A 13-year-old boy fell from a small ladder and injured his left wrist. He reported pain and inability to move his left wrist. X-rays showed a closed fracture of the distal radius and ulna with injury to the growth plate. The boy's wrist was placed in a long arm cast after closed reduction. Growth plate fractures in children risk unequal limb growth if not properly treated. Non-operative treatment involves immobilization while operative treatment may be needed for displaced fractures. Complications can include growth arrest or angular deformity if not managed correctly.

1. 25 Jan 2017
By Siravich Thamthitiwat

2. History Taking
 เด็กชาย อายุ 13 ปี
เหตุเกิด 21/1/2017 เวลา 16.30 น. ถึง ER เมื่อ 21.40 น.
 Chief Complaint
: 5 เจ็บข้อมือซ้าย ชั่วโมงก่อนมาโรงพยาบาล

3. History Taking
Present Illness
: 5 ชั่วโมง ก่อนมาโรงพยาบาล ผู้ป่วยให้ประวัติว่าขณะ
กาลังเกิดขึ้นบันไดสามเหลี่ยม สูงประมาณ 50 ซม. ผู้ป่วย
เสียหลักล้ม ใช้แขนและข้อมือซ้ายกระแทกลงกับพื้น มี
อาการปวดบริเวณที่ข้อมือซ้าย ไม่สามารถกระดกข้อมือได้
ปฏิเสธประวัติศีรษะกระแทกพื้น ไม่มีอาการหมดสติ ไปที่
โรงพยาบาลชุมชน จากนั้นจึงส่งตัวมาเพื่อรักษาต่อที่
โรงพยาบาล

4. PE : Primary Survey
 A : Able to tell name and event, spontaneous neck
movement
 B : Equal breath sound, CCT –ve, RR : 16/min
 C : No bleeding at long bone, pelvis, abdomen, external,
Vital sign; BP: 148/78 mmHg, P77 bpm
 D : E4V5M6, pupil 3 mm RTLBE
 E : No tenderness along spine, able to stand

5. Secondary Survey
S : Tenderness at Lt. wrist, no ecchymosis
A : Denied drug or food allergy
M : Denied any current medication
P : No known underlying disease
L : Last per oral 12.00
E : Fall from small ladder (0.5 meter)

6. Secondary Survey
Head and face : no wound at scalp and face
CVS : normal S1 S2, no murmur
Lung : normal breath sound, no adventitious
sound
Abdomen : soft, not tender
CNS : grossly intact

7. Secondary Survey
 Ext. (Lt forearm) : no deformities, marked swelling, marked
tenderness at both medial and lateral aspect of wrist, limit
ROM due to pain, able to flex and extend all digits and
unable supinate pronation.
No external wound
Neurovascular : Radial and ulnar pulse 2+
Motor : Can’t flexed wrist, able to flexed all phalanges
Sensory : Intact

8. Investigation
Lt. wrist AP, lateral

9. Plain film Lt. wrist
AP View
Thurston-Holland’s sign

10. Plain film Lt. wrist
lateral view

11. Diagnosis
 Closed fracture of distal radius and
distal ulnar with growth plate injury

12. Management
 Pain Control
 Pethidine 25 mg IV
 Closed reduction with long arm AP slab
 Advice about slab care, complication
 Follow-up on 1/2/2560 with filming
 HM
○ Paracetamol (500) 1 tab oral prn for pain q 4-6

13. Plain film Lt. wrist
AP after
reduction and
slab insertion

14. Plain film Lt. wrist
lateral after
reduction and
slab insertion

16. What is growth plate?
 Growth plates are found in the long bones of the body
 Located one at each end between the metaphysis and
the epiphysis.
 When a child is fully grown, the growth plates harden
into solid bone.
 If left untreated, may lead to unequal or crooked limb.

18. Growth plate fracture; cause
Usually happen with sport training/activity or
fall from height
Twice as often in boys as in girls.
The incidence of growth plate fractures peaks
in adolescence.

19. Clinical Manifestation
Visible deformity of the limb
An inability to move or put pressure on the limb
Swelling, warmth, and tenderness

20. Classification
 Salter-Harris classification

21. Classification
Type I Fractures
 Separating of bone end from the bone shaft and completely
disrupting the growth plate.
Type II Fractures
 Break through part of the bone at the growth plate and crack
through the bone shaft.
 Most common type.

22. Classification
Type III Fractures
 Cross through a portion of the growth plate and through a
piece of the bone end.
Type IV Fractures
 These fractures break through the bone shaft, the growth
plate, and the end of the bone.
Type V Fractures
 Occur due to a crushing injury to the growth plate from a
compression force.

23. Mnemonic

24. Other classification

25. Management
 Classification determine
management
 Non-operative
 Operative

26. Non-operative
 Salter-Harris type I and II can be treat
with conservative treatment
 Reduction and immobilization with splint/slab
 Children
 Follow-up every week and splint up to
3-4 weeks

27. Short arm slab
 Consider if no distal ulnar fracture seen

28. Long arm slab

29. Operative
 Displacement of more than 2 mm from
distal end to proximal end
 Salter Harris type III, IV with more than 1
mm displacement
 Acute carpal tunnel syndrome
 Associated with ipsilateral elbow fracture

30. Complication
 Growth arrest
 Complete arrest leads to length discrepancy
 Partial arrest leads to angulation

31. Partial arrest of
growth plate
Angulation

32. Complication: treatment
Bar resection with interposition
 indications
< 50% physeal involvement
> 2 years or 2cm growth remaining

33. Bar resection with interposition

34. Complication: treatment
Ipsilateral completion of arrest
indications
> 50% physeal involvement
can combine with contralateral epiphysiodesis
and/or ipsilateral lengthening

35. Thank you for your attention
35