Key Points
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Accept only minor fracture displacement in diaphyseal forearm fractures because the remodeling capacity is low and even mild malunion can result in impaired forearm rotation.
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Diaphyseal forearm fractures that are stable after reduction can be treated nonoperatively with an above-elbow cast followed by a below-elbow cast. Unstable fractures need additional fixation.
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Re-fractures occur frequently and give a higher change of impaired forearm rotation.
A 10-year-old girl visits the emergency department after a fall from a trampoline on her outstretched right arm. Radiographs show a both-bone diaphyseal forearm fracture with angulation in the sagittal and coronal plane ( Fig. 1 ).
After reduction in the emergency department, the maximum fracture angulation is still > 10 degrees. This is accepted by the attending physician and she is treated with an above-elbow cast.
Six weeks later the cast is removed. The radiographs ( Fig. 2 ) show a residual angulation and the girl has a limitation in pro- and supination. She is told this will improve as she ages. The girl is discharged from further care.
Three years later the girl attends your outpatient clinic with a persistent pro-supination impairment ( Fig. 3 ). Is this going to improve with age?
A further 5 years later ( Fig. 4 ), the patient is now 18 years old, and still has an impairment of pro-supination on the right side. Was the initial notion that the deformity and impairment will diminish with age correct?
Importance of the Problem
Forearm fractures are the most common fractures among children between 0 and 14 years of age. The most frequent mechanism of injury is a fall on the outstretched hand. Forearm rotation can be limited after a fracture and affects daily activities if pronation or supination is less than 50 degrees. When treating pediatric forearm fractures, the basic principle is to accurately align, angularly and rotationally, both the radius and the ulna.
Both-bone forearm fractures can be anatomically divided in distal (metaphyseal), midshaft (diaphyseal), and proximal fractures. Distal fractures are the most common, while proximal fractures are rare. Furthermore, a differentiation is made between incomplete fractures typical for children (torus/buckle, greenstick, and bowing/plastic deformation) and complete fractures that occur in children as well as in adults. The treatment of both-bone forearm fractures depends on anatomical location, fracture displacement (minimally or severely displaced), and the expected growth remaining. Remodeling of an angulated fracture during the remaining growth is highest in young children with a fracture location close to the most active distal growth plate and an angulation in the sagittal plane.
Main Question
What is the relative effect of closed reduction and cast immobilization versus closed reduction and internal fixation versus open reduction and internal fixation on functional outcome and complication rates in management of pediatric diaphyseal forearm fractures?
We divided the main question in the following three subquestions:
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Is it safe to switch to a below-elbow cast after 3 weeks in the nonoperative treatment of minimally displaced diaphyseal fractures and displaced diaphyseal fractures that are stable after reduction?
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What is the relative effect of closed reduction versus closed reduction and internal fixation (by intramedullary device) versus open reduction and internal fixation by plate on functional outcome and complication rates of unstable diaphyseal fractures?
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Is single bone fixation as effective as both-bone fixation on functional outcome and complication rates of unstable diaphyseal fractures?
Current Opinion
Both-bone diaphyseal forearm fractures which are minimally or nondisplaced can be treated nonoperatively. Displaced fractures need reduction and unstable fractures after reduction need additional fixation. Current opinion is divided with regard to the best fixation method.
Finding the Evidence
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Cochrane search: Pediatric forearm fracture
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Pubmed (Medline):
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Embase (‘forearm fracture’/de OR ‘radius fracture’/exp. OR ‘ulna fracture’/exp. OR ‘wrist fracture’/de OR ‘distal radius fracture’/exp. OR (((forearm* OR fore-arm OR radius* OR ulna OR wrist* OR antebrach* OR both-bone* OR colles* OR monteggia*) NEAR/3 (fracture*)) OR ((salter-harris* OR epiphys*-plate* OR growth-plate* OR intra-articul* OR intraarticul*) AND (wrist* OR radius* OR ulna))):ab,ti,kw) AND (‘fracture treatment’/exp. OR ‘closed reduction (procedure)’/exp. OR ‘open reduction (procedure)’/exp. OR ‘bone resection’/de OR ‘orthopedic surgery’/de OR (ORIF OR CRIF OR plaster* OR cast* OR k-wire* OR plate* OR nail* OR reduction* OR fixat* OR osteosynth* OR ilizarov* OR splint* OR ((therapy OR therapies OR treat* OR immobili*) NEAR/3 (fracture*)) OR ((orthoped*) NEAR/3 (surgic* OR surger* OR procedur*))):ab,ti,kw) AND (‘Controlled clinical trial’/exp. OR ‘Crossover procedure’/de OR ‘Double-blind procedure’/de OR ‘Single-blind procedure’/de OR ‘review’/exp. OR ‘meta-analysis’/de OR (meta-analys* OR meta-analys* OR review* OR random* OR factorial* OR crossover* OR (cross NEXT/1 over*) OR placebo* OR ((doubl* OR singl*) NEXT/1 blind*) OR assign* OR allocat* OR volunteer* OR trial OR groups):ab,ti,kw) AND (child/exp. OR adolescent/exp. OR adolescence/exp. OR pediatrics/exp. OR childhood/exp. OR ‘child welfare’/de OR ‘child development’/de OR ‘child growth’/de OR ‘child health’/de OR ‘child health care’/exp. OR ‘child care’/exp. OR ‘childhood disease’/exp. OR ‘pediatric ward’/de OR ‘pediatric hospital’/de OR ‘pediatric anesthesia’/de OR (adolescen* OR preadolescen* OR infan* OR child* OR kid OR kids OR toddler* OR teen* OR boy* OR girl* OR minors OR underag* OR (under NEXT/1 (age* OR aging OR ageing)) OR juvenil* OR youth* OR kindergar* OR puber* OR pubescen* OR prepubescen* OR prepubert* OR pediatric* OR paediatric* OR school* OR preschool* OR highschool* OR suckling* OR PICU OR NICU OR PICUs OR NICUs):ab,ti,kw) NOT ((animal/exp. OR animal*:de OR nonhuman/de) NOT (‘human’/exp)) NOT ([Conference Abstract]/lim)
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Bibliography of eligible articles
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Articles that were not in the English, French, or German language were excluded.
Quality of the Evidence
Level I:
Randomized controlled trials: 4
Level II:
Systematic review of observational studies: 2
Prospective studies: 2
Level III:
Retrospective comparative studies: 3
Findings
In this chapter, we will discuss the evidence about the most effective treatment for both-bone diaphyseal forearm fractures. Fractures of the distal forearm are discussed in the previous chapter (pediatric distal radius fractures).
Nonoperative Treatment of Diaphyseal Both-Bone Forearm Fractures
Maximum acceptable angulations according to age for both-bone forearm fractures and plastic deformation were defined according to the graphs minus one standard deviation, shown in the metaanalysis by Ploegmakers et al. ( Graph 1 A and B ). In a prospective cohort study by Barvelink et al., fracture remodeling in relation to functional outcome is observed in nonreduced minimally displaced forearm fractures. After 1 year, the mean fracture angulation of 12 degrees measured at initial presentation was reduced to a mean residual angulation of 4 degrees. No significant differences for either grip strength or range of motion between the affected and the unaffected forearm were found. These results suggest that residual angulation of 4 degrees is of no functional concern. Nonoperative treatment without reduction could therefore be a good treatment option in minimally angulated forearm fractures. However, the most important limitation of this study is the relatively small study population (26 children).
