- See:
- Green Stick Fractures
- Pediatric Distal Radius Fracture:
- Reduction of Both Bone Forearm Fractures:
- Pediatric Ulnar Fracture:
- Discussion:
- frx may be of green stick type or complete (latter may be undisplaced, minimally displaced, or markedly displaced w/ overridding);
- frx may be greenstick or complete in both the radius and ulna, or it may be complete in one bone and green stick in the other;
- angulation may be volar, dorsal, or toward or away from interosseous space (see: deforming forces):
- mechanism:
- indirect injury during fall on an outstretched hand;
- direct violence occassionally is cause of both bone forearm frx;
- frx location: 
- proximal third fractures:
- middle third:
- account for 18% of both bones fractures;
- these fracutres are often unstable and may be difficult to reduce with casting due
to the thickness of the overlying muscle mass;
- displaced midshaft fractures with the radial fracture proximal to the ulnar fracture
are especially unstable, and are prone to redisplacement;
- if near anatomic reduction is not possible, then consider limited incisions over radius and ulna and fixation by direct fixation w/ K wires; (see acceptable reduction)
- rotational alignment:
- look at the differences in cortical widths of frx edges;
- relation of bicipital tuberosity to radial styloid;
- in full supination bicipital tuberosity should be prominent on ulnar side of radius;
- in neutral rotation the bicipital tuberosity should not be seen;
- distal third frx:
- account for 75% of frx of the shaft of the radius and ulna;
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- Exam:
- evaluate
AIN and
PIN;
- note firmness of the volar and dorsal compartments;
- always consider
compartment syndrome;
- Radiographs:
- radiographs from the wrist to the elbow (r/o radial head fracture)
- when only one bone of forearm is broken, the integrity of the proximal & distal RU joint should always be determined by obtaining x-rays that include the
elbow and wrist with the entire forearm;
- rotational alignment:
- look at the differences in cortical widths of frx edges;
- relation of bicipital tuberosity to radial styloid;
- in full supination bicipital tuberosity should be prominent on ulnar side of radius;
- in neutral rotation the bicipital tuberosity should not be seen;
- Acceptable Reduction: (w/ references)
-
common pitfalls:
- the radiograph may not have been taken in the plane of maximal deformity, and therefore, x-rays will falsely minimize the degree of deformity;
- do not assume that the fracture position is static, ie, a fracture may show an "acceptable 15 deg" deformity at day 10, only to increase to 20 deg on day
20 (at which point closed reduction may not be possible);
-
Bowing fractures of the forearm in children: a long-term followup.
- Closed Treatment:
- unlike adults, both bones fractures in children can be treated closed w/ cast, however, it should be noted that the periosteal sleeve may be disrupted
in these fractures making them relatively unstable;
- technique of reduction:
- following reduction an assessment of forearm pronation and supination should be performed;
- arm should be placed in a long arm cast or splint;
- midshaft fractures may be best held in proper alignment with the elbow extended, especially when the radial shaft frx is proximal to the ulnar shaft frx;
- references:
- Mid third forearm fractures in children: an unorthodox treatment. JA Shear MD et al. Americal Journal of Surgery. Jan 1999. p 60.
- Forearm fractures treated in extension. JW Gainor and JH Hardy. J. Trauma. Vol 9. 1969. p 167-171.
- position of cast:
- position of wrist in cast varies w/ position of fracture;
- most proxial 1/3 frx need to be immobilized in supination;
- most middle 1/3 frx should be placed in neutral;
- most distal 1/3 frx require immobilization in pronation;
- references:
- Forearm fractures in children. Cast treatment with the elbow extended.
- Year Book: Forearm Fractures in Children: Cast Treatment With the Elbow Extended.
- Forearm fractures in children. Cast treatment with the elbow extended.
- Factors affecting fracture position at cast removal after pediatric forearm fracture. AS Younger et al. JPO. Vol 17. 1997. p 332-336.
- Operative Treatment: (see
synthese technique manual)
-
intramedullary fixation of these fractures is attractive in children because an incision is avoided, but the complication rate is high;
- limited open incisions and cross pinning allows direct anatomic fixation of the fractures and reliable healing;
- in the report by
Houshian et al., nail removal was undertaken at a median of 19 weeks (range 16-24 weeks) post-operatively;
- technique pearls:
- rather than using the traditional radial styloid approach, consider nail insertion in the ulnar aspect of the radius (proximal to physis);
- consider the more optimal reduction and the restoration of the radial bow, as compared to the photo out of the Synthes technique manual (right)
- references:
-
Closing intramedullary nailing for the treatment of diaphyseal forearm fractures in adolescence: a preliminary report.
-
Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases.
-
Use of pins and plaster in the treatment of unstable pediatric forearm fractures.
- Flexible intramedullary nailing as fracture treatment in children. RI Huber et al. JPO. Vol 16(5) 1996. p 602-605.
- Shaft forearm fractures in children: IM with immediate motion. A preliminary report. JPO Vol 8(4) 1988. p 450-453.
- Open reduction and internal fixation of forearm fractures in children. R Ortega et al. JPO Vol 16(5) 1996. p 651-654.
-
Open reduction and internal fixation of pediatric forearm fractures. B Wyrsch et al. JPO Vol 16(5) 1996. p 644-650.
-
Forearm fractures in children. Single bone fixation with elastic stable intramedullary nailing in 20 cases.
-
Treatment of unstable fractures of the forearm in children. Is plating of a single bone adequate?
-
Complications and outcomes of open pediatric forearm fractures.
-
Percutaneous transphyseal IM K wire pinning: a safe and effective procedure for treatment of displaced diaphyseal forearm frx in children.
-
Outcomes of intramedullary nail fixation through the olecranon apophysis in skeletally immature forearm fractures.
-
Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children.
-
Use and abuse of flexible intramedullary nailing in children and adolescents.
-
Comparison of Intramedullary Nailing to Plating for Both-Bone Forearm Fractures in Older Children.
-
Use of Elastic Stable Intramedullary Nailing for Treating Unstable Forearm Fractures in Children.
- plate fixation:
- in the report by AR Bhaskar et al, authors studied, retrospectively, 32 unstable fractures of forearm in children treated by compression plating;
- group A (20 children) had conventional plating of both forearm bones and group B (12 children) had plating of the ulna only;
- in group B an acceptable position of the radius was regarded as less than 10° of angulation in both AP and lateral planes, and with bone ends hitched;
- this was achieved by closed means in all except two cases, which were therefore included in group A;
- union was achieved in all patients, the mean time being 9.8 weeks in group A and 11.5 weeks in B;
- after a mean interval of at least 12 months, 14 children in group A and 9 in group B had their fixation devices removed;
- in group A, complications were noted in 8 patients (40%) after fixation and in six (42%) in relation to removal of the radial plate;
- no complications occurred in group B;
- final outcome for 23 patients was excellent or good in 12 of 14 (90%) in group A, despite the complications, and in eight of nine in group B (90%).
- authors recommend that if reduction and fixation of the fracture of the ulna alone restores acceptable alignment of the radius in unstable fractures of the forearm,
operation on the radius can be avoided;
- references:
-
Unstable diaphyseal fractures of both bones of the forearm in children: Plate fixation versus intramedullary nailing.
-
Flexible intramedullary nailing of displaced diaphyseal forearm fractures in children.
- Follow Up:
- accetable reduction:
- need follow-up radiographs at one & two-week intervals after initial reduction;
- > 5% are subject to reangulation or displacement, but note that in mid shaft frx w/ radial frx proximal to ulnar frx, rate of redisplacement may be > 50%;
- loss of acceptable alignment should be treated by remanipulation;
- nonepiphyseal frxs may be safely manipulated up to 24 days postfrx;
- frx at risk
- frx of the distal radius along w/ concomitant ulnar green stick or torus frx, were noted to have significant displacement in the majority of cases;
- these frx were best treated w/ initial percutaneous pinning, followed by casted;
- references:
- Redisplacement after closed reduction of forearm fractures in children.
- Immobilisation of forearm fractures in children: extended versus flexed elbow.
- Complications:
- neurologic injury:
- median, PIN, and ulnar nerve injuries;
- references:
- Combined entrapment of the median and anterior interosseous nerves in a pediatric both-bone forearm fracture.
- malunion:
- Outcome after corrective osteotomy for malunited fractures of the forearm sustained in childhood.
- Malunited fractures of the forearm in children.
- Malunited forearm fractures in children.
- refracture: most common is first 6 mo.
- The Healing Forearm Fracture: A Matched Comparison of Forearm Refractures.
- tendon rupture:
- Extensor pollicis longus rupture after fixation of radius and ulna fracture with titanium elastic nail (TEN) in a Child: a case report.
- synostosis: rare:
- risk factors:
- displaced frx w/ elevated thick periosteum;
- severe/surgical trauma (esp if treated w/ one incision)
- repeated manipulations;
- excision of the cross-union does not work as well in children as adults;
- in the report by Alan Aner et al, the authors discuss the interposition of Gore-Tex vascular graft material between the synostosis;
- reference:
- Cross-union complicating fracture of the forearm. Part II: Children.
- Posttraumatic radioulnar synostosis treated with a free vascularized fat transplant and dynamic splint: a report of two cases.
- Surgical Treatment of Posttraumatic Radioulnar Synostosis in Children
Alan Aner, MD Journal of Pediatric Orthopaedics 2002; 22(5):598-600
- More Case Examples:
Displaced diaphyseal forearm fractures in children: classification and evaluation of the early radiographic prognosis.
Pattern of forearm fractures in children.
Forearm fractures in children. Pitfalls and complications. Davis DR, Green DP: Clin Orthop 1976;120:172.
