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Orthopedic Services
Glendale Adventist Medical Center
1509 Wilson Terrace
Glendale, CA 91206
Ph: (818) 409-8000

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My wife is in the emergency room with our son who broke his wrist this afternoon. Guess he fell from the monkey bars at the local park. Busted the radial bone just above the wrist. Guess it's dicey because the broken ends shifted and now overlap each other. My job is to research the Internet for the safest, best treatment possible since we don't have any insurance. I guess my real question is: can they just cast it and avoid surgery?

When a bone is broken, separated, and off-angle, the treatment is usually with surgery to separate the ends of the bone and realign them. This type of reduction procedure cannot be done without sedating the patient in an operating room. The procedure may be a closed reduction, which does not require an incision to realign the bones. Or it may be an open reduction, in which case the surgeon must cut the arm open to get down to the bone and complete the reduction process. In either reduction procedure, it may be necessary to use pins to hold the bones together. This is called internal fixation. Internal fixation and is often needed to keep the bone fragments together until healing takes place. Redisplacement (bones shifting apart) is a common problem with displaced bone fractures, especially without internal fixation. The more unstable the fracture is and the more force placed on the bones by muscle contractions, the greater the risk of redisplacement. Whether an open or closed reduction, this approach increases the cost of care including hospital time and the surgeon's time -- not to mention the patient's time and risk of complications. But there is a new nonsurgical approach for overriding distal radial fractures that might be possible for your son. Overriding tells us the bones have separated and moved toward each other. Instead of the ends of the fractured pieces moving apart, they now overlap. The radius is one of the two bones in the forearm. The distal end is at the wrist while the proximal end is located up at the elbow. What is this new approach? As you suggested, the fracture can be allowed to heal in the shortened position without surgical manipulation to restore alignment first. To qualify for this type of management, children must be ten years old or younger and treated within 72 hours of the injury. A fiberglass cast can be applied from just below the elbow down to the wrist and including the hand. The overlap can't be too severe or the bone angulation more than 20 per cent with molding of the cast. The cast is removed when all trace of pain and tenderness is gone. A second sign that it was time to remove the cast is an X-ray showing the formation of a solid bone callus at the fracture site. Cost analysis comparing four different ways to treat a problem like this has been published. The four treatment scenarios include: 1) child receives a short-arm cast in the physician's office without reduction. 2) Child is sedated but still awake (called conscious sedation) while in the hospital emergency room. The fracture is then treated with a closed reduction. 3) Child is anesthetized (put into a deep sleep) and the fracture is reduced without the use of internal fixation. 4) Child is put to sleep with a general anesthesia. Fracture is closed without an incision. Pins are used to hold the bone together. They found that each successive treatment (options two through four) cost more and more compared to the conservative, nonoperative approach (option number one). For example, the most involved treatment (number 4: closed reduction under general anesthesia with internal fixation) costs eight and a half times more than closed treatment with cast only. Even the closed reduction under conscious sedation was 4.7 times more expensive compared with the proposed non-manipulative management of this problem. Although there is evidence that surgical treatment to reduce overriding distal radial (wrist) fractures may not be necessary in young children, this approach must be approved by the surgeon. Complete healing and bone remodeling in some young children (under the age of 11) is possible with this technique. The best chance for good results occurs when the growth plates are still open. Since the distal wrist growth areas provide 80 per cent of the total forearm length, young children can and do self-correct.


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