Distal radial physeal fractures - Fracture clinics

  • Fracture Guideline Index

    See also: Distal radial physeal fractures - Emergency Department

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the potential complications associated with this injury?
    4. When should I refer for an orthopaedic consultant opinion?
    5. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Long-term prognosis is based on the type of physeal injury. Salter-Harris III and IV will have longer follow-up (at 6-12 months) to watch for a growth arrest.  Table 1 shows the recommended follow-up schedule.

    Table 1: Recommended follow-up schedule for distal radial physeal fractures.

    Fracture

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    Type I & II -undisplaced

    Within 5 days post-immobilisation with x-ray

    At 4 weeks post-immobilisation. X-ray out of backslab or splint

    If x-ray findings satisfactory and clinical exam normal, discharge

    Parents should be warned to re-present if child develops angular deformity

    2-3 months for return to full contact sports

    Type I & II - displaced

    Within 5 days post-reduction with x-ray

    At 2 weeks post-reduction with x-ray

    At 4 weeks post-reduction with x-ray out of cast

    If x-ray findings satisfactory, discharge

    Older children (<2 years growth remaining) need closer follow-up due to less remodelling potential

    As above

    Type III & IV - displaced

    As per post-operative instructions

    Removal of pins usually occurs at 4 weeks

    Physeal fractures need a recheck with x-rays approx. 6 months after injury to check for a growth arrest

     

    2. What should I review at each appointment?

    The cast should be checked at each visit, to ensure that it is moulded properly and fitting well, so not to allow further loss of reduction.

    The risk of growth arrest should also be evaluated.  Physeal injuries to the distal ulna should be carefully checked as there is a higher risk of growth arrest.

    3. What are the potential complications associated with this injury?

    Physeal fractures should not be re-manipulated after five days from injury due to increased risk of further damaging the growth plate. Fractures with angulation up to 20 degrees (as seen on lateral x-ray) should remodel if there is two years or more of growth remaining.

    The overall risk of physeal arrest after distal radial physeal fracture is approximately 4%. The higher the Salter-Harris fracture classification number, the greater the chance of growth arrest.

    Malunion can occur if the fracture is mal-reduced or reduction is lost without close follow-up.

    4. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • loss of reduction at follow-up visit with >20 degrees angulation on lateral x-ray
    • malunion with concern that remodelling will not correct the deformity
    • follow-up for physeal arrest concerns.

    5. What are the indications for discharge?

    For Salter-Harris fracture types III and IV, after recheck at 6-12 months showing no growth plate injury or malunion, patients should be discharged.

    References (Outpatient setting)

    Bae D. Pediatric distal radius and forearm fractures. J Hand Surgery 2008; 33: 1911-23.

    Bae DS, Waters PM. Pediatric distal radius fractures and triangular fibrocartilage complex injuries. Hand Clin 2006; 22: 43-53.

    Waters PM, Bae DS. Fractures of the distal radius and ulna. In Rockwood and Wilkins'Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.292-346.

     

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