Management of Paediatric Forearm Fractures

A Briefing Document for Emergency Medicine Professionals

This document synthesizes guidance from the British Orthopaedic Association (BOA), the British Society for Children's Orthopaedic Surgery (BSCOS), The Royal College of Emergency Medicine, the Orthopaedic Trauma Society, and published clinical evidence (1, 2, 3).

Executive Summary

Paediatric forearm fractures are the most common fractures in childhood, typically resulting from a fall on an outstretched hand. The unique properties of growing bone—including a thick, osteogenic periosteum and the presence of physes (growth plates)—result in distinct fracture patterns and a significant capacity for remodelling. Casting is the gold standard of care for the majority of these injuries.

For fractures that exceed remodelling potential due to significant angulation or displacement, early closed reduction by manipulation in the Emergency Department is the treatment of choice, often avoiding the need for general anaesthesia and hospital admission. This approach is definitive for most displaced complete, greenstick, and Salter-Harris I or II fractures.

A thorough neurovascular assessment is mandatory both before and after any intervention. Indications for reduction are age-dependent, with younger children tolerating greater degrees of angulation. Urgent orthopaedic consultation is required for all open fractures, complex physeal injuries (Salter-Harris III, IV, V), and fractures associated with joint dislocation.

Post-reduction management involves appropriate immobilization, typically with a cast, and clear instructions for caregivers on recognizing complications. The most critical immediate complication is a tight cast leading to neurovascular compromise or compartment syndrome. Long-term, the primary concern, particularly with physeal injuries, is growth disturbance.

1. Definition and Classification

Paediatric bone has unique properties, including a thicker, stronger, and more metabolically active periosteum, which limits displacement and promotes rapid healing. This leads to specific fracture patterns not typically seen in adults.

Common Paediatric Fracture Patterns

Torus (Buckle) Fracture: The most common paediatric fracture, resulting from a compressive force causing the cortex to buckle without a complete break. It is mechanically stable.
Greenstick Fracture: An incomplete fracture where the bone is angulated, causing a break in one cortex while the other cortex and periosteum remain intact, analogous to breaking a "green" stick.
Plastic Deformation (Bowing): The bone bends without a visible fracture line on radiographs.
Complete Fracture: The fracture passes through both cortices of the bone, often with displacement, angulation, and/or malrotation.

Physeal (Growth Plate) Fractures

Injuries to the physis account for 21-30% of long bone fractures in children (21, 22). The Salter-Harris classification is the most widely used system to describe these injuries. The risk of growth disturbance generally increases with the grade.

A useful mnemonic is SALTER, referring to the fracture line's relationship to the growth plate (physis) and surrounding bone:

Type	Mnemonic	Description	Risk for Growth Disturbance
I	Straight across	Fracture runs straight through the hypertrophic zone of the physis.	Low risk
II	Above	Fracture runs through the physis and exits through the metaphysis.	Low risk
III	Lower or BeLow	Intra-articular fracture from the joint surface through the epiphysis to the physis.	Higher risk
IV	Two or Through	Intra-articular fracture from the joint surface through the epiphysis, physis, and metaphysis.	High risk
V	End or ERasure	A compression or crush injury to the physis, often diagnosed retrospectively.	Very high risk

The Ogden classification further subdivides the Salter-Harris types, providing more detail on fracture patterns and prognosis.

2. Epidemiology & Aetiology

Incidence: The forearm is the most common site for fractures in children. Musculoskeletal injuries comprise approximately 12% of paediatric Emergency Department visits in the United States (1). Distal radius fractures are the most frequent, accounting for 35-47% of all wrist fractures in children and adolescents.
Age and Sex: Physeal injuries peak during periods of rapid growth, typically between ages 9-12 in girls and 12-15 in boys (24).
Aetiology: The most common mechanism is a fall on an outstretched hand (FOOSH).
Predisposing Factors: The physis is the weakest point in paediatric bone, making it more susceptible to injury than ligaments. Children with increased body mass and decreased bone mineral density are at higher risk for distal radius fractures.
Pathology: The strength and thickness of the paediatric periosteum aid in fracture stability and healing. Fractures most commonly occur through the weakest part of the physis, the zone of hypertrophic cartilage.
Prognosis and Remodelling: Children have a significant capacity to remodel deformity following fracture union. This potential is greatest in younger children and for deformities in the plane of joint motion. The wrist is more tolerant of angulation and displacement than the forearm shaft. While most fractures heal without incident, approximately 30% of physeal fractures lead to a growth disturbance (6).

3. Clinically Relevant Anatomy

Bones: The forearm consists of the radius and ulna. Growing long bones are composed of the diaphysis (shaft), metaphysis (flared end), physis (growth plate), and epiphysis (secondary ossification center).
Joints:
- Distal Radioulnar Joint (DRUJ): The articulation between the ulnar head and the ulnar notch of the radius, crucial for forearm pronation and supination.
- Radiocarpal Joint: The articulation between the distal radius and the scaphoid and lunate, responsible for most wrist flexion and extension.
Physes (Growth Plates): These cartilaginous plates are responsible for the longitudinal growth of long bones. The distal radial physis contributes 75% of the radius's growth, while the distal ulnar physis contributes 20% to the ulna's growth. Physeal closure varies by bone and sex, but for the distal radius and ulna, it typically occurs between 17-19 years for males and 16-17 years for females.
Neurovascular Structures:
- Nerves: The median, ulnar, and radial nerves provide motor and sensory function to the wrist and hand. The median nerve traverses the carpal tunnel and is vulnerable in displaced fractures.
- Arteries: The radial and ulnar arteries are the main blood supply to the forearm and hand.

Nerve	Motor Function	Sensory Function
Median	Wrist flexion/abduction, thumb/index finger flexion, thumb opposition	Palmar aspect of thumb, index, middle, and radial half of ring finger
Ulnar	Wrist flexion/adduction, finger abduction/adduction	Little finger and ulnar half of ring finger (palmar and dorsal aspects)
Radial	Wrist and thumb extension, forearm supination	Dorsal web space between thumb and index finger

4. Clinical Assessment

History

A standard clinical narrative should be documented, including age, sex, and a detailed mechanism of injury. It is vital to consider non-accidental injury, especially in children under three or when the history is inconsistent with the injury pattern. Fractures highly suggestive of non-accidental injury include metaphyseal corner fractures and multiple fractures in various stages of healing.

Physical Examination (ABCDE Approach)

Airway, Breathing, Circulation: Assess as per standard trauma protocols.
Disability (Neurovascular Assessment): A meticulous neurovascular examination of the affected limb is critical and must be performed and documented before and after any reduction attempt.
- Neurological: Assess motor and sensory function of the median, radial, and ulnar nerves as detailed in the anatomy table above.
- Vascular: Check for pallor, cyanosis, temperature, and capillary refill time in the digits.
Exposure: Fully expose the limb, inspecting all surfaces for swelling, ecchymosis, and deformity. Carefully examine for any skin breaches, particularly on the volar aspect, which may indicate an open fracture. Palpate for focal bony tenderness. Tenderness directly over the physis in the absence of radiographic findings is suggestive of a Salter-Harris I fracture.

5. Investigations

Plain Radiographs

Views: Anteroposterior (AP) and lateral views of the forearm, including the wrist and elbow joints, are standard. Oblique views may be necessary if a fracture is clinically suspected but not visible on standard views.
Interpretation: A systematic description should include:
- Anatomic location (e.g., distal radial metaphysis).
- Fracture pattern (e.g., transverse, greenstick, buckle).
- Relationship of fragments (displacement, angulation, shortening).
- Physeal involvement (Salter-Harris classification).
- Joint involvement (intra-articular extension).

6. Management in the Emergency Department

Indications for Reduction

Closed reduction is indicated for significantly displaced or severely angulated closed distal forearm fractures. The acceptable degree of angulation and displacement is age-dependent due to remodelling potential.

Table: Indications for Reduction of Distal Forearm Fractures in Children

Parameter	0-5 years	5-12 years	>12 years
Dorsal/Ventral Angulation	35°	20°	15-20°
Lateral or Medial Tilt	15°	15°	10°
Displacement (of Bony Width)	100%	50-100%	< 50%

Consultation with an orthopaedic surgeon is warranted when there is uncertainty about the need for reduction.

Contraindications to ED Reduction

Immediate, urgent referral to an orthopaedic surgeon is required for:

Open fractures.
Salter-Harris III, IV, or V fractures.
Fractures complicated by joint dislocation (wrist or elbow).
Associated supracondylar fractures.
Neurovascular compromise.
Failed closed reduction.

Procedure: Closed Reduction and Immobilization

Informed Consent: Obtain written consent from caregivers, explaining the procedure, procedural sedation risks, potential for loss of reduction requiring surgery, and potential for adverse outcomes like growth arrest.
Preparation and Analgesia: Perform a pre-sedation evaluation. Procedural sedation is the standard of care. This may be augmented by a hematoma block or regional intravenous block.
Reduction Technique:
- Traction: An assistant provides counter-traction on the upper arm while longitudinal traction is applied to the hand. Finger traps can be used to provide sustained traction, which helps relax muscles and distract fracture fragments.
- Disimpaction: If bones are overlapping, gently increase the deformity (often to >90 degrees) to disengage the fragments.
- Reduction: Apply direct pressure with thumbs to push the distal fragment back into alignment with the proximal fragment.
- Alignment: Straighten the forearm into the reduced position.
Immobilization:
- Casting: This is the definitive treatment. A short arm cast is recommended for most distal forearm fractures. Long arm casts may be used in very young children.
- Cast Application: Ensure adequate padding (Webril) over a stockinette, especially over bony prominences. The forearm should be cast in a neutral position for supination/pronation.
- Moulding: Apply a three-point mould to maintain the reduction. The cast should be wider in the AP diameter than the lateral (ratio ~0.7).
- Splinting: If casting is not performed, a sugar-tong splint can provide temporary immobilization, but the patient must have definitive casting by an orthopaedic surgeon within 2-5 days.
Post-Procedure Checks:
- Radiographs: Obtain post-reduction AP and lateral radiographs to confirm adequate alignment. Bedside fluoroscopy is an alternative.
- Neurovascular Assessment: Re-assess and document distal neurovascular status. The patient must be able to fully extend fingers and thumb actively and passively without significant pain.

7. Complications

Condition-Related Complications

Growth Arrest: The most significant long-term complication of physeal injuries, potentially leading to limb shortening or angular deformity.
Malunion: Healing in an unacceptable position.
Refracture: Can occur after cast removal.

Treatment-Related Complications

Immediate/Early:
- Loss of Reduction: May occur within the cast, especially in the first week.
- Tight Cast/Compartment Syndrome: A surgical emergency. Swelling within a restrictive cast can compress neurovascular structures. Key warning signs include:
  - Severe pain, especially pain that is disproportionate or not controlled by simple analgesia.
  - Pain on passive extension of the fingers.
  - Inability to actively move the fingers.
  - Numbness, tingling, or a burning sensation.
  - Cold, pale, or blue fingers.
- Pressure Sores/Skin Breakdown: Due to inadequate padding or wrinkles in the cast material.
Delayed:
- Joint Stiffness & Muscle Atrophy: Common after a period of immobilization.
- Extensor Pollicis Longus (EPL) Tendon Rupture: A rare complication occurring 4-8 weeks post-fracture due to interruption of its vascular supply.

Management of Complications

If significant swelling is anticipated (e.g., after reducing a complete fracture), the cast should be split on both sides (bivalved) and secured with an elastic wrap. Any patient presenting with signs or symptoms of a tight cast or compartment syndrome requires immediate removal of all casting material down to the skin and urgent orthopaedic evaluation.

8. Discharge and Follow-Up

Discharge Instructions

Caregivers must be given explicit instructions to return for urgent evaluation if any of the warning signs of a tight cast or compartment syndrome develop. Provide information on cast care, elevation, and analgesia.

Follow-Up Schedule

Splinted Fractures: Orthopaedic follow-up for casting within 2-5 days.
Casted Salter-Harris I/II & Greenstick Fractures: Orthopaedic follow-up in one week.
Casted Complete Fractures: Require close orthopaedic follow-up within one week to monitor for displacement.

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Appendix: Example EHR Documentation (EPIC)

Procedure Note: Closed Reduction of Paediatric Forearm Fracture

HPI: [ ] Fall on outstretched hand (FOOSH) [ ] Direct trauma [ ] Other: _____ Patient complains of pain, swelling, and deformity of the [ ] Left / [ ] Right forearm/wrist.

Physical Examination:

General: Alert, in no acute distress other than limb pain.
Affected Limb Inspection:
- [ ] Visible deformity
- [ ] Swelling
- [ ] Ecchymosis
- [ ] No open wounds, skin intact.
Palpation:
- [ ] Point tenderness over distal radius.
- [ ] Point tenderness over distal ulna.
- [ ] Tenderness over radial/ulnar physis.
Pre-Reduction Neurovascular Exam:
- Motor: Full active/passive finger/thumb motion. [ ] Intact / [ ] Deficit noted: _____
- Sensory (Median): Sensation intact to light touch palmar index finger. [ ] Yes / [ ] No
- Sensory (Ulnar): Sensation intact to light touch palmar little finger. [ ] Yes / [ ] No
- Sensory (Radial): Sensation intact to light touch dorsal first webspace. [ ] Yes / [ ] No
- Vascular: Digits are warm, pink, with capillary refill <2 seconds. Radial pulse palpable and strong. [ ] Yes / [ ] No

Investigations:

Radiographs (Forearm/Wrist):
- Fracture Type: [ ] Torus (Buckle) / [ ] Greenstick / [ ] Complete / [ ] Salter-Harris Type (I, II, III, IV, V)
- Bone(s) Involved: [ ] Radius / [ ] Ulna / [ ] Both
- Location: Distal Metaphysis
- Description: Angulation of __ degrees [ ] dorsal / [ ] volar. Displacement of __% of shaft width.

Procedure:

Consent: Informed consent was obtained from parent/guardian after discussion of risks (including sedation risks, failure of reduction, need for surgery, neurovascular injury, compartment syndrome, growth arrest), benefits, and alternatives. All questions were answered.
Analgesia/Sedation: [ ] Procedural Sedation (see separate note) / [ ] Hematoma Block
Technique: Closed reduction was performed using longitudinal traction and counter-traction with manipulation to restore anatomic alignment.
Immobilization: A [ ] short arm / [ ] long arm cast was applied. [ ] Three-point moulding performed. [ ] Cast was bivalved and overwrapped with an elastic bandage due to anticipated swelling.

Post-Procedure Assessment:

Post-Reduction Radiographs: Confirmed acceptable alignment.
Post-Reduction Neurovascular Exam: Status remains unchanged from pre-reduction exam. Digits are warm, pink, with brisk capillary refill. Patient able to move all fingers without significant pain. Sensory exam intact. [ ] Yes / [ ] No

Medical Decision Making (MDM): The patient, a [age]-year-old, presented after a [mechanism] with a closed, displaced/angulated fracture of the distal [radius/ulna/both bones]. The fracture pattern and degree of deformity exceeded the age-appropriate guidelines for acceptable alignment, necessitating reduction to restore function and prevent malunion.

The procedure was performed under procedural sedation. A successful closed reduction was achieved, as confirmed by post-procedure radiographs showing significantly improved alignment. The limb was immobilized in a well-padded cast. The patient remained neurovascularly intact throughout.

The plan is for discharge home with strict return precautions (especially for signs of compartment syndrome), analgesia, and scheduled orthopaedic follow-up in one week. The risks and benefits were discussed extensively with the family, who understood and agreed with the plan.

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