Summary of Pediatric Wrist and Forearm Malformations

## Introduction Forearm and wrist surgery covers a range of procedures aimed at restoring alignment, stability, motion, and function of the distal forearm and wrist. This material focuses on general principles, preoperative evaluation, operative planning, postoperative care, and examples of common soft-tissue and bony procedures that are not covered elsewhere in your curriculum. It is written for a Not attending student and uses clear, practical language. > Definition: Forearm and wrist surgery is the set of surgical interventions targeting bones, joints, ligaments, tendons, and soft tissues of the distal forearm and wrist to relieve pain, correct deformity, restore motion, or improve hand function. ## Major concepts broken down ### 1. Goals of surgery - Restore or maintain alignment of bones and joints - Relieve pain from mechanical irritation or impingement - Improve or preserve range of motion (ROM) - Stabilize joints to permit functional use of the hand - Minimize growth disturbance in children ### 2. Preoperative evaluation - History: onset, progression, prior treatments, functional limitations, pain pattern - Physical exam: inspection (deformity, skin), palpation, ROM (wrist flexion/extension, pronation/supination), neurovascular status, tendon function - Imaging: standard radiographs (AP, lateral), specialized views as indicated, and CT/MRI when planning complex reconstructions - Growth considerations: skeletal maturity strongly influences choice and timing of procedures - Patient/family counseling: realistic goals, expected recovery timeline, complications, need for postoperative therapy > Definition: Skeletal maturity is the stage when the physes (growth plates) close and further longitudinal bone growth ceases. ### 3. Principles of operative planning 1. Define primary problem: instability, pain, limited ROM, deformity, or soft-tissue contracture 2. Identify contributing pathology: tendon imbalance, capsular contracture, malalignment, bone loss, scar 3. Choose least invasive effective option that preserves motion and growth (in children) 4. Plan fixation and postoperative immobilization to balance protection and early motion 5. Coordinate with rehabilitation team for timelines and milestone goals ### 4. Soft-tissue procedures commonly used - Tendon transfers: restore lost muscle function or rebalance wrist/hand forces - Indications: irreparable tendon loss, chronic paralysis, or imbalance - Example: transfer of a functioning extensor or flexor to reanimate a critical motion - Capsular releases and contracture release: improve ROM when scar or tight capsule limits motion - Debridement and tenolysis: remove adhesions limiting tendon glide Practical example: A patient with persistent wrist flexion contracture after trauma may benefit from a capsular release combined with tendinous lengthening to restore neutral wrist position and permit finger function. > Definition: Tenolysis is the surgical release of adhesions around a tendon to restore gliding motion. ### 5. Bone procedures (general principles) - Osteotomy: cutting and realigning bone to correct angular or rotational deformity - Fixation choices: plates and screws, intramedullary pins, external fixation; choice depends on bone quality, size of correction, and need for adjustability - Bone grafting: fill defects or augment healing when nonunion risk is high Practical example: An osteotomy to correct a symptomatic malunion should restore articular orientation and avoid creating new impingement; fixation should permit early controlled motion when possible. ### 6. Use of external fixation - Indications: open fractures, severe soft-tissue swelling, gradual lengthening or angular correction, temporary stabilization - Advantages: adjustability, minimal hardware within fracture site, can allow soft-tissue care - Disadvantages: pin-site infections, patient discomfort, need for careful pin care Did you know external fixation allows gradual correction of deform