Pediatric Forearm Fracture

synonyms: both bone forearm fracture, radius and ulna fracture

Pediatric Forearm Fracture ICD-9

Pediatric Forearm Fracture Etiology / Epidemiology / Natural History

• Associated with tromplines, monkey bars, obesity (Davidon P, J Peadiatr Child Health 2003;39:664), poor milk intake (Gouldig A, J Am Diet Assoc 2004;104:250).
• Generally fall onto outstretched arm.

Pediatric Forearm Fracture Anatomy

• radial tuberosity and radial styloid should be on opposite sides of the radius.
• Ulnar styloid is on the opposite side of the ulna form the coronoid process.

Pediatric Forearm Fracture Clinical Evaluation

• Pain, swelling, deformity in forearm.
• Document neurovascular exam before and after any treatment.

Pediatric Forearm Fracture Xray / Diagnositc Tests

• radial tuberosity and radial styloid should be on opposite sides of the radius.
• Ulnar styloid is on the opposite side of the ulna form the coronoid process.

Pediatric Forearm Fracture Classification / Treatment

• <10 y/o generally heal and remodel with no loss of rotation
• >10 y/o high risk of functional deficit, ORIF if unstable by closed means
• Acceptable reduction: complete displacement, angulation <10°(Price CT, JPO 1990;10:505-712): distal 1/3=20°, middle third=15°, proximal 1/3=10° for children <10 years old.
• acceptable reduction:<10 y/o angular correction of 1degree  per month or 10degree  per year, no rotational deformity, bayonet apposition with <1 cm shortening: >10yrs should be managed like adults(no deformity accepted)
• Reduction Analgesia: propofol/fentanyl (Godambe SA, Pediatrics 2003:112:116), ketamine/midazolam, axillary block (Kriwanek K:, JPO 2006:26:737), nitrous oxide with hematoma block (Luhmann JD, Pedicatrics 2006:118:e1078).
• Immobilize in LAC that incorporates thumb.
• IM Nailing indicated for refractures with displacement, open fx, displaced proximal forearm fx, unstable fx, unacceptable alignment following CR, polytrauma
• ORIF with plates is generally not recommend in pediatric patients due to an increased risk of subsequent fracture at the end of the plates.

IM Nailing Technique

• Lascombes P JPO 1990;10:167-171 , (Kapoor V, Injury 2005;36:1221).
• Use small Rush rod, Steinmann pin(0.062 in), or elastic titanium nail. 
• tourniquet, pre-op antibiotics, c-arm
• 2-cm incision over dorsoradial aspecdt of distal radial metaphysis.
• Preserve superficial branch of radial nerve.
• Incise periosteum proximal to the distal radial physis
• Drill 3.2mm entry point
• Prebend nail for the curved shape of the radius. Generaly 2-2.5mm nail.
• Reduce Fracture.
• Advance nail retrograde up into proximal radius within 1cm of proximal radial physis.
• Cut nail and advance slightly
• 1 cm incision over dorsal proximal ulna just lateral to the tip of the olecranon. 
• Drill 3.2mm entry point
• Place nail in antegrade fashion, cut and advance slightly.
• Irrigate wounds
• Close in layers.
• Anterior and posterior plaster splints
• If unable to pass nails in 1-2 attempts open reduction is indicated.  Multiple failed attempts at closed pinning increased risk of compartment syndrome

Pediatric Forearm Fracture Associated Injuries / Differential Diagnosis

Pediatric Forearm Fracture Complications

• poor results associated with proximal fxs, age >10, rotational malalignment, loss of radial bow
• Malunion=angulation >10, displacement >50%,  malrotation, encroachment on interosseous membrane.  Angulation of 20-30 degrees may be observed for 3 months for remodeling.  Angulation >30 degrees corrective osteotomy is indicated.  Restoration of motion is best if osteotomy is performed within 1year of injury. (Trousdale RT, JBJS Am 1995;77:894-902)
• Price CT, Scott DS, Kurzner ME, et al: Malunited forearm fractures in children.  J Pediatr Orthop 1990;10:705-712.
• Kay S, Smith C, Oppenheim WL: Both-bone midshaft forearm fractures in children.  J Pediatr Orthop 1986;6:306-310.
• refracture: greenstick fx’s have greatest risk of refracture.  Strongly consider ORIF/flexible nails (Schwartz N, JBJS Br 1996;78:740-744)
• compartment syndrome
• delayed union
• Non-union (usually involves the ulna)
• infection
• superficial radial nerve palsy (generally transient)
• Growth arrest

Pediatric Forearm Fracture Follow-up Care

• LAC for 6 wks

Pediatric Forearm Fracture Review References

• Huber RI, et al.: Flexible intramedullary nailing as fracture treatment in children. JPO, 1996;16:602-605.
• Flynn ICL 2002 51:355-60
• Flynn ICL 52:635-45
• CORR 402-245

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