OzEMedicine - Wiki for Australian Emergency Medicine Doctors

see also:

• paediatric limb fractures
• Bier's block - iv regional anaesthesia for LAMPs

• please see paediatric limb fractures for general principles, analgesia and tips
• any associated ulnar fracture can be managed on its merits (manipulated if angulated, otherwise ignored), EXCEPT in the very uncommon scenario of a Galeazzi fracture - dislocation of the distal radio-ulnar joint - these should be referred to ortho team for early Mx.
• it is also uncommon for a significant carpal injury to be also present in these wrist injuries, however, scaphoid fracture should be clinically excluded in the adolescent but is very rare in those under 10 years (and indeed has not ossified so won't be visible on Xray in those under 8 years).
• generally, children with bilateral fractures or ipsilateral supracondylar fracture with the distal radial fracture should be admitted for GAMP +/- ORIF rather than manipulation in ED.
• likewise, many ED's will generally admit children for GAMP rather than attempt manipulation in the ED after 10pm when the child is tired and less tolerant, as well as ED staffing tending to be less available to perform time consuming procedures that are really semi-elective.
• NB. international nomenclature usually refers a fracture with distal fragment being displaced posteriorly as being volar angulation (as the point of the angle faces volarwards) - this is opposite to how Australian clinicians refer to this as we often call these dorsally angulated - hence I have tried to avoid these terms below.

• here the distal radius is bent anteriorly and may need manipulation on clinical grounds rather than the rather inocuous angulation on Xray
• unlike dorsally bent fractures, these should be placed in supination and reduced and immobilised in supination.
• Mx is otherwise as for unstable distal metaphyseal fractures as below, although these fractures are quite stable even if they require manipulation.

• the key here is determining if the volar cortex has been breeched - if so, then regard as UNSTABLE - see next category.
• the majority of stable distal radial metaphyseal fractures (“buckle” or “torus” fractures) will not be significantly angulated and thus will not need manipulation (note: midshaft fractures are more likely to require manipulation and are not included here).
• these fractures as they are stable only require plaster for pain relief and protection from further falls if active.
• many of these children can be managed with either a tubigrip alone (to decrease swelling and let others know it is injured), or a plaster slab for a few weeks.
• they do not need repeat Xrays as by definition, they are stable.

• a distal radial metaphyseal fracture can be regarded as unstable if the volar cortex has been breeched (ie. there is a gap in it on XRay)
• if angulation is unacceptable for the age of the child, then manipulation should be attempted either via:
  • iv regional Bier's block:
    • if age over 5yrs, able to place iv access in each arm and patient likely to tolerate procedure
  • iv ketamine
    • if unlikely to tolerate Bier's block and nitrous is unlikely to be adequate
  • inhaled 70% nitrous oxide +/- iv fentanyl
    • if likely that ONE push will be sufficient then most children will tolerate this
  • if the above are not desirable, then consider admitting for GAMP.
• if the fracture is completely displaced and the bones are overlapping with shortening:
  • iv regional block or GAMP will be required
  • the manipulation technique should be altered to increase the angulation by bending the distal fragment dorsally, then with fingertips at the base of the fragment (NB. need short fingernails to avoid damaging skin), wiggle the base of the distal fragment distally until it can be reduced into place - just applying traction as in Colle's fractures in adults will not reduce these fractures.
  • ensure there is no lateral angulation as this will not correct with remodeling.
• apply above elbow POP with 3 point moulding to minimise slip in position which these fractures are prone to
  • some paediatric orthopaedic surgeons advocate BEPOP but for most ED staff, an AEPOP would be a safer option.
• warn parents of risk of fracture moving in the plaster as the swelling subsides, and thus the need for Xrays and potential for delayed GAMP.
• arrange weekly Xrays for at least 3 weeks
• duration of plaster is usually 6 weeks for > 12 years, 5 weeks for 8-12 years, 4 weeks for 3-8 years
• plaster instructions as usual with emphasis on strict elevation first 48hrs especially if fracture was manipulated.

• SH II fractures are particularly unstable even after careful manipulation, they can easily slip while applying plaster.
• in general, check the position of the anterior aspect of the epiphysis and if displaced dorsally from the anterior edge of the distal radius by more than 25% of width of distal radius then it should be manipulated.
• manage as for unstable metaphyseal fractures.