Forearm Fracture in Children

Aka: Forearm Fracture in Children, Pediatric Radius Ulna Fracture, Forearm Buckle Fracture, Forearm Torus Fracture, Forearm Greenstick Fracture, Radius Greenstick Fracture, Ulnar Greenstick Fracture, Radius Torus Fracture, Radius Ulna Torus Fracture, Ulna Torus Fracture

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II. Mechanism

  1. Fall on Outstretched Hand (similar to other Forearm Fractures)

III. Types

  1. Forearm Buckle Fracture (or Torus Fracture)
    1. Incomplete compression Fracture resulting in cortical bulging without cortical disruption
  2. Greenstick or complete Radius Fracture
    1. Similar to Buckle Fracture, but with cortical disruption on one side of Fracture
    2. Cortical disruption is seen on tension side of the Fracture (differentiates from buckle Fracture)
    3. Bulging is seen on compression side of Fracture (similar to buckle Fracture)
  3. Complete Radius-Ulna Fracture
    1. See Forearm Fracture

IV. Exam

  1. See Forearm Fracture

V. Signs

  1. See Forearm Fracture
  2. Distal radius (and/or ulna) metaphysis Fracture with tenderness and minimal to no deformity

VI. Imaging

  1. See Forearm Fracture

VII. Management: Partial or Non-displaced Fractures

  1. See Forearm Fracture
  2. Forearm Buckle Fracture (or Torus Fracture)
    1. Treated with short-arm splint, then Casting for total immobilization of 3 weeks
      1. Removable splint or nonrigid immobilization are reasonable alternatives
      2. Handoll (2018) Cochrane Database Syst Rev (12): CD012470 +PMID:30566764 [PubMed]
      3. Williams (2013) Pediatr Emerg Care 29(5):555-9 +PMID:23603644 [PubMed]
    2. Repeat Xray has been historically performed at 3 week follow-up visit
      1. However, some guidelines recommend follow-up imaging only for persistent symptoms or signs
      2. Riera-Alvarez (2019) J Pediatr Orthop B 28(6): 553-4 +PMID:32694434 [PubMed]
      3. Ling (2018) Radiol Res Pract +PMID:29686900 [PubMed]
  3. Greenstick Fractures or non-displaced Radius Fractures
    1. Short-arm splint, then Casting for total immobilization of 3 weeks
    2. Allowable deformity without reduction (closed or ORIF) in age <10 years old
      1. Angulation <20-30 degrees (sagittal alignment, lateral XRay)
      2. Displacement <50%

VIII. Management: Children with Displaced or Angulated Radius-Ulna Fractures

  1. See Forearm Fracture (includes indication for othopedic referral)
  2. Surgical intervention uncommon in children under age 10 years old
  3. Reduction Technique
    1. See Distal Radius Fracture
    2. Anesthesia
    3. Angulated Fractures
      1. Traction and Counter traction
      2. Greenstick Fractures
        1. Often require breakage of opposite cortex
        2. Prevents re-angulation in cast
    4. Displaced Fractures
      1. Traction and Counter traction
      2. Slight bayonet apposition is acceptable
      3. Alignment must be satisfactory
  4. Immobilization
    1. Start with sugar tong splint, then Long Arm Cast for 7-8 weeks
    2. Positioning
      1. Elbow flexed to 90
      2. Mold Forearm to avoid interosseus encroachment

IX. References

  1. Bhandari (2004) J Orthop Trauma 18(7): 473-5 [PubMed]
  2. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
  3. Patel (2021) Am Fam Physician 103(6): 345-54 [PubMed]

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