Forearm Fractures - Pediatric

Author: Jason McKean

Topic updated on 04/09/13 1:00pm

Introduction

Pediatric forearm fractures are very common, comprising 45% of all pediatric fractures.
Mechanism
- fall on outstetched hand is most common mechanism
- child abuse must be considered
Epidemiology
- 81% of these fractures occur in children who are older than 5
- peak incidence occurring from 10 to 12 years of age in girls and 12-14 in boys
  - most common fracture in children <16 years old
Fracture types
- diaphysis (20%)
  - both bone fx
  - Greenstick fx
- metaphysis (62%)
  - distal radius fx (Colle's fx)
  - Torus fx
- distal physis
  - Salter-Harris I
  - Salter-Harris II
  - Salter-Harris III
  - Salter-Harris IV
- fracture with dislocation
  - Monteggia’s fracture
  - Galeazzi fracture

Presentation

History
- wide range of mechanism for children
- rule out child abuse
Symptoms
- pain and deformity
Physical exam
- gross deformity may or may not be present
- check for puncture wounds indicating open fracture
- ecchymosis and swelling
- although rare, compartment syndrome should be ruled out in forearm fractures.

Imaging

Radiographs
- recommended views
  - AP and lateral of wrist
  - AP and lateral of forearm
  - AP and lateral of elbow
CT
- to better characterize fracture if intra-articular

Treatment

Acceptable Angulation for Closed Reduction in Pediatric Forearm Fractures (controversial)
	Shaft / Both bone fx			Distal radius/ulna
Age	Acceptable Bayoneting	Shaft Acceptable Angulations	Malrotation	Dorsal Angulation
< 9 yrs	< 1 cm	15°	45°	30 degrees
> 9 yrs.	< 1 cm	10°	30°	20 degrees
Bayonette apposition, or overlapping, of less than 1 cm, does not block rotation and is acceptable in patients less than 10 years of age. The radius and ulna function as a single rotational unit. Therefore a final angulation of 10 degrees in the diaphysis can block 20-30 degrees of rotation. Rotational deformities do not remodel and are not acceptable.

Nonoperative
- immobolization in short arm cast for 2-3 weeks without reduction
  - indications
    - greenstick fx with < 10 deg of angulation
    - torus fx
- closed reduction under conscious sedation followed by casting
  - indications
    - greenstick fx with > 10 degrees of angulation
    - both bone fx in children < 10 years
    - distal radius fx
    - Salter-Harris I
    - Salter-Harris II
  - reduction technique determined by fracture pattern
  - acceptable criteria (see table above)
    - acceptable angulations are controversial in the orthopedic community.
    - accepted angulation is defined on a case by case basis depending on
      - the age of the patient
      - location of the fracture
      - type of deformity (angulation, rotation, bayoneting).
  - follow-up
    - all forearm fractures serial radiographs should be taken every 1 to 2 weeks to ensure the reduction is maintained.
Operative
- open reduction and internal fixation
  - indications
    - Salter-Harris III and IV fractures of the distal radial physis
    - both-bone fracture in a child > 10 years of age

Treatment Techniques

Closed Reduction
- greenstick both bone fractures
  - most pediatric greenstick both bone fractures can be temporarily reduced by placing the palm in the direction of the deformity (pronate arm for supination injury with apex-volar angulation of fracture)
Casting
- usually consists of a long arm cast for 6 to 8 weeks with the possibility of conversion to a short arm cast after 4 weeks depending on the type of fracture and healing response.
  - no increased risk of loss of reduction with short arm vs. long arm casting
- loss of reduction is associated with increasing cast index (sagittal width/coronal width)

Complications

Casting Thermal Injury
- thermal injury may occur if
  - dipping water temperature is > 24C (75F)
  - more than 8 layers of plaster are used
  - during cast setting, the arm is placed on a pillow. This decreases the dissipation of heat from the exothermic reaction
  - fiberglass is overwrapped over plaster

Please Rate Educational Value!

4.0

Average 4.0 of 10 Ratings

Qbank (4 Questions)

TAG

(OBQ10.196) An 8-year-old boy fell while riding his bike and landed on his outstretched arm. Radiographs are provided in Figure A. Which of the following increases the risk of displacement following closed reduction and casting? Topic

Review Topic

FIGURES: A

1. Long arm cast immobilization
2. Short arm cast immobilization
3. Cast index greater than 0.85
4. Conscious sedation during reduction
5. Plaster cast immobilization

PREFERRED RESPONSE ▶

DISCUSSION: Pediatric both bone forearm fractures are generally treated with closed reduction and immobilization given the innate ability of the bone to remodel. Guidelines will vary by author, but fractures at any level in children less than 9 years of age, complete displacement, 15 degrees of angulation, and 45 degrees of malrotation are acceptable. In children 9 years of age and older, 30 degrees of malrotation, 10 degrees of angulation for proximal fractures, and 15 degrees for more distal fractures are acceptable. The cast index is defined as the sagittal width of the cast divided by the coronal width. If the fracture involves the physis, repeated closed reductions are not recommended due to potential injury of the physis. Therefore it is important to recognize acceptable alignment, know the potential for remodeling at certain ages, and the importance of a well-molded cast. Webb et al conducted a prospective, randomized study of 113 children who sustained fractures of the distal forearm. Patients were randomized to long arm or short arm casting. There was no difference in fracture displacement throughout the course of treatment. Loss of reduction was associated with poorly molded casts in both groups. The average cast index of patients who lost reduction was 0.79 compared to 0.70 in patients who did not lose reduction. Patients with short arm casts missed fewer school days and experienced less difficulty with activities of daily living. An example of the cast index from Webb's article is shown in Illustration A.

Illustrations: A

REFERENCES:

1. Waters PM, Mih AD. Forearm, wrist, and hand: pediatrics. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:715-726.

2. Cornwall R, Waters PM. Pediatric trauma and infections. In: Trumble TE, Budoff JE, eds. Hand Surgery Update 4. Rosemont, IL: American Society for Surgery of the Hand; 2007:745-753.

3. Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Joint Surg Am. 2006 Jan;88(1):9-17. PMID:16391244 (Link to Abstract)

Question Authors:

John Badylak MD, Patrick McCulloch MD, Eric Shirley MD,

Please Rate Educational Value!

3.0

Average 3.0 of 21 Ratings

TAG

(OBQ09.251) You are preparing to cast a child with a both-bone forearm fracture in the emergency room. During cast application, all of the following are directly related to the risk of thermal injury except? Topic

Review Topic

1. Layers of thickness of casting material
2. Water temperature used to dip casting material
3. Placing the limb on a pillow during the cast curing process
4. Fiberglass overwrapping of plaster casts
5. Type of fracture pattern

PREFERRED RESPONSE ▶

DISCUSSION: Causes for thermal burns during cast application are multi-factorial. Halanski et al. evaluated the internal and external temperature changes that occured during cast application on limb models. They found that excessively thick plaster, dip-water temperature of >24 degrees C, placing the limb on a pillow during the curing process, and fiberglass overwrapping all increase the risk for thermal injury. Lavalette et al. in a similiar study using a glass tube filled with water to simulate an extremity found that if the temperature of the dip water was higher than 24 degrees Celsius, thickness of the cast was greater than eight ply, and if the pillow was used to limit the dissipation of heat from the cast, temperatures became high enough to cause skin burns.

REFERENCES:

1. Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007 Nov;89(11):2369-77. PMID:17974878 (Link to Abstract)

2. Lavalette R, Pope MH, Dickstein H. Setting temperatures of plaster casts. The influence of technical variables. J Bone Joint Surg Am. 1982 Jul;64(6):907-11. PMID:7085719 (Link to Abstract)

Question Authors:

Patrick O'Donnell MD/PhD, Eric Shirley MD,

Please Rate Educational Value!

4.0

Average 4.0 of 13 Ratings

TAG

(OBQ05.97) Isolated pronation of the forearm will most likely achieve reduction of what type of fracture in a 7-year-old boy? Topic

Review Topic

1. Supination injury resulting in an apex-volar greenstick both bone forearm fracture
2. Pronation injury resulting in an apex-dorsal greenstick both bone forearm fracture
3. Supination injury resulting in an apex-dorsal greenstick both bone forearm fracture
4. Complete both bone forearm fracture with bayonete apposition of both the radius and ulna
5. Distal radius fracture with 25 degrees of apex-dorsal angulation

PREFERRED RESPONSE ▶

DISCUSSION: Noonan et al discuss the anatomy, diagnosis, treatment, and outcome in pediatric forearm and distal radius fractures in their review article. With regards to reduction and casting, the authors state that greenstick forearm fractures are usually supination injuries with apex-volar angulation (Illustration A), which can be reduced with varying degrees of forearm pronation. As a rule of thumb, most pediatric both bone fractures can be temporarily reduced by pointing the palm in the direction of the deformity. Complete both bone forearm fractures with bayonette apposition require traction to aide in reduction, and malaligned distal radius fractures can be reduced with a combination of traction, angulation, and rotation of the palm in the direction of the angulation.

Illustrations: A

REFERENCES:

1. Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998 May-Jun;6(3):146-56. PMID:9689186 (Link to Abstract)

2. . Price CT, Mencio GA: Injuries to the shafts of the radius and ulna, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins. 2001, pp 443-482.

Question Authors:

Joshua Blomberg MD, Eric Shirley MD, Dave Marcu MD,

Please Rate Educational Value!

4.0

Average 4.0 of 22 Ratings

Posts

	Treatment for rickets in a 6 year old? how do u treat vit-D resistant rickets ina 6yr old child? General - Treatment Consult - Forearm Fractures - Pediatric	3 weeks ago 2 responses 0
	Tested Article: Comparison of Short and Long Arm Plaster Casts for Displaced Fractures in the Distal Third of the Forearm in... Webb GR, Galpin RD, Armstrong DG. J Bone Joint Surg Am. 2006 Jan;88(1):9-1... Pediatrics - Journal Club - Forearm Fractures - Pediatric	2/13/2013 103 responses 4

See More Posts

Groups

ABOS II: Distal Radius Fractures - Pediatric

General - Oral Boards Review

7/29/2011

0 responses

See More Groups

Evidence & References Show References

Level of Evidence 1 (Randomized Control Trial)

Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Joint Surg Am. 2006 Jan;88(1):9-17. PMID:16391244 (Link to Abstract)

Level of Evidence 4 (Case Series)

Landin LA. Epidemiology of children’s fractures. J Pediatr Orthop B. 1997 Apr;6(2):79-83. PMID:9165435 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Halanski MA, Halanski AD, Oza A, Vanderby R, Munoz A, Noonan KJ. Thermal injury with contemporary cast-application techniques and methods to circumvent morbidity. J Bone Joint Surg Am. 2007 Nov;89(11):2369-77. PMID:17974878 (Link to Abstract)
Lavalette R, Pope MH, Dickstein H. Setting temperatures of plaster casts. The influence of technical variables. J Bone Joint Surg Am. 1982 Jul;64(6):907-11. PMID:7085719 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Waters PM, Mih AD. Forearm, wrist, and hand: pediatrics. In: Vaccaro AR, ed. Orthopaedic Knowledge Update 8. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005:715-726.
Cornwall R, Waters PM. Pediatric trauma and infections. In: Trumble TE, Budoff JE, eds. Hand Surgery Update 4. Rosemont, IL: American Society for Surgery of the Hand; 2007:745-753.

Undefined

Herman MJ. Principles of pediatric trauma care. In: Song KM, ed. Orthopaedic Knowledge Update: Pediatrics 4. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2011:317-327.
Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998 May-Jun;6(3):146-56. PMID:9689186 (Link to Abstract)
. Price CT, Mencio GA: Injuries to the shafts of the radius and ulna, in Beaty JH, Kasser JR (eds): Rockwood and Wilkins Fractures in Children, ed 5. Philadelphia, PA, Lippincott Williams & Wilkins. 2001, pp 443-482.

Topic Comments

Subscribe status: On Off

Recent on Bottom | Recent on Top

Page:1

Forearm Fractures - Pediatric

Qbank (4 Questions)

Question Comments

Question Comments

Question Comments

Posts

Groups

Evidence & References Show References

Topic Comments