summary Both Bone Forearm Fractures are one of the most common pediatric fractures, estimated around 40% of all pediatric fractures. Diagnosis is made with plain radiographs of the forearm. Treatment is closed reduction and casting for the majority of fractures. Surgical intervention is indicated for significantly displaced or angulated fractures in patients approaching skeletal maturity. Epidemiology Incidence one of the most common pediatric fractures estimated around 40% of all pediatric fractures Demographics more common in males than females Anatomic 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 taut 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 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 NOT 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 remanipulation after closed reduction has been associated with increased initial fracture displacement 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 the dorsal central start point can cause injury to the extensor pollicis longus (EPL) tendon 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