This document summarizes paediatric forearm fractures. [1] Forearm fractures are common in children, often resulting from falls or sports injuries. [2] Clinical examination focuses on pain, swelling, deformity and neurological status. [3] Treatment depends on fracture type and aims to restore function while allowing healing with minimal deformity. Conservative treatment is usually sufficient but surgery may be needed for more complex fractures.

1. Paediatric Forearm Fractures
By Hiren M Divecha
ST3
21/4/2011

2. • 40% of childhood fractures
• Mechanism
– FOOSH (trampolines, monkey bars etc…)
– Direct trauma
– NAI
• History
• Examination – pain, swelling, deformity,
neurological

3. Types
• Location – proximal, middle or distal
• Characteristics – displacement, angulation and rotation
• Plastic deformation
• Incomplete
– Buckle or torus fractures
– Greenstick fractures
• Complete
• Monteggia
• Both bone
• Galeazzi

6. Monteggia

7. Monteggia
• Fracture of the proximal ulna with dislocation of the
radial head
• Bado classification
1. Anterior dislocation/ anterior angulation (60%)
2. Posterior dislocation/ posterior angulation (15%)
3. Lateral dislocation/ lateral angulation (20%)
4. Anterior dislocation/ both bone proximal # (5%)

8. ‘Both Bone’ Fractures

9. Galleazzi

10. Treatment Goals
• Allow union of the fracture in a position that restores
functional range of motion
• Malunion affects supination/ pronation
• Supination/ pronation
– 50° either way for ADLs
• Cosmesis

11. Conservative
• < 6 yrs
– distal 1/3=20°, middle third=15°, proximal 1/3=10° angulation is
acceptable
– 5 deg of rotation “may” also be acceptable
• 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
• Above elbow cast + broad arm sling
– Proximal # in supination
– Middle # in neutral
– Distal # in pronation

12. Closed Reduction
• Attempt for
– Complete
displacement
– Angulation >15-20°
– Malrotation
• Traction
• Increase deformity
• Reduce fragments
• Correct rotation

16. Remodeling Potential
• Age
• Plane of deformity
– Remodel better if in the plane of motion of the joint
• Amount of deformity
• More growth at distal physis
– Distal fractures have more potential
• Rotational deformity remodel poorly

17. Aftercare
• 5-6/52 in above elbow cast
• Weekly x-rays to check position till 3/52
• Re-apply cast if slackening
• Remanipulation
– Angular deformity >10°
– Up to 3 weeks after injury

18. Indications for ORIF
• Open #
• Inability to maintain acceptable reduction
• Neurologic/vascular compromise
• Refracture with displacement

20. Implant Choice
• ‘Nancy’/ ESIN nails
– Minimal soft tissue dissection
– Fix most angulated/ displaced # (the other may be left)
– 20% unstable and require fixation of other #
– Short term above elbow cast immobilization
– Median time to healing 6.7 months
– Easy removal (3-6 months)
• Older children (>10 yrs) may be better treated as
adults with plates and screws

21. Complications
• Malunion
– angulation >10, displacement >50%, malrotation,
encroachment on interosseous membrane
– angulation of 20-30 degrees may be observed for 3 months for
remodelling
– angulation >30 degrees corrective osteotomy is indicated (best
within 1st year following injury)
• Non-union
• Refracture
– 5% in 6 months
– Greater risk in greenstick #
• Compartment syndrome
• Neurologic injury
• Synostosis

22. References
• “Forearm and distal radius fractures in children”,
Noonan K & Price C, JAAOS, 1998;6:146-156
• “Forearm fractures in children. Single bone fixation
with ESIN nailing”, S Houshian et al, Injury, 2005, 36:
1421—1426
• “Practical Fracture Management”, R McRae, 5th
edition
• “Fractures in children”, C A Rockwood