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FRACTURE RADIUS AND/OR ULNA AND/OR BOTH FOREARM BONES PEDIATRIC

Introduction

Fracture Nomenclature for Fracture Radius and/or Ulna and/or Both Forearm Bones Pediatric

Hand Surgery Resource’s Diagnostic Guides describe fractures by the anatomical name of the fractured bone and then characterize the fracture by the Acronym:

In addition, anatomically named fractures are often also identified by specific eponyms or other special features.

For the Fracture Radius and/or Ulna and/or Both Forearm Bones Pediatric, the historical and specifically named fractures include:

Galeazzi fracture

Monteggia fracture

Greenstick fracture

By selecting the name (diagnosis), you will be linked to the introduction section of this Diagnostic Guide dedicated to the selected fracture eponym.

Forearm shaft fractures are the most common fracture type in the pediatric population. Although either the radial shaft or ulnar shaft can be fractured in isolation, both bones are usually injured simultaneously, which is referred to as a “both bone” forearm fracture. Males between the ages of 9-12 are at the greatest risk for forearm fractures, and the mechanism of injury usually involves indirect trauma, such as a fall on an outstretched arm (FOOSH) with a rotational component. Most pediatric patients are treated conservatively with closed reduction and immobilization, although surgical intervention may be indicated for those that fall out of specific parameters for acceptable alignment after reduction. The rate of surgery has also been increasing in recent years.1-4,28

Definitions

  • Pediatric forearm fractures are a disruption of the mechanical integrity of the radial and/or ulnar shaft.
  • Pediatric forearm fractures produce a discontinuity in the radial and/or ulnar shaft contours that can be complete or incomplete.
  • Pediatric forearm fractures are caused by a direct force that exceeds the breaking point of the bone.

Hand Surgery Resource’s Fracture Description and Characterization Acronym

SPORADIC

S – Stability; P – Pattern; O – Open; R – Rotation; A – Angulation; D – Displacement; I – Intra-articular; C – Closed

S - Stability (stable or unstable)

  • Universally accepted definitions of clinical fracture stability are not well defined in the literature.5-7
  • Stable: fracture fragment pattern is generally nondisplaced or minimally displaced. It does not require reduction, and the fracture fragments’ alignment is maintained with simple splinting or casting. However, many definitions define a stable fracture as one that will maintain anatomical alignment after a simple closed reduction and splinting. Some authors add that stable fractures remain aligned, even when adjacent joints are put through a partial range of motion (ROM).
  • Unstable: will not remain anatomically or nearly anatomically aligned after a successful closed reduction and immobilization. Typically unstable pediatric radial and ulnar shaft fractures have significant deformity with comminution, displacement, angulation, and/or shortening.
  • An unstable ulnar shaft fracture is one that involves >50% displacement, >10° angulation, the proximal third of the bone, or which also features proximal radioulnar joint (PRUJ) or distal radioulnar joint (DRUJ) instability.8

P - Pattern

  • Radial shaft
    • Proximal third
    • Middle third
    • Distal third
    • Apex volar
    • Apex dorsal
  • Ulnar shaft
    • Proximal third
    • Middle third
    • Distal third
    • Apex volar
    • Apex dorsal

O - Open

  • Open: a wound connects the external environment to the fracture site. The wound provides a pathway for bacteria to reach and infect the fracture site. As a result, there is always a risk for chronic osteomyelitis. Therefore, open pediatric forearm fractures require antibiotic treatment with surgical irrigation and wound debridement.5,9,10
  • There is high risk for visible deformity and open injury in both bone forearm fractures due to the significant forces involved.11

R - Rotation

  • Forearm fracture deformity can be caused by proximal rotation of the distal fracture fragments in relation to the proximal fracture fragments.
  • Degree of malrotation of the fracture fragments can be used to describe the fracture deformity. In pediatric forearm fractures, this may be difficult to assess malrotation.3 Both bone forearm fractures are especially susceptible to rotational malalignment because the pronators and supinator muscles attach at different anatomic points on the radius and ulna, therefore, when a fracture occurs between these insertion sites, the muscles may pronate the distal fracture fragment while other muscles are supinating the proximal fracture fragments.
  • Greenstick fractures (incomplete fractures of the diaphysis) tend to be stable but can be angulated, while complete fractures can be shortened, as well as rotated and angulated.4

A - Angulation (fracture fragments in relationship to one another)

  • Angulation is measured in degrees after identifying the direction of the apex of the angulation.
  • Straight: no angulatory deformity
  • Angulated: bent at the fracture site
  • There are various ways to describe angulation, but an easy way is to describe the amount of angulation in degrees and the direction of the angulation by stating which way the apex of the angulation is pointing. For example, the radius fracture was angulated 35 degrees with the apex pointing dorsally.
  • Galeazzi fractures have been found to result in shortening and angulation, which is responsible for the disruption of the DRUJ.12

D - Displacement (Contour)

  • Displaced: disrupted cortical contours
  • Nondisplaced: one or more fracture lines define one or several fracture fragments; however, the external cortical contours of the bone are not significantly disrupted i.e., the fragments remain anatomically aligned.

I - Intra-articular involvement

  • Intra-articular fractures are those that enter a joint with one or more of the fracture lines.
  • Forearm fractures can have fragment involvement with the DRUJ, PRUJ, radiocarpal, humeroulnar, or humeroradial joints.  Pediatric forearm fractures are more frequently associated with dislocations of proximal or distal radioulnar joints than with true intra-articular fracture patterns.
  • If a fracture line enters a joint but does not displace the articular surface of the joint, then it is unlikely that this fracture will predispose to posttraumatic osteoarthritis. If the articular surface is separated or there is a step-off in the articular surface, then the congruity of the joint will be compromised and the risk of posttraumatic osteoarthritis increases significantly.

C - Closed

  • Closed: no associated wounds; the external environment has no connection to the fracture site or any of the fracture fragments.4-6

Pediatric forearm fractures: named fractures, fractures with eponyms and other special fractures

Galeazzi fracture

  • Also known as a reverse Monteggia fracture or Piedmont fracture, the Galeazzi fracture is fracture of the middle to distal third of the radial shaft combined with a subluxation or dislocation of the distal radioulnar joint (DRUJ).12,13
  • The Galeazzi fracture is considered a true forearm axis injury because of concomitant bone and soft tissue injuries.  The triangular fibrocartilage complex (TFCC) and/or interosseous membrane (IOM are particularly at risk and their injury can contribute to forearm instability.12,14
  • These injuries typically result from direct impact to the radius with forearm pronation. When a patient sustains a radial shaft fracture in the middle to distal third of the bone, the possibility of an associated DRUJ injury should be investigated.12,14
  • Galeazzi fractures are more common in pediatric patients than adults. In children and adolescents, they are usually caused by sports injuries, falls from a height, or motor vehicle accidents.11,13

Imaging13

  • Radiology studies - X-ray
    • Anteroposterior (AP) and lateral views are usually sufficient, but an oblique view may help to better classify the injury and define a fracture line that is present but not apparent on the AP and lateral views.
    • Because a coexistent joint injury is always possible, the distal wrist joint and elbow joint should always be included on the forearm X-rays or X-ray separately.
  • Radiology studies - Computerized tomography (CT) scanning
    • Not usually needed, but occasionally used to evaluate for nonunion or complex intra-articular fracture.
  • Magnetic resonance imaging - MRI without contrast
    • May be used in rare cases to detect TFCC tears and/or IOM disruption.

Treatment

Conservative

  • The gold standard for pediatric Galeazzi fractures is conservative treatment, as these injuries are typically stable due to the high elasticity of the ligaments and superior DRUJ strength compared to adults, the thicker periosteum, and greater chances for fracture remodeling.15
  • Treatment involves closed reduction performed under anesthesia, followed by above-elbow immobilization in supination with a cast or splint for up to 6 weeks.13,15

Operative

  • Surgery is only indicated if closed reduction fails to elicit satisfactory alignment; if there is loss of reduction after the initial reduction or significant DRUJ instability .15
  • Surgical options include K-wire fixation of the DRUJ, flexible intramedullary nailing, plate osteosynthesis, or open reduction without internal fixation. The preferred approach should be determined based on patient age, fracture location, and DRUJ stability after reduction.15

Complications

  • Nonunion
  • Malunion
  • DRUJ instability
  • Reduced grip strength

Outcomes

  • Children generally report better long-term outcomes than adults, and several studies have shown that conservative treatment can lead to successful results.13,15

Monteggia fracture

  • A Monteggia fracture involves a fracture of the proximal third of the ulna combined with a subluxation or dislocation of the radial head at the proximal radioulnar joint (PRUJ) and the humeroradial joint.1,11,12
  • These injuries most commonly occur secondary to a direct blow to the posterior aspect of the ulna, with the elbow extended and the forearm in hyperpronation.16,17
  • Monteggia fractures account for <2% of all forearm fractures and are more common in pediatric patients than adults.  In children and adolescents, they are usually caused by sports injuries, falls from a height, or motor vehicle accidents.11,13,16

Imaging17

  • Radiology studies - X-ray
    • AP and lateral orthogonal views with an oblique view are usually adequate.3
  • Sonographic studies - Ultrasound
    • An emerging alternative to radiography for diagnosis. Potential advantages including immediate results, lack of radiation, and less pain.3

Treatment

Conservative

  • Conservative treatment is indicated for incomplete fractures and if the ulna has undergone a plastic deformation.
    • Typically involves closed reduction and splint immobilization with the elbow flexed at approximately 110° in full supination for 6 weeks.17

Operative12,16,17

  • Surgery is often required when the Monteggia fracture of the ulnar shaft is complete.
    • Titanium elastic intramedullary nail fixation is recommended for short, oblique fractures.
    • Open reduction and internal fixation (ORIF) with plates and screws is recommended for comminuted or long oblique ulna fractures.17

Complications

  • Malunion
  • Nonunion
  • Elbow instability
  • Post-traumatic osteoarthritis
  • Restricted forearm rotation

Outcomes

  • Outcomes in children and adolescents are typically superior to adults. This is likely due to the remodeling ability of small angle deformities, shorter healing time, and the overall stability of Monteggia fractures in the pediatric population.17

Greenstick fracture

  • Pediatric forearm fractures are typically described as either complete or greenstick fractures.4
  • Greenstick fractures are incomplete, partial thickness fractures in which only the cortex and periosteum are interrupted on one side of the bone but intact on the other side.4,18
  • Greenstick fractures are more common among younger children under the age of 10 years, particularly boys, while completed or short oblique fractures are more common in older children.18,19
  • The most common mechanism of injury is a fall on an outstretched hand (FOOSH), but other possible causes include car accidents, bike accidents, sports injuries, and non-accidental trauma.18

Imaging

  • Radiology studies - X-ray

Treatment

Conservative

  • Immobilization with casting is indicated for all greenstick fractures and should be performed several days after the initial injury if possible.
    • Splinting may be sufficient if there is minimal angulation, appropriate patient compliance and close patient follow-up.
    • Closed reduction is also required if the degree of angulation is significant.3,18 See guidelines for acceptable post-reduction alignment in conservative treatment section below.

Complications

  • Refracture
  • Fracture displacement

Outcomes

  • The overall prognosis for greenstick fractures is good, as most patients will heal well without functional or gross changes in the appearance of the injured bone.18

Related Anatomy1-3,8,12,14,20,21

Radius

  • At its proximal end, the radius consists of a radial head that articulates with the humerus at the radiocapitellar joint and the ulna at the PRUJ. The radial head is attached to the radial shaft by a narrow radial neck. The shaft of the radius then extends from the neck and expands in diameter as it moves distally. In the distal region, the radial shaft expands to form a rectangular end. The lateral side projects distally as the radial styloid. In the medial surface, there is a concavity, called the ulnar notch, which articulates with the head of ulna to form the DRUJ. The distal surface of the radius has two facets for articulation with the scaphoid and lunate carpal bones. There is also an articulation between the distal radius and the triquetral bone facilitated the triangular fibrocartilage complex. Collectively, these articulations form the radiocarpal joint.
  • Ligaments associated with the radius include the radial collateral ligament, annular ligament, and quadrate ligament at its proximal end, and the TFCC at the DRUJ, dorsal and palmar radioulnar ligaments, dorsal radiocarpal ligament, radioscaphocapitate ligament, and long and short radiolunate ligaments at its distal end
  • Tendons associated with the radius dorsally include the extensor carpi radialis brevis (ECRB), extensor carpi radialis longus (ECRL), extensor pollicis longus (EPL), biceps brachii, and brachioradialis tendons.
  • In children, both the radius and ulna have proximal and distal physes. The distal physis contributes to 75% of the linear growth of the radius and 80% of the linear growth of the ulna. Forearm fractures in pediatric patients with open physes have a high rate of healing and remodeling.

Ulna

  • At its proximal end, the ulna consists of a trochlear notch formed by the olecranon and coronoid process, which articulates with the trochlea of the humerus to form the humeroulnar joint, and with the radius at the radial notch to form the PRUJ. The ulnar shaft is triangular and has three borders (posterior, interosseous, and anterior) and three surfaces (anterior, posterior, and medial). As it moves distally parallel to the radius, the ulnar shaft decreases in width. Its distal end is much smaller than the proximal end and terminates in a rounded head and distal projection called the ulnar styloid process. The head articulates with the ulnar notch of the radius to form the DRUJ.
  • Ligaments associated with the ulna include the ulnar collateral ligament, annular ligament, and quadrate ligament at its proximal end, and the TFCC, dorsal and palmar radioulnar ligaments, ulnocarpal ligament, ulnolunate ligament, and ulnotriquetral ligament at its distal end.
  • Tendons associated with the ulna include the flexor digitorum profundus, pronator quadratus, flexor carpi ulnaris, extensor carpi ulnaris, flexor digitorum profundus, supinator, abductor pollicis longus, EPL, and the extensor indicis propius tendons.
  • The radius and ulna are attached by the proximal annular ligament, the interosseous membrane along the diaphysis, and distally by the ligaments of the distal radioulnar joint and TFCC. The IOM is an important structure, as its integrity is crucial for fracture stability.

Incidence

  • Although fractures of the radius and ulna are the most common fracture type in the pediatric population, epidemiology studies are scarce.3
  • One study found that forearm fractures account for 17.8% of all fractures in children and adolescents,22 and the rate of these fractures has been steadily increasing.19
  • Both bone forearm fractures account for about 50% all forearm fractures and are significantly more common in male than female patients.23
  • Open radius and/or ulna fractures account for 32-80% of all open fractures in the pediatric population.2
  • The peak incidence for forearm fractures is 9-12 years, and the greatest risk factor in this age group is include sports activity, particularly football and wrestling.13
ICD-10 Codes

  • FRACTURE RADIUS AND ULNAR SHAFTS

    Diagnostic Guide Name

    FRACTURE RADIUS AND ULNAR SHAFTS

    ICD 10 Diagnosis, Single Code, Left Code, Right Code and Bilateral Code

    DIAGNOSISSINGLE CODE ONLYLEFTRIGHTBILATERAL (IF AVAILABLE)
    FRACTURE ULNA SHAFT    
    - TRANSVERSE     
     - DISPLACED S52.222_S52.221_ 
     - NONDISPLACED S52.225_S52.224_ 
    - OBLIQUE    
     - DISPLACED S52.232_S52.231_ 
     - NONDISPLACED S52.235_S52.234_ 
    - COMMINUTED    
     - DISPLACED S52.252_S52.251_ 
     - NONDISPLACED S52.255_S52.254_ 
    - SPIRAL    
     - DISPLACED S52.242_S52.241_ 
     - NONDISPLACED S52.245_S52.244_ 
    - GREENSTICK S52.212_S52.211_ 
    - SEGMENTAL    
     - DISPLACED S52.262_S52.261_ 
     - NONDISPLACED S52.265_S52.264_ 
    - MONTEGGIA'S S52.272_S52.271_ 
    FRACTURE RADIUS SHAFT    
    - TRANSVERSE     
     - DISPLACED S52.322_S52.321_ 
     - NONDISPLCED S52.325_S52.324_ 
    - OBLIQUE    
     - DISPLACED S52.332_S52.331_ 
     - NONDISPLACED S52.335_S52.334_ 
    - COMMINUTED    
     - DISPLACED S52.352_S52.351_ 
     - NONDISPLACED S52.355_S52.354_ 
    - SPIRAL    
     - DISPLACED S52.342_S52.341_ 
     - NONDISPLACED S52.345_S52.344_ 
    - GREENSTICK S52.312_S52.311_ 
    - SEGMENTAL    
     - DISPLACED S52.362_S52.361_ 
     - NONDISPLACED S52.365_S52.364_ 
    - GALEAZZI'S S52.372_S52.371_ 

    Instructions (ICD 10 CM 2020, U.S. Version)

    USE TWO DIAGNOSIS CODES - ONE FOR EACH BONE   
    THE APPROPRIATE SEVENTH CHARACTER IS TO BE ADDED TO EACH CODE FROM CATEGORY S52
     Closed FracturesOpen Type I or II or OtherOpen Type IIIA, IIIB, or IIIC
    Initial EncounterABC
    Subsequent Routine HealingDEF
    Subsequent Delayed HealingGHJ
    Subsequent NonunionKMN
    Subsequent MalunionPQR
    SequelaSSS

    ICD-10 Reference

    Reproduced from the International statistical classification of diseases and related health problems, 10th revision, Fifth edition, 2016. Geneva, World Health Organization, 2016 https://apps.who.int/iris/handle/10665/246208

Symptoms
History of trauma
Fracture pain or deformity
Swelling, ecchymosis and/or tenderness
Skin abrasion
Typical History

A typical patient is a 16-year-old male high school student who plays football. He was injured during a game, while tackling the quarterback of the opposing team. At the point of impact with the quarterback another player came in for a late tackle and hit the first player’s outstretched forearm with his helmet. This collision caused a complete closed fracture of both the radial and ulnar shafts.

Positive Tests, Exams or Signs
Work-up Options
Images (X-Ray, MRI, etc.)
Pediatric Double Bone Forearm Fracture X-rays
  • X-ray AP view of left transverse angulated double bone forearm fractures in middle third of the forearm in a six year male child.
    X-ray AP view of left transverse angulated double bone forearm fractures in middle third of the forearm in a six year male child.
  • X-ray lateral view of left transverse angulated double bone forearm fractures in middle third of the forearm in a six year male child.
    X-ray lateral view of left transverse angulated double bone forearm fractures in middle third of the forearm in a six year male child.
  • X-ray lateral/oblique view of left transverse severely angulated double bone forearm fractures in middle third of the forearm in a teenager.
    X-ray lateral/oblique view of left transverse severely angulated double bone forearm fractures in middle third of the forearm in a teenager.
Pediatric Monteggia Fracture/Dislocation X-rays
  • Pediatric Monteggia fracture/dislocation X-rays in a 5 year old child.
    Pediatric Monteggia fracture/dislocation X-rays in a 5 year old child.
Treatment Options
Treatment Goals

When treating closed pediatric double bone forearm fractures, the treating surgeon has 4 basic goals:7,14

  1. A hand with a normal appearance. The X-ray may not need to be perfect, but the forearm should have no obvious deformity (i.e., the forearm looks normal!)
  2. Avoid stiffness by maintaining a normal functional ROM (i.e., the forearm works!)
  3. The forearm is not painful (i.e., the forearm does not hurt!)
  4. If the forearm fracture involves any joint, then a congruent joint surface with none-to-minimal joint surface irregularities (i.e., the wrist, radioulnar and the elbow joints do not develop early posttraumatic arthritis!)
  5. For all open fractures, irrigation and debridement should be done to minimize the risk of infection and osteomyelitis.
Conservative

Conservative1,3,4

  • Most pediatric forearm fractures can be treated conservatively with splint or cast immobilization or with closed reduction and cast or splint immobilization.
  • When determining which patients are ideal candidates for conservative management, most experts use the recommendations from Noonan and Price,25 which set parameters for closed reduction based on age and location. These guidelines are summarized in the table below.
  • If a pediatric fracture presents with deformity that is less than these guidelines, then immobilization alone is an appropriate treatment with early follow-up to rule out loss of position and worsening deformity.
  • If a pediatric fracture presents with deformity at or greater than these guidelines, then reduction is indicated.25,28

Acceptable reduction parameters for forearm fractures in pediatric patients with ≥2 years of remaining growth25

Parameter

Girls ≤8 years

Boys ≤10 years

Girls > 8 years

Boys > 10 years

Distal shaft angulation

15°

15°

Midshaft angulation

15°

10°

Proximal shaft angulation

15°

10°

Rotation

45°

30°

Bayonet apposition

Up to 1 cm

Up to 1 cm

  • For complete both bone forearm fractures, reduction is performed with traction and manipulation, and immobilization involves either a fiberglass or plaster long-arm cast with the elbow at 90°. Casts are shaped with some anterior and posterior compression over the IOM to increase stability.  The forearm is an ellipse, not a circle in cross section.  Therefore, the cast should be gently molded to obtain an elliptical cross-sectional shape.
Operative

Operative1-3,11,14,19,24

  • Surgical treatment of pediatric forearm fractures must always be an individualized therapeutic decision. However, surgical forearm fracture care is most frequently recommended when:
    1. Closed reduction fails or the immobilization device does not maintain the reduction. For these irreducible or unstable fractures, operative treatment is recommended to achieve the 4 treatment goals of fracture care.
    2. There is a significantly displaced forearm fracture involving any of the associated joints.
    3. Open forearm fractures occur. These injuries require surgical care in the form of irrigation and debridement to prevent chronic infection.
  • In addition to the above, other indications for surgical intervention include comminuted fractures, concomitant dislocation, floating elbow, and fractures with severe soft-tissue complications. The table listed above should also be used to asses when surgery is needed by determining if the patient falls out of the acceptable treatment guidelines.19
  • The method of surgical fixation should be determined by the patient’s age, growth potential, and fracture pattern.2
  • Open reduction and internal fixation.
    • Radial shaft
      • Anterior approach or “volar approach of Henry”
        • Indicated for any radial shaft fracture from the proximal neck and bicipital tuberosity through the distal styloid region because it can expose the entire radius. This is the preferred approach for most radial shaft fractures and the disadvantages are minimal.
      • Posterior approach or “Thompson’s approach”
        • Used less frequently because it is less extensile than the volar approach, but it may be appropriate in certain situations.
        • Primary advantage is that it can be used for proximal fractures, especially if the soft tissues of the dorsal forearm is are injuried. The posterior approach also allows the posterior interosseous nerve to be identified and protected during fixation.
    • Ulnar shaft
      • A direct ulnar approach is typically recommended at the interval between the flexor carpi ulnaris and the extensor carpi ulnaris at the subcutaneous border. A plate is used for fixation which can be placed either dorsal or volar on the ulnar shaft.
    • Both bones
      • Similar surgical methods are used for both bone forearm fractures. The ulnar shaft fracture is typically fixated first through a direct ulnar approach, followed by repair of the radial shaft fracture, usually through the standard volar Henry approach.
  • Internal fixation with titanium elastic intramedullary nails
    • Indicated for complete fractures of the diaphyses, especially those that are oblique, occur on the same level or show significant displacement (>10 mm).
    • Elastic stable intramedullary nailing
      • Most commonly used osteosynthesis procedure for school-age children.
      • The use of intramedullary nails has been increasing, and titanium elastic nails are now a standard internal fixation method of children’s forearm fractures.
    • Radius and/or  ulna plating
      • Has the advantage of providing rigid fixation with an anatomic reduction that allows early, unprotected motion, plus complete correction of malrotation and radial bow restoration. This is especially useful in patients who are at or near skeletal maturity.
  • Hybrid fixation
    • Hybrid fixation involves the use of a plate and screws on one forearm bone and titanium elastic intramedullary nail in the other forearm bone.  
Treatment Photos and Diagrams
Left Double Bone Forearm Fractures Closed Reduction & Casting
  • AP X-ray of left double bone forearm fractures closed reduced and immobilized initially in a sugar tong splint.
    AP X-ray of left double bone forearm fractures closed reduced and immobilized initially in a sugar tong splint.
  • Lateral X-ray of left double bone forearm fractures closed reduced and immobilized initially in a sugar tong splint.
    Lateral X-ray of left double bone forearm fractures closed reduced and immobilized initially in a sugar tong splint.
  • AP and lateral X-ray of left double bone forearm fractures closed reduced and immobilized in a long arm cast.
    AP and lateral X-ray of left double bone forearm fractures closed reduced and immobilized in a long arm cast.
  • AP and lateral X-ray of left double bone forearm fractures healed and remodeling.
    AP and lateral X-ray of left double bone forearm fractures healed and remodeling.
Left Double Bone Forearm Fractures and Lost Closed Reduction
  • AP X-ray of mid-forearm right double bone forearm fractures. Anatomic reduction with fracture lines not apparent
    AP X-ray of mid-forearm right double bone forearm fractures. Anatomic reduction with fracture lines not apparent
  • Lateral X-ray of mid-forearm right double bone forearm fracture with lost reduction (arrow). Note 100% displaced with shortening
    Lateral X-ray of mid-forearm right double bone forearm fracture with lost reduction (arrow). Note 100% displaced with shortening.
  • AP X-ray of mid-forearm right double bone forearm fractures i
    AP X-ray of mid-forearm right double bone forearm fractures i
Left Severely Angulated Double Bone Forearm Fractures Treated with Plates
  • Left severely angulated double bone forearm fractures after initial closed reduction and splinting.
    Left severely angulated double bone forearm fractures after initial closed reduction and splinting.
  • Left severely angulated double bone forearm fractures in a teenager after ORIF with plates and screws
    Left severely angulated double bone forearm fractures in a teenager after ORIF with plates and screws
Pediatric Monteggia Fracture Dislocation
  • Pediatric Monteggia fracture/dislocation
    Pediatric Monteggia fracture/dislocation
  • Pediatric Monteggia fracture/dislocation after reduction of the radial head and ORIF of the olecranon fracture. Note proximal part of pin in cartilage
    Pediatric Monteggia fracture/dislocation after reduction of the radial head and ORIF of the olecranon fracture. Note proximal part of pin in cartilage
  • Pediatric Monteggia fracture/dislocation after healed and pin surgically removed
    Pediatric Monteggia fracture/dislocation after healed and pin surgically removed
Outcomes
  • Nonoperative treatment is the gold standard for pediatric forearm fractures, and this approach has been associated with successful outcomes in which patients typically have good or excellent forearm performance.3,4,19
    • In one study, 300 children aged up to 8 years with forearm fractures and angulation >10° were treated conservatively with closed reduction. All cases resulted in successful healing and did not require internal fixation, and only 22 patients required remanipulation.26
  • Favorable outcomes have also been identified with ORIF.
    • In one meta-analysis, 87% of pediatric patients reported excellent outcomes after undergoing plate fixation and 85% reported excellent outcomes after undergoing intramedullary nail fixation.27
Key Educational Points
  • Forearm fractures must be immobilized until radiographic fracture healing is complete and fracture is non-tender to avoid complications.
  • Underlying pathological conditions such as bone tumor should be expected in fractures that occur after trivial trauma.
  • The functional needs of each child and their capacity to heal and remodel a fracture must be considered when recommending treatment for forearm fractures.
  • For ulnar and radial shaft fractures—open and closed—separate approaches to each bone should be used to reduce the risk synostosis.14
  • Surgeons should be aware that adolescents generally utilize more elbow flexion and forearm pronation, with comparatively less supination than younger children. This underscores the need for more flexion and pronation when treating this population.3
  • Although treatment indications are clear for younger children, there is less agreement regarding treatment for older children, especially those with less than 1 or 2 years of growth remaining. The primary concern is that the desired degree of remodeling may not occur before the child reaches skeletal maturity.3
  • Pediatric fractures closer to the distal physes of the radius or ulna are more likely to remodel than fractures closer to the elbow.2
  • Little has changed over the years regarding the indications for surgical intervention of pediatric forearm shaft fractures, but there has been an ongoing trend towards higher rates of surgery in this population.3,4
  • Appropriate radiography is an essential first step in the diagnosis of patients with suspected fractures with the standard views being an AP view and lateral view
  • Oblique X-ray views are not always done initially to avoid extra radiation in children1,8,14,24
  • Standard AP and lateral orthogonal radiographs are usually sufficient, but dedicated elbow and wrist radiographs may be needed if there is suspicion of PRUJ or DRUJ involvement and if the wrist and elbow were not visible on the forearm X-rays.
  • Computerized tomography (CT) scanning is not typically needed during the initial examination of acute fractures, unless there is suspicion of intra-articular involvement.11,14
  • MRI without contrast should only be used to rule out other suspected pathologies, for example occult TFCC injury.24
References

Cited Articles

  1. Flynn, JM, Noonan, KJ and Waters, PM. Price CT, ed. Pediatric Upper Extremity Fractures. First ed. Rosemont, Il: American Academy of Orthopaedic Surgeons;2004.
  2. Elia, G, Blood, T and Got, C. The Management of Pediatric Open Forearm Fractures. J Hand Surg Am 2020;45(6):523-527. PMID: 32265052
  3. Caruso, G, Caldari, E, Sturla, FD, et al. Management of pediatric forearm fractures: what is the best therapeutic choice? A narrative review of the literature. Musculoskelet Surg 2020. Online ahead of print. PMID: 33058085
  4. Pace, JL. Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations. J Am Acad Orthop Surg 2016;24(11):780-788. PMID: 27755262
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