– unusual injury in kids; peak age 9-12
– fracture of the distal radius with separation of the DRUJ or fracture through the distal ulnar epiphysis
– hyperpronation injury – TFCC tears and dislocates dorsally at extreme of pronation
– brachioradialis tends to shorten the radius, and pronator quadratus rotates the distal fragment
– in kids, you can treat this closed, with full supination of the forearm, above elbow cast for 6 weeks
– beware the oblique fracture of the radius – these are unstable and tend to displace; if angulation more than 10 degrees, or shortening more than 4 mm, then do an ORIF
ORIF – Volar Approach
– through FCR; radial artery radial, peel pronator quadratus off medially.
– then be prepared to do a second incision for the acute carpal tunnel syndrome decompression –
– curved incision ulnar to and paralleling the thenar crease – angle it towards the ulnar side of the wrist to avoid going through the flexor crease at righ angles and to avoid the palmar cutaneous branch which comes off radial to the median nerve, emerges about 3-4 cm above the flexor retinaculum and usually runs between palmaris longus and FCR
– the dissection should stay ulnar to axis of middle finger and ulnar to palmaris longus (if present), in line with the ring.
– identify the proximal and distal extent of the carpal tunnel
– incise the fasica, put a blunt instrument under the transverse carpal ligament, and cut down onto it – stay ulnar to avoid the median nerve and its motor branch, which may actually perforate the transverse carpal ligament
– don’t go too far distal – 5-8 mm distal to the distal margin of the ligament is the superficial palmar arterial arch.