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Introduction
  • One of the most common pediatric fractures
  • Mechanism
    • usually occurs from fall from a height
Anatomy
  • Normal rotational alignment
    • relationship of bicipital tuberosity and radial styloid should be 180 degrees from each other on the AP radiograph 
    • relationship of coronoid process and ulnar styloid should be 180 degrees from each other on the lateral radiograph
Classification
  • Greenstick fractures 
    • are incomplete fractures
    • can be described as apex volar or apex dorsal
  • Complete fractures 
    • are categorized the same as adults
Presentation
  • Symptoms
    • forearm pain and deformity 
  • Physical exam
    • swelling and focal tenderness
    • should assess for neurovascular injury
    • should rule out compartment syndrome
    • open fracture
      • can be subtle poke-holes, and can often be missed if not evaluated by an orthopaedic surgeon 
Imaging
  • Radiographs 
    • help to describe apex dorsal vs apex volar injuries 
    • can help judge forearm rotation deformity based on relationship of bicipital tuberosity and radial styloid which are 180 degees apart on the AP view   
    • ulnar styloid and coronoid are 180 degrees apart on the lateral view  
Treatment
 
Table of Acceptable Reduction (Tolerances)
Age Angulation (°) Malrotation (°)
Bayonet Apposition
0-9 years <15 <45 Yes, if <1cm short
≥10y, mid to distal shaft <15 <30 No
≥10y, proximal shaft <10 0 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 
        • greenstick injuries
        • bayonet apposition ok if <10 years 
      • followup
        • weekly radiographs for first 3-4 weeks to monitor reduction
        • casting for 6-12 weeks total
      • Short arm cast vs above elbow cast 
        • short arm for distal 1/3 BBFA
        • above elbow immobilization for any fracture proximal to distal 1/3
  • Operative
    • percutaneous vs open reduction and nancy nailing 
      • absolute 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<13
      • relative indications
        • highly displaced fractures
      • technique
        • allows smaller dissection and advantage of a load-sharing device allowing rapid healing
        • fixation of one bone often sufficient stability 
      • considerations
        • shorter surgical time than ORIF
        • less blood loss than ORIF
        • equal union rates, radial bow and rotation as ORIF 
    • open reduction and internal fixation 
      • absolute indications
        • unacceptable alignment following closed reduction 
          • open fractures
          • refractures
          • angulation >15° and rotation >45° in children <10y 
          • angulation >10° and rotation >30° in children >10y
          • bayonet apposition in children older than 10 years
          • both bone forearm fractures in children> 13
      • relative indications
        • highly displaced fractures
      • technique
        • same technique as an adult
Techniques
  • Closed Reduction
    • steady three point bending of immobilization depending on fracture type 
      • apex volar fractures (supination injuries)
        • may be treated and reduced by forearm pronation 
      • apex dorsal fractures (pronation injuries)
        • may be treated and reduced by forearm supination
    • 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 long arm cast x 6-8wks, possible conversion to short arm cast after 4wks depending on fracture type 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) >0.8
Complications
  • Refracture
    • occurs in 5-10% following both bone fractures
    • is an indication for an ORIF
  • Malunion
    • loss of pronation and supination is common but mild
  • Compartment syndrome
    • may occur due to high energy injuries
    • may occur due to multiple attempts at reduction and rod passage
      • if unsuccessful nail passage after 2-3 attempts, open the fracture site to visualize rod passage
 

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