2. Introduction
• Injuries to the shafts of the radius and ulna are the most common
reasons for children to receive orthopedic care.
• 40% of childhood fractures.
• Frequency of # of radius and ulna are highest among in children aged
14 years or less.
3. Mechanism
• Falling on outstretched hands (Trampolines, Monkey bars, Etc.)
• Direct Trauma (ex: Nightstick Fracture)
• Non accidental injuries
• Biomechanical studies have suggested that the junction of the middle
and distal thirds of the radius and a substantial portion of the
shaft of the ulna have an increased vulnerability to fracture.
4. Mechanism
• If the radial and ulnar fractures are near the same level, a minimal torsional
component can be inferred.
• If comminution is present, higher-energy trauma
should be suspected.
• Significant hyperpronation forces are associated with isolated shaft
fractures of either the radius or the ulna and concomitant dislocation of
either the distal or the proximal radioulnar joint (PRUJ).
• Thus, in any single-bone forearm shaft fracture, these important joints
need to be closely scrutinized.
5. Assessment of the patient
• History
• Examination -> Pain, Swelling, Deformity
• Associated Injuries
• High index of suspicion for Compartment Syndrome.
6. Assessment, Signs and Symptoms
• More subtle fractures present special diagnostic challenges.
• Many minimally displaced fractures of the shafts of the radius and
ulna can be mistaken for a “sprain” or “just a bruise” for several days
to several weeks.
• As a general rule, a fracture should be suspected if the child has not
resumed all normal arm function within 1 or 2 days of injury.
8. Plastic Deformation
• Pediatric bone also is much more porous than
its adult counterpart and behaves somewhat differently from a
biomechanical standpoint.
• Because of its porosity, pediatric bone absorbs significantly more
energy prior to failure than the adult bone does.
• When relatively slowly applied, longitudinal forces bend the
immature bone beyond its elastic limits and into its plastic zone,
resulting in traumatic bowing.
9. Greenstick #
• Intermediate step between plastic deformation and complete
fractures.
• greenstick fractures show cortical violation of one, two, or three of
their radiographic cortices, and thus some bony continuity is
preserved.
11. Imaging
• Correct AP and lateral views are important in assessing the angulation
deformity.
• On a fully supinated AP radiograph of an unfractured forearm,
the bicipital tuberosity points predominantly in a medial direction.
13. Natural history
• Leads to high rate malunion.
• Nigerian authors have found that young age was not protective
against fracture malunion.
• More than 50% malunion and nonunion (25%) following traditional
bonesetter treatment have been observed.
14. Angulation Malalignment
• 10-degree deformities of either bone individually resulted in little or
no measurable motion loss (in the range of 3 degrees or less).
• When both bones were angulated 10 degrees dorsal, volar, or toward
the interosseous membrane, larger motion losses were documented
(approximately 10-degree pronation and 20-degree supination).
• When one or both bones were angulated 20 degrees, approximately
40 degrees of both pronation and supination were affected.
15. Angulation Malalignment
• Fracture angulation of 15 to 30 degrees led to greater
supination losses when the deformity was in the middle third of
the forearm (40 to 90 degrees).
• Greater pronation losses when in the distal third (30 to 80 degrees).
• Fracture angulation of 10 degrees or less in the proximal or middle
forearm rarely resulted in more than 15 degrees of motion loss.
16. Rotational Malalignment
• In isolated midshaft radial fractures, more than 30 degrees of
malrotation was a threshold for significant losses in motion
(approximately 15 degrees).
• Larger ulnar axial malalignment of 45 degrees decreased overall
forearm rotation by no more than 20 degrees.
• From studies and clinical experience, it appears that the radius is
more sensitive to rotational problems.
17. Goals of treatment
• The goal of treatment is to achieve satisfactory
healing of the forearm injury within the established
anatomic and functional guidelines while also taking
into account the reasonable degree of remodeling
that can be expected in growing children.
20. Recommended acceptable alignment
parameters
• In one of the largest studies examining pediatric forearm fractures, Jones
et al. looked at 730 patients from birth to age 17.
• Fractures were considered for closed reduction if children were 0 to 8 years
of age with angulation over 10 degrees.
• Of these, 22 patients required remanipulation. All of these cases resulted in
successful healing of the fractures and did not require any internal fixation.
• Additionally, final range of motion was within 15 degrees of the
contralateral forearm.
21. Treatment Strategy
• < 6 yrs
• Acceptable angulation
distal 1/3=20°
middle third=15°
proximal 1/3=10°
• 5 deg of rotation “may” also be acceptable
22. Treatment Strategy
• 6-10 yrs
< 15 deg of angulation should remodel especially if # is close to
distal epiphysis – bayonet apposition may be acceptable.
• > 12 yrs of age
no angulatory or rotational deformity is considered acceptable –
treat as adult
23. Treatment Strategy
• Above elbow cast + broad arm sling
• Proximal # in supination
• Middle # in neutral
• Distal # in pronation
26. Closed Reduction of Plastic deformation
• Significant angular
deformity > 10 degrees
need reduction.
• Specially in older children.
• Fracture reduced over a
fulcrum.
27. Closed Reduction of Green stick Fractures
• It is clear from large published reports that greenstick fractures
can almost always be successfully treated with nonoperative
methods.
• Two philosophies are reflected in the literature regarding greenstick
fracture reduction: One in which the greenstick fracture is purposely
completed.
• Completion of the fracture believed to increase callus formation, thus
better healing and lower refracture rate.
28. Casting Technique
• Good casting technique is of paramount importance to keep
reduction in place after closed reduction.
• The principles of good forearm casting technique include.
(a) interosseous molding
(b) supracondylar molding
(c) appropriate padding
(d) evenly distributed cast material
(e) straight ulnar border
(f) three-point molding
30. Casting Technique
• For fractures in the distal third of the forearm, below-elbow casting
has been shown to be as effective as above-elbow casting in
maintenance of satisfactory fracture alignment.
31. Aftercare Following Closed Reduction
• 5-6/52 in above elbow cast
• Weekly x-rays to check position till 3/52
• Re-apply cast if slackening
• Re-manipulation – if deformity Up to 3 weeks after injury
32. Operative Fixation
• Indications
• Open Fractures
• Inability to maintain acceptable reduction
• Neurological / Vascular compromise
• Refracture with displacement
33. Operative Fixation - methods
• Plates
• Intramedullary Nails
• K-nails
• Rush rods
• Steinman pins
• Elastic nails
• Intramedullary fixation is the current preferred method of internal fixation.
• Smaller scar, Less tissue dissection, Low risk of stiffness, Easier to remove
34. Plates vs IM nails
• A review of the literature illustrates fairly similar outcomes and
complication rates between plate fixation and flexible nailing.
• There are, however, differences reported that are unique to each
treatment.
• recent study comparing the operative treatment of both-bone mid-
shaft forearm fractures described minimal differences between
plating and intramedullary fixation among 34 children.
• Plating did result in a trend toward more anatomic restoration of
radial bow, however the difference was not significant.
35. Titanium elastic nail (TEN), Nancy nail
Into the radial styloid between the tendons
of the extensor carpi radialis longus and
extensor pollicis brevis.
36. The entry point through the radius styloid can endanger the superficial (sensory) branch of the radial nerve.
The entry points near the Lister’s tubercle can damage the extensor tendons of the second and third
compartments, especially when the nail is prominent.
37. Complications
• Compartment Syndrome
• In a recent series of 285 factures, compartment syndrome incidence was
evaluated in pediatric forearm fractures treated with intramedullary nails.
• 42 Of the 205 patients who were treated with closed reduction and
casting, none developed compartment syndrome.
• Eighty injuries were managed with intramedullary fixation, including 50
open fractures, and 7.5% (6/80) of these operatively treated patients
developed compartment syndrome (3/30 closed fractures, and 3/50 open
fractures).
38. Compartment Syndrome
• All cases of compartment syndrome developed within 24 hours of
initial fixation and were treated with fasciotomy and delayed wound
closure, and no patient developed permanent neurologic injury after
treatment.
• Other studies have reported a 0-1% incidence of compartment
syndrome, with notably shorter tourniquet times.
• It appears that longer tourniquet time can be correlated with risk
for compartment syndrome.
39. Other Complications
• Infection at the site of implantation
• skin irritation
• refracture after removal
• implant failure
• nerve/tendon injury
• decreased range of motion
