Overview of paediatric forearm fractures including management

1. Paediatric Forearm Fractures
By Hiren M Divecha
ST3
21/4/2011

2. • 40% of childhood fractures
• Mechanism
– FOOSH (trampolines, monkey bars etc…)
– Direct trauma
– NAI
• History
• Examination – pain, swelling, deformity,
neurological

3. Types
• Location – proximal, middle or distal
• Characteristics – displacement, angulation and rotation
• Plastic deformation
• Incomplete
– Buckle or torus fractures
– Greenstick fractures
• Complete
• Monteggia
• Both bone
• Galeazzi

6. Monteggia

7. Monteggia
• Fracture of the proximal ulna with dislocation of the
radial head
• Bado classification
1. Anterior dislocation/ anterior angulation (60%)
2. Posterior dislocation/ posterior angulation (15%)
3. Lateral dislocation/ lateral angulation (20%)
4. Anterior dislocation/ both bone proximal # (5%)

8. ‘Both Bone’ Fractures

9. Galleazzi

10. Treatment Goals
• Allow union of the fracture in a position that restores
functional range of motion
• Malunion affects supination/ pronation
• Supination/ pronation
– 50° either way for ADLs
• Cosmesis

11. Conservative
• < 6 yrs
– distal 1/3=20°, middle third=15°, proximal 1/3=10° angulation is
acceptable
– 5 deg of rotation “may” also be acceptable
• 6-10 yrs
– < 15 deg of angulation should remodel especially if # is close to distal
epiphysis
– bayonet apposition may be acceptable
• > 12 yrs of age
– no angulatory or rotational deformity is considered acceptable
– treat as adult
• Above elbow cast + broad arm sling
– Proximal # in supination
– Middle # in neutral
– Distal # in pronation

12. Closed Reduction
• Attempt for
– Complete
displacement
– Angulation >15-20°
– Malrotation
• Traction
• Increase deformity
• Reduce fragments
• Correct rotation

16. Remodeling Potential
• Age
• Plane of deformity
– Remodel better if in the plane of motion of the joint
• Amount of deformity
• More growth at distal physis
– Distal fractures have more potential
• Rotational deformity remodel poorly

17. Aftercare
• 5-6/52 in above elbow cast
• Weekly x-rays to check position till 3/52
• Re-apply cast if slackening
• Remanipulation
– Angular deformity >10°
– Up to 3 weeks after injury

18. Indications for ORIF
• Open #
• Inability to maintain acceptable reduction
• Neurologic/vascular compromise
• Refracture with displacement

20. Implant Choice
• ‘Nancy’/ ESIN nails
– Minimal soft tissue dissection
– Fix most angulated/ displaced # (the other may be left)
– 20% unstable and require fixation of other #
– Short term above elbow cast immobilization
– Median time to healing 6.7 months
– Easy removal (3-6 months)
• Older children (>10 yrs) may be better treated as
adults with plates and screws

21. Complications
• Malunion
– angulation >10, displacement >50%, malrotation,
encroachment on interosseous membrane
– angulation of 20-30 degrees may be observed for 3 months for
remodelling
– angulation >30 degrees corrective osteotomy is indicated (best
within 1st year following injury)
• Non-union
• Refracture
– 5% in 6 months
– Greater risk in greenstick #
• Compartment syndrome
• Neurologic injury
• Synostosis

22. References
• “Forearm and distal radius fractures in children”,
Noonan K & Price C, JAAOS, 1998;6:146-156
• “Forearm fractures in children. Single bone fixation
with ESIN nailing”, S Houshian et al, Injury, 2005, 36:
1421—1426
• “Practical Fracture Management”, R McRae, 5th
edition
• “Fractures in children”, C A Rockwood