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, Wrist Fracture in Children, Pediatric Wrist Fracture

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II. Epidemiology

  1. Peak age for Forearm Fractures: 14 years in boys (11 years in girls)
  2. Distal Radius Fractures account for 25 to 40% of all Pediatric Fractures
  3. Gender: Male predominance

III. Physiology: Unique Features of the Pediatric Wrist

  1. Growth Plates
    1. See Growth Plate
    2. Multi-layered cartilagenous tissue allows for linear growth, but more susceptible to injury
  2. Ossification Centers
    1. See Wrist Ossification Center
    2. See Forearm Ossification Center
    3. Gradual bone appearance as a child ages resulting in challenging XRay Interpretation
  3. Cartilage
    1. Pediatric wrist contains a higher proportion of cartilaginous tissue (more pliable)
  4. Ligaments
    1. Children have greater ligament laxity (higher risk for instability and injury)

IV. Mechanism

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

V. Types

  1. Forearm Buckle Fracture (or Torus Fracture)
    1. Incomplete compression Fracture resulting in cortical bulging without cortical disruption
    2. Distal Forearm Buckle Fractures account for 50% of Pediatric Wrist Fractures (esp. age 7 to 12 years old)
    3. Delayed sclerosis and periosteal reaction may lead to initially missed buckle Fracture
    4. Children's bones are protected by a thick periosteal sleeve
      1. Allows for a non-displaced, impacted buckle Fracture despite cortical Fracture
  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 the tension or convex side of the Fracture (differentiates from buckle Fracture)
    3. Bulging is seen on the compression or concave side of Fracture (similar to buckle Fracture)
  3. Epiphyseal Fracture (Growth Plate Injury)
    1. See Radial Epiphyseal Fracture
    2. See Salter-Harris Fracture
    3. Physis (Growth Plate) is injured in 20 to 30% of pediatric Distal Radius Fractures
    4. Type 2 Salter-Harris Fracture (physis to metaphysis) accounts for 74% of Growth Plate Fractures
    5. Risk for linear growth arrest (esp. Type 3 to 5)
  4. Complete Radius or Ulna Fracture
    1. See Forearm Fracture
    2. Metaphyseal Fractures (e.g. Colles Fracture, Smith Fractures)
    3. Diaphyseal Fractures (e.g. Distal Radius Fracture, Ulna Fracture or radius-Ulna Fracture)
    4. Associated Injuries (uncommon in children)
      1. Monteggia Fracture (ulna shaft Fracture and Radial Head Dislocation)
      2. Galeazzi Fracture (Distal Radius Fracture and radioulnar joint disruption)
  5. Scaphoid Fracture
    1. Most common Carpal BoneFracture, but account for <0.5% of Pediatric Fractures
    2. Typically occur at age 12 to 15 years and older
      1. Uncommon in age <10 years old (unless severe Traumatic Injury)

VI. Exam

  1. See Forearm Fracture
  2. Wrist and Hand Neurovascular Exam
  3. Exclude other associated injuries
    1. Nonaccidental Trauma (esp. nonambulatory children)
    2. Clavicle Fracture
    3. Humeral Fracture
    4. Elbow Injury
    5. Wrist Soft Tissue Injury

VII. Signs

  1. See Forearm Fracture
  2. Distal radius (and/or ulna) metaphysis Fracture
    1. Tenderness and often with minimal to no deformity
  3. Other findings
    1. Deformity
    2. Localized Edema
    3. Tenderness or pain (with and without movement)
    4. Reduced wrist or hand range of motion

VIII. Imaging

  1. See Forearm Fracture

IX. Management: Partial or Non-displaced Fractures

  1. See Forearm Fracture
  2. Epiphyseal Fracture (Growth Plate Injury)
    1. See Radial Epiphyseal Fracture
    2. Often missed on initial XRays (treat empirically if suspected)
    3. Splint and cast immobilization for Types 1, 2 and 5
    4. Surgery for internal fixation for Types 3 and 4
    5. Follow-up orthopedic provider in 3 to 5 days
  3. Forearm Buckle Fracture (or Torus Fracture)
    1. Historically treated with short-arm splint, then Casting for total immobilization of 3 weeks
      1. However, outcomes are better (faster healing, earlier function) without Casting
    2. Start with initial short-term, simple short arm volar splint or soft bandage for comfort
      1. Removable splint or nonrigid immobilization are reasonable alternatives
      2. Encourage early wrist mobilization as tolerated
      3. Avoid Casting in most buckle Fractures (harm outweighs benefit)
      4. Handoll (2018) Cochrane Database Syst Rev (12): CD012470 +PMID:30566764 [PubMed]
      5. Williams (2013) Pediatr Emerg Care 29(5):555-9 +PMID:23603644 [PubMed]
    3. 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]
  4. Greenstick Fractures or non-displaced Radius Fractures
    1. Less stable than buckle Fractures and require a period of immobilization
    2. Short-arm splint, then Casting for total immobilization of 3 weeks
    3. Follow-up orthopedic or sports medicine provider in 3 to 5 days
    4. Allowable deformity without reduction (closed or ORIF) in age <10 years old
      1. Dorsal Angulation <20-30 degrees (sagittal alignment, lateral XRay)
      2. Displacement <50%
    5. Reduction of Greenstick Fracture (if significant angulation)
      1. Rotate bone in opposite direction of deformity
      2. Historical approach has been to complete the Fracture (opposite cortex)
        1. Then manipulate bone ends for alignment
        2. Re-angulation may otherwise occur in cast

X. 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. Follow-up orthopedic provider in 3 to 5 days
  4. Reduction Technique
    1. See Distal Radius Fracture
    2. Anesthesia
    3. Angulated Fractures
      1. Traction and Counter traction (finger traps with 10-15 lb counter-traction at distal Humerus)
      2. Greenstick Fracture management as above
    4. Displaced Fractures
      1. Traction and Counter traction
      2. Slight bayonet apposition is acceptable
      3. Alignment must be satisfactory (no rotation, minimal angulation)
    5. Galeazzi Fractures
      1. Consult orthopedics
      2. Closed reduction may be possible
  5. Immobilization
    1. Start with sugar tong splint, then Long Arm Cast for 7-8 weeks
    2. Positioning
      1. Elbow flexed to 90 degrees
      2. Mold Forearm to avoid interosseus encroachment

XI. Complications

  1. Casting complications (Pressure Sores and skin maceration)
    1. Use sufficient padding beneath splints and casts
  2. Loss of reduction
    1. Initially reduced Fractures may displace despite Splinting and Casting
    2. Follow-up orthopedics or sports medicine with repeat imaging
  3. Malunion
    1. Spontaneous remodeling occurs in Distal Radius Fractures in age <14 years
    2. Midshaft Fractures in infants to age 8 years often remodels sufficiently
      1. However, age >8 years typically requires Fracture realignment to prevent malunion
  4. Linear growth arrest
    1. Complicates up to 14% of patients with Growth Plate Fractures
    2. Lower risk with fewer Fracture reduction attempts

XII. References

  1. Al-Salamah, Alkhalife and AlShebel (2024) Crit Dec Emerg Med 38(9): 5-13
  2. Bhandari (2004) J Orthop Trauma 18(7): 473-5 [PubMed]
  3. Black (2009) Am Fam Physician 80(10): 1096-102 [PubMed]
  4. Patel (2021) Am Fam Physician 103(6): 345-54 [PubMed]

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