32.1 Introduction

Forearm fractures are the most common group of pediatric fractures, representing 40–50% of all fractures in children. ^{1 , 2} The forearm midshaft, specifically, is the most common site of refracture as well as one of the most common sites of open fracture in this population. ³ The most common mechanism is a fall onto an outstretched hand (FOOSH). Direct blunt trauma to the forearm may also result in an isolated fracture, with the ulna affected more commonly than the radius. ^{2 , 4 , 5} Most fractures do not require operative treatment. However, indications for surgery include the following: ⁶

• 
  

  Unstable or unacceptable fixation with closed reduction

  
  
• 
  

  Open fracture

  
  
• 
  

  Compartment syndrome

  
  
• 
  

  Floating elbow (e.g., with ipsilateral supracondylar humerus fracture)

  
  
• 
  

  Refracture with displacement

  
  
• 
  

  Segmental fracture

  
  
• 
  

  Age (significant angulation should not be accepted in patients >10 years old)

In the absence of significant fracture comminution or segmental bone loss, fixation with the percutaneous insertion of flexible intramedullary nails/rods is the method of choice in skeletally immature individuals. ⁶ The technique for intramedullary nail fixation of forearm fractures in the pediatric population is similar to that in the adult population. However, in skeletally immature patients, the penetration of the physis should be avoided at all costs. ⁷ The technique for intramedullary nail fixation of pediatric midshaft forearm fractures is described in this chapter.

32.2 Preop

• 
  

  Patient exam. Assess neurovascular status of affected extremity preoperatively.

  
  
• 
  

  Determination of nail size. Nail should fill approximately two-thirds of medullary canal diameter at the narrowest part of diaphysis. Sizes generally used in the pediatric forearm include 1.5, 2.0, and 2.5 mm. In the case of both-bone fracture, nails with identical diameters should be chosen in order to avoid discrepancies in bending forces and ultimately malalignment. ⁷

  
  
• 
  

  Surgical table. Standard operating table with arm bars

  
  
• 
  

  Essential instruments of typical flexible IM nail kit. Nails, end caps, awls, inserter, extraction pliers, cutter, and impactors

  
  
• 
  

  Other instruments. Pin wrench (4.5 × 120 mm), spanner wrench, C-arm fluoroscopy, sterile tourniquet, basic orthopedic surgery tray including F-reduction tool in case open reduction becomes necessary.

  
  
• 
  

  Patient position. Supine with shoulder at edge of bed and arm board at level of shoulder. Table should be turned 90 degrees such that operative extremity is pointing directly away from anesthesia.

  
  
• 
  

  C-arm fluoroscopy should be positioned so as not to interfere with surgical field, entering either from the head or foot of the table.

32.3 Anesthesia

• 
  

  Anesthetic should be relatively safe and painless at all steps, including fracture reduction. Postreduction amnesia is also desirable. Relaxation of the patient and the forearm muscles greatly facilitates reduction.

  
  
• 
  

  Options include hematoma or intravenous regional block, axillary block, intravenous sedation, self-administered nitrous oxide (50:50 ratio of nitrous oxide and oxygen), and general anesthesia.