Treatment of pediatric distal radius fractures (DRFs) is challenging because of possible involvement of the physis and the remodeling capacity by growth.
Young children with a fracture close to the most active distal physis angulated in the sagittal plane have the highest remodeling capacity.
Predictors for secondary fracture displacement in cast are initial complete displacement and inadequate reduction. Cast index is not a predictor for failure.
Additional K-wire fixation of displaced distal radius fractures reduces re-displacement rates but does not improve functional outcome.
A 12-year-old, right-handed boy with a painful and swollen right wrist visits the emergency department after a fall from his bike. Radiographs show a Salter Harris type II (SH II) distal radius fracture ( Fig. 1 ). What is the most effective treatment of his fracture?
After a week, the boy visits your outpatient clinic for follow-up and the radiographs show secondarydisplacement of the fracture ( Fig. 2 ). What is the most effective treatment of his secondary displaced fracture?
Importance of the Problem
Distal forearm fractures are one of the most common fractures accounting for about 40% of all long bone fractures in children. A peak incidence is seen in girls between 10 and 12 years and in boys between 12 and 14 years. The key difference between the child’s bone and that of an adult is the physis that needs to be taken into account for the treatment of these fractures. Physeal injuries are very common in children, making up 15% of all distal forearm fractures. The distal physis of the radius accounts for 75% of the growth of the radius and 40% of the growth of the entire upper extremity, thereby remodeling potential in the distal forearm is highest in the sagittal plane because of the highest range of motion in this plane (flexion-extension). Multiple attempts at reduction, and late re-manipulation more than 7 days post injury are known risk factors for physeal growth arrest ( Fig. 3 ). Remodeling potential of pediatric distal radius fractures (DRFs) makes the choice between nonoperative treatment and operative treatment more complex than in the adult population.
What is the relative effect of additional K-wire fixation in closed reduction on functional outcome and complication rates in management of pediatric metaphyseal and physeal DRFs?
Relatively stable buckle/torus or greenstick DRFs with minimal angulation do not require closed reduction and can be treated with cast or pressure bandage treatment. Current opinion is divided with regard to more unstable displaced greenstick fractures, SH Type I–IV fractures, complete DRFs, or both-bone distal forearm fractures.
Finding the Evidence
Cochrane search: Pediatric DRF
Embase (“forearm fracture”/de OR “radius fracture”/exp. OR “ulna fracture”/exp. OR “wrist fracture”/de OR “distal radius fracture”/exp. OR (((forearm* OR fore-arm OR radius* OR ulna OR wrist* OR antebrach* OR both-bone* OR colles* OR monteggia*) NEAR/3 (fracture*)) OR ((salter-harris* OR epiphys*-plate* OR growth-plate* OR intra-articul* OR intraarticul*) AND (wrist* OR radius* OR ulna))):ab,ti,kw) AND (“fracture treatment”/exp. OR “closed reduction (procedure)”/exp. OR “open reduction (procedure)”/exp. OR “bone resection”/de OR “orthopedic surgery”/de OR (ORIF OR CRIF OR plaster* OR cast* OR K-wire* OR plate* OR nail* OR reduction* OR fixat* OR osteosynth* OR ilizarov* OR splint* OR ((therapy OR therapies OR treat* OR immobili*) NEAR/3 (fracture*)) OR ((orthoped*) NEAR/3 (surgic* OR surger* OR procedur*))):ab,ti,kw) AND (“Controlled clinical trial”/exp. OR “Crossover procedure”/de OR “Double-blind procedure”/de OR “Single-blind procedure”/de OR “review”/exp. OR “meta analysis”/de OR (meta-analys* OR metaanalys* OR review* OR random* OR factorial* OR crossover* OR (cross NEXT/1 over*) OR placebo* OR ((doubl* OR singl*) NEXT/1 blind*) OR assign* OR allocat* OR volunteer* OR trial OR groups):ab,ti,kw) AND (child/exp. OR adolescent/exp. OR adolescence/exp. OR pediatrics/exp. OR childhood/exp. OR “child welfare”/de OR “child development”/de OR “child growth”/de OR “child health”/de OR “child health care”/exp. OR “child care”/exp. OR “childhood disease”/exp. OR “pediatric ward”/de OR “pediatric hospital”/de OR “pediatric anesthesia”/de OR (adolescen* OR preadolescen* OR infan* OR child* OR kid OR kids OR toddler* OR teen* OR boy* OR girl* OR minors OR underag* OR (under NEXT/1 (age* OR aging OR ageing)) OR juvenil* OR youth* OR kindergar* OR puber* OR pubescen* OR prepubescen* OR prepubert* OR pediatric* OR paediatric* OR school* OR preschool* OR highschool* OR suckling* OR PICU OR NICU OR PICUs OR NICUs):ab,ti,kw) NOT ((animal/exp. OR animal*:de OR nonhuman/de) NOT (“human”/exp)) NOT ([Conference Abstract]/lim)
Bibliography of eligible articles
Articles that were not in the English, French, or German language were excluded.
Quality of the Evidence
Systematic Reviews/Metaanalyses: 9
Randomized trials: 9
Randomized trials with methodological limitations: 1
Prospective studies: 3
Retrospective comparative studies: 12
Case series: 2
For pediatric DRFs, we divided the evidence into fractures with and without involvement of the physis. The fractures without involvement of the physis were further divided into non-/minimally displaced fractures and displaced fractures.
For the fractures with involvement of the physis, we wanted to answer the question:
Can the fracture be treated with a closed reduction and cast alone or is additional K-wire fixation required?
For the fractures without involvement of the physis with minimal displacement, we wanted to answer the question:
Is a splint or swim cast as effective as a rigid below-elbow cast for nonoperative treatment?
Is a below-elbow cast as effective as an above-elbow cast for nonoperative treatment?
For the fractures without involvement of the physis with displacement, we wanted to answer the question:
What is the relative effect of additional K-wire fixation in closed reduction on the functional outcome and complication rate in management of displaced fractures without involvement of the physis?
Distal Forearm Fractures With Involvement of the Physis
There is a paucity of evidence on physeal fractures of the distal radius in children. The best evidence is on SH II fractures. We therefore discuss one systematic review and four retrospective case series.
Larsen et al. in 2016 performed a systematic review of the literature. They included 7 retrospective studies with a total of 434 SH II fractures. In this review, there were no studies directly comparing operative versus nonoperative treatment. Two studies reported long-term outcomes after treatment of SH II fractures. Out of 224 patients, 213 had good results. Eleven patients had moderate to poor results varying from nonspecific wrist pain with sports to radial shortening requiring additional intervention. The studies also showed a 22% re-displacement rate. The retrospective study of Houshian et al. concluded that although some remodeling occurred in all ages, complete remodeling only occurred in children below age 10. Nietosvaara et al. showed that 2 out of 109 patients had a high residual angular deformity and wrist symptoms. Both fractures occurred 6 months prior to skeletal maturity. There have been two case series on volar buttress plating of volarly displaced physeal fractures of the distal radius. Cha et al. presented nine cases in which a SH II fracture was treated with a volar buttress plate. In this case series, there was a minor impairment of flexion and extension of the wrist (140 vs 146 degrees). No complications were reported. Shah et al. presented eight cases in which a SH III fracture was treated with a volar plate. Patients were between 11 and 16 years of age. After 8 weeks, only one patient had mild wrist pain and the range of motion was 90%–100% compared to the contralateral side.
Distal Forearm Fractures Without Involvement of the Physis
In 2018, Handoll et al. did an extensive systematic review on pediatric DRFs. For this part of the chapter, this study will serve as a main guideline complemented with a number of newer studies. In most studies, DRFs and both-bone distal forearm fractures are not clearly separated. Therefore, in this section, we will discuss both the DRFS and the both-bone distal forearm fractures.
Because of the variation in treatment, metaphyseal fractures can be divided into two groups: Non-/minimally displaced distal radius and both-bone metaphyseal fractures, displaced distal radius, and both-bone metaphyseal fractures.
Non-/Minimally Displaced Fractures
While non- and minimally displaced fractures do not need fracture reduction, the threshold for reduction depends on several factors. Young children with a fracture close to the most active distal physis angulated in the sagittal plane have the highest remodeling capacity. Ploegmakers et al. performed a metaanalysis of acceptable angulation in the literature and combined this with expert opinions. The acceptable angulation for distal physeal-, torus-, greenstick-, distal radius-, and both-bone distal forearm fractures varies with age ( Graph 1 A–E ).