Edited by Nattaly Greene, David Evans - 7/1/2021
Descriptors
- Common pediatric fractures usually in children under 14 years old
- Usually occurs from fall from a height or off playground equipment
- Majority can be treated with closed reduction.
- The distal radial and ulnar physes account for around 80% of longitudinal forearm growth and on average close at around 17 years of age in girls and 19 in boys
Exam Pearls
Clinical deformity is usually obvious in fractures requiring reduction. Inspect skin for open fracture (which could be subtle poke-holes) as well as extent of forearm swelling and ecchymosis
Assess for ipsilateral fractures proximal or distal to forearm by palpating entire injured upper extremity
Neurovascular exam to include assessment of pulse, capillary refill and motor/sensory exam distally. 1% of both bone fractures can involve a nerve injury with the median nerve being the most commonly affected
Finally, assess for compartment syndrome!
Keep in mind a few things Physiologic lateral bowing of the radius and posterior bowing of the ulna
Deforming forces acting on the fractured segment at various level - these will help to determine your reduction technique
- Proximal third - primary deforming forces are from the biceps/supinator resulting in flexion and supination
- Middle and distal third - pronator teres and pronator quadratus, respectively. Brachioradialis dorsiflexes and radially deviates the distal fragment
Periosteum is often intact on the concave side of fracture and the interosseous membrane is taught in neutral to slight supination
Workup
Radiographs: Standard AP/Lateral forearm Xrays. Orthogonal views of the ipsilateral elbow and wrist
Pearls: - Bicipital tuberosity and radial styloid should be 180 degrees apart on the AP view - Ulnar styloid and coronoid are 180 degrees apart on the lateral view
Labs: None
Other: None
Management
Need for acute intervention: Yes, immobilization with reduction under conscious sedation
Standard care for these fractures is nonoperative management with closed reduction and casting. It is important to obtain adequate anesthesia/analgesia, often conscious sedation
Reduction will entail exaggeration of the deformity with longitudinal traction. The reduction can be checked with fluoroscopy.
A bivalved long arm cast with good intraosseous and supracondylar molds should be placed. Cast index (width of the cast on lateral Xray/width of the cast on the AP Xray) should ideally be < 0.7.
Table of Acceptable Reduction Parameters
Weight-bearing and range of motion: Non weight bearing and immobilized
Type of immobilization: Bivalved long arm cast
Admission or discharge status: Discharge home with follow up in a week for repeat forearm Xrays
Anticoagulation: None
Antibiotics: None, unless open fracture in which case use GA classification for management of open fractures
Surgical Indications
Absolute: Open fractures, compartment syndrome, refracture, malalignment