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Technique guide are not considered high yield topics for orthopaedic standardized exams including the ABOS, EBOT and RC.
An 11-year-old boy fell on his outstretched right hand. He has a closed injury and is neurovascularly intact. Injury films are shown in Figures A and B. The patient undergoes an anatomic closed reduction in the emergency department and the fracture is stable under fluoroscopic imaging. What would be your next step in management?
Sling for comfort
Splint in a backslab and admit for a closed reduction percutaneous pinning
Splint in a backslab and admit for a open reduction internal fixation
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The patient has sustained an angulated distal diaphyseal both bone forearm fracture. The optimal treatment is closed reduction and immobilization in a short-arm cast.
Both bone forearm fractures are common paediatric fractures, occurring after FOOSH injuries. Most paediatric forearm fractures can be treated non-operatively with a closed reduction and cast immobilization. Immobilization is best achieved with three-point molding. General indications for operative management are bayonet apposition in children older than 10 years of age, angulation >15 degrees and rotation >45 degrees in children <10 years, angulation >10 degrees and rotation >30 degrees in children >10 years, open fracture, and re-fracture. Less angulation is accepted for proximal fractures.
Paneru et al. randomized 42 children aged 4-12 to an above-elbow group and 43 to a below-elbow group. They found that pain and swelling on the next day and one week after reduction was significantly higher in the above-elbow group. As well, patients in the above-elbow group were more likely to undergo a re-manipulation than the below-elbow group (9.5% vs. 2.3%, p=0.173).
Webb et al. performed a RCT comparing short arm and long arm plaster casts for displaced distal both bone forearm fractures. They concluded that a well-molded short arm cast was equally as effective as a long arm cast, and interfered less with daily activity. They stressed the need for good cast molding, indicated by a lower cast index. Ideal cast index is less than 0.8.
Bohm et al. performed a RCT comparing below- and above-elbow casts. They found that below-elbow casts were as efficacious as above-elbow casts in maintaining reduction of distal both bone forearm fractures.
Figures A and B show AP and lateral radiographs of a distal both bone forearm fracture. Illustration A and B show AP and lateral radiographs of a distal both bone forearm fracture following closed reduction and immobilization in a short-arm cast. Illustration C demonstrates how to measure cast index (dividing the sagittal cast width (A) by the coronal cast width (B) at the fracture site). Illustration D demonstrates a typical reduction manoeuvre: 1) reproduce or exaggerate deformity to unlock fragments, 2) reduce fragments using periosteal hinge, 3) correct rotational deformity.
Answer 2: Long-arm casts are not necessary for immobilization of distal both bone forearm fractures.
Answer 3: A sling will not provide adequate immobilization, despite the fracture being stable under fluoroscopy.
Answers 4 and 5: Operative fixation is not required for most distal both bone forearm fractures.
Paneru SR, Rijal R, Shrestha BP, Nepal P, Khanal GP, Karn NK, Singh MP, Rai P.
J Child Orthop. 2010 Jun;4(3):233-7. Epub 2010 Mar 17. PMID: 21629372 (Link to Abstract)
Paneru, JCO 2010
Webb GR, Galpin RD, Armstrong DG
J Bone Joint Surg Am. 2006 Jan;88(1):9-17. PMID: 16391244 (Link to Abstract)
Webb, JBJS 2006
Bohm ER, Bubbar V, Yong Hing K, Dzus A
J Bone Joint Surg Am. 2006 Jan;88(1):1-8. PMID: 16391243 (Link to Abstract)
Bohm, JBJS 2006
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A 12-year old boy fell sustaining a both bone forearm fracture. Which of the following is true regarding the radiographic assessment of anatomic forearm alignment after reduction?
The ulnar styloid and coronoid process are best seen on the AP radiograph
On the lateral radiograph the radial styloid and biceps tuberosity are oriented 90 degrees apart
On the AP radiograph, the ulnar styloid and the coronoid process are oriented 180 degrees apart
On the AP radiograph, the radial styloid and biceps tuberosity are oriented 180 degrees apart
On the AP radiograph the radial styloid and biceps tuberosity are oriented 90 degrees apart
When a forearm fracture is properly reduced, the AP radiograph demonstrates the radial styloid and biceps tuberosty 180 degrees apart (Illustration A). On the lateral, the coronoid process and ulnar styloid will be 180 degrees apart.
Noonan et al reviewed pediatric forearm and distal radius fractures in children. They concluded that in children <9 years of age, complete displacement, 15 degrees of angulation, and 45 degrees of malrotation are acceptable. In children 9 years of age or older, 30 degrees of malrotation is acceptable, with 10 degrees of angulation for proximal fractures and 15 degrees for more distal fractures.
Complete bayonet apposition is acceptable, especially for distal radius fractures, as long as angulation does not exceed 20 degrees and 2 years of growth remains. For patients with less than two years of growth remaining, surgical indications and tolerances are the same as for adults.
Dumont et al studied the effect of malrotation of the radius and/or ulna on supination and pronation in cadaver forearms. They determined that malrotation of the radius in supination led to the largest decrease in rotation due to a single bone while a combined rotational malunion of the radius and ulna in opposite directions led to the largest limitation of the range of motion. They determined that rotational malunion may be isolated or part of a complex angular/rotational deformity with rotational malunion leading to increased impairment.
Dumont CE, Thalmann R, Macy JC
J Bone Joint Surg Br. 2002 Sep;84(7):1070-4. PMID: 12358375 (Link to Abstract)
Dumont, BJJ 2002
Noonan KJ, Price CT.
J Am Acad Orthop Surg. 1998 May-Jun;6(3):146-56. PMID: 9689186 (Link to Abstract)
Noonan, JAAOS 1998
Average 3.0 of 38 Ratings
A 10-year-old boy falls off his bicycle sustaining the injury seen in Figures A and B. After initial unsuccessful closed reduction, he undergoes operative fixation. When comparing ORIF with a plate to a percutaneous technique using intramedullary nails (IMN), which of the following is true?
Non-union rates are significantly higher in the IMN group
Blood loss is higher in the IMN group
Restoration of radial bow is similar in both groups
Surgical time is greater in the IMN group
Forearm rotation is greater in the ORIF group
The clinical scenario and radiographs depict a pediatric diaphyseal radius and ulna fracture. Operative indications include open fractures and fractures with unacceptable alignment after closed reduction. The optimal fracture patterns for IMN technique are midshaft pediatric both bone forearm fractures with minimal comminution in transverse and oblique patterns and acutely after injury prior to the presentation of fracture callus. Restoration of radial bow has been shown to be similar with both IMN and ORIF.
Reinhardt et al reviewed the outcomes of 31 pediatric both bone forearm fractures treated with intramedullary nailing (IMN) versus ORIF. The IMN group had shorter surgical time and less blood loss. No differences were found in rates of union, radial bow magnitude, or forearm rotation.
Reinhardt KR, Feldman DS, Green DW, Sala DA, Widmann RF, Scher DM
J Pediatr Orthop. 2008 Jun;28(4):403-9. PMID: 18520274 (Link to Abstract)
Reinhardt, JPO 2008
Average 4.0 of 24 Ratings
HPI - Patient presents with forearm pain after FOOSH injury when he fell while playing in the schoolyard.
How would you manage this fracture?
HPI - FOOSH-type injury that was managed at another hospital.
Patient was placed in the below-elbow cast.
Referred to our institution for a second opinion and further management.
Would you have accepted the original reduction? (See Post-Procedure P1 XRays above - AP and Lateral)