Slide 127 — Paed forearm fracture

Clean FRCS notes with inline figures

Paed forearm fracture

•Describe Xray: fracture of both radius and ulnar at shaft with shortening (bayonet) in skeletally immature patient

•Hx: age, mechanism of injury

r/o acute complication: compartment/ NV injury

Management

•Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)

Factors to consider:

•1. Site of deformity (affect position of cast due to different deforming force)

•2. Degree of deformity

•3. Age of patient (affect deformity we can accept)

•*Acceptable alignment: (Rockwood 2010)

•< 10y.o.: angulation <15, shortening and bayonetting <1cm

•>10y.o.: need anatomical reduction

•<10deg sagittal for 11-13, 0-5deg for >13

•0deg coronal for >=11

•NO rotational malalignment accepted

•Close reduction

•Both bone

•Temp reduce by pointing palm in the direction of apex of deformity

•Traction + angulation + rotation in the direction of angulation

•Bayonette deformity requires more traction to reduce

•Single bone - may need more traction

•Fixation

•K wire fixation – choose appropriately sized k wire (occupy at least 2/3 of diameter of medullary isthmus)

•Prebend radial wire to three times the diameter of the medullary canal and ensure the apex of bend corresponds to level of fracture

•Radial styloid – between EC I and II

•Ulnar olecranon

•Confirm correct rotation

Indication for plating:

•Close to skeletal maturity

•Meta-diaphyseal junction (width mismatch → hard to control by wire)

•Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)

•Deformity force: supinator, pronator teres, pronator quadratus (PNS)

•Proximal 1/3 fracture [prox fragment flexed (biceps) + supinated (supinator), distal pronated (PT +PQ)→ align distal with proximal by supinating)

•Middle 1/3 (proximal balanced by supinator and PT, distal pronated by PQ → align with distal in neutral position)

•Distal 1/3 (proximal pronated by PT + PQ, align with distal in pronation)

How to assess rotation?

•AP: radial styloid/ radial tuberosity 180deg

•Lat: coronoid process/ ulnar styloid 180deg

Complication

•Immediate – compartment syndrome 1-8%

•Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)

•Refracture (5% in 6 months)

•Synostosis

Direct Q&A

Q1 How is Paed forearm fracture managed?

•Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)

Q2 What are the indications listed for Paed forearm fracture?

Close to skeletal maturity

•Meta-diaphyseal junction (width mismatch → hard to control by wire)

•Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)

Q3 How to assess rotation?

•AP: radial styloid/ radial tuberosity 180deg

•Lat: coronoid process/ ulnar styloid 180deg

Q4 What complications are listed for Paed forearm fracture?

•Immediate – compartment syndrome 1-8%

•Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)

•Refracture (5% in 6 months)

•Synostosis

Raw speaker-note hierarchy audit

#	lvl	marL	indent	logical	original note line
1	0	None	None	0	Paed forearm fracture
2	0	None	None	0	Describe Xray: fracture of both radius and ulnar at shaft with shortening (bayonet) in skeletally immature patient
3	0	None	None	0	Hx: age, mechanism of injury
4	0	0	0	0	r/o acute complication: compartment/ NV injury
5	0	None	None	0	Mx:
6	0	None	None	0	Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)
7	0	None	None	0	Factors to consider:
8	0	None	None	0	1. Site of deformity (affect position of cast due to different deforming force)
9	0	None	None	0	2. Degree of deformity
10	0	None	None	0	3. Age of patient (affect deformity we can accept)
11	0	None	None	0	*Acceptable alignment: (Rockwood 2010)
12	0	171450	-171450	1	< 10y.o.: angulation <15, shortening and bayonetting <1cm
13	0	171450	-171450	1	>10y.o.: need anatomical reduction
14	1	628650	-171450	2	<10deg sagittal for 11-13, 0-5deg for >13
15	1	628650	-171450	2	0deg coronal for >=11
16	0	171450	-171450	1	NO rotational malalignment accepted
17	0	0	0	0	Close reduction
18	0	0	0	0	Both bone
19	0	171450	-171450	1	Temp reduce by pointing palm in the direction of apex of deformity
20	0	171450	-171450	1	Traction + angulation + rotation in the direction of angulation
21	0	171450	-171450	1	Bayonette deformity requires more traction to reduce
22	0	0	0	0	Single bone - may need more traction
23	0	0	0	0	Fixation
24	0	171450	-171450	1	K wire fixation – choose appropriately sized k wire (occupy at least 2/3 of diameter of medullary isthmus)
25	0	171450	-171450	1	Prebend radial wire to three times the diameter of the medullary canal and ensure the apex of bend corresponds to level of fracture
26	0	171450	-171450	1	Radial styloid – between EC I and II
27	0	171450	-171450	1	Ulnar olecranon
28	0	171450	-171450	1	Confirm correct rotation
29	0	0	0	0	Indication for plating:
30	0	228600	-228600	1	Close to skeletal maturity
31	0	228600	-228600	1	Meta-diaphyseal junction (width mismatch → hard to control by wire)
32	0	0	0	0	Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)
33	0	0	0	0	================
34	0	None	None	0	Deformity force: supinator, pronator teres, pronator quadratus (PNS)
35	0	171450	-171450	1	Proximal 1/3 fracture [prox fragment flexed (biceps) + supinated (supinator), distal pronated (PT +PQ)→ align distal with proximal by supinating)
36	0	171450	-171450	1	Middle 1/3 (proximal balanced by supinator and PT, distal pronated by PQ → align with distal in neutral position)
37	0	171450	-171450	1	Distal 1/3 (proximal pronated by PT + PQ, align with distal in pronation)
38	0	None	None	0	How to assess rotation?
39	0	171450	-171450	1	AP: radial styloid/ radial tuberosity 180deg
40	0	171450	-171450	1	Lat: coronoid process/ ulnar styloid 180deg
41	0	0	0	0	Complication
42	0	171450	-171450	1	Immediate – compartment syndrome 1-8%
43	0	171450	-171450	1	Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)
44	0	171450	-171450	1	Refracture (5% in 6 months)
45	0	171450	-171450	1	Synostosis

lvl

marL

indent

logical

original note line

None

Paed forearm fracture

None

Describe Xray: fracture of both radius and ulnar at shaft with shortening (bayonet) in skeletally immature patient

None

Hx: age, mechanism of injury

r/o acute complication: compartment/ NV injury

None

Mx:

None

Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)

None

Factors to consider:

None

1. Site of deformity (affect position of cast due to different deforming force)

None

2. Degree of deformity

None

3. Age of patient (affect deformity we can accept)

None

*Acceptable alignment: (Rockwood 2010)

171450

-171450

< 10y.o.: angulation <15, shortening and bayonetting <1cm

171450

-171450

>10y.o.: need anatomical reduction

628650

-171450

<10deg sagittal for 11-13, 0-5deg for >13

628650

-171450

0deg coronal for >=11

171450

-171450

NO rotational malalignment accepted

Close reduction

Both bone

171450

-171450

Temp reduce by pointing palm in the direction of apex of deformity

171450

-171450

Traction + angulation + rotation in the direction of angulation

171450

-171450

Bayonette deformity requires more traction to reduce

Single bone - may need more traction

Fixation

171450

-171450

K wire fixation – choose appropriately sized k wire (occupy at least 2/3 of diameter of medullary isthmus)

171450

-171450

Prebend radial wire to three times the diameter of the medullary canal and ensure the apex of bend corresponds to level of fracture

171450

-171450

Radial styloid – between EC I and II

171450

-171450

Ulnar olecranon

171450

-171450

Confirm correct rotation

Indication for plating:

228600

-228600

Close to skeletal maturity

228600

-228600

Meta-diaphyseal junction (width mismatch → hard to control by wire)

Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)

================

None

Deformity force: supinator, pronator teres, pronator quadratus (PNS)

171450

-171450

Proximal 1/3 fracture [prox fragment flexed (biceps) + supinated (supinator), distal pronated (PT +PQ)→ align distal with proximal by supinating)

171450

-171450

Middle 1/3 (proximal balanced by supinator and PT, distal pronated by PQ → align with distal in neutral position)

171450

-171450

Distal 1/3 (proximal pronated by PT + PQ, align with distal in pronation)

None

How to assess rotation?

171450

-171450

AP: radial styloid/ radial tuberosity 180deg

171450

-171450

Lat: coronoid process/ ulnar styloid 180deg

Complication

171450

-171450

Immediate – compartment syndrome 1-8%

171450

-171450

Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)

171450

-171450

Refracture (5% in 6 months)

171450

-171450

Synostosis

Improved semantic hierarchy used for the study notes

#	semantic level	section?	rewritten line
1	0		Paed forearm fracture
2	1		Describe Xray: fracture of both radius and ulnar at shaft with shortening (bayonet) in skeletally immature patient
3	1		Hx: age, mechanism of injury
4	0	yes	r/o acute complication: compartment/ NV injury
5	0	yes	Management
6	1		Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)
7	0	yes	Factors to consider:
8	1		1. Site of deformity (affect position of cast due to different deforming force)
9	1		2. Degree of deformity
10	1		3. Age of patient (affect deformity we can accept)
11	1		*Acceptable alignment: (Rockwood 2010)
12	1		< 10y.o.: angulation <15, shortening and bayonetting <1cm
13	1		>10y.o.: need anatomical reduction
14	2		<10deg sagittal for 11-13, 0-5deg for >13
15	2		0deg coronal for >=11
16	1		NO rotational malalignment accepted
17	1		Close reduction
18	1		Both bone
19	1		Temp reduce by pointing palm in the direction of apex of deformity
20	1		Traction + angulation + rotation in the direction of angulation
21	1		Bayonette deformity requires more traction to reduce
22	1		Single bone - may need more traction
23	1		Fixation
24	1		K wire fixation – choose appropriately sized k wire (occupy at least 2/3 of diameter of medullary isthmus)
25	1		Prebend radial wire to three times the diameter of the medullary canal and ensure the apex of bend corresponds to level of fracture
26	1		Radial styloid – between EC I and II
27	1		Ulnar olecranon
28	1		Confirm correct rotation
29	0	yes	Indication for plating:
30	1		Close to skeletal maturity
31	1		Meta-diaphyseal junction (width mismatch → hard to control by wire)
32	1		Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)
33	0		——
34	1		Deformity force: supinator, pronator teres, pronator quadratus (PNS)
35	1		Proximal 1/3 fracture [prox fragment flexed (biceps) + supinated (supinator), distal pronated (PT +PQ)→ align distal with proximal by supinating)
36	1		Middle 1/3 (proximal balanced by supinator and PT, distal pronated by PQ → align with distal in neutral position)
37	1		Distal 1/3 (proximal pronated by PT + PQ, align with distal in pronation)
38	0	yes	How to assess rotation?
39	1		AP: radial styloid/ radial tuberosity 180deg
40	1		Lat: coronoid process/ ulnar styloid 180deg
41	0	yes	Complication
42	1		Immediate – compartment syndrome 1-8%
43	1		Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)
44	1		Refracture (5% in 6 months)
45	1		Synostosis

semantic level

section?

rewritten line

Paed forearm fracture

Describe Xray: fracture of both radius and ulnar at shaft with shortening (bayonet) in skeletally immature patient

Hx: age, mechanism of injury

yes

r/o acute complication: compartment/ NV injury

yes

Management

Aim of treatment: restore full rotational range, promote union, avoid complication (malunion, synostosis, refracture)

yes

Factors to consider:

1. Site of deformity (affect position of cast due to different deforming force)

2. Degree of deformity

3. Age of patient (affect deformity we can accept)

*Acceptable alignment: (Rockwood 2010)

< 10y.o.: angulation <15, shortening and bayonetting <1cm

>10y.o.: need anatomical reduction

<10deg sagittal for 11-13, 0-5deg for >13

0deg coronal for >=11

NO rotational malalignment accepted

Close reduction

Both bone

Temp reduce by pointing palm in the direction of apex of deformity

Traction + angulation + rotation in the direction of angulation

Bayonette deformity requires more traction to reduce

Single bone - may need more traction

Fixation

K wire fixation – choose appropriately sized k wire (occupy at least 2/3 of diameter of medullary isthmus)

Prebend radial wire to three times the diameter of the medullary canal and ensure the apex of bend corresponds to level of fracture

Radial styloid – between EC I and II

Ulnar olecranon

Confirm correct rotation

yes

Indication for plating:

Close to skeletal maturity

Meta-diaphyseal junction (width mismatch → hard to control by wire)

Casting method: mold with 3 point fixation to correct angular deformity + AP compression (ligamentotaxis by interosseous membrane), sagittal width: coronal width of cast (Cast index): <0.75 (0.7)

——

Deformity force: supinator, pronator teres, pronator quadratus (PNS)

Proximal 1/3 fracture [prox fragment flexed (biceps) + supinated (supinator), distal pronated (PT +PQ)→ align distal with proximal by supinating)

Middle 1/3 (proximal balanced by supinator and PT, distal pronated by PQ → align with distal in neutral position)

Distal 1/3 (proximal pronated by PT + PQ, align with distal in pronation)

yes

How to assess rotation?

AP: radial styloid/ radial tuberosity 180deg

Lat: coronoid process/ ulnar styloid 180deg

yes

Complication

Immediate – compartment syndrome 1-8%

Malunion (10 deg angulation in 1 bone = 20-30 degrees of rotational block)

Refracture (5% in 6 months)

Synostosis

127. Paed forearm fracture

Clean FRCS notes with inline figures

Paed forearm fracture

r/o acute complication: compartment/ NV injury

Management

Factors to consider:

Indication for plating:

How to assess rotation?

Complication

Direct Q&A

Close to skeletal maturity

Raw speaker-note hierarchy audit

Improved semantic hierarchy used for the study notes