Distal radius and or ulna metaphyseal fractures - Fracture clinics

  • Fracture Guideline Index

    See also: Distal radius and / or ulna metaphyseal 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?

    Table 1: Recommended follow-up schedule for distal radius and/or ulna metaphyseal fractures.

    Fracture

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    Complete - undisplaced or minimally displaced

    Within 7 days post-immobilisation with x-ray

    At 6 weeks post-immobilisation. Removal of cast and x-ray out of cast

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

    Gradual return to sports 4-6 weeks post-removal of cast

    Complete - displaced fractures

    Within 7 days post-reduction with x-ray

    At 2 weeks post-reduction with x-ray

    At 6 weeks post-reduction. Removal of cast and x-ray out of cast. If x-ray findings satisfactory and clinical exam normal, discharge

    Complete fractures of both radius and ulna have higher risk of loss of reduction and need to be carefully observed. Older children (with less than 2 years growth remaining) may need further follow-up due to less remodelling potential

    2-3 months for return to full contact sports


     2. What should I review at each appointment?

    Check for redisplacement and whether the cast is appropriate. Assess neurovascular status and document findings.

    3. What are the complications associated with this injury?

    Loss of reduction and malunion are the most common complications:

    • Loss of reduction
      • One in ten fractures (10%) will lose position and will need re-reduction. Contributing factors are poor cast technique or residual angulation/displacement after the initial reduction. Loss of position and the opportunity for re-reduction can only happen with appropriately timed follow-up
      • Complete fractures in patients over 10 years of age have a high risk of loss of reduction, thus proper follow-up is important
    • Malunion can occur if the fracture is malreduced or reduction is lost

    Nonunion or physeal injury is rare.

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

    Indications for an orthopaedic consultant review are:

    • loss of reduction at follow-up visit with unacceptable alignment (see Table 1, acceptable angulations, ED Section)
    • shift of >15 degrees on lateral x-ray within 1 week of follow-up

    5. What are the indications for discharge?

    The indications for discharge are a healed fracture clinically (i.e. pain free on movement and non-tenderness at the fracture site) and radiographically, with acceptable alignment. This usually occurs at 6 weeks post-reduction and immobilisation.

    References (Outpatient setting)

    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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