Reduction of an Unusual Salter-Harris Type IV Fracture of th
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Fractures of the distal forearm are common in children and mostly involve the radius. Isolated fractures of the distal ulna are rare. Fractures involving the ulnar physis only account for approximately 4% of all physical injuries. Treatment consists of anatomic reduction to maximize chances for continued growth. Closed reduction is often unsuccessful due to soft tissue interposition, so this type of fracture is generally stabilized with open reduction and fixation.

A 14-year-old boy presented to the emergency department with a painful left wrist following a fall with his bike. Most of the impact was received on the left hand and wrist. On clinical examination, there was swelling but no gross deformity of the left wrist. The wrist was diffusely tender on palpation and range of motion (ROM) was limited by pain.There were no neurovascular deficits and the skin was intact. Anteroposterior and lateral X-rays of the left wrist showed a displaced Salter-Harris type IV fracture of the distal ulna. CT showed a displaced fracture through the epiphysis and metaphysis on the volar side of the distal ulna with an intraarticular step of 3 mm. The patient’s wrist was immobilized in a below-the-elbow plaster at the emergency department. Reduction and stabilization were, for practical reasons, planned 5 days later.

The procedure was performed under general anesthesia. First, an attempt at closed reduction was made, with pressure applied to the volar aspect of the wrist under radioscopic control. This resulted in a partial but insufficient reduction of the fracture, which led to conversion to an open reduction and fixation procedure. The fracture was approached through an ulnovolar incision. The fragment was reduced under radioscopic control using Kirschner pins to manipulate and lever the fracture fragments. Three Kirschner pins were placed parallel to the physeal plate. Two pins were placed in the coronal plane with one through the proximal fragment and one through the distal fragment. A third pin was drilled in the anteroposterior plane through the distal fragment. The patient was immobilized in an above-the-elbow cast for two weeks.

Follow-up after two weeks showed a favorable clinical evolution with the maintained position of the fracture fragments on X-ray. To encourage the mobilization of elbow and fingers, a wrist brace had to be worn for three more weeks.Three months later, the second pin was removed because of migration. X-ray of the wrist showed the fracture was fully healed with no evidence for a premature fusion of the physis or growth arrest.