Sometimes Forearm Fractures in Children Are Not So Simple

Children often fall and break their arms. The forearm with its two bones (radius and ulna) is one of the most common childhood fractures. Most of the time these types of breaks are clean and simple. The physician can line the bones back up without surgery.

The child wears a splint or cast for four to six weeks while the bone remodels and heals. And quite honestly, if the child has not yet completed his or her full growth and has not yet reached skeletal maturity, the bone does a remarkable job healing and even restoring normal anatomy.

But there are those cases we call bad actors: problematic forearm fractures that require recognition and special treatment. In the simplest of cases, the bones are displaced (separated). There may be a hidden dislocation along with the fracture that doesn't show up on a plain X-ray.

Or there could be a fracture with bone rotation so the ends no longer line up as they should. Putting the arm in a cast without realigning the bones could result in permanent loss of wrist and forearm motion. Sometimes one or both of the bones break and leave the bone at an angle. This type of deformity won't realign on its own. To add to that list, there could be cases where the forearm fracture affects the alignment of the elbow.

To address these "bad actors," Dr. Dan A. Zlotolow, orthopedic surgeon from Children's Hospital in Philadelphia, Pennsylvania offers some treatment guidelines. First, he reviews the potential mechanisms of injury stating that the surgeon must make every effort to identify the type of fracture and any other associated soft tissue or joint injury. It is especially important to look for damage to the ligaments, blood vessels, and/or nerves. Complete diagnosis may require additional imaging using computed tomography scans (CTs) or magnetic resonance imaging (MRI).

The child's age makes a big difference in planning treatment. Children up to age eight will have the capacity to heal, repair, and remodel angular deformities of the bones up to 15 degrees. X-rays will help determine the skeletal age of maturity and show how much more growth is left. If the child is within a year or two of full skeletal maturity, then he or she should be treated as an adult.

Closed reduction (realignment without surgery) is acceptable for many of the younger children. But open reduction with internal fixation (ORIF) is often required when the "bad actor" shows up with any of the complications described. A flexible titanium rod may be placed down through the length of the fractured bone. Metal plates and/or stainless steel pins may be used until union occurs.

And here's an important tip from Dr. Zlotolow: the surgeon must make sure the child has full forearm rotation before considering the case closed. It's all too easy for a child with limited forearm movement to make up the loss by compensating with the wrist and shoulder. The loss of forearm rotation (palm up and palm down) may not be evident until years later when they start to participate in sports and can't move as needed.

Corrective surgery may be needed if the desired range-of-motion has not been achieved within the first year after fracture treatment. Even with surgery, there is a risk that with soft tissue scarring and shortening, full motion won't be possible with corrective surgery.

In summary, surgeons treating children with forearm fractures must be vigilant in watching for complications that can leave the child with permanent deformities or loss of motion. Careful evaluation at the time of the injury AND close observation during healing, recovery, and follow-up are essential to recognize fractures referred to as "bad actors." Elbow joint instability (due to ligamentous damage or dislocation), malunion, and excess bone angulation require special surgical management.

Reference: 

Dan A. Zlotolow, MD. Pediatric Forearm Fractures: Spotting and Managing the Bad Actors. In The Journal of Hand Surgery. February 2012. Vol. 37A. No. 2. Pp. 363-366.

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