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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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Questions (6)
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(OBQ11.4) 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? Review Topic

QID: 3427
1

The ulnar styloid and coronoid process are best seen on the AP radiograph

1%

(37/4352)

2

On the lateral radiograph the radial styloid and biceps tuberosity are oriented 90 degrees apart

5%

(217/4352)

3

On the AP radiograph, the ulnar styloid and the coronoid process are oriented 180 degrees apart

3%

(116/4352)

4

On the AP radiograph, the radial styloid and biceps tuberosity are oriented 180 degrees apart

74%

(3199/4352)

5

On the AP radiograph the radial styloid and biceps tuberosity are oriented 90 degrees apart

17%

(756/4352)

Select Answer to see Preferred Response

PREFERRED RESPONSE 4

(OBQ11.156) 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? Review Topic

QID: 3579
FIGURES:
1

Non-union rates are significantly higher in the IMN group

10%

(201/1922)

2

Blood loss is higher in the IMN group

1%

(14/1922)

3

Restoration of radial bow is similar in both groups

69%

(1330/1922)

4

Surgical time is greater in the IMN group

5%

(88/1922)

5

Forearm rotation is greater in the ORIF group

15%

(287/1922)

Select Answer to see Preferred Response

PREFERRED RESPONSE 3

(OBQ13.230) 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? Review Topic

QID: 4865
FIGURES:
1

Short-arm cast

41%

(1365/3359)

2

Long-arm cast

52%

(1741/3359)

3

Sling for comfort

0%

(16/3359)

4

Splint in a backslab and admit for a closed reduction percutaneous pinning

4%

(133/3359)

5

Splint in a backslab and admit for a open reduction internal fixation

3%

(92/3359)

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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