RADIUS AND ULNA FRACTURES IN CHILDREN

Abstract

Number one in frequency of all fractures in children is the distal forearm fracture. The most common green-stick fracture with minor or no dislocation is treated by short or long arm cast. Depending on the age 4 or six weeks of immobilization is sufficient.

Displaced fractures of the distal radius and ulna are treated by closed reduction under general anaesthesia or lighter forms of analgesia. Reduction is followed by fixation in the “Schede position” (flexion, ulnar abduction) with obligatory change of cast after 10–14 days. Healing can be expected after 6 weeks. As an alternative percutaneous pinning of the reduced fracture allows immobilization in a short arm cast and without the the unpleasant flexion and ulnar abduction (Voto et al 1990, Mani et al 1993, Gibbons et al 1994, Choi et al 1959).

There is currently a prospective randomised study running organized by Mr Clarke from Southampton, to the advantages and disadvantages after use of pins or abstaining from them apparent risks.

For midshaft forearm fractures closed reduction and long arm cast immobilisation had been treatment of choice in the past. Remanipulation under anaesthesia because of lack of retention of both bone fractures have been common. Concerns came up mainly in the age group above 10 years with a high rate of unsatisfactory results (Kay et al 1986). Plate fixation of both bones is a difficult procedure and causes damage to the interosseous membrane and can enhance rotatory deficits. In addition ugly scars are not unusual. Intramedullary nails seemed advantageous. (Amit et al 1985)

J.L. Morote and the Spanish school of Sevilla were the first to use a minimal invasive method of reduction and K-wire fixation of midshaft and proximal forearm fractures. (Perez-Sicilia et al 1977).

The French group in Nancy and Metz had the some years later and developed their elastic stable intramedullary system for forearm fractures Metaizeau 1988, Lascombes et al. 1990). A high rate of excellent outcomes and hardly any complications were observed.

Intramedullary fixation with elastic stable nails even permits immediate motion (Verstreken et al 1988).

The surgical technique of Morote using blunt-ended 1,6 to 1,8 mm K-wires is described in “Operative Technique in Orthopaedics and Trauma” (Parsch 1990) The results were confirmed by Kaye Wilkins (1996), Luhmann et al 1998, and Richter et al 1998

An unacceptable high rate of complications was seen in groups, who used pins, which were not buried, who removed pins to early and before consolidation or who had fixed only one bone (Cullen et al 1998, Shoemaker et al 1999).

We recommend the intramedullary system for all displaced forearm fractures of children above 6 years until closure of the growth plate.(Parsch 1990). The learning curve is short, the time of surgery an average of 40 minutes. The radiation exposure can be limited by the use of short impulse image intensifier. There is virtually no blood loss. With the learning curve more than 80 % can be fixed by closed means. Open reduction might be necessary in adolescents, or in delayed fracture care.

Postoperative immobilisation is a plaster shell or brace is used for 2 weeks, this is not obligatory. Postoperative infections have not been observed after this minimal invasive method. Skin irritations can be avoided by complete bending of the K-wire ends.

In unacceptable malunion after conservative treatment closed or open realignment of the fractures followed by intramedullary Morote pinning is the treatment of choice.

Refractures may happen with wires in place shortly or a long time after removal of the hardware. They are not associated to the system, but rather to the fact that some children are subject to repeated falls, liable to break an arm.

Acute Monteggia fractures have the radial head reduced conservatively, usually under general anaesthesia. (Bado 1967). The ulnar fracture is reduced and than fixed by intramedullary K-wires (Fowles et al 1983)

In late reconstruction of Monteggia lesions we prefer plate fixation of ulna osteotomy.