Staying Out of Trouble while Treating Hand, Wrist, and Forearm Injury

Although a pediatric orthopaedist or a general
orthopaedist caring for children can handle the vast majority of hand
injuries in children, it is important to know which cases should be
transferred directly to a hand surgeon.

Physeal injuries represent 10% to 40% of all hand
fractures. Fortunately, growth arrest is very rare. To stay out of
trouble, it is important to recognize that an apparent “tendon
disruption” may instead be a physeal fracture in a young child (Fig. 7-1).
The flexor digitorum profundus inserts onto the distal phalanx and the
flexor digitorum superficialis inserts onto the middle phalanx. The
extensor tendons insert onto the epiphysis of the distal phalanges.

Evaluation of the pediatric hand can be challenging.
First, the orthopaedist should assess for an open injury, which can be
subtle in the hand. Neurologic examination can be very difficult in
children. One clue to a possible nerve injury is excessive bleeding
from a wound around the area of the digital nerve, since the digital
artery and nerve are often lacerated together. To stay out of trouble
in assessing a nerve, it is helpful to do the “wrinkle test.” Immerse
the digit in warm water for about 5 minutes. Denervated digits will not
have any wrinkling of the volar skin.

Radiographs of the injured hand should include an AP, lateral and oblique views. More complex imaging is rarely needed.

The treatment of any hand injury begins with proper pain
control. Digital blocks are very effective for phalangeal fractures and
nail bed injuries. To stay out of trouble, do not use epinephrine for
digital block, as it may lead to distal ischemia. Also, never inject a
circular weal around the digit as the circulation of the digit can be
compromised.

Fractures of the distal radius and ulna are exceedingly
common in children. The keys to staying out of trouble include
understanding remodeling, avoiding overtreatment, putting your
reductions in good casts, and being alert for associated injuries.
Remodeling is greatest in young children, in fractures near a rapidly
growing physis, in fractures that are in the plane of motion of the
adjacent joint, and in fractures with greater amounts of angulation.
Typically, the child can correct about 10 degrees of apex-volar
angulation for each year of growth remaining. Radial-ward angulation of
the distal radius, caused by the pull of the brachioradialis, corrects
more slowly. Bayonet apposition remodels reliably in younger children,
especially those less than about 8 years old.

Physeal injuries of the distal radius are the most
common growth plate injury in children. To stay out of trouble,
evaluate for open injuries, especially subtle pinpoint openings on the
volar skin. Higher energy injuries, such as when a teenager falls
rollerblading, can lead to neuropraxia of the median nerve, or even
acute carpal tunnel syndrome or compartment syndrome.¹
To stay out of trouble, do a careful nerve exam and get these fractures
reduced as quickly as is practical. The easiest injury to miss is the second
injury, so be certain to evaluate the elbow and hand carefully when
confronted with a distal radius fracture. Minimally displaced fractures
are often placed in a splint and an ace wrap in the emergency
department and sent on to an orthopaedist office for management. A
tight ace wrap can be trouble (Fig. 7-4).
Children will shift in the splint, or play with their ace wrap, which
can become rolled and cause a tourniquet-like effect. The ace wrap can
create a row of blisters at the seams between the ace wrap or create a
tremendous amount of swelling distally. Alert your emergency room
colleagues about the potential dangers of tight ace wraps in children,
and get these children into a proper cast as soon as is practical.

Displaced fractures can be reduced under conscious
sedation at the time of injury. It is a general principle to avoid
reductions or re-reductions of physeal injuries later than
approximately 10 days following injury, in order to avoid growth
arrest. Open or closed reduction with K-wire fixation is used in
special circumstances.²

To stay out of trouble with distal radius pinning, care
should be taken to avoid the radial sensory nerve and the extensor
tendons. Most agree that smooth K-wires across the physis are not a
significant risk for growth arrest.³

Up to 30 to 40 degrees of dorsal angulation at the site
of a distal radial physeal fracture will remodel satisfactorily in a
child with more than 3 years of growth remaining. Of course, this
should not be the goal at the first reduction. However, if an
8-year-old returns to your office with 30 degrees of angulation 10 days
later, that can be accepted with an excellent result. The risk of
growth arrest from a distal radius physeal fracture is considered to be
4%. However, the rate of growth arrest of a distal ulnar physeal
fracture⁴ is 60%.

Nondisplaced or minimally displaced distal radial
metaphyseal fractures can be treated in many ways with a good result.
Some orthopaedists use splints and ace wraps, some use removal Velcro
splints and many cast. In our experience, the least trouble occurs when
a well-padded short arm cast is used.

For completely displaced fractures requiring closed
reduction, it is important to understand the help and hindrance of
intact periosteum. In dorsally displaced fractures, the periosteum is
torn on the volar surface. With a good three-point mold, the intact
dorsal periosteum will help hold your reduction. However, the intact
dorsal periosteum also will make it impossible to reduce the fracture
with pure traction, as is done for an adult Colles fracture. Once
adequate conscious sedation is obtained, the fracture is reduced by
re-creation of the deformity, which may lead to fainting by one or both
parents. To avoid loss of reduction (Fig. 7-5),
a well-made cast is essential. There should be a three-point mold at
the distal radius. One common problem is a series of cast molds that
are so close together that they really are not working as three points,
but as just one diffuse, unhelpful pressure point. The cast should be
oval so that the anterior-posterior diameter is less than 0.7 of the
radioulnar diameter (this has been called the cast index). Extreme
pronation and supination should be avoided, as it is thought to
increase compartment pressures. A long-arm cast is used for completely
displaced fractures. A followup x-ray is often done about 5 to 10 days
after reduction.

In children less than 10 years of age, up to 30 degrees
of dorsal angulation or 20 degrees of radial-ward angulation will yield
a good result. One way to stay out of trouble with parents is to put a
chart up in your office or cast room that shows progressive radiographs
of a distal radius fracture remodeling over the course of several
months (Fig. 7-6). This will help to decrease
anxiety in parents when the parents see the crooked bone on radiograph.
It will also help you avoid the temptation to overtreat these injuries.
When a displaced distal radial metaphyseal fracture occurs with a
displaced ipsilateral supracondylar fracture, stay out of trouble by
pinning both.⁵,⁶
Growth arrest is possible after a metaphyseal fracture of the distal
radius, so at least one later followup visit may be advisable.⁷

Galeazzi fracture is a distal radius fracture with
disruption of the triangular fibrocartilage complex (TFCC). These are
very rare injuries in children. In children, the TFCC is rarely torn;
instead the distal ulnar physis is fractured and displaced (an
equivalent injury). Remember the 60% physeal arrest rate of displaced
distal ulnar physeal fractures. Most Galeazzi fractures can be treated
with closed reduction and a long-arm cast for about 6 weeks, with the
forearm in slight pronation.

Radial and ulnar diaphyseal fractures cause much more
trouble than distal radius and ulna fractures. The remodeling of the
shaft is much less extensive and the healing is slower. Much more
stringent reduction criteria are needed than for the distal fractures.
A significant malunion of a forearm diaphyseal fracture will lead

to
permanent loss of pronation and supination, and sometimes an unsightly
curvature or prominence in the forearm. To stay out of trouble,
understand that many of these fractures, especially greenstick
injuries, are rotational injuries and are reduced with derotation of
the forearm. Although upper extremity compartment syndrome is rare, the
most common cause in children today is a forearm fracture (and no
longer supracondylar fractures treated with flexion, causing Volkmann’s
ischemic contracture). Don’t be fooled by pseudo Volkmann’s contracture
due to tethering of the flexor digitorum profundus to fractures of the
ulna. One report described seven cases, detected 2 days to 16 years
after closed reductions of fractures of the shafts of the radius and
ulna. The children did not have nerve palsies or undue pain after the
reductions. Normal length, excursion, and function of the flexor
digitorum profundus were restored by untethering the muscle and its
tendons from the ulnar fracture by early manipulation or by late
localized myotenolysis. The authors recommended that the passive range
of motion of all fingers be routinely checked immediately after closed
reductions of fractures of the radius and ulna. If muscle tethering is
detected, the fracture is re-manipulated to release the muscle. If the
muscle is still tethered, then surgical release, through a small
incision, is recommended.⁸

Another key source of problems is missing a second
subtle injury. The most common and most important oversight is the
missed Monteggia fracture, especially in the apparently isolated ulna
injury. To stay out of trouble, the orthopaedist should insist on two
views of the entire forearm at right angles to one another, as well as
dedicated films of the elbow, to be assured that the radiocapitellar
relationship is satisfactory (Fig. 7-7). To
understand rotation, look at the width of the diaphyseal fragment at
the fracture site and study the relationship between the bicipital
tuberosity and the radial styloid (they should be opposite one
another). In all angulated or displaced radius and ulna diaphyseal
fractures, manipulative closed reduction under conscious sedation or
general anesthesia should be performed. Diaphyseal fractures in
children require 6 weeks of immobilization, at a minimum. In older
children, 8 weeks may be necessary. To stay out of trouble, warn
families that diaphyseal forearm fractures are among the rare fractures
in children that are at risk for refracture. Refracture seems to be a
risk in greenstick fractures and in the first 3 months after cast
removal. One study⁹ of 768 children
with displaced forearm fractures requiring reduction found a refracture
incidence of 4.9%. The median time to refracture was 8 weeks after
discontinuing cast immobilization. The authors found that diaphyseal
fractures were

eight
times more likely to refracture than metaphyseal fractures, and that
the risk of refracture was inversely proportional to the duration of
cast immobilization. Cast immobilization for a minimum of 6 weeks
reduces the risk of refracture by a factor of between four and six.
Midshaft forearm fractures are at risk of refracture for 16 weeks from
cast removal.

Intramedullary K-wires or titanium nails are
increasingly used to stabilize one or both bones of pediatric
diaphyseal forearm fractures. The preferred entry site for the ulna is
proximal in most cases. For the radius, the best entry site is at
Lister’s tubercle, or on the radial side of the radius, with caution to
avoid injury to the radial nerve.

To stay out of trouble, don’t make multiple passes in an
attempt to get the intramedullary wire across the fracture site. If you
don’t get the wire across in three attempts, it is safer to open the
fracture.¹⁰ Multiple missed passes
in a swollen forearm increase the risk for compartment syndrome. Single
bone fixation, usually with an ulnar intramedullary K-wire, is often a
simple solution, especially for fractures in the 8- to 12-year-old age
range. As children approach

maturity, adult style plating allowing rapid mobilization is usually the best way to stay out of trouble.

Plastic deformation of the forearm can be a source of
trouble. In young children in whom there is no cosmetic deformity in a
full range of motion, casting without reduction is acceptable. However,
if the arm appears bowed or motion is lost, reduction should be
attempted in the operating room. A great amount of force must be
applied at a very slow rate over a long period of time to correct
plastic deformation.¹¹ After
reduction, a long-arm cast is used for 4 to 6 weeks. Again, beware of
the plastically deformed ulna that distracts your attention from an
associated radial capitellar dislocation.

Although Monteggia fractures (Fig. 7-8)
represent less than 1% of all pediatric forearm fractures, they receive
great attention because they create so much trouble. Most of these
injuries occur in children younger than age 10. Many “isolated radial
head dislocations” that walk into your office as routine visits were
probably missed traumatic lesions rather than congenital dislocations.¹²
To stay out of trouble, high-quality radiographs are mandatory to
manage Monteggia fractures successfully. The views should include the
whole forearm, as well as isolated elbow radiographs. The ulna should
be “ruler straight”¹³ (Fig. 7-9).
A line drawn down the shaft of the radius should point to the center of
the capitellum. Be sure to assess this after initial reduction and at
each follow-up, as late dislocation of the radial head has been
reported.¹⁴ Remember, there is
normal angulation of the proximal ulna in children, and the proximal
radial neck can angulate up to about 12 degrees of valgus. Also, a
careful neurologic examination is essential, since up to 20% of
Monteggia fractures present with nerve palsy. The most common scenario
is a posterior interosseous nerve palsy associated with a Bado type III
lesion.

Treatment of Monteggia fractures involves an initial
attempt at closed reduction with conscious sedation or general
anesthesia. If the injury is acute, a very satisfying reduction “clunk”
is usually felt. Type I fractures are reduced with forearm supination
and complete elbow flexion, but they should not be casted in

hyperflexion.
A well-molded long-arm cast at 90 degrees for about 4 to 6 weeks is
satisfactory. For Type II fractures, the fractures are reduced with
elbow extension. This can be a difficult position to maintain in a
long-arm cast. Often fixation of the ulna is necessary for stability.
Type III fractures require a correction of the varus angulation in
order to reduce the radial head. Type IV fractures are very difficult
to treat with a simple closed reduction. Often, the radial shaft
fracture must be internally fixed with either a plate or a wire in
order to successfully reduce the radial head (Fig. 7-10).

Very close postinjury and postsurgical followup is
mandatory in Monteggia fractures. To stay out of trouble during the
followup period, immobilize the Monteggia fracture in a cast with only
thin fiberglass at the elbow. In this way, you will be able to
visualize the elbow joint clearly without obscuring plaster. If there
is any question about the relationship of the radius and capitellum
during the postoperative period, it is better to take the cast off and
get good x-rays and risk loss of reduction, than to continue to cast a
malaligned radiocapitellar joint obscured by plaster.

Complications with Monteggia fractures include failure
of recognition, failure of initial reduction, loss of reduction, nerve
injury, late stiffness, radial head avascular necrosis, and radial
ulnar synostosis. If a Monteggia fracture is missed, late
reconstruction involves restoring ulnar length and alignment and an
open reduction of the radial head, often with angular ligament
reconstruction.¹⁵ Even in the best
of hands, results of late reconstruction are often disappointing if
more than 6 to 12 months has elapsed since the injury.¹⁶

In children, intraarticular radial head fractures are
unusual, but metaphyseal proximal radius fractures are not. Since the
radial head’s relationship with the capitellum is critical in
maintaining forearm rotation, optimal reduction of angulation—and more
important, translation—offers the best chance of a good functional
result. Proximal radius fractures cause a remarkable amount of trouble,
especially persistent loss of motion after injury. Even compartment
syndrome has been reported after these troublesome injuries.¹⁷
Pay careful attention to the radial nerve on the initial neurovascular
examination. An attempt should be made to reduce displaced proximal
radius fractures under conscious sedation or general anesthesia. This
can be aided by injecting a local anesthetic into the radiocapitellar
joint and evacuating the hematoma prior to reduction. After an attempt
at closed reduction, up to 30 degrees of angulation and 3 mm of
translation can be accepted. If reduction under conscious sedation
fails, additional attempts should be made with fluoroscopic guidance in
the operating room.

To stay out of trouble, attempt a variety of different
maneuvers to reduce a proximal radius fracture before resorting to open
reduction. Many of the complications described in the literature for
radial head and neck fractures are the result

of
open reduction. Of course, these are probably the worst proximal radius
fractures, but it is clear that once you open these injuries you are
inviting a lot of trouble. A recent prospective multicenter study
concluded that the restricted use of open interventions may be the key
to improving results.¹⁸
Before opening a radial head or neck fracture, attempt reduction with
the elbow extended in a valgus force, attempt closed reduction with the
Israeli technique (flexion and pronation), and attempt a reduction
aided by percutaneous manipulation using a small K-wire or an awl. To
stay out of trouble with the percutaneous manipulation maneuver, be
certain you understand where the posterior interosseous nerve is. There
are reports of radial nerve injury using this technique (Fig. 7-11).
If you open a proximal radius fracture, it is wise to stabilize the
fracture after reduction. To support this concept, one study reviewed
nine cases of radial neck nonunion.¹⁹

The authors concluded that the severity of initial fracture
displacement and inadequate fixation technique contributed to radial
neck nonunion. Healing of the nonunion did not necessarily lead to
improvement of clinical symptoms.

To stay out of trouble with radial head and neck
fractures, be sure to warn families at the time of injury that loss of
motion is common, regardless of treatment. These fractures should not
be immobilized for more than about 3 to 4 weeks.

Olecranon fractures are relatively uncommon in children.
Most are minimally displaced and involve the metaphysis without
significant articular disruption. Be alert that an olecranon sleeve
fracture may be the first presentation of mild osteogenesis imperfecta²⁰ (Fig. 7-12).
Also beware that the fracture may have had a much more disruptive
effect on the articular surface than is seen on plain radiographs.²¹,²²
Displaced intraarticular olecranon fractures are managed with open
reduction and internal fixation, using either a tension band technique
or compression fixation with an interfragmentary screw. In children,
the tension band can be a strong permanent suture rather than a wire.
The K-wires can be placed percutaneously. This technique can allow you
to remove the K-wires in the clinic and leave the suture, saving the
child a hardware removal in the late postoperative period. To stay out
of trouble, use a large nonabsorbable suture.