Operative management of forearm shaft fractures in children has achieved wide acceptance for numerous reasons.1–5 Surgical stabilization with elastic intramedullary fixation is minimally invasive, provides excellent alignment, facilitates postoperative care, and eliminates concerns about acceptable alignment in most cases. However, angulated or displaced fractures of the forearm shaft in children may be managed operatively or nonoperatively depending on the nature of the injury, the experience of the orthopaedic surgeon, and the social needs of the family or child.6–8 Nonoperative management of forearm shaft fractures in children may be initiated in the emergency department with closed reduction under conscious sedation. When closed management fails or has a high likelihood of an unsatisfactory outcome, then reduction with internal fixation is indicated. The purpose of this study is to review some principles of closed management that may help surgeons decide when to abandon closed treatment in favor of internal fixation. Patients with open fractures, multiple fractures, neurovascular injuries, high-energy trauma, or adjacent joint dislocations often require internal fixation by percutaneous or open techniques. This review and discussion are limited to isolated angulated or displaced shaft fractures of the radius and/or ulna in immature patients.
Current textbooks indicate that following closed reduction, the limits of acceptable angulation range from 10 to 20 degrees depending on the age of the child and the location of the fracture.7–13 Lower limits of angulation are accepted for children older than 8 years and for proximal fractures, whereas upper limits are accepted for midshaft and distal diaphyseal fractures, especially for children younger than 8 years of age. Cadaver studies show little loss of motion when mid-shaft angulation is ≤10 degrees, but angulation of 20 degrees results in approximately 30% loss of forearm rotation.14 In younger children, remodeling can restore alignment. In children ≤8 years of age, approximately 50% correction of angulation can be expected for shaft fractures with less than 20 degrees of angulation.15–17 Clinical series are consistent with these findings and report satisfactory results with 15 to 20 degrees of angulation in children younger than 9 years of age.18–20 However, some loss of motion may occur when angulation is greater than 10 degrees in children older than 8 years, or for fractures in the proximal forearm.21,22
Rotational malalignment is poorly tolerated and cannot be expected to remodeled. Guidelines for acceptable malrotation range from 0 to 45 degrees, but rotational alignment may be difficult to judge accurately.20,22,23 When doubt exists about rotational alignment, Creasman et al23 recommended comparison radiographs of the opposite forearm in a position similar to the reduced fracture. Others recommend examining shape and diameter of the fragments at the level of the fracture, or assessing the position of the radial tuberosity opposite the radial styloid.24
Complete displacement does not interfere with the recovery of motion for the majority of the fractures.7,22,25 However, complete displacement combined with mild angulation or malrotation may compromise motion to a greater degree than complete displacement without angular or rotational malalignment.22 In addition, proximal forearm fractures have a worse prognosis for the recovery of motion compared with midshaft or distal shaft fractures.3,21,22,26
Although full recovery of the range of motion is desirable, some loss of forearm rotation may not interfere with activities of daily living7,20,27 or athletic performance.22 Minor loss of motion from residual angulation following closed treatment should be weighed against risks of surgery to achieve anatomic alignment.7,19,21,23,26,28–31
With proper follow-up and management it should be possible to avoid malunion for almost all forearm fractures in children. The variables of age, location of fracture, and rotational alignment make it difficult to propose exact guidelines for acceptable reduction during closed management. In the early phases of healing a properly reduced fracture may drift into further angulation in the cast. Therefore, the author recommends that the guidelines for acceptable alignment during early healing (Table 1) should be more stringent than the guidelines for correction of an established malunion.32
Fractures in the proximal third of the radius and ulna deserve special attention. As noted earlier, these have a high probability for loss of motion when managed closed. Range of motion may be compromised by residual angulation in proximal forearm because of the proximity of the radius and ulna during pronation. Greater soft tissue mass in the proximal forearm may also interfere with the maintenance of alignment in a cast. It is the author's recommendation that surgical stabilization should be strongly considered for all displaced fractures of the proximal third of the forearm shaft in children older than 6 years of age.
Fractures of the distal two-thirds of the forearm are more forgiving. Generally accepted guidelines for children with more than 2 years of growth remaining are 15 degrees of angulation, complete displacement, 1 cm of shortening, and 45 degrees of malrotation.7,12 Up to 20 degrees of angulation may be acceptable for more distal fractures in children younger than 8 years of age. However, radiographic remodeling does not always correlate with return of motion.16,22 Rotational alignment is difficult to judge accurately and may not remodel completely.20,21 Reduction in full pronation or full supination is rarely necessary for completely displaced shaft fractures but pronation may be appropriate for greenstick fractures that present with volar angulation (Fig. 1).13,24 This distinction can prevent excessive pronation for complete fractures. Malunion in pronation may lead to loss of supination, which is more difficult to accommodate than loss of pronation.26,33 Reduction in extension may help assess and maintain reduction, especially in younger children.34
Some forearm fractures that are reduced in the emergency department will lose reduction in spite of adequate cast immobilization. When this occurs, it is sometimes possible to gently replace the cast and mold the fracture in the clinic without analgesics while the cast is curing. More vigorous attempts at remanipulation require sedation or general anesthesia. When secondary reductions are required under general anesthesia, it is the author's practice to add intramedullary fixation to avoid repeated returns to the operating room for reduction.
In later stages of healing when the fractures are stable, up to 20 degrees of angulation in the distal or mid-shaft may remodel in children with more than 2 years of growth remaining.16–18,21 Ulnar deformity may be more visible than radial deformity, but function is rarely compromised following remodeling for angulation of less than 20 degrees. Very few cases have been reported of children requiring osteotomy for persistent malunion after forearm fractures in children.32,35–37 However, best results with osteotomy have been achieved within 1 year of the initial fracture.35,37 The author recommends observation for up to 6 months when remodeling may restore function and cosmesis. This usually involves residual angulation of 20 to 30 degrees. In rare cases with malunion greater than 30 degrees osteotomy is recommended after a brief period of motion to allow soft tissue recovery before surgical correction.
Closed reduction of forearm shaft fractures in children can produce satisfactory results in the majority of patients. Initial reduction in the emergency department is appropriate for displaced fractures of the middle and distal forearm shaft. Guidelines for acceptable alignment remain controversial, but some malalignment is well tolerated, especially in children younger than 8 years of age. For displaced proximal fractures, or when alignment cannot be maintained with gentle cast changes in the clinic, surgical stabilization is recommended rather than resorting to repeated attempts at closed reduction under general anesthesia.
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