(Kamat, 2012) Principles of cast application that are important to consider include use of an optimal amount of cast padding (i.e. Appropriate application of a cast or splint is one of the most important aspects of non-operative management of pediatric diaphyseal forearm fractures. (Zionts, 2005 Jones, 1999 Sinikumpu, 2014) Important principles to consider when choosing non-operative treatment include: obtaining adequate analgesia/anesthesia if closed manipulation is required, restoring adequate length, alignment, and rotation of the fracture, and careful application of a well-molded cast or splint. An acceptable functional outcome with closed treatment is the rule in a majority of fractures. The standard of care for the treatment of pediatric diaphyseal forearm fractures remains non-operative treatment with closed reduction and casting. (Eismann, 2013 Franklin, 2012) While most fractures can be adequately treated non-operatively, absolute surgical indications include open fractures and fractures associated with radio-capitellar (Monteggia) or distal radio-ulnar joint (Galleazzi) instability relative surgical indications include unacceptable residual deformity, loss of reduction, refracture, compartment syndrome, and fractures in those nearing or at skeletal maturity. Despite this, most authors abide by the radiographic criteria as described above.Ī vast majority of pediatric radial and ulnar shaft fractures can be successfully treated by closed means although interest in surgical treatment has continued to increase (Flynn, 2010 Westacott, 2012) despite the relative lack of high-quality evidence supporting this trend. (Bar, 1989) Additionally, radiographs following an acute injury are often suboptimal because of difficulty positioning the forearm due to patient apprehension. A potential shortcoming of using radiographic criteria alone when determining treatment of pediatric diaphyseal forearm fractures is the assessment of the “true” fracture angulation, since radiographs are not necessarily taken orthogonal to the plane of maximal deformity. (Vittas, 1991) Although controversy exists in the literature, generally accepted criteria for satisfactory residual deformity of diaphyseal forearm fracture in patients ≤10 years old include, angulation 10 years old, angulation 1 cm and/or bayonet apposition is generally unacceptable in older patients. There are acceptable radiographic limits for residual displacement, angulation, and rotation of diaphyseal forearm fractures in general, however, these limits become more stringent as patients approach skeletal maturity. Standard AP and lateral radiographs should be obtained when evaluating these injuries. Patients should be assessed for evidence of open fracture, ipsilateral fracture proximal or distal to the forearm, and baseline neurovascular status as these will all influence ultimate treatment. In fractures requiring reduction, clinical deformity is usually readily apparent. Radial and ulnar shaft fractures most commonly occur after a fall onto an outstretched arm. On average, the distal radial and ulnar physes close at age 17 in girls and 19 in boys, however, physiologic growth is likely complete prior to radiographic physeal closure. The distal radial and ulnar physes account for approximately 80% of longitudinal forearm growth. (Chung, 2001) Fractures of the radial shaft are the third most common fracture in children, after distal radius and supracondylar humerus fractures. Treatment recommendations are generally based on patient age, fracture characteristics, and associated injuries.įractures of the radius and ulna account for the most common fractures in children under 14 years old. Most forearm fractures in children can be treated non-operatively, however, the rate of operative management of pediatric forearm fractures is increasing (Flynn, 2010). Pediatric forearm fractures are one of the most common injuries sustained by children. Complications after treatment include loss of reduction, refracture, compartment syndrome, and hardware irritation.Surgical options include flexible intramedullary nailing or open reduction and plating. Surgical indications include open fractures, unacceptable fracture deformity, compartment syndrome and re-fracture.The vast majority of pediatric radial and ulnar shaft fractures can be managed with closed treatment.Study Guide Forearm - Radius and Ulnar Shaft Fractures Key Points:
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