Pediatric Distal Radius Fractures

We walk through how pediatric distal radius fractures behave differently from adult injuries, using real X-ray cases to show what to measure and why it matters. We focus on remodeling potential, age-based angulation limits, and practical casting choices that keep kids safe while they heal fast. 

• case study of a seven-year-old with a subtle metadiaphyseal distal radius fracture and dorsal angulation best seen on lateral view 
• why distal radius and forearm fractures are so common in children and how buckle fractures can look deceptively mild 
• how the distal radial physis drives growth and remodeling potential 
• age-based acceptable angulation targets and why malalignment can block pronation and supination 
• immobilisation strategy including short arm casting, cast moulding and typical timelines for cast then brace 
• older teen sports injury example and why acceptable alignment is stricter after age 10 
• red flags and associated patterns to rule out including Monteggia, Galeazzi and DRUJ injury 
• urgent care and ER options including sugar tong or volar splint with orthopaedic follow-up 

So you can log on to the YouTube channel and see the x-rays and the images that we discuss during the presentation itself.

Transcript

Welcome And Video X-Ray Setup

SPEAKER_00 0:00

Hello, everyone, and welcome back to the podcast. Again, my name is Chuck Dowell. I will be the host of today's episode. Today is going to be part two regarding our distoradius fractures. If you listened last week to part one, we discussed a distortius fracture in a young gentleman that we performed a hematoma block on. Today is going to be part two where we're going to briefly discuss kind of our younger patients, our pediatric patients with these distortius fractures and some thought processes behind this. Again, today's presentation will be a video presentation. So you can log on to the YouTube channel and see the x-rays and the images that we discuss during the presentation itself.

Case Study Seven-Year-Old Fall

SPEAKER_00 0:45

So if you're logged on or looking, uh, here's an x-ray of a patient that came in. So this is a six-year-old female who came and saw me in clinic. Two days prior, she was climbing down the ladder of her bunk beds and she fell backwards. She landed onto her left wrist. She had some pain at that time. Mom states that she just isn't using the wrist as much. She's cradling the wrist, kind of refusing to do some activities with it. She gave it a few days to try to see if it would get better, and unfortunately, it was not improving. So she brought her to the orthopedic urgent care two days later for evaluation of the wrist. On examination, uh, there was uh some tenderness topation diffusely throughout the distal radius area. Uh the tenderness was mainly within the distal third of the radius, extending into the uh metadiaphysal junction and distal area. No evidence of angulation was noted on the examination. Uh some mild diffuse edema was noted throughout the area as well. She was able to wiggle her fingers distally. X-rays were performed, which you can see on the um screen now. These x-rays included at an AP of the wrist and forearm, uh, oblique and a lateral view. Um, you can see on this AP view, this is a seven-year-old, so she is skeletally immature. Um, and it's it's faint, but you can see that there is a fracture line uh directly through here at this kind of metadiaphaseal uh junction and the distal third of the radius. Again, if we go to our oblique view here, you can see this fracture line as well, and also start to see some slight angulation noted. And then when we go to our lateral view, this is much more apparent. So sometimes hard to interpret with these lateral views as far as the overlap, our ulna dorsal cortex is here, our ulna volar cortex is here, our radial dorsal cortex is here, and then our radial volar cortex is here. So you can see there is a fracture through that kind of metadiaphaseal junction at the distortius area. There is some evidence of dorsal angulation within that fracture. So a

Why These Fractures Are Common

SPEAKER_00 3:00

couple things to think about when we talk about fractures in young patients, especially pediatric patients. We know that distoradius fractures or forearm fractures account for approximately 40% of all pediatric long bone fractures. And distortix fractures are the most common site of all pediatric forearm fractures. They generally occur uh on a fall on an outstretched hand with the wrist in an extended position. Some of the patients will come in like this. It'll be these unicortical or um bicortical fractures, the so-called torus or buccal type fractures. Um, the patients oftentimes won't complain of significant symptoms. There won't be significant deformity noted. Um the peak incidences do occur in our younger patients. So our girls typically between 10 and 12 years of age, and our gentlemen are boys between uh 12 to 14 years of age. Most commonly they happen in children under the age of 16. Now, we just you know, when we're evaluating these distortius fractures, um, especially in our younger patients, um, these can be treated slightly different than our older patients because they do have what we call remodeling potential. They have continued growth throughout this bone, and as they've grown throughout the bone, the bone will be able to straighten itself back out. So there are some acceptable degrees of angulation with these fractures in these younger patients. We know that this distoradial physis, so the growth plate within the distortius here that you can see on the image itself, uh, contributes to 75% of the growth of the radius itself. It contributes to 40% of the entire upper extremity growth, and typically this growth is at a rate of 5.25 millimeters per year. Most commonly, when we do see these fractures, they are at this metaphyseal uh junction

Remodeling And Acceptable Angulation

SPEAKER_00 4:56

or fracture area uh distally, and that's typically where these occur, such as as uh did occur in this patient. Um so again, 62% were occur within this distal metaphysis or metadiaphysal area. 20% will occur within the diaphysis itself. Um and then the other 18% can occur uh throughout the forearm. We always want to evaluate uh anytime we see these distal radius fractures, especially these more proximal and diaphysal fractures, the proximal um radiocarpal and ulnar junction to make sure there's not evidence of a montasia or a galliolety type fracture in these patients. So again, the workup typically involves um x-rays. Uh, in this patient, you can see these x-rays did show some evidence of some slight dorsal angulation. Now, knowing that this patient is younger, seven years old, and has a lot of remodeling potential and growth plate potential throughout this area does um kind of change or distinguish the way that we treat this fracture. So you can see on the screen now, this is kind of our thought process regarding the remodeling potential in these patients and the acceptable degrees of angulation. Now, one thing to keep in mind, uh generally we know that um fractures that andor deformities that are in the plane of the joint motion are typically more accessible, uh, excuse me, acceptable. And distal deformities, anything closer to that distal physis, we can typically accept more angulation than these mid shaft fractures. Because again, a lot of the growth is going to come through this distal physial area, and this is a lot of the remodeling potential will come from. So this one doesn't necessarily apply specifically to our patient, but in general, uh patients 10 years and younger have quite a bit of remodeling potential. So you could see acceptable angulations in 10 years and younger on the AP view are approximately about 15 degrees, and uh also on the lateral view, 15 degrees of angulation. In five years and younger, we can accept up to 20 degrees of angulation. Anybody over the age of 10, we want less than 10 degrees of angulation because we know that they're getting closer to reaching skeletal maturity. Um, and these uh degrees of angulation can cause uh possible rotational um issues. So again, any any fracture that heals with a final angulation or degree of angulations of more than 10 degrees, especially in this diaphysal area, can block approximately 20 to 30 degrees of rotation, including supination pronation activities. So anybody over the age of 10, we definitely want less than 10 degrees of angulation when we're measuring. Anybody under the age of 10, we can accept 15 degrees or so. Um again, this is in these mid shaft fractures. In these proximal third fractures, um, again, the growth potential throughout that area is less. And so, again, less than 10 degrees of angulation proximally, and ideally anatomic reduction, anybody over the age of 10. Again, a little bit of another um kind of diagram here. Excuse me, let me adjust this slightly. Um, when we're talking about angulations of fractures, so again, this mainly and this diagram applies to these mid shaft diaphysical fractures. Uh, these are acceptable angulations through these distal radius and distal fractures as well, but we can accept slightly more angulation as mentioned because of the growth potential throughout this area. So again, we know five and younger up to 20 degrees of angulation, five to nine years old up to 15 degrees of angulation, and then anybody over the age of 10, again, um, ideally less than 10 degrees of angulation. And um some of the literature here, kind of going back, there's multiple studies that have

Casting Choices And Healing Timeline

SPEAKER_00 8:55

you know shown the ability of remodeling potential regarding these patients themselves. So, in my patient um that did have um this distoradius fracture, these were the initial x-rays when they came and saw me. So you could see there's minimal change, um, but you can't see the angulation within the fracture itself. Um, we did immobilize this patient, so they were placed uh into a shortarm cast at the time. We know that these fractures, especially these kind of unicortical buckle type fractures, typically don't swell quite a bit. And so oftentimes, even when I'm seeing these acutely, especially these buckle fractures, we can typically cast these right away and the patients will do well. I would say the more proximal the fractures are, the older the patient is, the more we're trying to hold reduction. We may go to a long arm cast in some of these patients. But this patient we placed into a short arm cast, we did try to mold that cast again to try to prevent any further dorsal angulation of the fracture. So after the cast was applied, I did uh try to perform a little bit of volar molding as well as an interosseous mold, trying to kind of compress that fracture together to hold it in a good position. Approximately two weeks later, uh, this is the patient uh back into the um hand specialist's office. You can see the short arm cast is in place. You can see that the mold allowed for that fracture to stay in a good position. Um and these are x-rays showing that the the fracture looks like it's in a stable position. Um and then again, one month after the fracture, you can see here that the fracture remained in a stable position. There was good cortical healing in this area. And again, you could see a lot of good cortical healing on all four cortices here remaining this in a stable position. So in a seven-year-old patient, typically three to four weeks in a cast, followed by two to three weeks in a splint and/or a brace that they can remove, and then they can progress back to activities and usually full healing. Again, the healing potential in younger patients is a little bit quicker. As we get older, our ability to remodel and our bone, you know, kind of healing potential gets a little bit less. And so this will change kind of you know how we

Teen Hockey Case And Key Red Flags

SPEAKER_00 11:15

uh treat these fractures. Again, a couple kind of uh examples of some other patients. This was a slightly older patient. So this is another gentleman that I saw, a 13-year-old patient who was playing hockey. Uh, he collided with someone and immediately had pain within his wrist area. Uh, these are the initial x-rays upon presentation. You can see he has, again, this metaphyseal distoradius fracture with these cortical bucklings noting on the AP view, a little bit of an ulnar styloid fracture noted there as well. Uh he's 13, so he's over that 10 uh 10-year age. So our acceptable degrees of angulation is a little bit less. So, again, ideally we want this within 10 degrees of angulation. When I measured this in clinic, this was less than 10 degrees. Uh, so we discussed with the patient as well as his family members that we can place them in a cast, again, mold the cast to try to get a good volar mold. Sometimes I can even, especially in these acute fractures, do a little bit of a reduction in the cast itself. So, oftentimes what I'll have the um cast techs do is I'll have them put the cast on, leave it pretty wet. Um, in these casts, especially an older patient, we'll do a monster cast or a bit of a long arm cast. And then as the cast is drying, I'll try to reduce the fracture a little bit and mold that fracture into a good position to try to prevent further loss of deformity and maybe even correct some of the loss of deformity that was there. Um, about 10 days later, he uh came back and saw our hand specialist. Um, you could see it didn't get much improvement with the molding of the fracture, but is remaining in a stable position, uh was able to get kind of a good mold on the cast there, um, and then kind of follow-along x-rays. He was seen a few weeks after that to make sure that, you know, kind of things remained stable and were healing well. And you could see these x-rays um, you know, would be approximately three weeks after I initially saw them. And then his last x-rays upon discharge are here. Um, and you could see there's good cortical kind of thickening here, uh, excellent fracture healing scene. Um, and you could see that fracture kind of remained in a stable position on those x-rays. And so he was in that cast um for approximately four weeks and then was placed into a velcro brace for approximately three weeks. No contact or sports-related activities for approximately six weeks as not to fall and have a reinjury to the area. Um, so again, I hope this was kind of insightful. Um, you know, we do see these younger patients that come in with these distortius fractures. Sometimes these are bicortical and as they're through both of the cortex. Sometimes these are just buckle fractures where they're unicortical fractures. We can treat these slightly differently depending upon the age of the patient, their remodeling potential, their continued growth throughout that distortius, their proximity to the radial physis, and/or the ulnar physis, depending on where the fracture is at. Again, always want to make sure we evaluate the joint above. So make sure there's no pain within the elbow area that could be consistent with a galeossi or monasia type fracture. And again, quick reminder here just going over again, um, a montagia fracture would be uh a radial head dislocation uh with an ulnar kind of mid shaft or proximal fracture. And a galeazzi fracture would be a distortius fracture with an injury to the DRUJ or distor joint. Um, again, Smith's and Barton fractures are discussed here as well, but um, when we're looking, that's kind of what we're looking for as far as fracture patterns. So again, um we can treat these fractures a little bit differently, um, depending on how close they are to the growth plate and their remodeling potential. Uh I hope this was helpful uh and insightful regarding you know seeing these younger patients and potentially treating them. I think, again, oftentimes these don't tend to swell a lot, so you can cast these right away if you're in an orthopedic clinic. If you're not in an orthopedic clinic, an urgent care and ER, you can put these into a splint, um, either a sugar tong type splint or just a volar splint and allow them to follow up with orthopedics and get kind of definitive casting at that point. Uh, thank you very much for listening and have a good day.