Pediatric Forearm, Wrist, and Hand Trauma
Kathleen D. Rickert, MD, FAAOS
Jessica Burns, MD, MPH
Neither of the following authors nor any immediate family member has received anything of value from or has stock or stock options held in a commercial company or institution related directly or indirectly to the subject of this chapter: Dr. Rickert and Dr. Burns.
ABSTRACT
Pediatric fractures most often occur in the forearm, wrist, and hand. Accurate diagnosis with under-standing of appropriate management in the context of the patient’s fracture type and age is critical to providing the best care and outcomes for pediatric patients. Most forearm fractures can be managed with closed reduction and long arm casting within accepted parameters of residual displacement dependent on fracture location and patient age. Proximal fractures in older children have lower remodeling potential. Pediatric acute compartment syndrome of the forearm typically occurs second-ary to trauma with associated fracture and requires compartment release. Distal radius fractures have significant remodeling potential in children but high risk of a loss of reduction. Fractures that extend into the physis warrant long-term follow-up with appropriate and timely management of growth arrest. Orthogonal views of the elbow and wrist are critical for the diagnosis and management of Monteggia or Galeazzi fracture-dislocations, respectively. Galeazzi and Monteggia fractures are more successfully managed with closed reduction than adults but require surgical management if unstable. Scaphoid fractures can present late with nonunion, but most acute fractures are visible on initial radiographs. Hand and finger fractures can largely be managed nonsurgically with a short period of immobilization, including for phalangeal neck fractures.
Keywords: both-bone forearm fracture; Monteggia; pediatric; phalangeal neck; Seymour fractures
Introduction
Fractures of the forearm, wrist, and hand are the most common types of pediatric fractures that present to the emergency room.1 Different from fractures around the elbow, fractures of the forearm have great remodeling potential. Correct management of pediatric forearm, wrist, and hand fractures requires appropriate initial workup and diagnosis, with consideration for the location and type of fracture in the context of the age and body habitus of the patient. As with the evaluation of other fractures, it is important to obtain orthogonal views of the elbow, wrist, and hand or finger. Missed or delayed diagnosis can occur with Monteggia or Galeazzi fracture-dislocations, scaphoid fractures as well as open fractures with small puncture wounds. The treating orthopaedic surgeon should complete a full, independent evaluation of each patient to ensure the optimal treatment of the patient.
Monteggia Fracture-Dislocation
With ulnar fracture or deformity, there can be subluxation or dislocation of the radiocapitellar joint, known as a Monteggia fracture-dislocation. This fracture type was first described as an ulnar fracture with anterior dislocation of the radial head before the first radiograph and later was further classified by the direction of the radial head dislocation/subluxation and associated fractures2 (Table 1). This type of injury should be suspected in cases where there is any shortening or deformity of the ulna, especially in cases of isolated ulnar injury. The recognition of radial head dislocation or subluxation is critical but can be missed or inadequately treated. This clinical problem can lead to chronic elbow morbidity, including pain, valgus elbow instability, loss of motion, osteoarthritis, or even posterior interosseous nerve palsy.3,4,5,6
When this type of fracture is recognized acutely, closed management is successful in more than 80% of cases.4,7,8,9 A treatment strategy was proposed based on the fracture pattern of the ulna, with closed treatment only for incomplete or length-stable ulnar fractures.10
Intramedullary fixation was recommended for all complete but length-stable fractures, whereas plate fixation of the ulna was recommended for complete length-unstable fractures (long oblique, comminuted).10 This treatment algorithm was validated by a multicenter study group in 2015 in which there would have been no recurrent instability in 112 Monteggia lesions if the ulna-based strategy had been used.11 It has subsequently been shown, however, that the ulna-based strategy may indicate surgery when a trial of nonsurgical management should be pursued. In a study of 59 Monteggia lesions with complete ulnar fractures, 76% were successfully managed with closed reduction and casting.7 In a 2021 study, 86.1% of patients with complete ulnar fractures maintained reduction without surgery.11
Intramedullary fixation was recommended for all complete but length-stable fractures, whereas plate fixation of the ulna was recommended for complete length-unstable fractures (long oblique, comminuted).10 This treatment algorithm was validated by a multicenter study group in 2015 in which there would have been no recurrent instability in 112 Monteggia lesions if the ulna-based strategy had been used.11 It has subsequently been shown, however, that the ulna-based strategy may indicate surgery when a trial of nonsurgical management should be pursued. In a study of 59 Monteggia lesions with complete ulnar fractures, 76% were successfully managed with closed reduction and casting.7 In a 2021 study, 86.1% of patients with complete ulnar fractures maintained reduction without surgery.11
Table 1 Bado Classification of Monteggia Fracture-Dislocation | ||||||||||||||||||||
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After successful closed reduction, close follow-up is recommended with weekly radiographs for the first 3 weeks to confirm maintenance of reduction. Cast removal at 4 to 6 weeks can be performed once there is sufficient healing of the ulna.7,11 If further immobilization is needed, a short arm cast or a removable forearm splint can be used, and elbow range of motion can begin.7
Loss of reduction usually occurs after more than 1 week, but within 15 days.11 Risk factors for unsuccessful closed reduction include Bado classification, with type I more likely to succeed with closed reduction and casting and type III more likely to require surgical management.7,11 Residual angulation of the ulna (>36°) is a risk factor independent of fracture type.7
In cases of unsuccessful closed reduction or loss of reduction, surgical management can include an intramedullary device or open reduction and internal fixation (ORIF) with plate-and-screw construct. The intramedullary device can be an elastic stable intramedullary nail (ESIN)12 or Steinmann pin,13 which can be buried or left out of the skin without significant differences in maintenance of reduction or complications.14 Buried pins necessitate a subsequent procedure for removal, whereas those left out of the skin can be removed in the clinic (Figure 1). ORIF may be required if the length of the ulna cannot be maintained with an intramedullary device.5,9,10,15,16
Chronic Monteggia lesions occur because of either an initial failure of diagnosis or a loss of reduction following management, which occurs in up to 50% and 20% of cases, respectively.16,17 Approximately 85% of chronic Monteggia fracture-dislocations are Bado type I.18 Initially, there may not be significant symptoms, which can further delay the diagnosis. The ulna usually heals in a shortened and angulated position, which remodels over time, and symptoms are related to the chronic radial head dislocation. With prolonged dislocation, the radial head, capitellum, and radial notch of the ulna undergo dysplastic changes.3,5,6,16,18,19 Without the radiocapitellar joint, the elbow loses approximately one-third of its valgus stability, and an increased carrying angle subsequently develops with possible associated tardy ulnar nerve palsy. Nerve tenting over the dislocated radial head can also lead to tardy median nerve and posterior interosseous nerve palsies.18 The loss of anatomic relationships reduces the range of motion, leading to contractures that abnormally load the joints, later resulting in osteoarthritis.6,16,18,19
There is no consensus regarding the appropriate treatment of chronic Monteggia lesions, although there is little role for nonsurgical management. Surgical considerations include ulnar osteotomy, radiocapitellar pinning, open reduction of the radiocapitellar joint, and annular ligament reconstruction.18 Some authors report that ulnar osteotomy is the only necessary procedure, whereas others contend that interposed capsuloligamentous tissue blocks concentric reduction of the radiocapitellar joint.18 Regardless, ulnar osteotomy should be performed without excessive lengthening to decrease the risk of nonunion. Assessment of radiocapitellar stability should then be performed with consideration for annular ligament repair.3,18 Outcomes for management of chronic Monteggia lesions are improved with decreased time from injury and younger age.3
 Figure 1 Lateral forearm radiographs of Bado type I Monteggia fracture-dislocation that was missed initially (A), likely due to splint obscuring the radiocapitellar joint. The patient underwent closed reduction and intramedullary fixation with a Steinmann pin left out of the skin 10 days after the original injury (B). The Steinmann pin was removed 4 weeks postoperatively (C) and was recasted for 2 additional weeks due to incomplete fracture healing. Ten weeks after surgery, the patient had no pain and had symmetric elbow range of motion (D). |
Radial and Ulnar Diaphyseal Forearm Fractures
Diaphyseal radial and ulnar shaft fractures are relatively common, representing up to 30% of all pediatric fractures.1 These fractures are typically sustained with a fall onto an outstretched hand commonly with rotation, in either supination or pronation. Closed reduction and casting are the standard of care for pediatric patients and are successful in most cases. The ulna is a relatively straight bone, while the apex anterolateral radial bow allows for rotational movement. The goal with closed reduction is anatomic alignment; however, with remodeling potential, there are general guidelines for what is considered acceptable reduction20 (Table 2).
Greenstick fractures can usually be managed successfully with closed reduction, taking care to reduce the rotational component. In one study, 94% of 109 greenstick fractures were successfully managed with a single reduction. The study authors recommended two clinical follow-up visits and three interval radiographs to reduce overall costs and radiation exposure.21
Complete fractures can still be successfully managed with closed reduction and casting in most cases; however, malreduction can lead to deformity and lack of rotation of the forearm. Functional motion of the adult elbow has been reported to be 30° to 130° of flexion/extension and 50° of both supination and pronation, whereas children and adolescents have greater demands for flexion and pronation, with the mean arc of motion for functional tasks being 28° to 146° of flexion/extension and 54° of supination and 65° of pronation for contemporary tasks of typing and use of a cellular phone.22
Reduction in the emergency department or operating room of both-bone fractures can be performed with traction and manipulation while a child is under
regional block or conscious sedation. The splint or cast should be applied with the elbow in 90° of flexion with neutral forearm rotation or position of stability. An interosseous mold of the splint or cast is critical for fracture reduction maintenance with a relatively straight ulnar border and mold over the distal humeral condyles to prevent cast slippage. The cast index, or ratio of sagittal-to-coronal diameter of the cast, should be below 0.80 to decrease the risk of loss of reduction.20,23,24 Follow-up radiographic evaluation after closed reduction is recommended at 1, 2, 4, and 6 weeks after reduction, with consideration to exclude radiographs at 4 weeks after reduction because most cases that need repeat intervention are noticed within 2 weeks.25
regional block or conscious sedation. The splint or cast should be applied with the elbow in 90° of flexion with neutral forearm rotation or position of stability. An interosseous mold of the splint or cast is critical for fracture reduction maintenance with a relatively straight ulnar border and mold over the distal humeral condyles to prevent cast slippage. The cast index, or ratio of sagittal-to-coronal diameter of the cast, should be below 0.80 to decrease the risk of loss of reduction.20,23,24 Follow-up radiographic evaluation after closed reduction is recommended at 1, 2, 4, and 6 weeks after reduction, with consideration to exclude radiographs at 4 weeks after reduction because most cases that need repeat intervention are noticed within 2 weeks.25
Table 2 Acceptable Reduction Variables | |||||||||||||||||||
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Closed reduction and casting are more likely to fail in proximal radius diaphyseal fractures, and displacement to an unacceptable alignment occurs in 70% to 80% of cases, likely due to longer time to callus formation, more significant soft-tissue envelope, and greater demand for near-anatomic alignment (<10°).26,27 There should be a lower threshold for surgical intervention for this particular fracture group (Figure 2).
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