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https://upload.orthobullets.com/topic/4126/images/radius180.jpg
https://upload.orthobullets.com/topic/4126/images/greenstick.jpg
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Introduction
  • Epidemiology
    • incidence
      • one of the most common pediatric fractures estimated around 40% of all pediatric fractures
    • demographics
      • more common in males than females
    • 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 taught 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
An acceptable reduction is also driven by patient age and location of fracture with younger patients having more remodeling potential and proximal fractures having lower tolerances.
 
  • 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 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
  • 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
    • 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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Questions (7)
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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%

(39/4761)

2

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

5%

(232/4761)

3

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

3%

(128/4761)

4

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

74%

(3508/4761)

5

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

17%

(823/4761)

ML 2

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%

(208/2033)

2

Blood loss is higher in the IMN group

1%

(14/2033)

3

Restoration of radial bow is similar in both groups

70%

(1416/2033)

4

Surgical time is greater in the IMN group

5%

(92/2033)

5

Forearm rotation is greater in the ORIF group

15%

(297/2033)

ML 3

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%

(1481/3637)

2

Long-arm cast

52%

(1883/3637)

3

Sling for comfort

0%

(17/3637)

4

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

4%

(142/3637)

5

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

3%

(102/3637)

ML 5

Select Answer to see Preferred Response

PREFERRED RESPONSE 1
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