Pediatric orthopedic cases 38
CASE 38
You are on-call in the emergency room and are paged to see three different patients who came in around the same time with trauma to their wrists.
Your first patient is a 6-year old who fell off a swing and complained of pain in the wrist. Her family iced it overnight, and she was able to use the arm some, so they decided to monitor for a day. When she continued to have pain into the next day (today), they brought her in for evaluation. On examination, she is tender over the distal radius. There is no tenderness over the ulna. She has full elbow flexion and extension with no pain. You order an x-ray and it shows (Figs. 10–61 and 10–62):
 |
Figure 10–61
 |
Figure 10–62
What do you offer the family in terms of treatment options?
-
Long-arm cast
-
Nothing
-
Short-arm cast
-
Velcro wrist brace
-
C or D
Discussion
The correct answer is (E). The patient has a distal radius buckle fracture, and this
fracture is at low risk of displacement due to the stability conferred by the intact volar cortex. Long-arm cast is more immobilization than is needed for this fracture and would be unnecessarily difficult for the patient and family. B is not a good option because the child has a broken bone and to give them no support is not appropriate since a nonimmobilized fracture is a source of pain. Either a prefabricated velcro wrist brace or a short-arm cast can be used effectively for this fracture. Williams et al. conducted a randomized trial for treatment of buckle fractures with wrist splints (Velcro wrist brace) versus cast finding that those in the splint group reported higher levels of satisfaction, preference, and convenience overall, but did have more pain than the casted group initially. You can therefore inform the family of this and give them the option of either.
After ordering a splint for your first patient, you move on to say hello to your next patient—a 6-year-old boy who fell while riding a scooter about 2 hours ago. The ER had already obtained x-rays, and you are able to review them before meeting the family. He has a distal radius fracture that is in bayonet apposition, there is no angulation and there is about 3 mm of shortening.
In discussing options with the family, what do you tell them about the current position of his radius?
-
It is unacceptable and a closed reduction under conscious sedation should be performed.
-
It is unacceptable and a closed reduction under general anesthesia should be performed.
-
It is acceptable and a cast is needed for immobilization.
-
It is acceptable and a wrist brace is all that is needed for immobilization.
Discussion
The correct answer is (C). This patient has a distal radius fracture with bayonet apposition and shortening of only 3 mm. Patients who undergo closed reduction to bring these fractures out to length often have redisplacement. Recent work by Crawford, Lee, and Izuka demonstrated that an overriding distal radius fracture (bayonet apposition) is acceptable and will sufficiently remodel under the age of 10. There is significant cost savings and good patient satisfaction associated with this treatment. A and B are not correct because the alignment as described is acceptable. A wrist brace, although acceptable for a buckle fracture, would not be acceptable for a complete fracture and one that needs to be held in a stable position.
You place a cast on the patient with gentle molding to prevent angulation. After
instructing the family on cast care, you move on to the next patient.
The third patient is an 11-year-old male who fell while playing soccer and had immediate pain and deformity of the wrist. You review the x-rays (Figs. 10–63 and 10–64) and explain the injury to the family. They are very inquisitive and ask a lot of questions—they want to know exactly what type of distal radius fracture this is. After reviewing the x-rays, you tell them:
 |
 |
Figure 10–63
 |
 |
Figure 10–64
-
Salter–Harris I fracture
-
Salter–Harris II fracture
-
Salter–Harris III fracture
-
Salter–Harris IV fracture
-
Salter–Harris V fracture
Discussion
The correct answer is (B). The Salter–Harris classification of physeal fractures is basic knowledge for anyone in orthopaedics. A Salter–Harris I fracture is a transverse fracture through the growth plate (Fig. 10–65). A type II fracture is through a portion of the growth plate, but goes out through the metaphysis. A type III goes into the epiphysis. Type IV fractures cross all three—metaphysis, physis, and epiphysis. A type V fracture is a crush injury to the physis and there are not necessarily any findings on initial x-ray.
 |
Figure 10–65
You explain to the family that their child has a displaced Salter–Harris II fracture and you have recommended conscious sedation and closed reduction with casting. They agree, and you perform a reduction. You are able to reduce the fracture some, but not completely—there is about 25% displacement and no significant angulation. What do you tell the family?
-
Alignment is unacceptable and you need to perform the reduction again.
-
Alignment is unacceptable and the child needs an operation to reduce and stabilize the fracture.
-
Alignment is acceptable because of remodeling potential of the distal radius, but there is no harm in trying again to “get it perfect,” so you attempt another reduction.
-
Alignment is acceptable because of remodeling potential of the distal radius, and there is potential for harm if you do another reduction, so you will accept it as is. Follow-up in 1 week.
Discussion
The correct answer is (D). The alignment is acceptable in this patient because there is less than 50% displacement through the physis. There is not true consensus on the amount of angulation that is acceptable, but in general, angulation up to 20 degrees would be accepted in this patient over age 9 with open growth plates. Angulation as high as 25 to 30 degrees would be accepted in a child less than 9 years of age. Given
that 75% of the growth happens from the distal growth plate in the radius, there is a fair amount of remodeling potential with distal radius fractures. A study by Lee demonstrated that premature arrest of the physis was related to multiple reduction attempts, not to degree of angulation. If you were to re-reduce this patient’s fracture, you would be exposing him to the risk of premature physeal arrest unnecessarily.
Objectives: Did you learn...?
Different types of distal radius fractures have different treatment options? Management of buckle fractures of the distal radius?
Management of displaced distal radius fractures in children under age 10— nonprocedural options?
Salter–Harris classification of physeal fractures?
Treatment of distal radius physeal fractures in children given remodeling potential?
Importance of knowing what is acceptable and what is not in terms of alignment so as to avoid performing unnecessary procedures on children?