 150
distal radial metaphyseal fractures.⁶³ Wilkins and O’Brien²⁴⁶
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. 9-63)¹⁶⁹,¹⁷⁰ and in essence is a physeal fracture. These fractures should be monitored for growth arrest.

Both undergrowth and overgrowth of the distal radius after fracture were described by DePablos.⁴²
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.

Both the median and ulnar³⁰,²²⁹
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,¹¹,¹⁶⁵ entrapment of the nerve in the fracture site,⁸,²⁴⁷ rare laceration of the nerve (Fig. 9-64),
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.

Infection after distal radial fractures is rare and is associated with open fractures or surgical intervention. Fee et al.⁵⁹
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.

The method of reduction for greenstick radial fractures
depends on the type of displacement. With apex volar dorsally displaced
fractures of the radius, the rotatory deformity is supination.
Pronating the radius and applying a dorsal-to-volar reduction force
should align the fracture and reduce the DRUJ. Similarly, if the
incomplete radial fracture is an apex dorsal volar displaced fracture,
the rotatory deformity is pronation. Supinating the forearm and
applying a volar-to-dorsal force should reduce the incomplete fracture
of the radius and the DRUJ dislocation.¹²⁶,¹²⁷,¹⁴⁴,²⁴⁶
In both these situations, portable fluoroscopy can be used to evaluate
the fracture-dislocation reduction and to test the stability of the
distal ulna. If anatomically reduced and stable, a long-arm cast is
applied with appropriate rotation and three-point molds. The cast is
left in place for 6 weeks to allow the soft tissue injuries to heal.

In a Galeazzi equivalent injury with a radial fracture
and an ulnar physeal fracture, both bones should be reduced. Usually,
this can be accomplished with the same methods of reduction as when the
radial fracture is incomplete. The distal ulnar physis can remodel a
nonanatomic reduction if there is sufficient growth remaining and the
ulnar physis continues to grow normally. Unfortunately, the risk of
ulnar growth arrest after a Galeazzi equivalent has been reported to be
as high as 55%.⁸¹

Complete fractures of the distal radius have a higher
rate of loss of reduction after closed treatment than do incomplete
fractures (Fig. 9-71).²⁴⁶
If not monitored closely and rereduced if necessary, loss of reduction
can lead to malunion with loss of motion and function. These injuries
may be best treated with open reduction as in adults.

The indication for open reduction of the radial fracture
is failure to obtain or maintain fracture reduction. This most often
occurs with unstable complete fractures. 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. 9-72). 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.

Occasionally, the DRUJ dislocation cannot be reduced (Fig. 9-73)
because of interposed soft tissues, most commonly the periosteum,
extensor tendons (extensor carpi ulnaris, extensor digit quinti), TFCC,
or other ligamentous structures.¹⁴,²⁶,¹⁰⁰,¹²⁷
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. 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 distal radioulnar joint may be
used, providing the advantage of more direct visualization and
extraction of interposed soft tissues in irreducible cases. Smooth pin
fixation of the DRUJ can be used to maintain reduction and allow
application of a loose-fitting cast. The pin is removed in the office
at 4 weeks with continuation of the cast for 6 weeks.

Similarly, the ulnar physeal fracture can be irreducible
in a Galeazzi equivalent injury. This also has been reported to be
secondary to interposed periosteum,¹¹⁷,¹⁸² extensor tendons,¹⁶⁰ or joint capsule.⁵³ Open reduction must be executed with care to avoid further violating the physis.

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 used. If the
fracture is apex volar with dorsal displacement of the radius and volar
dislocation of the DRUJ, then

pronation
and volar-to-dorsal force on the radial fracture is used for reduction.
If the fracture is apex dorsal with volar displacement of the radius
and dorsal dislocation of the DRUJ, then supination and dorsal-to-volar
force is applied to the distal radius for reduction. The reduction and
stability of the fracture and DRUJ dislocation are checked on dynamic
fluoroscopy before long-arm cast immobilization. If both are
anatomically reduced and stable, the cast is used for 6 weeks to allow
soft tissue and fracture healing. In a Galeazzi equivalent injury,
there is potential for remodeling of the physeal fracture if sufficient
growth remains. As long as the DRUJ is reduced, malalignment of less
than 10 degrees can remodel in a young child. The risk of physeal
growth arrest is high with this physeal injury, and operative exposure
may increase the risk of growth impairment. 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.²⁴⁶

Open reduction and internal fixation with an anterior
plate and screws are used for complete Galeazzi fractures of the
radius. The DRUJ usually reduces anatomically and is stable with
reduction and fixation of the radius. The patient is immobilized in a
long-arm cast for 4 weeks and a short-arm cast for 2 more weeks. Return
to unrestricted activities and sports depends on restoration of full
motion and strength.

Irreducible dislocations are treated with open
reduction. Extensile exposure is necessary to define the pathologic
anatomy and carefully reduce the DRUJ. The interposed soft tissues are
extracted and repaired. Depending on the stability of the reduction and
repair, a supplemental smooth pin may be used across the DRUJ for 4
weeks to maintain the joint reduction. This is particularly true if the
patient presents late.

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 débridement 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.¹⁸
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.

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.

Injuries to the ulnar nerve¹⁴³ and anterior interosseous nerve²⁰⁹,²³⁵ have been described with Galeazzi fracture-dislocations. These injuries have had spontaneous recovery. Moore et al.¹⁴⁸
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.