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Evidence-based Medicine: Management of Pediatric Forearm Fractures

Franklin, Corinna C. MD*; Robinson, Jonathan MD*; Noonan, Kenneth MD; Flynn, John M. MD*

Journal of Pediatric Orthopaedics: September 2012 - Volume 32 - Issue - p S131–S134
doi: 10.1097/BPO.0b013e318259543b
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Forearm fractures are common injuries in the pediatric population. Successful treatment of these fractures should result in complication-free functional pronosupination. Traditionally, these have been treated with closed reduction and casting, but the last several decades have seen a dramatic increase in the operative treatment of these fractures. However, little high-level evidence exists to guide management. The data from the limited set of studies available suggest that closed treatment does usually result in satisfactory outcomes, particularly in younger patients; operative fixation is usually successful as well but comes with a significantly increased complication rate. The ideal study to aid in evidence-based decision-making for pediatric forearm fractures would be a randomly controlled trial comparing closed reduction and casting versus intramedullary nailing versus plating; in children ranging from 8 years old to skeletally mature; with closed forearm fractures, complete or greenstick with >20 degrees of angulation; with a minimum of 5 years of follow-up (or to maturity); with the primary outcome defined as final pronation and supination; using an validated functional outcome tool; and precisely defining the complications from each treatment.

*Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, PA

American Family Children’s Hospital, Madison, WI

Performed at the Children’s Hospital of Philadelphia, Philadelphia, PA.

The authors declare no conflict of interest.

Reprint: John M. Flynn, MD, Division of Orthopaedic Surgery, The Children’s Hospital of Philadelphia, 34th and Civic Center Blvd., Philadelphia, PA 19104. E-mail: flynnj@email.chop.edu.

Forearm fractures are common injuries in the pediatric population. Traditionally, these have been treated with closed reduction and casting, but the last several decades have seen a dramatic increase in the operative treatment of these fractures.1 However, high-level evidence for decision-making in this setting is extremely limited. There exist no randomized controlled trials or clinical guidelines on this topic—no clear answer to the question of how best to maximize function while minimizing risk.

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PRONOSUPINATION AND ACCEPTABLE LOSS

Maintenance of pronosupination is a key element in the management of forearm fractures. “Normal” pronation and supination are somewhat difficult to accurately quantify, secondary to wrist and hand movement as well as difficulty in determining the neutral position.2 The American Academy of Orthopaedic Surgeons defines normal pronation at 71 degrees and supination at 84 degrees,3 and this—or something close to it—has been widely accepted.4–7 This is considerably more than what is required for most activities of daily living, which is about 50 degrees each of pronation and supination.8

The crucial element to define, then, appears to be how much motion loss can be tolerated without significant functional loss. Several studies in following up forearm facture malunions found symptomatic or disabling loss of motion to be between 45 to 90 degress of loss of pronosupination.2,9–11 Cadaveric studies have correlated fracture angulation with loss of motion. Matthews et al12 found that 20 degrees of angulation in the middle third of the forearm lead to a significant loss of motion, whereas Kasten et al13 found that 40 degrees of rotational deformity of the radius led to a loss of 20 degrees of pronation and supination. Tarr et al4 also correlated malrotation of the radius with loss of pronosupination, as well as finding that 15 degrees of angulation led to a 27% loss of rotation and that midshaft angulation was more problematic than distal angulation, and attributing the loss of motion to interosseous membrane tightness. However, in clinical studies there has not been a similar correlation between angular deformity and functional range of motion (ROM).9,10,14 Angular deformity in forearm malunions does have the potential to remodel in children; this decreases with distance from the physis and with increasing age. Several studies have found limited remodeling potential in forearm fractures in children older than 10 years.11,14–17

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OSTEOTOMY FOR MALUNION

Osteotomy is a surgical option that has been described to potentially increase ROM in cases of malunion. Several series have described osteotomies for significant loss of motion, and found that results were improved if performed 6 to 12 months from the time of injury.18–21 Nagy and colleagues, in a series of 17 malunions from 2008, found that interosseous membrane release led to a better outcome as well.

Osteotomy remains an uncommon procedure. Although malunions of forearm fractures do exist and can remodel only in some patients, significant functional loss is unlikely in all but the most severe angular deformities. The central question then becomes whether closed management of pediatric forearm fractures that result in malunions leads to a greater functional loss than similarly fractured arms treated with surgery, provided the costs and risks of surgery are accounted for.

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CLOSED REDUCTION AND CASTING

Successful treatment of pediatric forearm fractures should result in complication-free functional pronosupination. Again, despite a changing ratio of operative to nonoperative management of these fractures, no high-level evidence exists to guide management. Several lower-level studies have shown good outcomes with closed reduction and casting, particularly for younger patients. Tarmuzi et al22 reviewed 48 forearm fractures treated with closed reduction and casting in children aged 4 to 12, and found that all but 1 had a satisfactory outcome. Zionts et al23 examined diaphyseal forearm fractures treated conservatively in 25 older children (8.8 to 15.5 y old) and found that loss of pronation and supination averaged 4 and 6.8 degrees, respectively, with all patients achieving full ROM. This contradicted an earlier study from Kay et al,24 in 1986, who found poorer results in children over 10 years old treated conservatively; Carey et al,25 in 1992, also found that children older than 10 with conservatively treated forearm fractures sustained residual angulation and some loss of motion, but without functional detriment. Lower-level evidence points to generally excellent results with closed reduction and casting, although less so for older patients (Fig. 1) (Table 1).

FIGURE 1

FIGURE 1

TABLE 1

TABLE 1

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OPERATIVE MANAGEMENT

In the last decade, a number of lower-level studies have reviewed the results of operative management of pediatric forearm fractures. Kang et al26 found that in 90 consecutive pediatric patients treated with intramedually nailing, all ultimately were pain free and unlimited in their activities; however, there were 11 complications, including 1 compartment syndrome. Flynn et al,1 in reviewing 11 years of forearm fracture management in children, found intramedullary fixation to have an overall complication rate of 14.6%, again including compartment syndrome; Shah et al,27 in a review of 61 adolescents treated operatively, reported no major complications when using intramedullary nailing, but 5 when performing open reduction and internal fixation. Smith et al28 retrospectively compared 50 children with both-bone fractures treated with closed reduction and casting versus intramedullary nailing versus open reduction internal fixation and found significantly higher complication rates in the operative groups, 33% for open reduction internal fixation and 42% for intramedullary nailing. A number of other lower-level studies comparing plating to intramedullary fixation suggest that plating takes longer to perform and is less cosmetic28–31 (Figs. 2A and B) (Table 1).

FIGURE 2

FIGURE 2

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CONCLUSIONS

Taken as a whole, the data from the limited set of studies available suggest that closed treatment does usually result in satisfactory outcomes, particularly in younger patients; operative fixation is usually successful as well but comes with a significantly increased complication rate. Maintenance or restoration of pronosupination and minimization of complications are 2 essential elements in evaluating the success of forearm facture management. Currently available literature is much clearer on the complication rate of each method of treatment than final ROM; most published studies do not adequately address true, final range of pronation and supination.

On the basis of the implications of the currently available lower-level evidence and the paucity of high-level evidence, a well-designed prospective study could dramatically aid in evidence-based decision-making for the treatment of pediatric forearm fractures. Such a study might be: a randomized controlled trial comparing closed reduction and casting versus intramedullary nailing versus plating; in children ranging from 8 years old to skeletally mature; with closed forearm fractures, complete or greenstick with >20 degrees of angulation; with a minimum of 5 years of follow-up (or to maturity); with the primary outcome defined as final pronation and supination; using an validated functional outcome tool; and precisely defining the complications from each treatment. Such a study would help to precisely delineate when and in which patients the likely functional loss of motion would be debilitating enough to warrant the added cost and risks associated with operative fixation, and might either justify the recent increase in surgical management of pediatric forearm fractures or argue for a return to more traditional conservative management (Fig. 3).

FIGURE 3

FIGURE 3

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REFERENCES

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26. Kang SN, Mangwani J, Ramachandran M, et al. Elastic intramedullary nailing of paediatric fractures of the forearm: a decade of experience in a teaching hospital in the United Kingdom. J Bone Joint Surg Br. 2011;93:262–265
27. Shah AS, Lesniak BP, Wolter TD, et al. Stabilization of adolescent both-bone forearm fractures: a comparison of intramedullary nailing versus open reduction and internal fixation. J Orthop Trauma. 2010;24:440–447
28. Smith VA, Goodman HJ, Strongwater A, et al. Treatment of pediatric both-bone forearm fractures: a comparison of operative techniques. J Pediatr Orthop. 2005;25:309–313
29. Teoh KH, Chee YH, Shortt N, et al. An age- and sex-matched comparative study on both-bone diaphyseal paediatric forearm fracture. J Child Orthop. 2009;3:367–373
30. Reinhardt KR, Feldman DS, Green DW, et al. Comparison of intramedullary nailing to plating for both-bone forearm fractures in older children. J Pediatr Orthop. 2008;28:403–409
31. Fernandez FF, Egenolf M, Carsten C, et al. Unstable diaphyseal fractures of both bones of the forearm in children: plate fixation versus intramedullary nailing. Injury. 2005;36:1210–1216
Keywords:

evidence-based medicine; forearm fractures; pediatrics

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