Working Diagnosis:
Displaced distal radius Salter-Harris type II fracture status post reduction

Treatment:
X-rays in clinic demonstrated displacement of the epiphysis greater than 25% relative to the physis. This met literature criteria for closed reduction. Consent from the patient and parent was obtained. A hematoma block with 1% lidocaine without epinephrine for anesthesia was completed under ultrasound. Closed reduction was then completed with one clinician holding counter-traction and the other applying traction and a volarly directed force at the dorsal epiphysis. Two reduction attempts were made. Repeat x-rays demonstrated improvement and sufficient reduction. The patient was then placed in an Exos short arm splint. The patient followed up every 2 weeks until 7 weeks post-injury. Repeat x-rays at these appointments demonstrated no further displacement, healing and eventually, improved alignment through remodeling. He reported full clinical improvement. At 4 weeks post-injury, the patient was placed in a hard cast that was padded by his athletic trainer to allow athletic participation. At his final appointment, 7 weeks post-injury, the hard cast was removed. It was recommended that he use the Exos short arm splint for an additional two weeks, then wean out. The patient was scheduled for follow-up appointments and x-rays at 6 months and 1 year post-injury to document normal growth at the physis.

Outcome:
The x-rays taken 7 weeks after injury demonstrated healing and improved alignment through remodeling.

Author's Comments:
Salter Harris type II fractures of the distal radius are some of the most common adolescent fractures. These most often occur secondary to a FOOSH injury. Displacement of the epiphysis relative to the physis most commonly occurs in a dorsal direction. Based on the literature, indications for reduction in a patient of this age includes greater than 20 degrees of dorsal angulation, or as in our case, greater than 25% displacement of the epiphysis relative to the physis. Closed reduction is ideally performed as soon as possible after the injury and not greater than 5-7 days post-injury. Adequate analgesia is necessary for reduction success. Hematoma blocks have been shown to be just as effective as intravenous pain control and sedation but do not require inpatient or vitals monitoring. If closed reduction fails, reduction under sedation or surgical management may be required. This case highlights the importance of reduction knowledge and procedural skill to allow for efficient adolescent athlete management.

Editor's Comments:
Non-displaced, extraarticular distal radius fractures are generally amenable to closed reduction. However, more complicated fracture patterns (i.e. intraarticular involvement, fracture-dislocation, comminution, etc.) may necessitate surgical management. Reduction restores normal articular congruity and alignment. Adequate reduction requires no dorsal tilt to the distal radial articular surface, less than 3mm of radial shortening, and less than 2 mm of displacement of fracture fragments.
Surgical fixation may be necessary when more than 10-20 degrees of dorsal angulation persists after closed reduction in this age group. Patients are initially immobilized in a removal splint. After swelling begins to subside, they are transitioned to a rigid short or long-arm cast with the wrist in slight flexion and ulnar deviation. Depending upon patient age and fracture morphology, 4-8 weeks of immobilization is generally needed for healing. Complications can result from the fracture itself, positioning when immobilized, and immobility itself and can include decreased range of motion, neuropathy, or complex regional pain syndrome.

References:
Eiff, Hatch, and Calmbach. Fracture Management for Primary Care, Second Ed. 2002. pp. 129-32.
Eiff and Hatch. Fracture Management for Primary Care and Emergency Medicine, Fourth Ed. Co-author: Michaudet. 2020. pp. 115-145.
Myderrizi, Neritan, and Bilal Mema. "The hematoma block an effective alternative for fracture reduction in distal radius fractures." PubMed, 2011, doi:https://pubmed.ncbi.nlm.nih.gov/21950232/..
Qudsi, Rameez, and Chris Souder. Orthobullets, June 2021, www.orthobullets.com/pediatrics/4014/distal-radius-fractures--pediatric.

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