Segmental Radius and Ulna Fracture with Epiphyseal...

131 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005

Abstract

Segmental fractures of the radius and ulna are relatively common in adults, often occurring after high energy trauma. Segmental forearm fractures in children have not previously been reported, and their optimal management is unclear. We report a child of eight years of age who underwent fixation of these injuries with a good outcome.

Fracturesoftheforearmarecommoninbothadultsand children.1,2 Simple closed fractures that aredeemedtoberelativelystableinbothgroupscan

bemanagedbyclosedreductionunderappropriateanal-gesiaoranesthesiaandexternalimmobilization.3

In adults, unstable forearm fractures, such as seg-mental fracturesof theulna and radius are commonlymanagedwithopenreductionandplatefixationtoreducethe incidenceofnon-union,malunion,andsubsequentlossof function.4,5However, in children these injuriesare lesscommon,and therefore theirmanagementcanbemorecontroversial.3,6

Children’s ability to remodelbonealongwith theirexcellent bone healing often means that internal fixa-tion isunnecessary.Forearmfractures inchildren that

cannotbe reducedorheld in the reducedpositioncanbemanagedbycompressionplating,externalfixation,orKirschnerwirestabilization.7-10

Case ReportAn8-year-oldboypresented to theemergencydepart-menthavingfallen8feetfromatreeontohisleftfore-arm.Clinicalexaminationrevealedagrosslydeformedleftforearmwithnoneurovascularcompromise. Plain radiographs revealed a radially and dorsallydisplaced Salter Harris II lesion of the distal radius.Therewasalsoadisplacedfractureof themidshaftoftheradiusandadisplacedsegmentalulnafracture(Fig.1). Thepatientwaspreparedfortheoperatingroomandthefracturemanipulatedundergeneralanesthesia.Thediaphysealfracturesoftheradiusandulnacouldnotbereducedclosed.TheSalterHarrisIIlesionwasreducedclosedandheldwithtwoKirschnerwires. Openreductionofthefractureoftheproximalulnawascarriedout.Alargesleeveofperiosteumwasfoundwithinthefracturesite,preventingclosedreduction.TheradiuswasexposedusingHenry’sapproach.Thefracturewasreducedandheldwithafour-holesemi-tubularplate.Theulnawasthenplatedwithafour-holesemi-tubularplate.Finally,thedistalulnafracturewasreducedunderdirectvisionandheldwithasingleKirschnerwire(Fig.2). Thepatientwasimmobilizedinanabove-elbowPlas-terofPariscastuntilremovaloftheKirschnerwiresatfourweeks.Removaloftheplateswascarriedoutat6months(Fig.3).Recoveryhasbeenuneventful,andthepatient has regained full flexion and extension of thewristandelbowandfullpronationandsupinationoftheforearm.Onmanualstrengthtestingoneyearfollowingremovaloftheplates,therewasnodetectablestrength

Segmental Radius and Ulna Fracture with Epiphyseal InvolvementA Case Report

Joe Grainger, B.Med.Sci., M.R.C.S., Francesco Oliva, M.D., and Nicola Maffulli, M.D., M.S., Ph.D., F.R.C.S.(Orth.)

Joe Grainger, B.Med.Sci., M.R.C.S., is a Senior House Office,Trauma and Orthopaedic Surgery; Francesco Oliva, M.D., isa Senior House Office,Trauma and Orthopaedic Surgery; andNicolaMaffulli,M.D.,M.S.,Ph.D.,F.R.C.S.(Orth.),isaProfes-sorofTraumaandOrthopaedicSurgery,ConsultantOrthopaedicSurgeonintheDepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,UniversityHospitalofNorthStaffordshire,Stoke-on-Trent,StaffordshireST47QBEngland.Correspondence: Nicola Maffulli, M.D., M.S., Ph.D.,F.R.C.S.(Orth.),DepartmentofTraumaandOrthopaedicSurgery,KeeleUniversitySchoolofMedicine,UniversityHospitalofNorthStaffordshire,ThornburrowDrive,Hartshill,Stoke-on-Trent,Staf-fordshireST47QBEngland.

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deficitinflexionandextensionofthewristandelbowandpronationandsupinationoftheforearm,whencomparedtotheuninjuredcontralateralarm.

DiscussionSegmental fracturesof the radiusandulna inchildrenare uncommon.3,6Accurate reduction of these injuriesisessentialtoreducetheriskofpotentialcomplicationssuchasnon-union,malunion,andcrossunion.Ifclosedreduction isunsuccessful, thenopenreductionand in-

ternalfixationisnecessary. Severalmethodscouldbeusedinthemanagementoffracturesoftheforearminchildren.ApossibilitywouldbetoperformretrogradeintramedullaryKirschnerwir-ingoftheradiusandantegradeintramedullaryKirschnerwiringoftheulna.10Thismethod,althoughlessinvasivethantheoneweelectedtouse,allowslessstabilitythanplatingofthemidshaft.However,weacknowledgethat,had we used it, another formal operation for removalof metalwork would not have been necessary. Indeed,

Figure 1AnteroposteriorandlateralradiographsoftheinitialinjuryshowingaSalterHarrisIIfrac-tureofthedistalradius,midshaftradiusfracture,andsegmentalulnafracture.

Figure 2 Postoperative plain radiographsshowing result of open reduction and internalfixation.

Figure 3Plainradiographshowingfractureunionfollowingremovalofplates.

133 Bulletin• Hospital for Joint Diseases Volume62,Numbers3&4 2005

removalofmetalworkfollowingforearmfracturefixa-tioncanbedifficultandrecentevidencesuggeststhatitshouldbeundertakenbeforecorticalassimilationoftheimplanttakesplace.11

Inoursetting,platingofforearmfracturesinchildrenisperformedroutinelywithexcellentclinicaloutcomeandwethereforerecommendthisapproachintheserareinjuries.

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