Forearm Fractures - Pediatric

• Radius and ulna connected by proximal and distal radioulnar joints
• Interosseous membrane provides stability
• Rotation occurs through supination/pronation
• Neutral rotation: thumb up, radial bow lateral

The natural radial bow allows clearance for muscle bellies and is essential for full pronation-supination. Loss of radial bow restricts rotation.

• Proximal fragment supinated by biceps and supinator
• Distal fragment pronated by pronator teres
• Reduce in supination

• Proximal and distal fragments both have pronation/supination forces
• Reduce in neutral

Reduce in pronation (most common reduction position).

• Less common in children than adults
• Distal radius fracture (typically distal third)
• DRUJ subluxation or dislocation
• Often more stable in children (intact periosteum)

Reduce radius fracture. DRUJ usually reduces spontaneously in children. Above elbow cast in supination.

Measure coronal plane angulation (apex medial or lateral). Less forgiving to residual deformity.

Measure sagittal plane angulation (apex anterior or posterior). Better remodeling in this plane.

Compare to opposite side if concerned about loss of radial bow.

Stable cortical compression injury without displacement.

Splint or removable cast for 3-4 weeks. Parent-directed removal is safe. No follow-up X-rays usually needed.

These are inherently stable. Do not overtreat them with above elbow casts. Early mobilization is safe.

Below elbow cast, serial X-rays as can re-angulate.

• Complete the fracture (break intact cortex) under sedation or GA
• This allows full reduction without spring-back
• Apply above elbow cast with proper 3-point mold
• Close follow-up for first 2 weeks (loss of reduction common)

Incomplete reduction leads to cast loosening and re-angulation.

• Finger trap traction or manual traction
• Correct length, then rotation, then angulation
• Above elbow cast with well-molded interosseous space
• Post-reduction X-rays to confirm alignment

• Proximal fracture: forearm supinated
• Mid-shaft: forearm neutral
• Distal: forearm pronated

Length re-established, less than 10° angulation (over 10 years), rotation anatomic.

• Unacceptable reduction after closed attempt
• Re-displacement in cast
• Open fracture
• Polytrauma
• Older child/adolescent with unstable pattern
• Segmental fractures

Retrograde radius (above Lister's or lateral), antegrade ulna (olecranon or proximal metaphysis). Pre-bend nails, avoid physis. Remove at 6-12 months.

• Dorsal entry just proximal to Lister's tubercle OR
• Lateral entry above distal radial physis
• Avoid palmar entry (flexor tendons)

• Proximal/antegrade entry at olecranon or proximal metadiaphysis
• Avoid distal ulnar physis (small, subcutaneous)

Pre-bend nails for radial bow. Seat nails well to avoid irritation and protrusion. Both bones should ideally be nailed. Use 2-2.5mm nails typically.

• Failed closed reduction
• Open fracture
• Associated vascular injury
• Irreducible Monteggia
• Late presentation Monteggia

Henry (anterior) for radius, direct subcutaneous for ulna. Preserve periosteum. Avoid extensive stripping.

Ulna fracture + radial head dislocation + disrupted annular ligament.

Apex anterior ulna angulation, anterior radial head dislocation. Extension injury mechanism.

Closed reduction of ulna usually reduces radial head. Above elbow cast in flexion and supination. If radial head remains dislocated, open reduction may be needed (annular ligament may be entrapped). Check radiocapitellar line post-reduction.

Bowing of bone without visible fracture line. Causes restricted rotation if significant.

• Less than 10° bow: Accept
• 10-20° bow: Consider reduction
• Greater than 20° bow: Requires reduction under GA with sustained force

Sustained pressure over apex of deformity for 2-3 minutes. Bone slowly straightens. Cannot "snap" it - must bend gradually.

• Early return to full activity
• Removal of cast too early
• Initial cortical comminution
• Stress risers from previous fracture

Continue protective splinting for sport for 6 months. Avoid high-risk activities. Some surgeons do not recommend specific protection; counsel family about risk.

There is no universally agreed figure. Published thresholds vary by age, fracture level and plane, and most are based on retrospective series rather than trials. Numbers such as 10-15 degrees (over 10 years) and 15-20 degrees (under 10 years) are pragmatic conventions, not hard biological limits.

When operating on a both-bone fracture, some surgeons nail only the more unstable bone, arguing the second reduces and stays once one is stabilised. Others routinely fix both to maximise stability. Evidence is limited and practice varies.

As children approach skeletal maturity, remodelling falls and ESIN may fail to restore the radial bow. Comparative data (Freese et al.) suggest plating restores anatomy more reliably with fewer major complications in this group, but at the cost of a larger scar and a planned removal in some practices.