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Recommendations for Early Surgical Intervention in Adolescents With Salter-Harris II (SH2) Distal Radius Fractures
Micah K Sinclair1, Rachel Semus, Tristen Noble
1From the Department of Orthopaedic Surgery, Shriners Children's Northern California, Sacramento, CA (Sinclair), the Department of Orthopaedic Surgery, University of California Davis Health, Sacramento, CA (Sinclair), the Texas Children's Hospital, Houston, TX (Semus, Noble, and Bell), the Baylor University Medical Center, Houston, TX (Semus, Noble, and Bell), the University of Missouri-Kansas City School of Medicine, Kansas City, MO (Etebari, Warren, and Pruss), the Children's Mercy Hospitals and Clinics, Kansas City, MO (Etebari, Warren, Pruss, and Noel-Macdonnell), the University of Kansas Medical Center, Kansas City, KS (Pruss), the IDDI, Raleigh, NC (Staggs), and the Division of Health Services and Outcomes Research, Children's Mercy, Kansas City, MO (Noel-Macdonnell).
Introduction:
Nonsurgical management is the standard of care for most distal radius fractures involving the epiphyseal plate. However, because of the lack of remodeling potential in adolescents, nonanatomic reduction can result in a symptomatic malunion necessitating late complex surgical correction. Guidelines outlining optimal management strategies for SH2 distal radius fractures in the adolescent population are needed.
Methods:
This study is a retrospective review of isolated SH2 distal radius fractures from two, large, regional, referral pediatric ACS trauma level 1 hospitals between 2017 and 2020 in patients aged 9 to 18 years. Patients were identified by Current Procedural Terminology coding associated with their fracture management. Demographics, timing and type of treatment, and fracture displacement at relevant time points were recorded. Bivariate analysis was used to identify predictors of decision for acute surgery and/or correlates with the need for malunion correction. A Classification and Regression Tree model was fit to identify predictors of surgeon decision making for acute surgical intervention.
Results:
Sixty (11%) of 556 patients underwent acute surgical intervention following closed reduction. Seventeen cases (3%) were done to correct late malunion. A Classification and Regression Tree model correctly classified the decision for acute surgery in 77% of patients using sagittal translation post reduction of ≥35% followed by age at injury of ≥12 years. The decision for acute surgery included older patients (median age 13.8 vs. 12.6 years, P < 0.001), with greater coronal (11.6% vs. 0%, P < 0.001) translation, sagittal (30% vs. 0%, P < 0.001) translation and increased dorsal tilt (5.2° vs. 0°, P < 0.001).
Conclusion:
Decision for acute surgical intervention of SH2 distal radius fractures is done most often with persistent deformity of sagittal translation ≥35% in patients ≥12 years following closed reduction at the time of injury. Additional parameters are identified as associated with the decision for acute surgery and progression to symptomatic malunion.
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