Forearm Fractures - Pediatric

Topic updated on 08/23/15 1:42am
  • Epidemiology
    • incidence
      • very common, comprising 45% of all pediatric fractures.
    • demographics
      • 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 
  • Pathophyiology
    • mechanism
      • usually fall on outstretched hand
  • 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  
  • 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.
  • 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
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



30 degrees

> 9 yrs.

< 1 cm



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 with angulation outside of acceptable tolerances
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)
  • 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


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Qbank (6 Questions)

(OBQ12.134) An 11-year old boy presents to fracture clinic 1 week after sustaining a displaced metaphyseal distal radius fracture that was managed with closed reduction and cast application. While the initial post-reduction radiographs showed near anatomic alignment with a well molded cast, radiographs 1 week later show 22 degrees of apex volar angulation and dorsal re-displacement. What is the best management at this time? Topic Review Topic

1. Accept the deformity, cast change and follow-up in 3 weeks
2. Closed reduction and cast application, follow-up in 1 week
3. Closed reduction and percutaneous fixation
4. Closed reduction and flexible intramedullary rod fixation
5. Open reduction and internal fixation with a plate and screws

(OBQ12.243) What is the most common fracture in children younger than 16-years-old? Topic Review Topic

1. Hand phalanges
2. Femoral shaft
3. Clavicle
4. Distal radius
5. Supracondylar

(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

(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

(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


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