Chapter 12: Diaphyseal Radius and Ulna Fractures

Charles T. Mehlman, Eric J. Wall

Chapter Outline

Introduction to Diaphyseal Radius and Ulna Fractures

Injuries to the shafts of the radius and ulna are the most common reasons for children to receive orthopedic care60,62,203 and are among the most challenging to the orthopedist because of their treatment complexity and risk of complications.79,233,257 Because of numerous differences in both treatment and prognosis, shaft fractures are considered to be clinically distinct from fractures of the distal (metaphyseal fractures and physeal fractures) and proximal (radial neck fractures and physeal fractures) ends of the same bones.71,145,282,323,328,329 Many shaft injuries in children are effectively treated with skillful closed fracture care,162,256,354 but failures continue to occur despite good orthopedic intentions.40 Care by reduction, splint/cast molding, remanipulation, and recasting, as well as treatment of delayed union, malunion, and refracture must be mastered. 
Over the past 10 years there has been a dramatic increase in surgical fixation of forearm shaft fractures,139,301 primarily with elastic nails.103 Shaft fractures of the forearm are also the most common reason for operative care of the forearm in children.60,128 The evolving indications for surgical treatment of forearm shaft fractures and the resulting outcomes will be covered in detail in this chapter. Thus, it is very important for orthopedic surgeons who treat children to skillfully manage the cognitive and technical aspects of both nonoperative and operative treatment for injuries to the shafts of the radius and ulna. 
Risk is a central concept in clinical epidemiology.215 Landin185 has shown that the overall risk of fracture in children slowly increases for both males and females until they are 11 or 12 years old and then drops for females and increases further for males (Fig. 12-1). This risk difference is starkly illustrated by the fact that males who are 13 or older have approximately double the fracture rate of their female peers.185 Forearm fractures have been reported to be the most common pediatric fracture associated with backyard trampoline use27 and the second most common one (supracondylar humeral fractures were first) associated with monkey bars.342 Using a national database, Chung and Spilson62 looked at the frequency of upper extremity fractures in the United States and found that the single largest demographic group was fractures of the radius and ulna in children aged 14 years or less, with a rate approaching 1 in 100. Two groups of researchers have recently evaluated the relationship between bone mineral density and forearm fractures in children. Using DXA scans Andre Kaelin and his co-authors in Geneva, Switzerland prospectively studied 50 teenagers presenting with their first forearm fracture and 50 healthy controls and found no significant differences between the groups.54 These same authors suggested that forearm fractures in such teenagers do not appear to be related to osteopenia.54 However, Laura Tosi and her fellow researchers studied African American children (5 to 9 years of age) in Washington, DC. and found that those who sustained forearm fractures did demonstrate lower bone mineral density and lower vitamin D levels.276 Therefore taking a calcium intake history on forearm fracture patients remains a prudent practice. 
Figure 12-1
Annual incidence of all fractures in children.
 
(From Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B. 1997; 6:79–83.)
(From 


Landin LA
.
Epidemiology of children's fractures.
J Pediatr Orthop B.
1997;
6:79–83.)
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Figure 12-1
Annual incidence of all fractures in children.
(From Landin LA. Epidemiology of children's fractures. J Pediatr Orthop B. 1997; 6:79–83.)
(From 


Landin LA
.
Epidemiology of children's fractures.
J Pediatr Orthop B.
1997;
6:79–83.)
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X
Large studies that distinguish distal radial fractures from forearm shaft fractures indicate that overall, radial shaft injuries rank as the third most common fracture of childhood (behind distal radial and supracondylar humeral fractures).60 Open fractures in children are most often fractures of the shaft of the radius and ulna or tibial shaft fractures.60 Among pediatric fractures, forearm shaft injuries are the most common site of refracture.185 Forearm shaft fractures have been shown to occur most commonly in the 12- to 16-year-old age group, a challenging age group to treat.60 The impact of increasing age on fracture incidence is further illustrated by Worlock and Stower,353 who showed that the rate of forearm shaft fractures in school-age children (more than 5 years old) is more than double than that in toddlers (1.5 to 5 years old). Age also may have an effect on injury severity. Many experienced clinicians have pointed out the increasing level of treatment difficulty as the level of forearm fracture moves proximally,71,145,243,328,329 and more proximal fractures tend to occur in older patients.71 

Assessment of Diaphyseal Radius and Ulna Fractures

Mechanisms of Injury for Diaphyseal Radius and Ulna Fractures

The primary mechanism of injury associated with radial and ulnar shaft fractures is a fall on an outstretched hand that transmits indirect force to the bones of the forearm.3,66,167 Biomechanical studies have suggested that the junction of the middle and distal thirds of the radius and a substantial portion of the shaft of the ulna have an increased vulnerability to fracture.151 Often, a significant rotational component is associated with the fall, causing the radius and ulna to fracture at different levels (Fig. 12-2).93,210 If the radial and ulnar fractures are near the same level, a minimal torsional component can be inferred (Fig. 12-3). If comminution is present, higher-energy trauma should be suspected.84 Significant hyperpronation forces are associated with isolated shaft fractures of either the radius or the ulna and concomitant dislocation of either the distal or the proximal radioulnar joint (PRUJ). Thus, in any single-bone forearm shaft fracture, these important joints need to be closely scrutinized. Galeazzi and Monteggia fracture dislocations are discussed in Chapters 11 and 14, respectively. 
Figure 12-2
Radius and ulna shaft fractures occurring at different levels, implying rotational mechanism.
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Figure 12-3
Radial and ulnar shaft fractures occurring at same level, implying no significant rotation.
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A direct force to the arm (such as being hit by a baseball bat) can fracture a single bone (usually the ulna) without injury to the adjacent distal or PRUJs.31 Isolated ulnar shaft fractures have been referred to as “nightstick fractures.” Alignment of the radial head should be confirmed in any child with such a fracture to avoid a “missed Monteggia” injury.149 Isolated radial shaft fractures are rare but notoriously difficult to reduce with closed methods.70,92 
The mechanisms of injury of two particular forearm fracture patterns, traumatic bowing (also known as bow fractures or plastic deformation)264 and greenstick fracture, also bear mentioning. The bone behaves differently based on the direction of the forces applied to it. This is the so-called anisotropic property of bone, and it can be simply explained as follows: Bone is more resistant to axial forces than to bending and rotational forces.51 Pediatric bone also is much more porous than its adult counterpart and behaves somewhat differently from a biomechanical standpoint.55,236 Because of its porosity, pediatric bone absorbs significantly more energy prior to failure than the adult bone does.74 When relatively slowly applied, longitudinal forces bend the immature bone beyond its elastic limits and into its plastic zone, resulting in traumatic bowing.36,201 Thus, when a bending force is applied relatively slowly, many microfractures occur along the length of the bone, leading to macroscopic deformity without discernible radiographic fracture. This bending can usually be seen radiographically if suspected. 
Greenstick fractures represent an intermediate step between plastic deformation and complete fractures.52 On anteroposterior (AP) and lateral radiographs, greenstick fractures show cortical violation of one, two, or three of their radiographic cortices, and thus some bony continuity is preserved. Rotational deformity is considered to be intimately related to the clinical deformity seen with greenstick fractures of the forearm, and the analogy of a cardboard tube that tends to bend as it is twisted has been offered by Holdsworth.145 Specifically, hyperpronation injuries usually are associated with apex-dorsal greenstick fractures of the forearm, and hypersupination injuries usually are associated with the opposite, apex-volar injuries.92,223 The treatment of these greenstick fractures requires a derotation maneuver in addition to correction of any angulation.52,133 

Associated Injuries with Diaphyseal Radius and Ulna Fractures

Most fractures of the shafts of the radius and ulna occur as isolated injuries, but wrist and elbow fractures may occur in conjunction with forearm fractures, and the elbow and wrist region needs to be included on standard forearm radiographs.26,75,167,314,351,358 If clinical suspicion is high, then dedicated wrist and elbow films are necessary. The so-called floating elbow injury (fracture of the bones of the forearm along with ipsilateral supracondylar humeral fracture) is a well-described entity that must not be missed.26,272,314,351 Surgical stabilization of both the supracondylar fracture and the forearm fractures has been recommended by multiple authors in recent years30,138,271,272,319,322 to avoid the risk of a compartment syndrome. Galeazzi and Monteggia fracture dislocations also must be ruled out. Compartment syndrome can also occur in conjunction with any forearm shaft fracture.73,362 This rare but potentially devastating complication can lead to a Volkmann ischemic contracture, which has been shown to occur after forearm shaft fractures almost as often as it does after supracondylar humeral fractures in children.224 Patients with severe pain unrelieved by immobilization and mild narcotic medication should be reassessed for excessive swelling and tight forearm compartments. If loosening of the splint, cast, and underlying cast materials fails to relieve pain, then measurement of compartment pressures and subsequent fasciotomy may be necessary. 
Abrasions or seemingly small unimportant lacerations that occur in conjunction with forearm fractures must be carefully evaluated because they may be an indication of an open fracture. Clues to the presence of an open fracture include persistent slow bloody ooze from a small laceration near the fracture site and subcutaneous emphysema on injury films. Careful evaluation and, in some situations, sterile probing of suspicious wounds will be necessary. Open forearm fractures are discussed later in this chapter. 
Vascular or neurologic injuries are rarely associated with forearm shaft fractures, but the consequences of such injuries are far-reaching. Serial neurovascular examinations should be performed and documented. Radial and ulnar pulses along with distal digital capillary refill should be routinely evaluated. Davis and Green79 reported nerve injuries in 1% (5/547) of their pediatric forearm fracture patients, with the most commonly injured nerve being the median nerve. Combined data from three large series of pediatric open forearm fractures reveal an overall nerve injury rate at presentation of 10% (17/173), with the median nerve once again being the one most commonly injured.128,135,198 To screen for these rare but significant injuries, every child with a forearm fracture should routinely have evaluation of the radial, ulnar, and median nerves for both motor and sensory function.70 Nerve injuries occurring at the time of injury must be differentiated from treatment-related or iatrogenic neurologic deficits. 
Davidson78 suggested using the game of “rock-paper-scissors” for testing the median, radial, and ulnar nerves (Fig. 12-4). The pronated fist is the rock and tests median nerve function. The extended fingers and wrist depict paper and test radial nerve function. Fully flexed small and ring fingers, an adducted thumb, and spreading the index and ring fingers mimic scissors and test ulnar nerve function. Further focused testing should also be done on two important nerve branches: The anterior interosseous nerve (branch of median nerve) and the posterior interosseous nerve (branch of radial nerve). The anterior interosseous nerve provides motor function to the index flexor digitorum profundus, the flexor pollicis longus, and pronator quadratus and is best tested by having the patient make an “OK” sign. The posterior interosseous nerve typically innervates the extensor carpi ulnaris, extensor digitorum communis, extensor digiti minimi, extensor indicis, and the three outcropping muscles of the thumb (abductor pollicis longus, extensor pollicis brevis, and extensor pollicis longus).42 Its function is best documented by full extension of the phalangeal and metacarpophalangeal joints. This is especially difficult to test in a patient in a cast or splint that partially covers the fingers. Most injuries that occur in association with forearm fractures are true neurapraxias and typically resolve over the course of days to weeks.73,79 
Figure 12-4
Upper extremity motor nerve physical examination.
 
A: Rock position demonstrates median nerve motor function. B: Paper position demonstrates radial nerve motor function. C: Scissor position demonstrates ulnar nerve motor function. D: “OK” sign demonstrates function of anterior interosseus nerve.
A: Rock position demonstrates median nerve motor function. B: Paper position demonstrates radial nerve motor function. C: Scissor position demonstrates ulnar nerve motor function. D: “OK” sign demonstrates function of anterior interosseus nerve.
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Figure 12-4
Upper extremity motor nerve physical examination.
A: Rock position demonstrates median nerve motor function. B: Paper position demonstrates radial nerve motor function. C: Scissor position demonstrates ulnar nerve motor function. D: “OK” sign demonstrates function of anterior interosseus nerve.
A: Rock position demonstrates median nerve motor function. B: Paper position demonstrates radial nerve motor function. C: Scissor position demonstrates ulnar nerve motor function. D: “OK” sign demonstrates function of anterior interosseus nerve.
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Signs and Symptoms of Diaphyseal Radius and Ulna Fractures

The signs and symptoms indicating fracture of the shafts of the radius and ulna usually are not subtle. Deformity and pain are the classic findings. Patients typically experience exquisite pain emanating from the involved area. Decreased pronation and supination motion are also usually noted.309 Neither practitioners nor parents are always reliable assessors of children's pain, and ideally patients should rate their own pain.172,299 Significant anxiety and muscle spasm almost always amplify a child's painful experience.46,117 It has been suggested that muscle spasm is a protective effort by the body to splint or otherwise protect the injured body part.117 When such muscle spasm occurs in association with certain fracture patterns (e.g., a radial shaft fracture proximal to the pronator teres insertion), it produces predictable fracture displacement (e.g., a pronated distal radial fragment and a supinated proximal fragment). 
More subtle fractures present special diagnostic challenges. Certain pathologic fractures of the forearm may occur in the absence of overt trauma.157,181 Many minimally displaced fractures of the shafts of the radius and ulna can be mistaken for a “sprain” or “just a bruise” for several days to several weeks. This usually occurs in young children who continue to use the fractured arm during low-level play activities. As a general rule, a fracture should be suspected if the child has not resumed all normal arm function within 1 or 2 days of injury. 

Imaging and Other Diagnostic Studies for Diaphyseal Radius and Ulna Fractures

Because important forearm fracture treatment decisions frequently are based on radiographic measurement of angular deformities, it must be remembered that these angles are projected shadows that are affected by rotation.102 If angulation is present on both AP and lateral views (commonly called two orthogonal views), the true deformity is out of the plane of the radiographs, and its true magnitude is greater than that measured on each individual view. Certain forearm shaft fracture deformities are clearly “two-plane deformities” whose maximal angular magnitude is in some plane other than the standard AP or lateral plane (Fig. 12-5).16 Bar and Breitfuss16 produced a table (based on the Pythagorean theorem) that predicts the true maximal angulation. Accurate deformity measurement can be made when angulation is seen on only one view and there is no angulation on the other orthogonal view. 
Figure 12-5
Underestimation of true angulation.
 
A: “Out of the AP and lateral plane” underestimates angulation at 30 degrees. B: True AP and lateral demonstrates that true maximal angulation is 40 degrees.
A: “Out of the AP and lateral plane” underestimates angulation at 30 degrees. B: True AP and lateral demonstrates that true maximal angulation is 40 degrees.
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Figure 12-5
Underestimation of true angulation.
A: “Out of the AP and lateral plane” underestimates angulation at 30 degrees. B: True AP and lateral demonstrates that true maximal angulation is 40 degrees.
A: “Out of the AP and lateral plane” underestimates angulation at 30 degrees. B: True AP and lateral demonstrates that true maximal angulation is 40 degrees.
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Evans pointed out the importance of tracking the rotational alignment of the free-moving radial fragment by ascertaining the relative location of the bicipital tuberosity. This was a major step forward in refining the orthopedic care of these forearm injuries. On a fully supinated AP radiograph of an unfractured forearm, the bicipital tuberosity points predominantly in a medial direction (nearly 180 degrees opposite of the radial tuberosity).94 The radius and ulna are also nearly parallel to each other on such a view. On a fully pronated AP radiograph of an unfractured forearm, the bicipital tuberosity points in a lateral direction and the radial tuberosity is situated medially.94 The radius also crosses over the ulna in a pronated AP view. Rang265 noted that in an unfractured limb, the bicipital tuberosity tended to align with a point near the thenar eminence (Fig. 12-6), more nearly a 165-degree relationship than a true 180-degree one. These relationships are best assessed on standard radiographs that include the entire forearm on one film75,257,329 rather than the specialized bicipital tuberosity view originally suggested by Evans.94 A CT scan of both forearms with cuts through the bicipital tuberosity and the radial styloid is probably the best way to accurately identify a rotational malunion after a fracture that could be causing a loss of forearm rotation. The ulna can be similarly assessed by comparing the distal ulnar styloid to the proximal coronoid process on orthogonal views (similar to bicipital tuberosity and radial styloid, the coronoid process, and ulnar styloid should be 180 degrees apart). CT scan cuts of the coronoid process and the ulna styloid on the fractured and nonfractured sides are most reliable for measuring the rotational alignment of the ulna. 
(From 


Rang M
. Children's Fractures. Philadelphia, PA: JB Lippincott, 1974:126.)
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Figure 12-6
Rang's illustration depicting the position of the bicipital tuberosity on AP and lateral views with the forearm in pronation, supination, and neutral position.
(From Rang M. Children's Fractures. Philadelphia, PA: JB Lippincott, 1974:126.)
(From 


Rang M
. Children's Fractures. Philadelphia, PA: JB Lippincott, 1974:126.)
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Classification of Diaphyseal Radius and Ulna Fractures

Fractures of the shafts of the radius and ulna often are described in rather imprecise terms such as “both-bone forearm fracture” and “greenstick fracture.” Radiographs confirm the diagnosis of forearm shaft fracture and are the basis for most classification systems. The most comprehensive classification of forearm fractures is the one adopted by the Orthopaedic Trauma Association (OTA).10 Although this system is sound in concept, its 36 discrete subtypes10 make it impractical for everyday clinical use, and it has not been widely used by clinical researchers.269 Despite its complexity, the OTA classification does not account for one of the most important prognostic factors in pediatric forearm shaft fracture: Location of the fracture in the distal, middle, or proximal third of the shaft. 
Clinicians and clinical researchers have favored simpler descriptions of forearm shaft fractures. An orderly and practical approach to forearm shaft fracture classification should provide information about the bone (single bone, both bones), the level (distal, middle, or proximal third), and the pattern (plastic deformation, greenstick, complete, comminuted). Bone involvement is important because it not only indicates the severity of injury but also influences suspicion regarding additional soft tissue injury (e.g., single-bone injury increases the likelihood of a Monteggia or Galeazzi injury)333 and affects reduction tactics (unique single-bone fracture reduction strategies can be used) (Fig. 12-7). Single-bone shaft fractures occur, but both-bone fractures are far more common. Level is important for anatomic reasons relative to muscle and interosseous ligament attachments, as well as differences in prognosis for distal-, middle-, and proximal-third shaft fractures. The pattern is important because it significantly alters the treatment approach. For example, the primary reduction strategy is very different for greenstick fractures (rotation) compared to that for complete fractures (vertical traction). Certain comminuted fractures (e.g., comminution of both bones) may preclude reduction and casting and require surgical fixation.104,106 Fortunately, comminuted fracture patterns are rare in children. For all practical purposes, the buckle fracture pattern that is common in the distal radial metaphysis never occurs in isolation in the shaft region. The typical buckle fracture “speed bump” may accompany either plastic deformation or greenstick fractures. Thus, there are two bones, three levels, and four common fracture patterns (Fig. 12-8). We believe this is a practical and clinically relevant way to describe forearm shaft fractures.216 
Figure 12-7
Isolated ulnar shaft reduction technique (Blount).
 
Valgus force applied to fracture site and direct thumb pressure over distal ligament.
Valgus force applied to fracture site and direct thumb pressure over distal ligament.
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Figure 12-7
Isolated ulnar shaft reduction technique (Blount).
Valgus force applied to fracture site and direct thumb pressure over distal ligament.
Valgus force applied to fracture site and direct thumb pressure over distal ligament.
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Figure 12-8
Practical classification of forearm shaft fractures.
 
(Distal dotted line defined by proximal extent of the Lister tubercle and proximal dotted line defined by proximal extent of bicipital tuberosity.)
(Distal dotted line defined by proximal extent of the Lister tubercle and proximal dotted line defined by proximal extent of bicipital tuberosity.)
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Figure 12-8
Practical classification of forearm shaft fractures.
(Distal dotted line defined by proximal extent of the Lister tubercle and proximal dotted line defined by proximal extent of bicipital tuberosity.)
(Distal dotted line defined by proximal extent of the Lister tubercle and proximal dotted line defined by proximal extent of bicipital tuberosity.)
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Once the forearm fracture has been described in the terms of this practical classification, fracture displacement must be evaluated. Fracture displacement can occur as angulation, rotation, shortening, or translation. Angulation is important in treatment decision-making and can be measured with reasonable reliability.189,320 Rotation is a simple concept, but it is difficult to assess clinically.93,257 The best that usually can be done is to roughly estimate rotation within a 45-degree margin of error.71,257 Based on available clinical studies, it appears that less than 1 cm of shortening should be accepted in either single-bone or both-bone fracture patterns.50,80,85,214,274 It has also been suggested that the shortening that accompanies displaced fractures may help preserve future motion through interosseous membrane relaxation.257 Completely (100%) translated fractures of the middle third71,257 and distal third85,214,274 of the forearm have been shown to reliably remodel. Certain situations may raise concern regarding complete translation, such as isolated middle-third radial fractures with medial (ulnar) displacement that significantly narrows the interosseous space and translation in children who have less than two full years of growth remaining, because remodeling of the translated fracture site is less predictable than in younger children.233,236 

Outcome Measures for Diaphyseal Radius and Ulna Fractures

The fundamental reason for treating fractures of the shafts of the radius and ulna relates to the likelihood of bad results in the absence of adequate care. Data from certain developing countries may be as close as we come to natural history studies of untreated fractures. Archibong and Onuba12 reported on 102 pediatric fracture patients treated in Southeastern Nigeria. Their patients most commonly had upper extremity fractures, and they frequently experienced significant delays in seeking medical treatment, which led to high rates of malunion requiring surgical treatment.12 Other Nigerian authors have found that young age was not protective against fracture malunion (more than 50%) and nonunion (25%) following traditional bonesetter treatment.239 It is unclear whether children treated in this fashion are better or worse off than if they had received no treatment at all. The rationale for treating pediatric forearm shaft fractures is thus based on the premise that the results of modern orthopedic treatment will exceed “pseudo-natural histories” such as these. 
The consequences of excessively crooked (and malrotated) forearm bones are both aesthetic and functional (Fig. 12-9).28,33,145,209,232,329 Limited forearm supination following a forearm shaft malunion is illustrated in Figure 12-10. Despite their great concern to parents, aesthetic issues have not been formally studied, and as a result the practitioner must interpret forearm appearance issues on a case-by-case basis. Clinical experience has shown that the ulna appears to be less forgiving from an aesthetic standpoint because of its long subcutaneous border. Early and repeated involvement of the parents (or other legal guardians) in an informed and shared decision-making process is essential. 
Figure 12-9
Effect of forearm malunion on forearm motion.
 
A: Normal arc of forearm motion. B: Angulated radius leads to diminished arc of forearm motion.
 
(From Ogden JA. Skeletal Injury in the Child. Philadelphia, PA: Lea & Febiger; 1982:56–57.)
A: Normal arc of forearm motion. B: Angulated radius leads to diminished arc of forearm motion.
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Figure 12-9
Effect of forearm malunion on forearm motion.
A: Normal arc of forearm motion. B: Angulated radius leads to diminished arc of forearm motion.
(From Ogden JA. Skeletal Injury in the Child. Philadelphia, PA: Lea & Febiger; 1982:56–57.)
A: Normal arc of forearm motion. B: Angulated radius leads to diminished arc of forearm motion.
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Figure 12-10
A 6-year-old male who suffered a right forearm shaft malunion.
 
A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
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A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
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Figure 12-10
A 6-year-old male who suffered a right forearm shaft malunion.
A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
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A: Radiograph one week after fracture showing complete midshaft ulnar and proximal-third radial fractures. B: Healed fractures at 6-month follow-up. C: Twenty-month follow-up. D: Twenty-six month follow-up. E: Symmetrical pronation. F: Limited supination on the right G: Axial alignment with palms together. H: An effort at supination. I: Axial alignment in pronation.
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Bony malunion and soft tissue fibrosis have both been implicated as causes of limited forearm motion after forearm shaft fractures.144,232 Limited forearm pronation and supination can have significant effects on upper extremity function.26,245,257 Inability to properly pronate often can be compensated for with shoulder abduction, but no easy compensatory mechanism exists for supination deficits.70,145,245,257 Daruwalla75 identified a nearly 53% rate of limited forearm rotation (subtle in some, dramatic in others) in his series of 53 children with forearm fractures and attributed it to angular deformity and rotational malalignment. Several patients in Price's257 classic series of pediatric forearm malunions had severe forearm range-of-motion losses that significantly limited vocational and recreational activities. Trousdale and Linscheid329 reported range-of-motion losses severe enough to prompt corrective osteotomies in many of their predominantly pediatric (less than 14 years old at time of injury) patients with forearm malunions. Meier217 also reported significant range-of-motion deficits in association with pediatric forearm malunion. 
Range-of-motion losses caused by deformity have been studied by numerous authors using adult cadaveric forearm specimens. Matthews et al.209 studied 10- and 20-degree midshaft angular deformities of the radius and ulna in 10 forearm specimens. They found that 10-degree deformities of either bone individually resulted in little or no measurable motion loss (in the range of 3 degrees or less). When both bones were angulated 10 degrees dorsal, volar, or toward the interosseous membrane, larger motion losses were documented (approximately 10-degree pronation and 20-degree supination). Significantly greater losses of motion occurred when one or both bones were angulated 20 degrees (approximately 40 degrees for both pronation and supination). Some of the 10-degree angulated specimens demonstrated “cosmetically unacceptable deformity.”209 These findings indicate that relatively small angular deformities can be clinically significant. 
Additional important information about the influence of fracture level on forearm motion was provided by a series of adult cadaver experiments conducted by Sarmiento et al.281,321 They found that fracture angulation of 15 to 30 degrees led to greater supination losses when the deformity was in the middle third of the forearm (40 to 90 degrees) and greater pronation losses when in the distal third (30 to 80 degrees).321 Fracture angulation of 10 degrees or less in the proximal or middle forearm rarely resulted in more than 15 degrees of motion loss,281,321 but the same angulation in the distal third of the forearm was at times (usually with isolated radius fracture) associated with pronation losses of 20 degrees.281,321 These findings challenge commonly held beliefs that the distal third of the forearm is the most forgiving. These same authors asserted that rotational malalignment led to rotational motion losses that usually were equal in magnitude and opposite in direction to the deformity (e.g., a 10-degree pronation deformity led to a 10-degree loss of supination).321 
Rotational malalignment of the forearm has been studied in greater detail in recent years, mostly in adults and in the laboratory.88,169,330 In isolated midshaft radial fractures, more than 30 degrees of malrotation was a threshold for significant losses in motion (approximately 15 degrees).169 Isolated midshaft ulnar fracture malrotation did not alter the total arc of forearm motion but did change the set point (e.g., a 30-degree pronation deformity took away 30 degrees of pronation and added 30 degrees of supination).330 Larger ulnar axial malalignment of 45 degrees decreased overall forearm rotation by no more than 20 degrees.330 Large residual ulnar shaft translation has similarly been found to have little impact on forearm rotation.212 Simulated combined radial and ulnar midshaft rotational malunions resulted in the worst motion (more than 50% losses of pronation and supination when 60-degree rotational malunions were in opposite directions).88 Rotational malunions that approximated recommended limits in the literature (45 degrees)257 produced less extreme but real limitations of motion (Table 12-1).88 From these studies and our clinical experience, it appears that the radius is more sensitive to rotational problems and less sensitive regarding aesthetic issues, whereas the ulna is exactly the opposite. 
 
Table 12-1
Condensed Range-of-Motion Information
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Table 12-1
Condensed Range-of-Motion Information
Ulna 40 Degrees Pronated
  •  
    Radius 40 degrees pronated
  •  
    102/52
  •  
    105/57
  •  
    62/65
Ulna 0 Degrees Neutral
  •  
    Radius neutral
  •  
    97/58
  •  
    90/90
  •  
    69/107
Ulna 40 Degrees Supinated
  •  
    Radius 40 degrees supinated
  •  
    53/55
  •  
    52/95
  •  
    46/110
 

Numerator is pronation whereas denominator is supination.

 

Data from: Dumont CE, Thalmann R, Macy JC. The effect of rotational malunion of the radius and ulna on supination and pronation. J Bone Joint Surg Br. 2002; 84:1070–1074; with permission.

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Several generations of orthopedic surgeons have been taught that 50 degrees of pronation and 50 degrees of supination represent adequate forearm motion.222 It must be remembered that this classic study performed by Morrey and his Mayo Clinic colleagues involving 33 normal subjects (18 female, 15 male) from 21 to 75 years of age is not the only study that addresses forearm motion. The average arc of normal forearm motion for the Mayo group (68-degree pronation to 74-degree supination)222 was approximately 20 degrees less than that measured in 53 healthy male subjects who were not older than 19 years old (77-degree pronation to 83-degree supination) reported by Boone and Azen35 and 35 degrees less than that reported by Rickert et al.270 (75-degree pronation to 100-degree supination) in 141 subjects of both sexes between 20 and 30 years of age. Contemporary three-dimensional motion analysis has revealed that maximal pronation occurs when pouring liquid from a pitcher and maximal supination commonly occurs during personal hygiene activities.262 Thus, it seems clear that the forearm motion “goals” reported by Morrey et al.222 are not necessarily ideal or even optimal, but rather they may be considered as the minimal limits of forearm function. Stated another way, losing 20 degrees or 30 degrees of either pronation or supination carries the potential for significant functional impact upon important activities of daily living. At the present time, loss of pronation can affect keyboarding and computer usage. 
The goal of treatment is to achieve satisfactory healing of the forearm injury within the established anatomic and functional guidelines while also taking into account the reasonable degree of remodeling that can be expected in growing children.156 Most of the time, these goals can be achieved with closed fracture care, and little or no radiographic or clinical abnormality can be detected following healing. A paradox exists in pediatric forearm fractures whereby anatomic radiographic alignment is not always associated with normal motion, and normal motion often is associated with nonanatomic radiographic healing.144,228,232,321 Herein lies the inherent controversy between operative and nonoperative treatment approaches (Table 12-2). In patients with anatomic radiographs, range-of-motion problems usually have been attributed to scarring of the interosseous membrane.170,245,257 With nonanatomic radiographs (incomplete remodeling), range-of-motion deficits usually are attributed to the radiographic abnormalities. Thus, treatment of forearm shaft fracture must balance the risk of allowing stiffness to occur secondary to malunion against the risk of creating stiffness secondary to surgical procedures. 
 
Table 12-2
Pros and Cons of Cast Versus Surgical Treatment
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Table 12-2
Pros and Cons of Cast Versus Surgical Treatment
Pros and Cons
Cast Treatment
  •  
    Long track record
  •  
    Anatomic reduction rare
  •  
    Negligible infection risk
  •  
    Stiffness may still occur
  •  
    Fine-tuning possible
  •  
    Frequent follow-up visits
Surgical Treatment
  •  
    Anatomic reduction
  •  
    Risk of infection
  •  
    Minimize immobilization
  •  
    Need for implant removal
  •  
    Fewer follow-up visits
  •  
    Stiffness from surgery
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The rationalization for the remodeling of pediatric forearm fractures has strong historical support,22,31,48,241 but knowledge of the limits of remodeling must be taken into consideration. Established reduction criteria state that complete (100%) translation is acceptable,214,257 as well as up to 15 degrees of angulation and up to 45 degrees of malrotation.257 The fundamental reason for treating fractures of the shafts of the radius and ulna relates to the likelihood of bad results in the absence of adequate care or acceptable remodeling. As noted earlier, data from certain developing countries may be as close as we come to natural history studies of untreated fractures. Nigerian12,239 studies indicate high rates of malunion with untreated or bonesetter treatment of diaphyseal fractures. 
Published clinical studies have shown that pediatric forearm shaft fractures have great remodeling potential that occurs through several mechanisms.288 The distal radial epiphysis will redirect itself toward normal at about 10 degrees per year. As long as the physis is open, this rate is independent of age. Although the epiphysis will return to normal direction, it will have much less effect on correcting an angular deformity at the midshaft compared to fractures at the subphyseal level. Remodeling also occurs with lengthening of the bone through growth, which produces an apparent decrease in angulation, especially if measured as the difference between the proximal and distal ends of the bone. The bone also remodels by intramembranous apposition on the concave side and resorption on the convex side.74,156,288 This occurs throughout life, but more rapidly when driven by the thick periosteum found in children. Larsen186 found that although the epiphyseal angle realigns quickly, children older than 11 years correct bone angulation less than the younger children. Thomas stated the following regarding pediatric forearm remodeling potential: “We should not fail to recall that the remodeling capabilities of the bones of children have not changed in the last million years and that open reduction and internal fixation must be undertaken only after due deliberation.”323 Others such as Johari158 would state that if one critically evaluates the limits of forearm shaft remodeling capacity you will find a much higher rate (approximately 50%) of incomplete remodeling in children over 10 years of age. 
The perfect (or nearly perfect) pediatric diaphyseal forearm fracture outcome study has not yet been performed, therefore scientific answers regarding optimal treatment are lacking.107 However, there is a growing consensus among pediatric orthopedic trauma surgeons that there are patient subsets (usually older patients with more proximal fractures) whose outcomes are clearly improved by flexible intramedullary nail surgical intervention.347 A large retrospective cohort study focusing on radiographic outcomes has indicated that among pediatric forearm shaft fracture patients who underwent reduction, most (51%) exceed established radiographic criteria over the course of 2 to 4 weeks.40 This is greatly concerning as a very clear relationship exists between radiographic and clinical outcomes for forearm shaft injuries in both adults and children.37,87,166 For those patients deemed at higher risk, the risk–benefit ratio also appears to be favorable as flexible nail surgical complications are mainly minor and in some respects measurably lower than nonoperative forearm shaft fracture care.279,300 

Pathoanatomy and Applied Anatomy Relating to Diaphyseal Radius and Ulna Fractures

The forearm is a large nonsynovial joint with nearly a 180-degree arc of motion. Its bones, the radius and ulna, are not simple straight bony tubes. The shaft of the radius is a three-sided structure with two prominent curvatures. One major gradual convexity (approximately 10 degrees with its apex lateral-radial) is present along its midportion; a second, more acute curve of approximately 15 degrees with its apex medial occurs proximally near the bicipital tuberosity.100,127,278 The deviation along the midportion is commonly referred to as the radial bow, and maintenance of this normal contour is a goal of forearm shaft fracture care.260,284,285 The most important bony landmarks of the radius are the radial styloid (lateral prominence) and the bicipital tuberosity (anteromedial prominence), which are oriented about 135 degrees away from each other (Fig. 12-11).220 Maintenance of the styloid-tuberosity rotational relationship is another forearm shaft fracture principle. The nutrient artery of the radius enters the bone in its proximal half and courses anterior to ulnar (medial).120 Such nutrient vessels typically are seen on only one orthogonal view and should not be confused with fracture lines. In cross section, most of the shaft of the ulna is also shaped like a classic three-sided prism, although its more distal and proximal portions are much more circular. The most important bony landmarks of the ulna are its styloid process (distally) and its coronoid process (proximally). These two landmarks are oriented nearly 180 degrees from one another, with the styloid aimed in a posterior (dorsal) direction and the coronoid in an anterior (volar) direction.220 Tracking styloid–coronoid rotational alignment of the ulna is another part of forearm shaft fracture care. The ulnar shaft has mild curvatures in both its proximal (apex lateral/radial) and distal (apex medial/ulnar) portions but is otherwise relatively straight.127,278 The nutrient artery to the ulna enters the bone in its proximal half and courses anterior to radial (lateral).120 
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Figure 12-11
Radial and ulnar anatomy.
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The classic works of Evans helped focus attention on rotational deformity associated with fractures of both bones of the forearm.94,210,264 Evans stated, “The orthodox position in which to immobilize these fractures is that of full supination for the upper third, and the midposition for fractures of the middle and lower thirds, these positions being based on the anatomical arrangement of the pronators and supinators of the forearm. However, it is unreasonable to suppose that all fractures at a given level will present the same degree of rotational deformity.”94 The radius and ulna are joined by three major passive restraints: The PRUJ, the distal radioulnar joint (DRUJ), and the interosseous membrane complex, all of which have important stabilizing and load-transferring functions. These structures allow rotation of the radius about the ulna along an axis that runs approximately from the center of the radial head to the center of the distal ulna.146,245 The PRUJ and DRUJ are discussed elsewhere in this book (Chapters 9 and 11). The structure and biomechanic function of the interosseous membrane have been studied extensively in recent years. Hotchkiss et al.150 showed that the central band of the interosseous membrane (the interosseous ligament) courses from a point near the junction of the proximal and middle thirds of the radius to a point near the junction of the middle and distal thirds of the ulna. It is an important longitudinal stabilizer of the forearm in that 71% of forearm longitudinal stiffness is provided by the interosseous ligament after radial head excision.150 Transverse vectors have also been identified248 and reflect the stabilizing effect of the interosseous ligament during pronation and supination movements. The interosseous ligament demonstrates tensile properties comparable to the patellar tendon and the anterior cruciate ligament,249 indicative of the magnitude of the arm forces to which this structure is subjected. 
Although some difference of opinion still exists,81,110,304 multiple studies have shown that the most strain in the central band of the interosseous membrane is generated when the forearm is in the neutral position.206,207,304 These findings of maximal strain in neutral in cadaver studies also are consistent with radiographic measurement studies71 and dynamic magnetic resonance imaging studies of the forearm showing that the interosseous space is maximal near a neutral position.229 This may help explain certain pathologic situations such as the fixed supination deformity of neonatal brachial plexus palsy211 as well as limitations of pronation and supination because of encroachment on the interosseous space from malangulated fractures (Fig. 12-12).359 The interosseous membrane also serves as an important anchoring point for several forearm muscles: The flexor digitorum profundus, flexor pollicis longus, extensor indicis, and the outcropping muscles (extensor digitorum brevis, abductor pollicus longus). 
Figure 12-12
Anatomy of interosseous ligament.
 
A: Central oblique orientation of interosseous ligament. B: Interosseous ligament attachment in terms of percentage forearm length.
 
(From Skahen JR III, Palmer AK, Werner FW, et al. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg Am. 1997; 22:986–994.)
A: Central oblique orientation of interosseous ligament. B: Interosseous ligament attachment in terms of percentage forearm length.
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Figure 12-12
Anatomy of interosseous ligament.
A: Central oblique orientation of interosseous ligament. B: Interosseous ligament attachment in terms of percentage forearm length.
(From Skahen JR III, Palmer AK, Werner FW, et al. Reconstruction of the interosseous membrane of the forearm in cadavers. J Hand Surg Am. 1997; 22:986–994.)
A: Central oblique orientation of interosseous ligament. B: Interosseous ligament attachment in terms of percentage forearm length.
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The paired and seemingly balanced radial and ulnar bones have an unbalanced number of muscular connections. The ulna typically has 14 attached muscles and the radius only 10 (Tables 12-3 and 12-4).86,127 Powerful supinators attach to the proximal third of the forearm, whereas important pronators attach to its middle and distal thirds (Fig. 12-13). The accompanying vasculature of the forearm is complex: These muscles are supplied by more than 248 vascular pedicles arising from the brachial artery, its branches, or other collateral vessels.268 The radial, ulnar, and median nerves (or their branches) along with the musculocutaneous nerve provide all of the key innervations to the motors that attach to the forearm bones. As mentioned earlier, the median nerve is the most commonly injured nerve with forearm fractures.78,79,128,135 
Table 12-3
Ten Muscles that Attach to the Radius (and their Innervation)
  1.  
    Abductor pollicis longus (PIN)
  2.  
    Biceps (musculocutaneous nerve)
  3.  
    Brachioradialis (radial nerve)
  4.  
    Extensor pollicis brevis (PIN)
  5.  
    Extensor pollicis longus (PIN)
  6.  
    Flexor digitorum superficialis (median nerve)
  7.  
    Flexor pollicis longus (AIN)
  8.  
    Pronator quadratus (AIN)
  9.  
    Pronator teres (median nerve)
  10.  
    Supinator (PIN)
 

AIN, anterior interosseous innervation; PIN, posterior interosseous nerve.

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Table 12-4
Fourteen Muscles that Attach to the Ulna (and their Innervation)
  1.  
    Abductor pollicis longus (PIN)
  2.  
    Anconeus (radial nerve)
  3.  
    Biceps (musculocutaneous nerve)
  4.  
    Brachialis (musculocutaneous and small branches; median and radial nerves)
  5.  
    Extensor carpi ulnaris (PIN)
  6.  
    Extensor indicis proprius (PIN)
  7.  
    Extensor pollicis longus (PIN)
  8.  
    Flexor carpi ulnaris (ulnar nerve)
  9.  
    Flexor digitorum profundus (AIN, index and long; ulnar nerve, ring and small)
  10.  
    Flexor digitorum superficialis (median nerve)
  11.  
    Pronator teres (median nerve)
  12.  
    Pronator quadratus (AIN)
  13.  
    Supinator (PIN)
  14.  
    Triceps (radial nerve)
 

AIN, anterior interosseous innervation; PIN, posterior interosseous nerve. Occasionally, the accessory head flexor pollicis longus (aka Gantzer muscle; from coronoid region in 15% of specimens) is innervated by AIN.

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Figure 12-13
Muscle forces acting in proximal, middle, and distal thirds.
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The radial nerve proceeds from a posterior to anterior direction and enters the forearm after passing the lateral epicondyle between the brachialis and brachioradialis muscles. Near this same level, it divides into superficial and deep terminal branches. The deep motor branch of the radial nerve is also known as the posterior interosseous nerve. In addition to its routine innervation of the brachioradialis and extensor carpi radialis longus, most commonly (55% of the time) a motor branch arises from the radial nerve proper or its superficial terminal branch to innervate the extensor carpi radialis brevis, whereas the rest of the time (45%) this motor branch comes from the posterior interosseous nerve.2 The superficial branch travels along with and beneath the brachioradialis. The posterior interosseous nerve enters the supinator muscle, passing the fibrous thickening called the arcade of Frohse shortly after branching from the radial nerve proper. It courses within the supinator past the proximal radius, later exiting this muscle dorsally (posteriorly) near the junction of the proximal and middle thirds of the radius. Following its emergence from the supinator, the posterior interosseous nerve branches repetitively to the superficial extensors and the deeper outcropping muscles. The ulnar nerve enters the forearm between the two heads of the flexor carpi ulnaris.122 It traverses the forearm between the flexor carpi ulnaris and the flexor digitorum profundus. In the distal forearm, it lays just beneath the flexor carpi ulnaris. The median nerve enters the forearm as it passes between the two heads of the pronator teres.57 It next passes beneath the archway created by the two heads of the flexor digitorum superficialis. The median nerve then continues down the course of the forearm nestled between the flexor digitorum superficialis and the flexor digitorum profundus. It becomes much more superficial as it nears the level of the carpal tunnel. The anterior interosseous branch arises from the median nerve at the level of the pronator and travels deep with the anterior interosseous vessels. Abundant muscles shield the radial, ulnar, and median nerves from the shafts of the radius and ulna through most of the forearm except for the posterior interosseous nerve near the proximal radius. 

Common Surgical Approaches of Diaphyseal Radius and Ulna Fractures

The large exposure required for plate fixation of pediatric forearm fractures can be achieved with: The Henry (anterior) or Thompson (posterior) approaches to the radial shaft and the direct (medial) approach to the ulnar shaft.72,226 Compartment syndrome release usually requires the serpentine incision of McConnell's combined approach.142 These approaches and their variations are well described and illustrated in detail elsewhere.4,18,90,148,296 For open reduction of both the radius and the ulna, most authors favor separate incisions to minimize the possibility of communicating hematoma and the development of a radioulnar synostosis.184,260,332 The Thompson approach to the radius is generally used for fractures of its proximal third357 but requires special care to protect the posterior interosseous nerve.83,218,318 Other authors have emphasized the utility of the Henry approach for plating of the entire radius including the proximal aspect.218 When open reduction is done in conjunction with other internal fixation techniques (e.g., intramedullary fixation), limited versions of the same surgical approaches are used. 
Indirect reduction and internal fixation of forearm fractures require knowledge of appropriate physeal-sparing entry portals about the distal and proximal forearm. Because of the relative inaccessibility of its proximal end, the radius usually is approached only distally through either a dorsal or radial entry point. The dorsal entry point is near the proximal base of the Lister tubercle or just lateral to it in a small bare area between the second and third dorsal compartments. This location is a short distance proximal to the physis of the distal radius. Another dorsal alternative is pin entry just medial to the Lister tubercle, between the third and fourth dorsal compartments,273 but this may entail greater risk to the extensor tendons, especially the extensor pollicus longus. The most commonly used radial entry point is located in line with the styloid process just proximal to the physis.354 Entry in this area passes adjacent to the first dorsal compartment, and thus the tendons of abductor pollicis longus and extensor pollicis brevis (as well as branches of the superficial radial nerve) must be protected (Fig. 12-14). Because of its extensive branching pattern, portions of the superficial branch of the radial nerve may be at risk when dorsal or radial intramedullary entry points are used.1,14 
Figure 12-14
Distal radial entry.
 
A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
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A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
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Figure 12-14
Distal radial entry.
A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
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A: Distal radial incision in proximity to superficial branch of radial nerve. B: Distal radial entry position for intramedullary rod placement in relationship to superficial branch of radial nerve. C: Radiograph of lateral starting point for intramedullary nail. D: Alternate entry point just proximal to the Lister tubercle between second and third dorsal compartments.
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Both distal and proximal intramedullary entry sites for the ulna have been described.192,197,256,297,335 In the distal portion of the ulna, an entry site can be made proximal to the physis and in the interval between the extensor carpi ulnaris and flexor carpi ulnaris tendons. Care must be taken to avoid branches of the dorsal cutaneous sensory nerve. Ulnar entry is most easily accomplished in the proximal portion of the bone along its lateral metaphyseal border (just distal to the olecranon apophysis), piercing peripheral fibers of the anconeus (Fig. 12-15).45,188,194 This anconeus entry site described by the Nancy group avoids the physis and avoids the painful bursa that tends to form over “tip of the olecranon” pins. 
Figure 12-15
Proximal ulnar entry.
 
A: Anconeus entry point. B: Radiograph of proximal ulnar entry point.
A: Anconeus entry point. B: Radiograph of proximal ulnar entry point.
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Figure 12-15
Proximal ulnar entry.
A: Anconeus entry point. B: Radiograph of proximal ulnar entry point.
A: Anconeus entry point. B: Radiograph of proximal ulnar entry point.
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Transphyseal approaches to both the distal radius363365 and the proximal ulna8,197,318 have been suggested by some authors. Significant growth potential exists at the distal radius (approximately 10 mm per year), whereas there is proportionately less from the olecranon apophysis (approximately 2 mm per year). There is an unnecessary risk to the radial physis and few if any technical advantages to transphyseal entry of the radius in diaphyseal level fracture fixation. The ulna apophyseal entry site is used in many centers. 

Treatment Options for Diaphyseal Radius and Ulna Fractures

Nonoperative Treatment of Diaphyseal Radius and Ulna Fractures

Indications/Contraindications (Table 12-5)

 
Table 12-5
Diaphyseal Radius and Ulna Fractures
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Table 12-5
Diaphyseal Radius and Ulna Fractures
Nonoperative Treatment
Indications Relative Contraindications
Closed fractures Open fractures
Skeletally immature, displaced and nondisplaced Displaced and skeletally mature
Irreducible by closed means
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Most pediatric radial and ulnar shaft fractures can be treated by nonoperative methods.365 Low-energy, undisplaced, and minimally displaced forearm fractures can be immediately immobilized in a properly molded (three-point mold concept of Charnley) above-elbow cast.8 If post-traumatic tissue swelling is a concern, noncircumferential splint immobilization (e.g., sugar-tong splint) can be used initially.70,325,361 For fractures in the distal third of the forearm, below-elbow casting has been shown to be as effective as above-elbow casting in maintenance of satisfactory fracture alignment.61,113 Appropriate follow-up is important for these undisplaced fractures (an initial follow-up radiograph usually is taken 7 to 14 days after injury) because displacement may still occur for a variety of reasons: New trauma to the extremity, male gender, and poor casting technique.70,114,289,361 
Good casting technique is infrequently discussed in contemporary orthopedic textbooks and sometimes is underemphasized during orthopedic residency training. The principles of good forearm casting technique include: (a) interosseous molding, (b) supracondylar molding, (c) appropriate padding, (d) evenly distributed cast material, (e) straight ulnar border, and (f) three-point molding (Fig. 12-16). The risk of excessive cast tightness can be minimized through the use of the stretch-relax fiberglass casting technique described by Davids et al.76 Chess et al.61 described a cast index for distal radial fractures defined as the sagittal cast width divided by the coronal cast width at the level of the fracture site; a normal ratio is considered to be 0.70. The cast index has not been validated for forearm shaft fractures, but it embodies the sound concept of good interosseous molding. Techniques such as pins and plaster and cast wedging also have had a role in fracture care.17,89 Cast wedging is almost always done with an opening wedge technique because this entails less risk of soft tissue impingement.171 
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Figure 12-16
Interosseous mold technique.
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Displaced fractures usually require reduction following appropriate analgesia.85,334 Options include hematoma block,108,141,160 regional intravenous (IV) anesthesia43,77,164 and inhalational methods,95,129,141 and IV sedation with propophol. After informed consent for sedation and reduction is obtained, monitored sedation can be used in the emergency department with a combination of narcotics and anxiolytics.175 This typically requires a dedicated nurse to administer oxygen and perform appropriate monitoring functions (vital signs, continuous electrocardiogram, and pulse oximetry).7,64,143 Ketamine protocols are also being used with increased frequency.121,175 Young children with less than 5 or 10 degrees of angulation in the plane of wrist and elbow motion probably do not require the additional trauma, time, expense, and sedation risk involved in a formal reduction because of the predictable remodeling in this age group as long as immobilization brings stability to the fracture and prevents late displacement.12 It has been shown that the more displaced the fracture, the more likely that formal monitored sedation techniques will be used for pediatric forearm fracture reduction as opposed to other techniques.334 
More specific closed treatment options are discussed for pediatric forearm injuries in terms of their common fracture patterns: Bow (plastic deformation), greenstick, complete, and comminuted. 

Traumatic Bowing/Plastic Deformation

Although traumatic bowing was described by Rauber in 1876,298 it was not widely recognized until Spencer Borden's classic paper was published in 1974.36 This injury occurs almost exclusively with children's forearm fractures.178 Bow fractures (Fig. 12-17) show no obvious macroscopic fracture line or cortical discontinuity, but they do demonstrate multiple microfractures (slip lines) along the length of the bow.280 At times, a nearly classic buckle fracture (torus fracture) coexists with a bow fracture. The most common clinical scenario is a plastically deformed ulna along with a more typical fracture of the radius.201 
Figure 12-17
Bow fracture: Approximately 15 degrees of apex-dorsal bowing of radius and ulna shaft.
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Borden36 and subsequent authors stressed the importance of natural remodeling potential in these injuries but voiced concern about this approach in older children (especially those over 10 years of age).36,201,280 Vorlat and De Boeck337 reported incomplete remodeling in 3 of 11 children at long-term follow-up (average 6.7 years) after traumatic bowing of the forearm. Because these three children were between the ages of 7 and 10 at the time of injury, the authors recommended more aggressive efforts at reduction in all patients with clinically significant deformity (more than 10 degrees) older than 6 years of age.337 Traumatic bowing that causes aesthetically and/or functionally unacceptable angular deformity277 should be manipulated under general anesthesia or deep sedation because strong (20 to 30 kg) gradual force applied over 2 to 3 minutes is required to obtain acceptable alignment (Fig. 12-18).280 Application of this reductive pressure over a rolled towel, block, or surgeon's knee fulcrum followed by a three-point molded cast can substantially (although at times still incompletely) correct the deformity. Care must be taken to avoid direct pressure over adjacent epiphyses for fear of creating a physeal fracture. 
Figure 12-18
Reduction technique of bow fracture over fulcrum.
 
(From Sanders WE, Heckman JD. Traumatic plastic deformation of the radius and ulna: A closed method of correction of deformity. Clin Orthop Relat Res. 1984; 188:58–67.)
(From 


Sanders WE,

Heckman JD
.
Traumatic plastic deformation of the radius and ulna: A closed method of correction of deformity.
Clin Orthop Relat Res.
1984;
188:58–67.)
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Figure 12-18
Reduction technique of bow fracture over fulcrum.
(From Sanders WE, Heckman JD. Traumatic plastic deformation of the radius and ulna: A closed method of correction of deformity. Clin Orthop Relat Res. 1984; 188:58–67.)
(From 


Sanders WE,

Heckman JD
.
Traumatic plastic deformation of the radius and ulna: A closed method of correction of deformity.
Clin Orthop Relat Res.
1984;
188:58–67.)
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Greenstick Fractures

Greenstick fractures present special issues in terms of diagnosis and treatment. Angulated greenstick fractures of the shafts of the radius and ulna at different levels indicate a significant rotational component to the injury (Fig. 12-2). Evans, Rang, and others have stated that the apex-volar angulation pattern usually is associated with a supination-type injury mechanism, whereas most apex-dorsal greenstick fractures involve a pronation-type injury mechanism (Fig. 12-19),92,94,233,265 although exceptions certainly occur.92,132 Often, the apparent angular deformity can be corrected by simply reversing the forearm rotational forces (e.g., reducing an apex-dorsal pronation-type injury with supination). Noonan and Price233 observed that it is difficult to remember whether to use pronation or supination reductive forces and suggested that most fractures can be reduced by rotating the palm toward the deformity. They also noted that most greenstick fractures are supination injuries with apex-volar angulation and thus can be reduced by a pronation movement.233 Pediatric orthopedic researchers from the Arnold Palmer Hospital for Children have recently proposed the “radius crossover sign” as an indicator of significant angular and torsional deformity in greenstick fractures of the radial shaft.355 Proper interpretation of this sign relies on full length forearm films that include a good AP view of the distal humerus. 
Figure 12-19
Shaft fractures at different levels implies rotational mechanism.
 
A: Apex-volar angulation with supination deformity of the forearm. B: Apex-dorsal angulation with pronation deformity of forearm.
A: Apex-volar angulation with supination deformity of the forearm. B: Apex-dorsal angulation with pronation deformity of forearm.
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Figure 12-19
Shaft fractures at different levels implies rotational mechanism.
A: Apex-volar angulation with supination deformity of the forearm. B: Apex-dorsal angulation with pronation deformity of forearm.
A: Apex-volar angulation with supination deformity of the forearm. B: Apex-dorsal angulation with pronation deformity of forearm.
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Greenstick fractures that occur near the same level probably have little to no rotational component and are best corrected by manipulative reduction and three-point molding techniques (Fig. 12-3). Charnley believed that greenstick fractures of the forearm in children perfectly illustrated his dictum that “A curved plaster is necessary to make a straight limb.”59 He also stated that “The unsuspected recurrence of angular deformity in greenstick fractures of the forearm, while concealed in plaster, is an annoying event if it takes the surgeon by surprise and is not discovered until the plaster is removed. Parents, quite understandably, may be more annoyed about this happening to their children than if it had happened to themselves, and do not easily forgive the surgeon.”59 Despite these concerns, it is clear from large published reports that greenstick fractures can almost always be successfully treated with nonoperative methods.363 
Two philosophies are reflected in the literature regarding greenstick fracture reduction: One in which the greenstick fracture is purposely completed and another in which it is not. Those who favor completing the fracture (dating back at least to the 1859 work of Malgaigne) cite concerns about lost reduction and recurrent deformity that can be prevented only by converting the greenstick into a complete fracture.23,31,106,153 Others prefer to maintain and perhaps exploit some of the inherent stability of the greenstick fracture.5,61,79,92,323 In addition to the traditional view that loss of reduction is less likely if a greenstick fracture is completed, there also is the theoretical advantage of a lower refracture rate because of more exuberant callus formation.61,233 To the best of our knowledge, these theories have not been validated in any controlled clinical studies. Davis and Green79 advocated a derotational approach to greenstick fracture reduction and reported a 10% (16/151) reangulation rate in their series of patients with greenstick fracture. They compared this to the 25% (12/47) reangulation rate in patients with complete fractures and questioned the wisdom of routinely completing greenstick fractures.79 In a prospective study, Boyer et al.41 showed statistically that greenstick fractures maintain their reduction better than complete forearm fractures. 

Complete Fractures

Complete fractures in different regions of the shaft of the forearm behave differently from a clinical perspective and have classically been divided into distal-, middle-, and proximal-third fractures. Single-bone complete fractures usually are caused by direct trauma (nightstick fracture) and are difficult to reduce. Blount described a reduction technique that may be effective for reduction of a displaced single-bone shaft fracture. The intact bone is used as a lever to re-establish the length of the fractured bone, and then transverse forces are applied to realign the bone ends (Fig. 12-7). Both-bone complete fractures (often with bayonet shortening) are common and are best treated with finger-trap or arm traction applied over 5 to 10 minutes. This stretches out the soft tissue envelope and aids in both reduction and cast or splint application. Traction allows complete fractures to “seek their own level of rotation” and allows correction of rotational malalignment.79 
The position of immobilization for forearm fractures has been an area of debate since the days of Hippocrates.31 Theoretically, the position of forearm rotation in an above-elbow cast or splint affects rotational alignment of complete fractures at all levels; however, a study of distal-third forearm fractures found no significant effect of forearm rotation position on ultimate alignment.41 We are aware of no similar studies analyzing the effects of forearm position on middle- or proximal-third shaft fractures, and treatment is influenced by certain anatomic considerations. Because of the strong supination pull of the biceps, aided by the supinator, complete proximal radial fractures may be best immobilized in supination so that the distal forearm rotation matches that of the proximal forearm (Fig. 12-13). The position of immobilization of fractures in the middle third of the forearm commonly is dictated by whether the radial fracture occurs distal or proximal to the insertion of the pronator teres. Fractures proximal to its insertion are best treated by fully supinating the distal fragment, whereas those distal to its insertion are probably best treated in a neutral position. Fractures at different levels in the midshaft that require pronation or supination as part of the reduction maneuver should be immobilized in the position of reduction. 
Manipulated fractures should be evaluated weekly for the first 2 to 3 weeks because most position loss can be recognized and corrected during this time.182,338 Any significant shift in position between visits necessitates cast wedging or a cast change, with remolding and possible fracture remanipulation if unacceptable displacement is present. Voto et al.338 found that, in general, 7% of forearm fractures redisplace; this can occur up to 24 days after the initial manipulation. Davis79 reported a 25% reangulation rate in complete fractures. Remanipulation can be done in the office following administration of oral analgesics. Judicious use of benzodiazepines may also be valuable because of their anxiolytic effects. 
Although in adults the above-elbow cast generally is changed to a below-elbow cast after 3 to 4 weeks, this is unnecessary in most children because they heal more quickly and permanent elbow stiffness is rare.173 A cast change at week 3 or 4 also can be traumatic to a young child and carries the additional small risk of cast saw injury. Once the fracture shows good callus formation, the cast can be removed. Because shaft fractures of the radius and ulna in children have a significant rate of refracture,13,185,328 they should be splinted for an additional period of time.69 Parents should be warned that forearm shaft fractures have the highest risk of the risk of refracture, which can occur even 6 to 12 months after the original injury. 
Above-elbow casting with the elbow in extension has been suggested for some complete fractures of the middle and proximal thirds.292,341,345 The supination moment exerted by the biceps has been shown to be diminished when the elbow is extended.227 Walker and Rang341 reported successful treatment of 13 middle- or proximal-third forearm shaft fractures with this method (some following failed flexed-elbow casting). They suggested that the “short fat forearms” of some young children prevented successful flexed-elbow casting.341 Shaer et al.292 also reported 20 children treated with this method and emphasized full supination of the forearm. Three of their patients required cast wedging, but at final follow-up 19 of the 20 patients had excellent results.292 One patient who was lost to follow-up for 6 months (presumably removing his own cast) did suffer “mild residual deformity.”292 Walker and Rang341 recommended that benzoin be applied to the skin, in addition to creation of an adequate supracondylar mold, to further secure the cast. Casting the thumb in abduction with extra padding may prevent the cast from sliding. Turco293 suggested that reduction should be obtained with horizontal traction applied to the extended upper extremity, followed by additional steps outlined in Table 12-6. Based on published clinical results, concerns related to cast slippage and elbow stiffness appear to have been overstated.292,341 The main drawback of this technique is its awkwardness as compared to flexed-elbow casting341 (Fig. 12-20). 
 
Table 12-6
Technique for Extended Elbow Cast Treatment
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Table 12-6
Technique for Extended Elbow Cast Treatment
  1.  
    Closed reduction under sedation
    1.  
      Supine patient, fully supinated forearm
    2.  
      Abducted shoulder
    3.  
      Elbow extended (approximately 170 degrees)
  2.  
    Above-elbow cast applied
    1.  
      Interosseous mold
    2.  
      Supracondylar mold
  3.  
    Weekly radiographs first 3 weeks
  4.  
    Cast changes based on “Rule of 3s”
    1.  
      3 weeks at 170 degrees
    2.  
      3 weeks at 135 degrees
    3.  
      3 weeks at 90 degrees
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Figure 12-20
A forearm fracture lost of position while treated in an above-elbow cast with elbow at standard 90-degree elbow flexion.
 
At 3 weeks post injury the arm was remanipulated and placed in an above-elbow cast with elbow extended down to only 45 degrees of flexion, with three- point mold placed. The fracture healed anatomically.
At 3 weeks post injury the arm was remanipulated and placed in an above-elbow cast with elbow extended down to only 45 degrees of flexion, with three- point mold placed. The fracture healed anatomically.
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Figure 12-20
A forearm fracture lost of position while treated in an above-elbow cast with elbow at standard 90-degree elbow flexion.
At 3 weeks post injury the arm was remanipulated and placed in an above-elbow cast with elbow extended down to only 45 degrees of flexion, with three- point mold placed. The fracture healed anatomically.
At 3 weeks post injury the arm was remanipulated and placed in an above-elbow cast with elbow extended down to only 45 degrees of flexion, with three- point mold placed. The fracture healed anatomically.
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Because radius and ulna shaft fractures have the highest rate of childhood refracture, casting is generally recommended for 6 to 8 weeks. This is followed with a forearm splint until all four cortices are healed and there is no transverse lucency at the site of the original fracture (complete healing). 

Comminuted Fractures

Although comminuted forearm fractures are less common in children than in adults,323 they do occur.24,104,106,153,184,357 Comminuted fractures tend to occur in conjunction with high-energy injuries, such as open fractures.153,208 Comminuted forearm fractures deserve special attention because they often require specially tailored treatment approaches. If satisfactory reduction cannot be achieved or maintained by closed methods, then other treatment alternatives should be considered. 
One option is to accept some shortening; according to Price,257 this may help maintain motion through interosseous membrane slackening. Shortening of more than 1 cm is unacceptable in either single-bone or both-bone comminuted patterns. Standard closed fracture treatment generally is unsuccessful when both bones are comminuted, and surgical stabilization may be necessary.106 Bellemans and Lamoureux24 reported intramedullary nailing of all comminuted forearm fractures in their pediatric series. Other reported fixation methods for comminuted forearm fractures in children include plate-and-screw devices,104,106 flexible intramedullary nailing for single-bone comminution,269 and pins-and-plaster techniques.339 Bone grafting is rarely if ever indicated in acute comminuted forearm features in children. 

Operative Treatment of Diaphyseal Radius and Ulna Fractures

Indications/Contraindications

Duncan and Weiner89 cited an “aggressive surgical mentality” as the reason for frequent operative treatment of pediatric forearm fractures, and Wilkins350 expressed concern about “impetuous” surgeons who are too eager to operate. Cheng et al.60 and Flynn et al.103 documented a 10-fold and sevenfold increase in the rate of operative treatment of forearm shaft fractures in children, but it is unclear as to whether this increase in operative treatment has led to a commensurate improvement in clinical outcomes. 
Operative treatment of radial and ulnar shaft fractures usually is reserved for open fractures, those associated with compartment syndrome, floating elbow injuries, and fractures that develop unacceptable displacement during nonoperative management. Residual angulation after closed treatment is much better tolerated by younger children than older adolescents and adults because of the increased remodeling potential in the younger age group.113 As a consequence, adolescents are more likely to benefit from surgical treatment of their forearm fractures than are younger children. Although internal fixation is the standard of care for displaced forearm fractures in adults, the success of nonoperative methods and the complications associated with internal fixation have tempered enthusiasm for its application to pediatric forearm fractures. Compared to closed treatment methods, healing is slower after open reduction and internal fixation,24 no matter what type of implant is used.106 Crossed Kirschner wire (K-wire) fixation techniques that often are used successfully in the distal radius are technically difficult in the shaft region of the radius and ulna. In rare situations, external fixation has been used for pediatric forearm fixation.290 
Preoperative planning is essential regardless of which surgical technique is chosen. Assessment of the fracture, including rotation and the presence or absence of comminution, is important. Bone–plate mismatch (because of narrow bones and wide plates) and extensive soft tissue dissection are risks when adult-sized plates are applied to pediatric bones.354 Before intramedullary nailing of fractures, the forearm intramedullary canal diameter should be measured, especially at the narrowest canal dimension; typically this is the central portion of the radius305 and the distal portion of the ulna near the junction of its middle and distal thirds. Precise canal measurement can be difficult,278,306 and the consequences of a nail or pin that is too large are probably worse than those of a nail or pin that is too small.237,287 Modern digital radiography systems have made these measurements easier.244 

Plate Fixation

Open reduction and internal fixation of pediatric forearm shaft fractures with plates and screws is a well-documented procedure in both pediatric series242,310,324,332 and adult series that include patients as young as 1358 and even 758 years of age. In one of the early series of pediatric forearm fractures fixed with plates,82 dynamic compression plates and one-third tubular plates applied with standard atlas orthogonal technique (six cortices above and below the fracture site) obtained good results.230 Four-cortex fixation on either side of the fracture site has been shown to be equally effective in pediatric forearm fractures.357 
Plate fixation uses the standard adult approach and technique except that smaller plates (2.7-mm compression and stacked one-third tubular), fewer screws, and single-bone fixation often are acceptable.357 Plate fixation may allow more anatomic and stable correction of rotational and angular abnormalities and restoration of the radial bow than with noncontoured intramedullary rods; however, the larger incisions and extensive surgical exposures required for plate fixation have raised concerns regarding unsightly scars273,332,354 and muscle fibrosis with consequent motion loss.357 Although the aesthetic concerns seem valid, ultimate forearm motion is similar with the two techniques, with only minor losses reported in the literature after both plating and intramedullary nailing.73,170,297,331 Fernandez et al.97 recently documented these precise issues very nicely in that they found no significant differences in functional outcome in their plate fixation versus intramedullary nailing patients, but they noted the longer operating room time and inferior appearance of the plated patients' scars. 
Open reduction and internal fixation with plates and screws may be appropriate in the management of fractures with delayed presentation or fractures that angulate late in the course of cast care,135,357 when significant fracture callus makes closed reduction and percutaneous passage of intramedullary nails difficult or impossible.11 Other indications for plate fixation include shaft fractures with significant comminution106 and impending or established malunion329 or nonunion.136,193,237 Several authors have reported good results with plate fixation of the radius only47,105,242,265 or the ulna only (Fig. 12-21).25 Bhaskar and Roberts25 compared 20 children with both-bone plate fixation to 12 with ulna-only fixation and found significantly more complications in the dual plating group, although motion was equal at 1-year follow-up. Single-bone fixation requires satisfactory reduction of both bones. Flynn and Waters105 stated that they would preferentially plate the radius only when the fracture could not be reduced by closed means. Two patients in Bhaskar and Roberts'25 study required open reduction and internal fixation of the radius when it was not adequately reduced after plate fixation of the ulna. 
Figure 12-21
Single bone plate fixation (radius only).
 
A: A 12-year-old female with both bone forearm fracture (AP and lateral). B: Immediate postoperative images. C: Two-year follow-up images.
 
(Courtesy of Tom Welle, DO.)
A: A 12-year-old female with both bone forearm fracture (AP and lateral). B: Immediate postoperative images. C: Two-year follow-up images.
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Figure 12-21
Single bone plate fixation (radius only).
A: A 12-year-old female with both bone forearm fracture (AP and lateral). B: Immediate postoperative images. C: Two-year follow-up images.
(Courtesy of Tom Welle, DO.)
A: A 12-year-old female with both bone forearm fracture (AP and lateral). B: Immediate postoperative images. C: Two-year follow-up images.
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Kirschner Wire, Rush Rod, and Steinmann Pin Intramedullary Fixation

Currently, intramedullary fixation is the preferred method for internal fixation of forearm fractures in children.8,45,184,192,197,260,261,335 Intramedullary fixation of children's forearm fractures dates back at least to Fleischer's 1975 report in the German literature in which he called it “marrow wiring.”101 Closed intramedullary nailing (also known as indirect reduction and internal fixation) of diaphyseal forearm fractures in adolescents was later reported in the English literature by Ligier et al.,194 Amit et al.,8 and others.29,188,354 A variety of implants have been used for forearm intramedullary nailing, including K-wires, Rush rods, and Steinmann pins. Continued favorable reports from around the world (e.g., England, Germany, New Zealand, Turkey, and the United States) have established intramedullary fixation as the surgical treatment of choice.53,116,163,192,267 
Intramedullary fixation has several advantages over plate fixation, including improved aesthetics because of smaller incisions and less deep tissue dissection, potentially leading to a lower risk of stiffness.73,184,297,354 Contoured pins are used in the radius to preserve its natural anatomic bow;8,73,260,267,343 contoured pins are not necessary for the ulna.8 Although the rotational stability of pediatric forearm fractures treated with intramedullary fixation has been questioned, Blasier and Salamon29 suggested that the strong periosteum in children resists torsional stresses. In a cadaver study of the rotational stability of fractures of the ulna and radius treated with Rush rods, Ono et al.240 found that intramedullary fixation of both bones reduced fracture rotation to one-eighth of that in unfixed fractures. 

Elastic Stable Intramedullary Nailing

In the early 1980s, Metaizeau et al.219 described elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures with small-diameter (1.5 to 2.5 mm) contoured implants.194 No effort was made to fill the medullary canal as with other intramedullary nailing techniques,269 and the “summit of the curve must be calculated preoperatively to lie at the level of the fracture.”188 The prebent flexible rods (known as Nancy nails) were reported to maintain satisfactory fracture alignment while encouraging development of normal physiologic fracture callus.194,219,253 Biomechanically, these implants have been shown to act as internal splints provided the nails extend three or more diameters beyond the fracture site.159 Good results with this technique have been reported by numerous authors (Figs. 12-22 and 12-23).131,228,269,286,294,326,327,356 
Figure 12-22
A 10-year-old male whose both bone complete forearm fracture near the junction of the middle and distal thirds was treated with elastic stable intramedullary nailing (ESIN).
 
A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
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A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
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Figure 12-22
A 10-year-old male whose both bone complete forearm fracture near the junction of the middle and distal thirds was treated with elastic stable intramedullary nailing (ESIN).
A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
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A: Injury radiographs demonstrating completely displaced radial and ulnar shaft fractures. B: Postreduction radiographs reveal unsatisfactory angular alignment as well as significant loss of radial bow. C: Anatomic appearance following ESIN. D: One-and-a-half-year follow-up radiographs. Nails were removed 6 months postoperatively. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination.
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Figure 12-23
An 11-year-old male whose both bone midshaft complete forearm shaft fracture was treated with ESIN.
 
A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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Figure 12-23
An 11-year-old male whose both bone midshaft complete forearm shaft fracture was treated with ESIN.
A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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A: Injury AP radiograph. B: Injury lateral radiograph. C: Postreduction radiographs demonstrating unacceptable angular alignment. D: Improved alignment status after ESIN. E: Clinical appearance with extended elbows and forearm midposition. F: Clinical appearance with extended elbows and pronated forearms. G: Clinical appearance with extended elbows and supinated forearms. H: Symmetrical pronation. I: Symmetrical supination. J: Thirty-nine month follow-up AP wrist radiograph and lateral (K) wrist radiograph (taken because of new trauma) demonstrating normal bony anatomy. Nails were removed 6 months postoperatively.
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Because the ESIN technique emphasizes the interdependence of the radius and ulna, if both bones are fractured, both bones are internally fixed.188 It is also dependent on anchorage of the nails in the upper and lower metaphyseal portions of the bone to produce an internal three-point fixation construct.188 Technique principles include fixing first the bone that is easiest to reduce, using physeal-sparing entry points, and using small nails varying in diameter from 1.5 to 2.5 mm.188 A nail that is too large may lead to nail incarceration and distraction at the fracture site, especially in the ulna.237 Large nails may also increase the fixation rigidity which may decrease the amount of callus formation, leading to delayed union and nonunion. Contouring of both nails is recommended, with particular attention to restoration of the appropriate radial bow (Fig. 12-24). Initially, nails were removed by about the fourth postoperative month, but several refractures led the originators of the technique to delay nail removal until one full year after surgery.188 Pin ends should be cut short and buried to maintain prolonged fixation. 
Figure 12-24
Metaizeau ESIN technique.
 
The radial rod is twisted 180 degrees in step 4 to re-establish the radial bow.
The radial rod is twisted 180 degrees in step 4 to re-establish the radial bow.
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Figure 12-24
Metaizeau ESIN technique.
The radial rod is twisted 180 degrees in step 4 to re-establish the radial bow.
The radial rod is twisted 180 degrees in step 4 to re-establish the radial bow.
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Immediate motion has been recommended by some authors after ESIN of pediatric forearm fractures,24,131,188,335 whereas others have recommended immobilization for variable periods of time.45 Early refracture with nails in place has been reported. Bellemans and Lamoureux24 considered displaced oblique or comminuted midshaft forearm fractures in children older than 7 years of age to be an indication for ESIN. They considered bayonet apposition (overriding) to be unacceptable at any age because of concerns about rotational malalignment and frequent narrowing of the interosseous space.24 Their fixation technique involved passage of the intramedullary nails followed by rotation of each nail until the greatest distance between the two bones was achieved in full supination.24 

Management of Open Fractures of Diaphyseal Radius and Ulna Fractures

In one large epidemiologic study, open fractures of the shafts of the radius and ulna and open tibial shaft fractures occurred with equal frequency, making them the most common open fractures in children.60 Although the infection rate is extremely low for open fractures, even grade I open forearm fractures in children have been associated with serious complications such as gas gangrene.96 Early irrigation and debridement213,302 are indicated for open forearm fractures, and care should be taken to inspect and properly clean the bone ends.167 Roy and Crawford273 recommended routinely inspecting both of the bone ends for the presence of intramedullary foreign material (Fig. 12-25). Once debrided, open forearm fractures can be stabilized by any of the available internal fixation methods without undue risk of infection (Fig. 12-26).128,135,198 Open fractures tend to be more unstable than closed fractures (because of soft tissue stripping and comminution) and more commonly require internal fixation. Internal fixation also may facilitate soft tissue management and healing.357 Professor Lim195 and his colleagues from the KK Children's Hospital in Singapore recently reminded us that internal fixation is not an absolute prerequisite and many children with such open fractures may still be successfully managed with casting alone. 
Figure 12-25
Intramedullary organic soil contamination from open forearm fracture with benign appearing skin laceration.
Flynn-ch012-image025.png
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Figure 12-26
A 13-year-old female with open forearm fracture.
 
A: AP and lateral radiographs; note extrusion of ulna on lateral view. B: After irrigation and debridement and flexible nail internal fixation. Note the Penrose drain in the ulnar wound.
A: AP and lateral radiographs; note extrusion of ulna on lateral view. B: After irrigation and debridement and flexible nail internal fixation. Note the Penrose drain in the ulnar wound.
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Figure 12-26
A 13-year-old female with open forearm fracture.
A: AP and lateral radiographs; note extrusion of ulna on lateral view. B: After irrigation and debridement and flexible nail internal fixation. Note the Penrose drain in the ulnar wound.
A: AP and lateral radiographs; note extrusion of ulna on lateral view. B: After irrigation and debridement and flexible nail internal fixation. Note the Penrose drain in the ulnar wound.
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The amount of periosteal stripping and possible foreign body reaction associated with open forearm fractures may produce an unusual radiographic appearance: The “ruffled border sign” (Fig. 12-27). Usually, this seems to represent a normal healing response in growing children, but occasionally it is an early sign of osteomyelitis. The infection rate ranges from 0% to 33% for open fractures in children.73,128,135,182,198,233,242,257,357 Even grade I open forearm fractures in children can be complicated by gas gangrene or osteomyelitis, and therapeutic amputation has been reported.79,96,153 Open fracture grade does not appear to correlate with the infection rate in childhood forearm fractures, with most of the serious forearm infections reported in the literature occurring after grade I fractures. 
Figure 12-27
Ruffled border sign at the site of previous open fracture of ulna; same patient from Figure 12-23 at 1-month follow-up.
Flynn-ch012-image027.png
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Fracture Reduction/Conscious Sedation Protocol

Significantly displaced forearm shaft fractures are usually manipulated in the emergency department using a conscious sedation protocol. After obtaining informed consent for conscious sedation and fracture manipulation, an IV line is started, and the child's blood pressure, pulse, respirations, electrocardiogram, and peripheral oxygen level are monitored during the procedure and for about 30 minutes after the procedure. We use ketamine/atropine or fentanyl/midazolam administered intravenously in divided doses. Although many children moan or cry briefly during the manipulation, very few recall pain. Two recent reports have drawn attention to ketamine-related concerns. Perez-Garcia et al. reported the disturbing complication of severe hypertension in a 12-year old who had undiagnosed coarctation of the aorta and Kinder et al. found that children with a high body mass index were at greater risk for nausea and vomiting.179,246 Reductions are done under mini-C-arm (fluoroscopy) control. The initial position of forearm rotation is based on the level of the fracture, and the final position is based on the best reduction under fluoroscopy. Small portable fluoroscopy units improve the quality of the reduction, decrease the radiation exposure to the patient, and decrease the need for repeat fracture reduction and save time.10 Finger-trap traction with 10 to 15 lbs of counterweight frequently is used for completely displaced both-bone forearm fractures (especially those with shortening). We do not complete greenstick fractures because the partial bone continuity adds stability. 
Because of concerns about soft tissue swelling, we place nonmanipulated and manipulated fractures into a plaster sugar-tong splint (incorporating the elbow). We avoid the circumferential wrapping of the arm with cast padding by using a “sandwich splint” technique. Before manipulation, the sugar-tong splint is prepared by laying out 7 to 10 layers of appropriate-length 3-in plaster casting material on top of a work surface. A four-layer matched length of cotton cast padding also is laid out and will form the inner padding (skin side) of the splint. A final single layer of cast padding is laid out and will form the outer layer of the splint to prevent elastic wrap adherence to the plaster. Once manipulation is completed, the plaster is dipped, wrung out, smoothed, and then sandwiched between the dry four-ply and one-ply cotton padding. This splint is then placed with the four-ply cotton side against the skin and secured with an elastic bandage (ace wrap). We prefer to avoid the circumferential application of cotton padding because it may limit splint expansion during follow-up swelling. If necessary, parents also can unwrap and loosen the elastic bandage at home to relieve pressure if swelling makes the splint too tight. Patients are given a prescription for mild narcotic analgesics, and discharge instructions to call back or return to the emergency room for pain not relieved by the pain medicine. 
Patients usually return to the office within a week for repeat radiographs and clinical assessment. Provided that satisfactory alignment has been maintained, we remove the elastic wrap but leave the plaster sugar-tong splint in place. Nonmanipulated fractures can be converted to a conventional or waterproof cast on the first visit if it is >48 hours after the injury, but manipulated fractures that maintain good position are overwrapped with fiberglass for at least a week before converting to the definitive cast. The splint is “boxed in” by applying cotton cast padding over the splint and the exposed upper arm, and by wrapping with fiberglass to convert the splint into an above-elbow cast. Follow-up radiographs are taken of manipulated fractures at about 1-week intervals for the next 2 weeks. Fractures that are losing position but are still in acceptable alignment usually require removal and remolding of a new cast to prevent further position deterioration in the upcoming week. Fractures that show increasing displacement at the initial follow-up visits, can continue to angulate up until 4 to 5 weeks post injury. Minor remanipulations can be done in the office after appropriate administration of oral analgesics and anxiolytics. Major remanipulations are best done with general anesthesia. The decision regarding the need for remanipulation may be tipped by viewing the arm position by the parents and physician after all splint and cast materials are removed. 
We rarely convert an above-elbow cast to a below-elbow cast at 3 to 4 weeks post injury as is common in adults. This step may be omitted in younger children because of their faster healing and their minimal inconvenience from temporary elbow immobilization.173 Patients can return to sports after conversion to a below-elbow cast as long as the cast is padded during play and league rules allow casts. Patients usually are required to have a physician's note allowing sports participation with a cast. This decision is made with the patient's and parents' understanding of potential increase in refracture risk. Adequate fracture healing (4/4 cortices completely healed and no transverse shaft lucency) usually has occurred after several more weeks of cast treatment but should be confirmed by radiographic and physical examination before unlimited athletic participation. Older children are given home elastic band strengthening exercises and allowed to participate in normal activities while they continue to be protected in either a removable Velcro fracture brace or a customized thermoplastic forearm gauntlet brace. Formal physical therapy rarely is required. This fracture protocol is aimed at minimizing refracture risk. 

Acceptable Limits of Angulation

Based on available evidence in the literature, we accept approximately 20 degrees of angulation in distal-third shaft fractures of the radius and ulna, 15 degrees at the midshaft level, and 10 degrees in the proximal third (provided the child has at least 2 years of growth remaining).360 We accept 100% translation if shortening is less than 1 cm. Although other authors recommend accepting up to 45 degrees of rotation, we find this is extremely difficult to measure accurately using the bicipital tuberosity and radial styloid as landmarks because of the lack of anatomic distinction in younger children. Plastic deformation fractures seem to have less remodeling potential than other fractures, and radiographically or aesthetically unacceptable angulation may require gradual, forceful manipulation under sedation or general anesthesia. Children approaching skeletal maturity (less than 2 years of remaining growth) should be treated using adult criteria because of their reduced remodeling potential. Parents should be cautioned that even mild angulation of the ulna, especially posterior sag, will produce an obvious deformity after cast removal because of the subcutaneous location of the bone (Fig. 12-28). This aesthetic deformity is exacerbated by abundant callus formation, but it will ultimately remodel if it falls within acceptable angulation criteria. Ulnar sag may be countered by placing the child in an extended elbow cast. Mild-to-moderate angulation of the radius usually produces much less aesthetic deformity but may limit motion more (Fig. 12-29). 
Figure 12-28
Ulnar sag on serial radiographs.
 
Note the prominent ulnar fracture callus.
Note the prominent ulnar fracture callus.
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Figure 12-28
Ulnar sag on serial radiographs.
Note the prominent ulnar fracture callus.
Note the prominent ulnar fracture callus.
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Figure 12-29
A 7-year-old female with left both bone complete forearm fracture.
 
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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Figure 12-29
A 7-year-old female with left both bone complete forearm fracture.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Two-year follow-up radiograph shows mild residual deformity. D: Pronation. E: Supination. F: Axial alignment at 2-year follow-up. G: Five-year follow-up radiographs of left forearm with mild loss of radial bow. H: Comparison radiographs of right forearm. I: Pronation. J: Supination. K: Axial alignment at 5-year follow-up.
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Surgical Procedure of Diaphyseal Radius and Ulna Fractures

Most forearm shaft fractures continue to be successfully treated with closed methods at our institution. Our top two indications for surgical treatment of these injuries are open shaft fractures and shaft fractures that exceed our stated reduction limits. If surgical treatment is deemed necessary, intramedullary fixation is preferred over plate fixation because of reduced soft tissue disruption. We occasionally fix one bone when both bones are fractured if overall forearm alignment is acceptable and stable after single-bone fixation. 
If single-bone fixation is done, the ulna usually is treated first because of its more benign entry site, subcutaneous location, and relatively straight canal compared to the radius. Our preferred intramedullary ulnar entry site is just distal to the olecranon apophysis (anconeus starting point), just anterior to the subcutaneous border of the proximal ulna on its lateral side. Care is taken not to enter the ulna more than 5 mm anterior to its subcutaneous crest to avoid encroachment into the region of the PRUJ. Pins placed directly through the tip of the olecranon apophysis have a strong tendency to cause bursitis and pain until removal. We prefer to open the cortex with an awl because it tends to wander less than motorized drills and it allows ulnar entry with little or no formal incision. The awl technique also simplifies operating room setup in that no pneumatic hose hookups or battery packs are necessary (Table 12-7). 
 
Table 12-7
Elastical Nailing of Diaphyseal Radius and Ulna Fractures
Preoperative Planning Checklist
  •  
    OR table: Standard table with radiolucent hand table. Rotate table 90 degrees to position arm opposite anesthesiologist.
  •  
    Position/positioning aids: Supine with restraint strap across chest placed high in axilla. Traction on arm must not pull patients head off of the table.
  •  
    Fluoroscopy location: Bring in parallel to the OR table on the foot (axilla) side. One fluoro monitor should be on the opposite side of the table where anesthesiologist sits, and the other should be caudal to the arm.
  •  
    Equipment: Elastic nail set, small bone wrench (small femoral wrench), vice grips, awl, nail grip device, mallet, ragnell retractors, small fragment set bone reduction clamps, K-wire set.
  •  
    Tourniquet (nonsterile): Placed high in axilla.
  •  
    Etc: Need a Kerlix gauze around distal humerus or a blunt mallet to apply counter traction against the hand with elbow flexed 90 degrees (see video).
     
    To improve the torque needed to rotate the rod, a locking plier or extra heavy duty needle driver can be clamped to the rod near its insertion into the T-handle. The handle alone will frequently slip during rotation in the diaphysis.
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The patient is positioned supine with the arm abducted 90 degrees on a hand table. A wide sturdy strap is placed in the axilla to allow traction without pulling the patient off the table. Traction helps to gain length of overriding fracture ends and allows the bones to seek their normal rotation. If dual-bone fixation is elected, then the radius is fixed first as it is usually more difficult to rod, and it is always more difficult to approach with an open reduction than the ulna. If the ulna is fixed first it will limit forearm mobility and make it very difficult to manipulate the radius and pass the nail which forces a risky and complex open reduction on the radius. Optimizing the closed rodding of the radius by fixing it first makes the ulna reduction a little more difficult, but open reduction of the ulna is vastly simpler than an open reduction of the radius fracture at any fracture level. The distal radial entry site can be either through a physeal-sparing direct lateral approach through the floor of the first dorsal compartment or dorsally near the proximal extent of the Lister tubercle between the second and third dorsal compartments. Both of these entry points are approximately 1 cm proximal to the physis of the distal radius. We insert the radial nail through a 1- to 2-cm incision, protecting the superficial radial nerve and the dorsal tendons with small blunt retractors. An awl is used to gain intramedullary access to the radius. We typically use small intramedullary nails (2 to 2.5 mm in diameter) to maintain some flexibility at the fracture site and stimulate appropriate callus formation. Larger nails may become incarcerated in either the narrow central canal of the radius or that of the distal third of the ulna. Care must be taken not to overbend the tip of the nail as this effectively increases the diameter of the implant and may impede its intramedullary passage. If the rod gets stuck, the tip has often been pounded into a rut (Fig. 12-30). 
Figure 12-30
This illustrates the “rod rut” incurred during a femur Nancy nail insertion.
 
In left figure the tip of the rod has dug a rut in the cortex and is stuck. It was backed up 5 mm, leaving behind a visible rut. The rod was twisted 90 degrees and then passed up the shaft freely.
In left figure the tip of the rod has dug a rut in the cortex and is stuck. It was backed up 5 mm, leaving behind a visible rut. The rod was twisted 90 degrees and then passed up the shaft freely.
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Figure 12-30
This illustrates the “rod rut” incurred during a femur Nancy nail insertion.
In left figure the tip of the rod has dug a rut in the cortex and is stuck. It was backed up 5 mm, leaving behind a visible rut. The rod was twisted 90 degrees and then passed up the shaft freely.
In left figure the tip of the rod has dug a rut in the cortex and is stuck. It was backed up 5 mm, leaving behind a visible rut. The rod was twisted 90 degrees and then passed up the shaft freely.
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Backing the rod up 5 mm and rotating it away from the rut will ease passage down the shaft isthmus. If the nail fails to engage the shaft on the other side of the fracture, tap it back to the fracture, rotate it 90° to 180° and then retry. A “shoehorn” technique can be used to percutaneously align the fracture. A 2 mm K-wire is placed into the fracture between the two ends of the translated bone. It is then levered to allow the bone ends to translate into alignment. With the K-wire lever in place, then pass the nail across the fracture (Fig. 12-31). 
Figure 12-31
Shoehorn indirect reduction technique.
 
A: Initial K-wire placement. B: Intrafocal location between fragments. C: AP view intramedullary purchase and fracture reduction. D: Lateral view intramedullary purchase and fracture reduction. E: Successful passage of intramedullary nail.
A: Initial K-wire placement. B: Intrafocal location between fragments. C: AP view intramedullary purchase and fracture reduction. D: Lateral view intramedullary purchase and fracture reduction. E: Successful passage of intramedullary nail.
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Figure 12-31
Shoehorn indirect reduction technique.
A: Initial K-wire placement. B: Intrafocal location between fragments. C: AP view intramedullary purchase and fracture reduction. D: Lateral view intramedullary purchase and fracture reduction. E: Successful passage of intramedullary nail.
A: Initial K-wire placement. B: Intrafocal location between fragments. C: AP view intramedullary purchase and fracture reduction. D: Lateral view intramedullary purchase and fracture reduction. E: Successful passage of intramedullary nail.
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Failure to pass the intramedullary nail across the fracture site after several attempts may necessitate a limited open reduction with at least a 2-cm incision to directly pass the rod across the fracture site (Fig. 12-32). Because of the thick soft tissue envelope, an open approach to the radius needs to be twice this long. Placing a bone clamp on either side of the fracture allows bone alignment control. Persistence in attempting to achieve closed reduction and rodding has been associated with compartment syndrome.362 We are sensitive to both time and attempts during ESIN of forearm shaft fractures in our pediatric patients and recommend surgeons not to do prolonged attempts at reduction and fixation closed and recommend relatively rapid conversion to a small open reduction if needed. 
Figure 12-32
A 12-year-old female with midshaft both bone complete forearm fracture.
 
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
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Figure 12-32
A 12-year-old female with midshaft both bone complete forearm fracture.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
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A: AP and lateral injury radiographs. B: Two-month follow-up radiographs. C: Six-month follow-up radiographs (ulnar nail removed). D: Pronation. E: Supination. F: Axial alignment.
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If single-bone fixation is done, the ulna usually is treated first because of its more benign entry site, subcutaneous location, and relatively straight canal compared to the radius. Our preferred intramedullary ulnar entry site is just distal to the olecranon apophysis (anconeus starting point), just anterior to the subcutaneous border of the proximal ulna on its lateral side. Care is taken not to enter the ulna more than 5 mm anterior to its subcutaneous crest to avoid encroachment into the region of the PRUJ. Pins placed directly through the tip of the olecranon apophysis have a strong tendency to cause bursitis and pain until removal. We prefer to open the cortex with an awl because it tends to wander less than motorized drills and it allows ulnar entry with little or no formal incision. The awl technique also simplifies operating room setup in that no pneumatic hose hookups or battery packs are necessary (Table 12-8). 
 
Table 12-8
Elastic Nailing of Diaphyseal Radius and Ulna Fractures
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Table 12-8
Elastic Nailing of Diaphyseal Radius and Ulna Fractures
Surgical Steps
  •  
    Always expose the radius first with a 1–2 cm incision, just proximal to the Lister tubercle between the second and third tendon compartments. Alternatively, perform a styloid approach through the first dorsal compartment just proximal to the physis.
  •  
    Avoid major branches of the superficial radial nerve and clearly identify the tendons to avoid damage.
  •  
    With the Lister approach there is a “bare area” of bone between the EPL and ECRB tendons that is elevated clear of its periosteum.
  •  
    Use an awl to create a start window in the “bare area” for the Lister approach, or between the APL and EPB tendons for styloid approach.
  •  
    Forcibly tighten the T-handle on the rod and insert the rod by hand with an oscillating twist motion.
  •  
    Pull traction on arm against the axillary strap
  •  
    Use mallet to advance to fracture if impossible by hand. If rod fails to advance, the tip could be stuck in a rut. Tap the rod 5 mm backward; rotate the tip, then advance down the shaft again to the fracture.
  •  
    Pull heavy traction on the hand, manipulate the fracture, and use the small femoral wrench align the bone ends. If you miss, pull the nail back, rotate the rod 90 degrees, reattempt to pass, and repeat until it passes.
  •  
    If the fracture ends remain 100% translated despite manipulation, try the “shoehorn” K-wire technique before opening.
  •  
    If you have to open, make a 3–4 cm incision, grip the bone ends with small reduction clamps and hold reduced while assistant passes nail. Use the volar (Henry's approach to open, carefully avoiding the posterior interosseous nerve as it.
  •  
    Only advance the nail 1 cm past the fracture so it is just “perched.” Full insertion will make it nearly impossible to manipulate the ulna next.
  •  
    Start the ulna about 3 cm distal to the olecranon tip about 4 mm lateral to the posterior crest. Palpate the radial head and stay clear of it. The starting incision can be 3–4 mm long and made percutaneously.
  •  
    Advance the nail with an oscillating twist technique to the fracture, past the rod similar to radial rod. With the radius rod just perched across the fracture by 1 cm, the ulna can be freely manipulated to ease nail passage across the ulna fracture.
  •  
    Insert nail about 1 cm short of the distal ulna physis to leave room for final impaction.
  •  
    Remove the T-handle, put about a 45 degree bend in the rod just as it enters the bone. Do not lever the rod against the bone because it will plough or fracture through the metaphyseal bone.
  •  
    Cut the nail as close to the bone as possible, then final impact the nail so only 3 mm stick outside the bone for purchase during removal.
  •  
    Rotate the radial rod so that the bow in the nail follows the natural bow of the radius. Leave 1 cm short of the end of the bone to allow for final impaction after cutting the rod similar to the ulna.
  •  
    If using the Lister approach, make sure that the EPL tendon is not rubbing on the protruding nail end to avoid rupture.
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We prefer to leave the nails buried beneath the skin because complete fracture healing takes at least 2 months, and often much longer. Because refracture can even occur with nails in place, we protect children for at least the first month with a removable fracture brace. If a single bone of a both-bone fracture is fixed, above-elbow cast immobilization usually is necessary instead of a below-elbow cast or brace, as is used after dual-bone fixation. After the appearance of satisfactory callus, splint and activity restrictions are progressively relaxed. We recommend nail removal after complete four-cortex healing of each bone (6 to 12 months in most patients). 
Plating is preferred to intramedullary nailing when early malunion is present and callus formation is noted radiographically. Plating allows open osteoclasis and reduction. The plating technique is similar to that used in adults, except that smaller plates can be used and fewer cortices (often only four cortices above and below the fracture) are required for adequate fixation. In children with both-bone forearm fractures, plating of a single bone may be adequate and reduce the morbidity associated with dual-bone plating.25 Significant comminution of both bones also may be an indication for plate fixation (Table 12-9). 
 
Table 12-9
Keep Elastic Nails in Place for at Least Six Months
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Table 12-9
Keep Elastic Nails in Place for at Least Six Months
Refracture Keep elastic nails in place for nearly a year. Splint or cast for at least 6–8 weeks after elastic nailing
Delayed union Use the smallest nail that will pass to allow callus formation (1.75–2.5 mm)
Use a plate instead of a nail after skeletal maturity
Infection Wash out all open fractures, especially if they occur on organic surface (soccer field, fall from tree, dirt bike). Beware of the lawn biopsy in which a dirt clod gets stuck in the intramedullary canal
Nail incarceration in canal Back up out of rut, rotate nail, then advance down canal
Difficult nail passage across fracture Use a percutaneous K-wire to lever the ends of the fracture into alignment
Muscle/tendon entrapment or rupture Make sure that elastic nail does not rub on or impale EPL tendon
Neurapraxia Most will resolve spontaneously if noted prereduction. Fix radius first to minimize need to open which could injury PIN. Identify or avoid PIN during open reduction
Compartment syndrome During elastic nailing, perform an open reduction if nail does not pass after multiple attempts (20–30 min). Perform fasciotomy in any patient who has increasing anxiety, analgesia requirements, and apprehension.
Complex regional pain syndrome Early recognition and referral to physical therapy or pain service for treatment
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Management of Expected Adverse Outcomes and Unexpected Complications in Diaphyseal Radius and Ulna Fractures (Table 12-10)

 
Table 12-10
Diaphyseal Radius and Ulna Fractures
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Table 12-10
Diaphyseal Radius and Ulna Fractures
Common Adverse Outcomes and Complications
Malunion
Delayed or Nonunion
Stiffness
Refracture
Nail Prominence
Compartment Syndrome
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Redisplacement/Malalignment in Diaphyseal Radius and Ulna Fractures

The most common short-term complication of forearm shaft fracture treatment is loss of satisfactory reduction in a previously well-reduced and well-aligned fracture, a complication that occurs in 10%56,63,79,162,339 to 25% of patients.56,79 Initial follow-up radiographs are a screening test aimed at identifying redisplacement. Kramhoft and Solgaard182 recommended that children with displaced diaphyseal forearm fractures have screening radiography at 1 and 2 weeks after reduction. Voto338 also pointed out that most fractures that redisplace do so within the first 2 weeks after injury. Inability to properly control fracture alignment with closed methods is the most commonly reported indication for operative intervention.192,260,273,297,363 
The most common explanations for loss of fracture reduction are cast related (poor casting technique, no evidence of three-point molding).61,339 The more experienced the surgeon, the greater the likelihood of successful reduction.56 Other factors that have been found to be associated with forearm fracture redisplacement are quality of initial reduction,361 missed follow-up appointments,70 proximal-third fractures,71 and failure of the doctor to respond to early warning signs such as slight loss of reduction at 1-week follow-up.114 Strategies for dealing with redisplacement include allowing the deformity to remodel,144 cast wedging,17,153,171 rereduction and recasting,79,339 pins and plaster,32,89,339 indirect reduction and internal fixation,8 and open reduction and internal fixation.357 Reports in the literature suggest that most forearm shaft fractures that redisplace can be successfully managed with repeat closed reduction and casting.79,339 

Forearm Stiffness in Diaphyseal Radius and Ulna Fractures

The forearm is a predominantly nonsynovial joint with high-amplitude motion as its main function. The most common long-term complication of forearm shaft fracture treatment is significant forearm stiffness,144 with pronation loss occurring almost twice as frequently as supination loss.145 Loss of pronation or supination motion sometimes occurs despite perfectly normal-appearing radiographs.170,232,257 Abnormal bony alignment of the forearm bones can lead to motion deficits.168 However, stiffness can exceed that expected from bony malalignment alone168 and stiffness can occur with normal radiographs and both situations may be indicative of fibrosis of the interosseous membrane and/or contracture of the interosseous ligament.170,257 
With focused testing of forearm motion, between 18%49 and 72%145 of patients show at least some minor deficits after nonsurgical treatment. Most minor deficits are not even noticed by patients and rarely are associated with functional limitations.49,75,232 More severe losses of forearm rotation have far greater impact.222 In their series of malunited forearm fractures (thus strongly weighted to demonstrate forearm stiffness), Price et al.257 reported a 15% (6/39) rate of mild stiffness (up to 25-degree loss) and an 8% (3/39) rate of severe forearm stiffness (loss of 45 degrees or more of either pronation or supination). Holdsworth's145 series of malunited pediatric forearm fractures had a similar rate (6%) of severe forearm stiffness. Holdsworth145 told the classic story of a female whose inability to properly pronate caused her to elbow her neighbors when eating at the table. Patrick245 pointed out that it is possible to compensate for pronation losses with shoulder abduction, but no similar compensation mechanism exists for supination losses. Such severe motion loss is a very undesirable outcome. For surgical treatment of these injuries to be a rational choice, the rates of stiffness after surgery must be lower than those after cast treatment.130 
Bhaskar and Roberts25 published one of the only studies of plated pediatric forearm fractures to report goniometric pronation and supination data. Both their single-bone (ulna) and both-bone plated patients showed mild forearm motion losses (maximal 18% loss of pronation).25 Variable rates of mild forearm range-of-motion losses have been reported after intramedullary fixation. Amit et al.8 reported a 40% rate of mild stiffness (5 to 10 degrees) in 20 pediatric patients after Rush rod fixation of forearm fractures. Combined data from five series of the flexible intramedullary nailing (K- wires, Steinmann pins, Nancy nails) reveal a 1.6% rate (2/128) of mild forearm stiffness (up to a 20-degree loss) and a 0% (0/128) rate of severe motion loss (40 degrees or more loss of either pronation or supination).8,24,98,184,297,363 No published series of nonoperatively treated forearm shaft fracture patients has exceeded these results relative to preservation of forearm motion. 

Refracture in Diaphyseal Radius and Ulna Fractures

Refracture occurs more often after forearm shaft fractures in children than after any other fracture.185 Tredwell328 found that forearm refractures occurred at an average of 6 months after original injury and were more common in males (3:1) and in older children (approximately 12 years old). Baitner and his San Diego colleagues suggested that middle- and proximal-third forearm shaft fractures created a higher risk of refracture for pediatric patients.15 Refracture rates of 4%98 to 8%196 have been reported in pediatric diaphyseal forearm fractures. Bould and Bannister39 reported that diaphyseal forearm fractures were eight times more likely to refracture than metaphyseal fractures. Schwarz et al.291 found that 84% (21/28) of the forearm refractures in their series had initially presented as greenstick fractures. Based on the stage of bony healing, refractures may occur through the original fracture site, through both the original site and partially through intact bone or completely through intact bone,348 but most seem to occur through the original fracture site. 
Several authors have suggested that internal fixation is necessary after refracture,13,254,269 but Schwarz et al.291 reported good results with repeat closed reduction and casting in 14 of 17 patients with refractures. Closed reduction of the fracture and the bent rods has been shown to be effective for forearm refractures that occur with flexible nails in place (Fig. 12-33).225 The best treatment of refracture is prevention, and patients should be splint protected (removable forearm splint or thermoplastic gauntlet) for a period of 2 months depending on the activity after initial bone healing.233,257 Refracture is rare during splint wear. Parents must be cautioned about the risk of refracture despite apparently adequate bone healing on radiographs. 
Figure 12-33
A 14-year-old ESIN patient who suffered refracture with the nails in place.
 
A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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Figure 12-33
A 14-year-old ESIN patient who suffered refracture with the nails in place.
A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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A: Injury AP radiograph. B: Injury lateral radiograph. Skateboard mechanism. C: Early postoperative radiograph status post ESIN. D: Two-month postoperative AP radiograph. E: Two-month postoperative lateral radiograph. F: Refracture at 2.5 months postoperative. G: Refracture elbow radiograph. H: Closed reduction of titanium nails and angulated radius and ulna fractures. I: Five months after refracture. J: AP radiograph 1 year after refracture. K: Lateral radiograph 1 year after refracture. L: Clinical appearance with extended elbows and forearm midposition. M: Clinical appearance with extended elbows and pronated forearms. N: Clinical appearance with extended elbows and supinated forearms. Note mild supination loss on right. O: Symmetrical pronation. P: Asymmetrical supination. Approximately 15-degree loss on right.
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Refracture after plate removal has been discussed frequently in the literature106,230,256,331 and appears to be associated with decreased bone density beneath the plate.176 This has led many authors to question the routine use of plate fixation for pediatric forearm fractures.29,70,256,332 Refractures also have been reported after removal of intramedullary forearm fixation in children.73,135,170,188,297,327,364 The main strategies aimed at decreasing the risk of refractures after implant removal are documentation of adequate bony healing before implant removal, and an additional period of splint protection after implant removal until the holes have filled in. 

Malunion in Diaphyseal Radius and Ulna Fractures

Evaluation of pediatric forearm fracture malunion must take into account established malreduction limits and expected pediatric remodeling potential. Thus, a malunion of 30 degrees may become less than 10 degrees during the course of follow-up. The level of the malunited fracture also must be considered, because the consequences of malreduction vary according to level.281,360 More deformity in the predominant plane of motion is acceptable in fractures near physes of long bones than in diaphyseal fractures. Normal motion can be preserved despite persistent radiographic abnormality (Fig. 12-34). 
Figure 12-34
An 11-year old with midshaft both bone complete forearm fracture.
 
A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
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A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
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Figure 12-34
An 11-year old with midshaft both bone complete forearm fracture.
A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
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A: AP and lateral injury radiographs. B: One-month follow-up radiographs. C: Two-year follow-up radiogaphs. D: Pronation. E: Supination. F: Axial alignment. G: Six-year follow-up radiographs with substantial remodeling of radius and ulna fractures.
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Malunion of radial and ulnar shaft fractures can lead to an aesthetic deformity and loss of motion; however, significant loss of function occurs in only a small percentage of patients.49,75,232 Some authors have recommended more aggressive efforts at correction of forearm fracture malunions.217,255 Early malunions (up to 4 or 5 weeks after injury) can be treated with closed osteoclasis under anesthesia. If closed osteoclasis fails to adequately mobilize the fracture, a minimally invasive drill osteoclasis can be done.28 A small-diameter drill (or K- wire) is used to make multiple holes in the region of the malunion before forcefully manipulating the bone back into alignment.28 Internal fixation is rarely, if ever, needed. 
Once significant callus is present, indirect reduction and internal fixation with flexible intramedullary nails can be difficult or impossible because the fracture site is now blocked with callus. Thus, established or impending malunions that cannot be adequately controlled with a cast may require formal open reduction and plate fixation (Figs. 12-35 and 12-36). Many fractures that heal with angulation or rotation of more than the established criteria regain full motion and have an excellent cosmetic outcome. Fractures may require corrective osteotomy if they fail to remodel after an adequate period of observation or if adequate motion fails to return.217,329 Such corrective osteotomies have been done long after injury (up to 27 years) and additional motion has still been regained.329 There is a minor subset of malunions that do not remodel, that have functional limits (especially when there is limited supination deformity), and therefore, are candidates for osteotomy. 
Figure 12-35
An 8-year-old male who underwent corrective osteotomy for forearm shaft malunion.
 
A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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Figure 12-35
An 8-year-old male who underwent corrective osteotomy for forearm shaft malunion.
A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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A: Radiographs demonstrating significant angular malunion. B: Preoperative clinical appearance (dorsal view). C: Preoperative clinical appearance (volar view). D: Preoperative demonstration of full passive supination. E: Preoperative demonstration of marked limitation in passive pronation. F: Early postoperative radiographs following corrective osteotomies (note intraosseous Kirschner wire tip from provisional fixation). G: Clinical appearance with extended elbows and forearm midposition. H: Clinical appearance with extended elbows and pronated forearms. I: Clinical appearance with extended elbows and supinated forearms. J: Symmetrical pronation. K: Symmetrical supination. L: AP radiograph 18 months after osteotomies (plates and screws have been removed). M: Lateral radiograph at 18-month follow-up. N: AP radiograph uninjured left forearm. O: Lateral radiograph uninjured left forearm.
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Figure 12-36
A 16-year-old male who underwent corrective osteotomy for forearm shaft malunion.
 
A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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Figure 12-36
A 16-year-old male who underwent corrective osteotomy for forearm shaft malunion.
A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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A: AP radiograph at time of presentation. B: Lateral radiograph at time of presentation. Note rotational malunion of radius in addition to angular abnormalities of both bones. C: Clinical deformity (bump). D: Relatively symmetrical pronation noted preoperatively. E: Dramatic lack of supination on the right noted preoperatively. F: One-year postoperative radiographs following osteotomies. Note improved rotational alignment of radius. G: Uninjured left forearm radiographs. H: Clinical appearance with extended elbows and forearm midposition. I: Clinical appearance with extended elbows and pronated forearms. J: Clinical appearance with extended elbows and supinated forearms. K: Symmetrical pronation. L: Symmetrical supination.
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Delayed Union/Nonunion in Diaphyseal Radius and Ulna Fractures

The diagnosis of delayed union is based on documentation of slower-than-normal progression toward union.193 Daruwalla75 stated that normal healing of closed pediatric forearm shaft fractures occurs at an average of 5.5 weeks (range 2 to 8 weeks). Delayed union can be practically defined as a failure to demonstrate complete healing (four cortices) on sequential radiographs by 12 weeks after injury, which exceeds the upper limit of normal healing by about 1 month. Nonunion can be defined as the absence of complete bony union by 6 months after injury, which exceeds the upper limit of normal healing by about 4 months. 
Delayed unions and nonunions are rare after closed forearm shaft fractures in children.99,193,308 In six large series of pediatric diaphyseal forearm fractures treated by closed methods, a less than 0.5% rate (1/263) of delayed union and no nonunions were reported.49,75,145,170,182,257 Delayed unions and nonunions are more common after open reduction and internal fixation and open fractures. Particular concern has been raised about the potential of antegrade ulnar nailing (olecranon starting point) to distract the fracture site.237 Combined data from four series of plated pediatric forearm fractures indicated a 3% (3/89) nonunion rate;25,230,332,357 24% (21/89) of these were open fractures and at least one357 of the three nonunions occurred after a grade III open fracture.230,332 Large series of open pediatric forearm fractures (treated by a variety of internal fixation methods) reported comparable numbers: 5% (8/173) delayed union rate and 1% (2/173) nonunion rate.78,128,135 In a series of 30 nonunions in children, only 6 were in the forearm, and half of these were after open fractures.193 
Because of the overall rarity of nonunions in children, the possibility of unusual diagnoses such as neurofibromatosis must be considered.65,67,155,205 After open injury or surgical intervention for other reasons, the possibility of septic nonunion must be ruled out. In the absence of such extraneous factors, nonunion of pediatric forearm fractures seems to be related to surgical treatment.65,67,155,205,308 Weber and Cech346 divided nonunions into atrophic and hypertrophic types. Atrophic nonunions probably are best treated with bone grafting and compression plating. Compression plating or other stable internal fixation without grafting usually is sufficient for hypertrophic nonunions.190 

Cross-Union/Synostosis in Diaphyseal Radius and Ulna Fractures

Posttraumatic radioulnar synostosis results in complete loss of forearm rotation. Most cross-unions that form after pediatric forearm shaft fractures are type II lesions (diaphyseal cross-unions), as described by Vince and Miller (Fig. 12-37).336 Although some series of adult forearm fractures reported synostosis rates of 6% to 9%,21,317 posttraumatic radioulnar synostosis is a rare complication of pediatric forearm shaft fractures.336 In children, it is usually associated with high-energy injuries,336 radial neck fractures,275 and surgically treated forearm fractures.73,238 Some have suggested a familial predisposition to this complication.202 Postoperative synostosis after forearm fractures in children is almost exclusively associated with plate fixation.352,357 The risk of cross-union is increased when open reduction and internal fixation of both-bone fractures are done through one incision.21,70 
Figure 12-37
Radioulnar synostosis following closed injury.
 
A: Injury radiographs. B: Plain radiographs showing synostosis. C: CT scan showing synostosis.
 
(Courtesy of Alan Aner, MD.)
A: Injury radiographs. B: Plain radiographs showing synostosis. C: CT scan showing synostosis.
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Figure 12-37
Radioulnar synostosis following closed injury.
A: Injury radiographs. B: Plain radiographs showing synostosis. C: CT scan showing synostosis.
(Courtesy of Alan Aner, MD.)
A: Injury radiographs. B: Plain radiographs showing synostosis. C: CT scan showing synostosis.
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Both osseous and nonosseous cross-unions may form in the forearm,9,63,340 but the more common type is osseous. After a synostosis matures (6 to 12 months), it can be excised along with any soft tissue interposition.235,336 The results of synostosis resection may be better in adults than children,336 perhaps because of the more biologically active periosteum in children.84,336 Interposition of inert material (such as Gore-tex [W. L. Gore & Associates, Inc., Elkton, MD] or bone wax) has been used to decrease the chances of recurrent synostosis.9,19,238,336 Nonsteroidal anti-inflammatory drugs and radiation treatment have been reported after synostosis excision in adults, but their use in children remains undefined. An alternative treatment is corrective osteotomy if the patient is synostosed in a position of either extreme pronation or supination. If the patient is stuck in a neutral position after posttraumatic synostosis, surgical intervention is usually not recommended. 

Infection in Diaphyseal Radius and Ulna Fractures

Infection occurs only in surgically treated forearm shaft fractures and open fractures. Appropriately timed preoperative antibiotic prophylaxis is believed to diminish the risk of infection. Children with open forearm fractures are considered to be at high risk for infection, and early (usually less than 24 hours)302 irrigation and debridement in the operating room is indicated.273 Whether in the backyard, the barnyard, the football field, or the hay field, open forearm fractures that occur in organic settings are best treated with early irrigation and debridement with inspection of the intramedullary canal of both bone ends, where soil contamination tends to occur during injury (Fig. 12-25). Soil contamination has been reported to lead to gas gangrene and subsequent upper extremity amputation in children with grade I open forearm fractures.96 Emergency room irrigation and debridement is not recommended and is considered inadequate with increased risk of serious infection. 
In four published series of plated pediatric forearm fractures (25% open fractures), deep infection (osteomyelitis) occurred in 5% (4/83).222,230,332,357 Such deep infections usually require extensive additional surgical treatment to eradicate them. Combined data from 12 series of similar pediatric forearm fractures (15% open fractures) treated with intramedullary K-wires, Steinmann pins, or Rush rods revealed a deep infection rate of 0.46% (2/437)8,45,73,184,197,260,261,297,343,363 and a superficial infection rate of 2.5% (11/437). Six studies of ESIN fixation reported a 0.2% (1/370) deep infection rate and a 3% (12/370) superficial infection rate.45,131,188,204,269,335 Superficial infections may require oral antibiotics, pin removal, or both. 
Open forearm fractures clearly are at increased risk for infection. Most (96%) open forearm fractures in children are Gustilo and Anderson134 grade I or II.128,135,198 Two studies specifically investigated the relationship between the time from injury until irrigation and debridement and the risk of later infection. Luhmann et al.198 reported on 65 fractures (52 type I, 12 type II, 1 type III) that were irrigated and debrided an average of 5.6 hours (range 1.5 to 24 hours) after injury, and Greenbaum et al.128 reported 62 fractures (58 type I, 4 type II) that were irrigated and debrided an average of 14.6 hours (range 1.7 to 37.8 hours) after injury. No statistically significant association was found in either of these studies; however, most (87%) of these fractures were grade I injuries. Pooled data revealed an overall 1.2% rate (2/173) of deep infection and a 0.6% rate (1/173) of superficial infection after current open fracture treatment protocols.128,135,198 

Neurapraxia in Diaphyseal Radius and Ulna Fractures

The median nerve is the most commonly injured nerve with forearm shaft fractures (whether closed or open injuries),79,128,135,198 but any peripheral nerve and at times multiple nerves may be involved.73 Most of these injuries are simple neurapraxias that occur at the time of injury and resolve spontaneously over weeks to months.79,134,231 Actual nerve entrapment within or perforation by the bony fragments has been reported,6,112,118,119,152,258,259,313 most often with greenstick fractures.119,152,258,259 Constricting fracture callus and fibrous tissue also have been known to cause nerve palsies.259,313 In patients who fail to recover normal nerve function within a satisfactory time period,6 nerve exploration, decompression, and possible nerve repair should be considered. If signs of progressive nerve recovery (e.g., advancing Tinel sign, return of function) are not present by the end of the third month after injury, further diagnostic work-up (electromyography with nerve conduction studies) is indicated. Prolonged waiting can be harmful to long-term outcome. 
Nerve injury after internal fixation is always a concern. Operative treatment of pediatric forearm fractures by either indirect reduction and internal fixation techniques or classic open reduction and internal fixation techniques requires fracture manipulation and soft tissue retraction, which have the potential to worsen existing subclinical nerve injury or to create a new injury. Such injuries are rare and may be underreported. Nerve injury after pediatric forearm plate fixation has been alluded to but not discussed extensively.184 Luhmann et al.197 reported an 8% (2/25) iatrogenic nerve injury rate after fixation with intramedullary K-wires or Rush rods: Both were ulnar nerve injuries that resolved in 2 to 3 weeks. Cullen et al.73 reported one ulnar nerve injury that took 3 months to resolve in a group of 20 patients treated with K-wires or Rush rods. 
Certain sensory nerves also are at risk for iatrogenic damage during surgical forearm fracture treatment, especially the superficial branch of the radial nerve.45,197,315 Pooled data from six series that included 370 ESIN procedures revealed a 2% (7/370) rate of injury to the superficial branch of the radial nerve.45,131,188,204,269,335 The branching pattern of this sensory nerve is complex, and efforts must be taken to protect it during insertion of intramedullary nails through distal radial entry points.1,14 

Muscle or Tendon Entrapment/Tendon Rupture in Diaphyseal Radius and Ulna Fractures

Severely displaced forearm fractures may trap portions of muscle between the fracture fragments.147,260 Often, interposed tissue can be effectively removed during standard fracture reduction, but the muscle may become an obstacle to successful closed reduction. Much of the volar aspects of the shafts of the radius and ulna are covered by the flexor pollicis longus and flexor digitorum profundus, respectively. Many displaced forearm shaft fractures also have apex-volar angulation.233 As a result, portions of these muscles (or their tendons) are particularly prone to fracture site incarceration (Fig. 12-38). The pronator quadratus also is vulnerable to fracture site entrapment in the distal third of the radius and ulna, and it can block reduction of distal-third forearm fractures.147 
Figure 12-38
Muscle/tendon incarceration.
 
A: Injury radiograph showing mild apex-volar fracture angulation. B: Flexor digitorum profundus entrapment in the ulnar fracture site required surgical extirpation.
A: Injury radiograph showing mild apex-volar fracture angulation. B: Flexor digitorum profundus entrapment in the ulnar fracture site required surgical extirpation.
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Figure 12-38
Muscle/tendon incarceration.
A: Injury radiograph showing mild apex-volar fracture angulation. B: Flexor digitorum profundus entrapment in the ulnar fracture site required surgical extirpation.
A: Injury radiograph showing mild apex-volar fracture angulation. B: Flexor digitorum profundus entrapment in the ulnar fracture site required surgical extirpation.
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Flexor digitorum profundus entrapment within ulnar140,180,266,295 and radial344 shaft fractures has been reported. Entrapment of the flexor digitorum profundus typically causes an inability to fully extend the involved finger (usually index, long, or ring fingers alone or in combination)140,295 Isolated ring finger flexor digitorum profundus entrapment has also recently been reported.307 Even if identified early, this complication rarely responds to occupational or physical therapy. Surgical intervention is the preferred treatment and requires only a small incision (usually over the ulna) through which the adherent tissue is elevated with a blunt instrument from the bone at the site of the fracture. Excellent restoration of finger motion can be achieved, even when the release is done up to 2 years after the fracture.266 
Extensor tendon injury has been reported after intramedullary nailing of pediatric forearm shaft fractures.131,188,250,260 The extensor pollicis longus appears to be at particular risk for this injury if a dorsal entry point is utilized near the second and third dorsal compartments.183,312 Primary tendon disruption may be caused by direct trauma during either nail insertion or extraction. Delayed tendon disruption may be caused by slow erosion of the tendon as it glides past a sharp nail edge. The possibility of this complication can be minimized by using surgical incisions large enough to allow insertion of small blunt retractors to protect adjacent tendons during nail insertion and extraction. Avoidance of tendon erosion requires pin lengths that extend beyond the tendon level into either the subcutaneous tissues73,297 or through the skin (external pins).260 Conceivably, the pins could be buried completely within the bone, but this would require either accepting them as permanent implants (something not commonly practiced at this time) or significantly increasing the level of difficulty of nail removal. The extensor pollicis longus is more at risk near the Lister tubercle and may require a late tendon reconstruction with extensor indicis proprius transfer if ruptured. 

Compartment Syndrome in Diaphyseal Radius and Ulna Fractures

Compartment syndrome is rare after closed forearm fractures in children, but its consequences can be devastating. Yuan et al.362 found no compartment syndromes in 205 closed forearm injuries, and Jones and Weiner162 reported no compartment syndromes in their series of 730 closed forearm injuries. A single compartment syndrome that developed during cast treatment of a 12-year-old female with a closed both-bone forearm fracture was reported by Cullen et al.73 Because the diagnosis of compartment syndrome can be difficult in children,263 the index of suspicion must be high. 
Compartment syndrome should be suspected in any child who is not reasonably comfortable 3 to 4 hours after adequate reduction and immobilization of a forearm fracture.68 The risk of compartment syndrome is higher with open fractures135,362 and fractures that are difficult to reduce and require extended operative efforts.362 Yuan et al.362 voiced concern that the 10% (3/30) rate of compartment syndrome in their patients with closed fractures might be caused by multiple passes or “misses” with intramedullary devices during efforts at indirect reduction and internal fixation. Compartment syndrome was reported by Haasbeek and Cole135 in 5 (11%) of 46 open forearm fractures in their series. The so-called floating elbow injury has been associated with a rate of compartment syndrome as high as 33%.362 In children, the three A's of increasing analgesia, anxiety, and agitation are the most reliable clinical signs of a pending compartment syndrome. Forearm compartment syndrome is best treated with fasciotomy, releasing both the superficial and deep volar compartments and the mobile wad. Both the lacertus fibrosis and the carpal tunnel should be released as part of the procedure. 

Complex Regional Pain Syndromes in Diaphyseal Radius and Ulna Fractures

Complex regional pain syndromes such as reflex sympathetic dystrophy are uncommon complications after pediatric forearm shaft fractures.332 Paradoxically, relatively minor injuries seem to place patients at greatest risk.316,349 The most reliable sign in children is true allodynia: Significant reproducible pain with light touch on the skin. Swelling and other vasomotor changes often are accompanying signs.191 The diagnosis in children is made based almost exclusively on the history and physical examination, with little reliance on studies such as bone scans.316 These pain syndromes are best treated initially with physical therapy aimed at range of motion and desensitization.316,349 Failure to respond to physical therapy may warrant a referral to a qualified pediatric pain specialist.174,191 

Author's Preferred Treatment for Diaphyseal Radius and Ulna Fractures

Closed Fracture Care for Diaphyseal Radius and Ulna Fractures

We agree with Jones and Weiner that “closed reduction still remains the gold standard for closed isolated pediatric forearm fractures” (Fig. 12-39).162 Most nondisplaced and minimally displaced radial and ulnar shaft fractures can be splinted in the emergency department and referred for orthopedic follow-up within 1 week. Radiographs are repeated at the first orthopedic visit, and a cast is applied. During warmer weather, when fracture incidence peaks, we tend to use waterproof cast liners. We avoid flexing the elbow past 80 to 90 degrees in waterproof casts because the soft tissue crease that forms in the antecubital fossa tends to trap moisture. Because waterproof cast lining alone does not shield the skin from cast saw cuts and burns as well as traditional padding does, specialized material may be added along the anticipated course of the cast saw to protect the skin during cast removal. 
Flynn-ch012-image039.png
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Figure 12-39
Author recommended treatment.
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We prefer an above-elbow cast for all forearm fractures in children under the age of 4 years, because young children tend to lose or remove a below-elbow cast because of soft tissue differences (baby fat) common to the age group.85 Most older children with forearm shaft fractures also are treated with above-elbow casting, except for those with distal-third fractures. Good forearm casting technique should focus on the principles outlined earlier in this chapter. Patients with nondisplaced fractures usually are reevaluated radiographically in 1 to 2 weeks after initial immobilization to check for fracture displacement. Forearm shaft fractures heal more slowly than metaphyseal and physeal fractures of the distal radius and ulna.13,79 The cast is removed in 6 to 8 weeks if adequate healing is present on radiographs. Because of the significant refracture rate after forearm shaft fractures, we splint these fractures for several weeks or even a few months until all transverse lucency of the original fracture disappears and all four cortices are healed. It is extremely helpful to warn patients and their parents about the high rate of refracture with forearm shaft fracture throughout their treatment. Fractures that heal in bayonet apposition (complete translation and some shortening) can take longer to heal than those with end-to-end apposition and may require prolonged splinting to prevent refracture.85,274 

Summary, Controversies, and Future Directions Related to Diaphyseal Radius and Ulna Fractures

Fracture Risk/Fracture Prevention

Over the past three decades, the rate of forearm fractures has increased dramatically in the United States: 33% higher for males and 56% higher for females.177 Certain risk-taking behaviors demonstrated by children, as well as increased use of roller blades, skateboards, scooters, trampolines, Heelys skate shoes, bicycle ramping, snowboarding, and motorized vehicles like all-terrain vehicles, may be at least partly to blame.44,200 Increased general physical activity patterns and decreased calcium intake also have been suggested as explanations,177 but gaps persist in our epidemiologic understanding. Preventing these injuries remains an admirable but elusive goal. Two main avenues of research have been explored: Optimizing safety during activities known to be associated with forearm fractures and investigating biologic mechanisms related to fracture risk. 
The relationship between in-line skating (rollerblading) and pediatric forearm fractures has been shown,21,251 with 1 in 8 children sustaining a fracture on his or her first skating attempt.221 Prevention efforts have focused largely on protective gear. Wrist guards have been shown to decrease distal forearm bone strain311 and injury rates.283 Similar protective effects of wrist guards in snowboarders have been shown.234 Trampolines are another target of injury prevention efforts aimed at a specific play activity.91 Dramatic increases in trampoline-related injuries were reported during the 1990s, with rates doubling305 or even tripling.109 Safety recommendations have ranged from constant adult supervision and one-child-at-a-time use187 to outright bans on public trampoline use.109,305 
A variety of biologic risk factors have been studied relative to forearm fractures. Children who avoid drinking milk have been shown to have increased fracture risk,126 as well as those who prefer to drink fruit juice and soda.247 Several studies have shown an increased risk of fractures in females aged 3 to 15 years with low bone density.123,125 Diet, nutrition, and exercise are being explored as causative factors, but the precise reason for the low bone density has not been confirmed. Too little physical activity (as measured by television, computer, and video viewing) has been associated with increased fracture risk, presumably because of decreased bone mineral density.199 Caution also must be exercised when obtaining dual-energy x-ray absorptiometry data in children, as up to 88% of scans may be misinterpreted.111 Childhood obesity is a growing problem in our society.115,154 Increased body weight and decreased cross-sectional dimensions of the forearm bones also have been found in females who fracture their forearms.303 Other researchers have found an increased risk of forearm fracture in obese children.124,161 

Parental Presence During Fracture Reduction in Diaphyseal Radius and Ulna Fractures

Parental presence is becoming increasingly popular for pediatric emergency department procedures. Several studies on chest tubes, IV cannulation, lumbar puncture, and urethral catheterization have shown increased parental satisfaction when parents are allowed to stay for these procedures.20,137,252 Parental presence during induction of anesthesia also has been shown to have favorable effects on children older than 4 years of age.165 To the best of our knowledge, there are no published studies on parental presence during orthopedic procedures performed in the emergency department setting. There are also no parental presence studies on any emergency department procedures performed on children who are under sedation, when the child is probably not aware of the parent's presence. 
Certain relationships between perceived procedural invasiveness and parental presence have been borne out in the literature. Four hundred parents from the Indiana area were surveyed, and with increasing invasiveness, the parents' desire to be present decreased.34 A survey of academic emergency medicine attendings, residents, and nurses from across the country also showed that there is an inverse relationship between increasing invasiveness and support for parental presence.22 Boudreaux et al. published their critical review of the parental presence literature and concluded that “randomized controlled trials are mixed regarding whether family presence actually helps the patient.”38 
Extrapolation of information from the previously mentioned studies to pediatric orthopedic settings should be done with caution. We typically allow parents to be present for the induction of sedation, and once the patient is sedated the parents are asked to wait in a designated area. If parents are allowed to be present, we strongly recommend a dedicated employee to attend to the parent or parents (a “spotter”). Several parents (typically fathers) have fainted during such orthopedic procedures and injured themselves. Parents who stay for a reduction also should be counseled that the patient may moan or cry during reduction but will not remember it. Parents who are not present during reduction should be asked to wait far enough away from the procedure room so they cannot hear the child. 

Acknowledgments

The authors wish to acknowledge the priceless teaching and constructive feedback afforded us by our senior partner, Alvin H. Crawford, MD, FACS. 

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