Pediatric Distal Radius Fractures

Key Points

Treatment of pediatric distal radius fractures (DRFs) is challenging because of possible involvement of the physis and the remodeling capacity by growth.
Young children with a fracture close to the most active distal physis angulated in the sagittal plane have the highest remodeling capacity.
Predictors for secondary fracture displacement in cast are initial complete displacement and inadequate reduction. Cast index is not a predictor for failure.
Additional K-wire fixation of displaced distal radius fractures reduces re-displacement rates but does not improve functional outcome.

Panel 1: Case Scenario

A 12-year-old, right-handed boy with a painful and swollen right wrist visits the emergency department after a fall from his bike. Radiographs show a Salter Harris type II (SH II) distal radius fracture ( Fig. 1 ). What is the most effective treatment of his fracture?

$Fig. 1, Radiographs of a 12-year-old child with a SH II fracture before and after reduction.$

After a week, the boy visits your outpatient clinic for follow-up and the radiographs show secondarydisplacement of the fracture ( Fig. 2 ). What is the most effective treatment of his secondary displaced fracture?

$Fig. 2, Radiographs of a 12-year-old child with a SH II fracture with secondary fracture displacement in cast.$

Importance of the Problem

Distal forearm fractures are one of the most common fractures accounting for about 40% of all long bone fractures in children. A peak incidence is seen in girls between 10 and 12 years and in boys between 12 and 14 years. The key difference between the child's bone and that of an adult is the physis that needs to be taken into account for the treatment of these fractures. Physeal injuries are very common in children, making up 15% of all distal forearm fractures. The distal physis of the radius accounts for 75% of the growth of the radius and 40% of the growth of the entire upper extremity, thereby remodeling potential in the distal forearm is highest in the sagittal plane because of the highest range of motion in this plane (flexion-extension). Multiple attempts at reduction, and late re-manipulation more than 7 days post injury are known risk factors for physeal growth arrest ( Fig. 3 ). Remodeling potential of pediatric distal radius fractures (DRFs) makes the choice between nonoperative treatment and operative treatment more complex than in the adult population.

$Fig. 3, Physeal arrest of the distal radius after physeal fracture.$

Main Question

What is the relative effect of additional K-wire fixation in closed reduction on functional outcome and complication rates in management of pediatric metaphyseal and physeal DRFs?

Current Opinion

Relatively stable buckle/torus or greenstick DRFs with minimal angulation do not require closed reduction and can be treated with cast or pressure bandage treatment. Current opinion is divided with regard to more unstable displaced greenstick fractures, SH Type I–IV fractures, complete DRFs, or both-bone distal forearm fractures.

Finding the Evidence

Cochrane search: Pediatric DRF
Pubmed (Medline):
- Embase (“forearm fracture”/de OR “radius fracture”/exp. OR “ulna fracture”/exp. OR “wrist fracture”/de OR “distal radius fracture”/exp. OR (((forearm* OR fore-arm OR radius* OR ulna OR wrist* OR antebrach* OR both-bone* OR colles* OR monteggia*) NEAR/3 (fracture*)) OR ((salter-harris* OR epiphys*-plate* OR growth-plate* OR intra-articul* OR intraarticul*) AND (wrist* OR radius* OR ulna))):ab,ti,kw) AND (“fracture treatment”/exp. OR “closed reduction (procedure)”/exp. OR “open reduction (procedure)”/exp. OR “bone resection”/de OR “orthopedic surgery”/de OR (ORIF OR CRIF OR plaster* OR cast* OR K-wire* OR plate* OR nail* OR reduction* OR fixat* OR osteosynth* OR ilizarov* OR splint* OR ((therapy OR therapies OR treat* OR immobili*) NEAR/3 (fracture*)) OR ((orthoped*) NEAR/3 (surgic* OR surger* OR procedur*))):ab,ti,kw) AND (“Controlled clinical trial”/exp. OR “Crossover procedure”/de OR “Double-blind procedure”/de OR “Single-blind procedure”/de OR “review”/exp. OR “meta analysis”/de OR (meta-analys* OR metaanalys* OR review* OR random* OR factorial* OR crossover* OR (cross NEXT/1 over*) OR placebo* OR ((doubl* OR singl*) NEXT/1 blind*) OR assign* OR allocat* OR volunteer* OR trial OR groups):ab,ti,kw) AND (child/exp. OR adolescent/exp. OR adolescence/exp. OR pediatrics/exp. OR childhood/exp. OR “child welfare”/de OR “child development”/de OR “child growth”/de OR “child health”/de OR “child health care”/exp. OR “child care”/exp. OR “childhood disease”/exp. OR “pediatric ward”/de OR “pediatric hospital”/de OR “pediatric anesthesia”/de OR (adolescen* OR preadolescen* OR infan* OR child* OR kid OR kids OR toddler* OR teen* OR boy* OR girl* OR minors OR underag* OR (under NEXT/1 (age* OR aging OR ageing)) OR juvenil* OR youth* OR kindergar* OR puber* OR pubescen* OR prepubescen* OR prepubert* OR pediatric* OR paediatric* OR school* OR preschool* OR highschool* OR suckling* OR PICU OR NICU OR PICUs OR NICUs):ab,ti,kw) NOT ((animal/exp. OR animal*:de OR nonhuman/de) NOT (“human”/exp)) NOT ([Conference Abstract]/lim)
Bibliography of eligible articles
Articles that were not in the English, French, or German language were excluded.

Quality of the Evidence

Level I:

Systematic Reviews/Metaanalyses: 9
Randomized trials: 9

Level II:

Randomized trials with methodological limitations: 1
Prospective studies: 3

Level III:

Retrospective comparative studies: 12

Level IV:

Case series: 2

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