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Updated: May 19 2024

Both Bone Forearm Fracture - Pediatric

Images
https://upload.orthobullets.com/topic/4126/images/bothbones.jpg
https://upload.orthobullets.com/topic/4126/images/greenstick.jpg
https://upload.orthobullets.com/topic/4126/images/ap_forearm.jpg
https://upload.orthobullets.com/topic/4126/images/lateral_forarm.jpg
https://upload.orthobullets.com/topic/4126/images/plastic_deformation.jpg
  • summary
    • Both Bone Forearm Fractures are one of the most common pediatric fractures, estimated around 40% of all pediatric fractures.
    • Diagnosis is made with plain radiographs of the forearm. 
    • Treatment is closed reduction and casting for the majority of fractures. Surgical intervention is indicated for significantly displaced or angulated fractures in patients approaching skeletal maturity. 
  • Epidemiology
    • Incidence
      • one of the most common pediatric fractures estimated around 40% of all pediatric fractures
    • Demographics
      • more common in males than females
    • Anatomic location
      • 14% distal physis
      • 60% distal metaphysis
      • 20% midshaft
      • 4% proximal third
  • Pathophysiology
    • Mechanism of injury
      • usually occurs from fall from a height, sporting event, or playground equipment injury
    • Pathophysiology
      • peak incidence is during peak bone turnover leading to a mismatch in bone remodeling
    • Associated conditions
      • floating elbow
        • 15% present with an ipsilateral supracondylar fracture or "floating elbow"
      • nerve injury
        • 1% have a neurologic injury most commonly to the median nerve
  • Anatomy
    • Osteology
      • physiologic apex lateral bowing of radius
      • physiologic apex posterior bowing of ulna
    • Muscles
      • Biceps and supinator flex and supinate the proximal fragment
      • Pronator teres and pronator quadratus pronate the distal fragment
      • Brachioradialis dorsiflexes and radially deviates the distal fragment
    • Soft tissues
      • periosteum is often intact on the concave side of the fracture
      • interosseous membrane is taut in neutral to slight supination
  • Classification
    • Fracture type
      • Incomplete
        • greenstick fractures
        • torus fracture
        • plastic deformation
      • Complete fractures
    • Fracture location and pattern
      • proximal-third, middle-third, distal-third
      • apex volar or apex dorsal pattern
  • Presentation
    • Symptoms
      • forearm pain and refuses to use arm
    • Physical exam
      • inspection
        • swelling, deformity, and ecchymosis
        • open fracture
          • can be subtle poke-holes, and can often be missed if not evaluated by an orthopedic surgeon
        • tenderness to palpation
          • a complete examination of injured extremity for ipsilateral injury
      • neurovascular
        • assess for neurovascular injury
        • should rule out compartment syndrome
  • Imaging
    • Radiographs
      • recommended views
        • AP and lateral forearm x-rays
        • obtain orthogonal x-rays of elbow and wrist for ipsilateral injury
      • findings
        • fracture of both radius and ulna
        • fracture of a single bone with plastic deformation of the other bone
        • no fracture with atypical bowing patterns suggesting plastic deformation
        • rotational malalignment
          • the bicipital tuberosity and radial styloid should be 180 degrees apart on the AP view
          • ulnar styloid and coronoid are 180 degrees apart on the lateral view
          • the diameter of proximal and distal fragments should match
          • thickness of cortices should match on proximal and distal fragments
  • Treatment
      • Table of Acceptable Reduction (Tolerances) 
      • Angle (°)
      • Malrotation (°)
      • Bayonet Apposition
      • 0-10 years
      • <15
      • <45
      • Yes, if <1cm short
      • ≥ 10 years
      • <10
      • <30
      • No
      • Approaching skeletal maturity (< 2y growth remaining)
      • 0
      • 0
      • No
    • Nonoperative
      • closed reduction and immobilization
        • indications
          • most pediatric forearm fractures can be treated without surgery when an adequate reduction is maintained
          • greenstick injuries
          • plastic deformation if NOT over 20 degrees
          • bayonet apposition ok if <10 years and growth remains
        • modalities
          • closed reduction with analgesia and casting or splinting
            • options for analgesia vary from local block, regional block, conscious sedation, and general anesthesia
    • Operative
      • percutaneous vs open reduction and intramedullary nailing
        • indications
          • unacceptable alignment following closed reduction
            • angulation >15°, rotation >45° in children <10y
            • angulation >10°, rotation >30° in children >10y
            • bayonet apposition in children older than 10 years
          • both bone forearm fractures in children >13y
        • relative indications
          • highly displaced fractures
      • open reduction and internal fixation
        • indications
          • unacceptable alignment following closed reduction
            • angulation >15° and rotation >45° in children <10y
            • angulation >10° and rotation >30° in children >10y
            • bayonet apposition in children older than 10 years
          • open fractures
          • refractures
          • both bone forearm fractures in children >13y (nearing skeletal maturity)
        • relative indications
          • highly displaced fractures
          • highly comminuted or segmental fractures
  • Techniques
    • Closed Reduction
      • plastic deformation
        • bone work
          • steady three-point bending to counteract bending deformity
        • complications
          • a fracture may occur with abrupt force rather than a slow gradual increase in force
      • greenstick fracture
        • bone work
          • reduction is achieved through a combination of traction, direct pressure with thumb, rotation, and three-point bending
          • apex volar fractures are treated with pronation and apex dorsal fractures are treated with supination
        • instrumentation
          • reduction can be aided with finger traps and counterweights
          • casting maintains reduction through three-point molding and interosseous mold
            • no increase in loss of reduction with short arm versus long arm casting
            • there is an increase in loss of reduction with increased cast index >0.8
        • complications
          • compartment syndrome with excessive swelling and tight circumferential casting, can bivalve cast to mitigate this risk
          • remanipulation after closed reduction has been associated with increased initial fracture displacement 
    • Percutaneous vs. Open Intramedullary Nailing
      • approach
        • the ulnar nail is inserted through the tip of the olecranon or through the anconeus to avoid damage to the ulnar nerve
        • the radial nail is inserted just proximal to the radial styloid or in the dorsal aspect of the distal radius proximal to the physis
          • the dorsal central start point can cause injury to the extensor pollicis longus (EPL) tendon
      • bone work
        • reduce bone prior to passage of the nails
          • start with whichever bone is easiest to reduce
        • open fracture if unsuccessful passage with three attempts
      • instrumentation
        • rod removal is often required 3 to 4 months after surgery
      • complications
        • multiple unsuccessful attempts at passage of the nail increases the risk of compartment syndrome
      • outcomes
        • shorter surgical time than ORIF
        • less blood loss than ORIF
        • equal union rates, radial bow, and rotation as ORIF
    • Open reduction internal fixation
      • approach
        • often a combination of a volar approach and ulnar approach centered over the fracture
      • soft tissue
        • minimize soft tissue damage and avoid excessive periosteal stripping
      • bone work
        • simple patterns can be rigidly stabilized after anatomic reduction
        • comminuted patterns or bone loss requires relative stability over fracture sites
      • complications
        • rotational malalignment, nonunion, malunion
  • Complications
    • Refracture
      • occurs in 5-10% following both bone fractures
      • plate removal and greenstick patterns are risk factors for refracture
      • treatment consists of open reduction and internal fixation
    • Malunion
      • the incidence of symptomatic malunion seen as the loss of pronation and supination
      • may be related to initial reduction or delay in diagnosis
      • if symptomatic, treatment consists of corrective osteotomies
    • Compartment syndrome
      • risk factors include high energy trauma or multiple attempts at reduction and rod passage
      • if unsuccessful nail passage after 2-3 attempts, open the fracture site to visualize rod passage
      • treatment consists of forearm fasciotomies
    • Synostosis
      • rare complication
      • occurs following head injury and high-energy trauma
      • resection rarely leads to an improved range of motion
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