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Children's forearm fractures
CHILDREN’S ORTHOPAEDICS
Children’s forearm fractures
This article will encompass forearm fractures in children distal to the elbow region as well as Monteggia fractures, which are forearm fractures with associated elbow involvement. Primary injuries of the elbow region in children are outside the scope of this article.
Michael Mokawem Brian Scott
Principles of management
Abstract Forearm fractures in children are commonly encountered by orthopaedic surgeons, who are expected to manage these fractures with a thorough understanding of the nature of fracture, the acceptable displacement which will remodel and the appropriate treatment modalities available should intervention be indicated. The incidence of these fractures remains high, as children are prone to participation in high-risk activities on a regular basis. Activities such as trampolining, ice skating, cycling and the use of climbing frames will ensure that these fractures continue to present in large numbers. Treatment modalities are well established but not universally well followed. Distal fractures are most commonly amenable to closed treatment methods. In contrast, there should be a low threshold for surgical stabilization in shaft fractures. Flexible intramedullary nailing has contributed significantly to the better management of shaft fractures, which can be very difficult to treat successfully with other methods. An increased awareness of those fractures that have a high risk of displacement following reduction will lead to better selection of fractures likely to benefit from early surgical stabilization. Overall, excellent outcomes can be expected if care is taken to treat these fractures appropriately.
Epidemiology Numerous epidemiological studies have shown the incidence of fractures in the paediatric population to be in the region of 20/ 1000/year. This is almost twice the incidence seen in adults and it is thought to be increasing due to increased participation in high risk sporting activities as well as increased levels of obesity. It is estimated that nearly one third of all children will, at some time, experience a fracture. Forearm fractures account for about 40 percent of all paediatric fractures and distal radius fractures make up three quarters or more of these. There is a predominance in males seen in both distal (55%) and shaft (66%) fractures. Distal radius fracture incidence shows a unimodal pattern with a steady increase in both sexes through early childhood, peaking at the age of 12e14 and then decreasing. The incidence of shaft fractures differs between boys and girls. Girls have a unimodal distribution peaking at around 6 years of age but boys have a bimodal distribution with a peak at around 6e7 and then a large spike in the teenage years, highest at 14 years of age.1
Keywords forearm fractures; flexible nailing; growth plate; Monteggia; redisplacement
Children’s bone
Michael Mokawem MB ChB MRCS Specialty Registrar in Trauma and Orthopaedic Surgery, Leeds General Infirmary, Leeds, West Yorkshire, UK. Conflicts of interest: none declared.
Enchondral ossification at the physis leads to bone lengthening, while peripheral growth at the physis takes place in the zone of Ranvier. Peripheral growth along the diaphysis is due to deposition of bone beneath the periosteum, referred to as appositional ossification.2 Compared with adults, the periosteum in a child is an enormously strong, thick structure. Even in complete fractures, the periosteum is often intact. This allows most paediatric fractures to be treated non-operatively, as it will aid reduction and then assist in controlling the reduction. When the periosteum is disrupted, fractures are much more difficult to reduce and a low threshold for surgical stabilization should exist. Paediatric bone is less dense than adult bone due to a lower mineral content. It has a lower bending strength but also a lower modulus of elasticity which allows it to absorb more energy before it fractures.3 Three unique incomplete fracture patterns are seen in paediatric bones: Buckle or Torus fractures Metaphyseal fractures. The bone fails in compression. Plastic deformation Angulation exceeds the elastic limit, leading to microscopic failure of the tension side which does not propagate to the compression side. Greenstick fractures A continuum of plastic deformation in which an increased bending force causes the tension side to fracture but the fracture does not propagate to the compression side.3
Brian Scott MB BS FRCS (Orth) Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds, West Yorkshire, UK. Conflicts of interest: none declared.
Physeal micro-anatomy A well organised process of chondrocyte maturation takes place at the physis through four layers arranged perpendicular to the long axis of the bone (Figure 1). As the chondrocytes mature through the
Introduction Children’s forearm fractures present a challenge to trauma and orthopaedic surgeons throughout their career. These fractures make up a significant portion of the work in both major trauma centres and smaller units. Correct management of these injuries relies upon a sound understanding of the specific injury, as well as an ability to accurately predict the remaining growth and remodelling potential of the developing skeleton. Trauma and orthopaedic surgeons need to be proficient in closed reduction and casting techniques, which lay a strong foundation for the competent management of these fractures. Vitally, they need to be skilled in the art of open reduction and surgical stabilization to confidently intervene surgically when the correct indications are present. Furthermore, being adept at the outpatient management of these fractures requires an ability to accurately assess the fracture as well as effectively communicate with the child and the parents, often reassuring parents regarding remodelling potential, stiffness and the risk of refracture.
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CHILDREN’S ORTHOPAEDICS
Figure 1 Physeal microanatomy with growth plate layers.
1 m (þ-25%).1 Sports (football and gymnastics) related injuries and falls from bicycles are commonly seen. Trampolines and monkey bars are frequently implicated, while activities such as ice skating and skiing also contribute significantly to the genesis of these fractures.9
layers, they progressively hypertrophy, resulting in less space for the strong surrounding extracellular matrix. This is most evident in the hypertrophic layer where the physis is most susceptible to fractures. In the final layer (Zone of calcification) metaphyseal vascularization leads to programmed cell death of chondrocytes, calcification of the extracellular matrix and formation of osteoblasts and osteoclasts which produce primary bone and are involved in remodelling. The ring of La Croix is a strong, fibrous structure which stabilizes the epiphysis on the metaphysis.2
Presentation The mechanism of injury often dictates the presentation and any patient who presents following a high energy mechanism should be managed according to Advanced Trauma Life Support principles. Children usually present with pain shortly after the incident, although with less severe injuries such as torus fractures the presentation may be delayed, as the symptoms will be mild. An obvious deformity may be present and the child or accompanying adult may be cradling or supporting the limb. It is important to give the child appropriate analgesia as soon as possible once it has been established that there are no contraindications such as head injury or allergy. This settles the child to allow a full history, examination, imaging and initial splinting. As soon as the child has settled sufficiently to allow examination, this should take place along the established formula of ‘look, feel and move’. Be sure to get a circumferential view of the arm so as not to miss a wound or open fracture. The examination should include the whole of the ipsilateral limb because simultaneous injuries may occur. No more than gentle palpation should be attempted at the site of injury. The entire forearm should be carefully examined to include the wrist and elbow joints, as well as the distal radio-ulna joint. A careful neurovascular examination is then carried out to specifically establish whether this is intact. A radial pulse is identified and capillary refill time is tested: the findings are documented. Sensation is tested by light touch over the ulna side of the little finger (ulna nerve), palmar side of the index finger and thumb (median nerve) and dorsum of first web space (radial nerve). Motor function is tested by asking the patient to give a “thumbs up” (extensor pollicis longus
Remodelling potential Although there is great scope for remodelling in the plane of joint movement, rotation will not remodel. Angulation will remodel more in distal fractures due to approximately 75% of radial growth taking place at the distal physis.4 The following is a guide as to how much angulation can be expected to remodel satisfactorily.5 Distal 0 Under 10 years of age: up to 30 degrees 0 Over 10 years of age: up to 15 degrees Shaft 0 Under 6 years of age: up to 15 degrees 0 6e12 years of age: up to 10 degrees 0 Over 12 years of age: minimal These figures are supported in the literature: Armstrong et al.6 and Price et al.7 have shown that distal fractures remodel in the sagittal plane at þ- 0.9 degrees per month and in the frontal plane at þ- 0.8 degrees per month. Only minimal remodelling takes place after the age of 12 years and only very limited remodelling of angular deformities in the frontal plane will take place after the age of 9 years.8
Mechanism of injury Falls from a height of less than 1 m (þ-50%) are responsible for nearly twice as many fractures as fall from a height of more than
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CHILDREN’S ORTHOPAEDICS
innervated by the posterior interosseous nerve e branch of radial nerve), make an “O” sign, observing for flexion at the thumb interphalangeal joint (flexor pollicis longus innervated by anterior interosseous nerve e branch of median nerve), resisted thumb abduction (abductor pollicis brevis e median nerve), crossing index over middle fingers (first palmar and second dorsal interosseous muscles e ulnar nerve) and flexing the little finger distal interphalangeal joint (flexor digitorum profundus e ulnar nerve). These findings must be clearly documented prior to any attempt at manipulation and casting. A thorough examination may be difficult due to the child’s anxiety and level of pain.
Type of fracture Incomplete: 0 Torus/buckle 0 Plastic deformation 0 Greenstick Complete Associated injury Open fracture Joint disruption: Monteggia (radiocapitellar) and Galeazzi (DRUJ) fractures 0 Monteggia (Bado classification) ➢ Type 1 e Anterior radial head dislocation with apex anterior proximal ulna fracture (most common) ➢ Type 2 e Posterior radial head dislocation with apex posterior proximal ulna fracture ➢ Type 3 e Lateral radial head dislocation with apex lateral proximal ulna fracture ➢ Type 4 e Proximal radius and ulna fractures with dislocation of radial head 0 Galeazzi (rare in children) Interosseous membrane disrupted (Essex Lopresti) e possibly not seen in children
Imaging Standard anteroposterior and lateral radiographs of the whole forearm including the wrist and elbow are obtained. These are usually adequate for diagnosis. Be vigilant for disruptions of either the radiocapitellar or distal radioulnar (DRUJ) joints. A line drawn along the axis of the medullary cavity of the radius directed proximally should bisect the capitellum in any view. Discrepancy in the cortical widths either side of the fracture site is a good indicator of rotation. Further imaging is rarely needed but occasionally computed tomography (CT) scans are obtained for intraarticular distal radius or proximal ulna fractures. With a markedly deformed fracture, it is not necessary to repeat the radiographs if splinting alone has been applied. However, if any manipulation has been attempted, or the original images showed an unstable fracture in a good position, repeat radiography after splinting or casting is essential.
Displacement This can be broken down further into angulation, translation, rotation and shortening, with bayonetting being an independent consideration. Although there is literature to support treating bayonetting non-operatively as it will remodel, it is rare in modern practice for this not to be reduced and stabilized.
Classification Physeal fractures are classified separately (Salter e Harris) (Figure 2): Type 1 e usually displace dorsally Type 2 (most common) e usually displace dorsally (Figure 3) Type 3 (rare in forearm fractures) Type 4 (rare in forearm fractures) Type 5 (usually identified retrospectively)
Forearm fractures may be classified by four descriptors, namely: 1. Anatomical location 2. Type of fracture 3. Associated injury 4. Displacement Anatomical location Distal radius and or ulna fractures: physeal (Salter-Harris classification) or metaphyseal Shaft/diaphyseal fractures: proximal third, middle third or distal third. Proximal radius and or ulna fractures
Criteria for reduction Distal fractures 1. Angulation
Figure 2 Salter-Harris classification of physeal fractures.
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CHILDREN’S ORTHOPAEDICS
Figure 3 Salter-Harris II distal radius fracture.
Under 10 years of age: more than 30 degrees Over 10 years of age: more than 15 degrees 2. Translation More than 50% 3. Intra-articular displacement Most surgeons would have a lower threshold for reducing distal radius fractures, as they normally only require closed reduction and angulation of 30 would otherwise take approximately 30 months to remodel.
separation distance between the radius and ulna to be greater distally. In full supination the radial styloid should be seen laterally and the radial tuberosity should be medial, indicating the correct rotational alignment of the radius.
Treatment options Non-operative 0 Splinting for comfort in stable fractures ➢ These include minimally displaced physeal injuries (Salter-Harris 1 and 2 with less than 5 mm translation), torus fractures and minimally displaced greensick fractures (less than 15 degrees angulation). It has been shown in a randomized controlled trial that these fractures may be treated satisfactorily with a flexible cast, removed at home after 3 weeks.12 Many centres treat torus fractures satisfactorily with a removable wrist splint, patient advice leaflet for the parents and discharge from further follow up. 0 Moulded cast immobilization in the plaster room when the fracture is in a satisfactory position 0 Closed reduction and application of a moulded cast (usually in theatre under general anaesthetic) ➢ Applying a well moulded plaster cast is a vital skill when managing forearm fractures. A cast index diameter of <0.7e0.8 has been shown to be a factor in preventing loss of reduction when this was revisited by Kamat et al. in 2012.13 Cast index diameter (Figure 4) is measured at the fracture site and is the sagittal width inside the cast divided by the coronal width inside the cast. Although only validated for distal fractures, the same principles apply to shaft fractures. ➢ Pronated or supinated: Proximal fractures should be immobilized in supination and distal fractures should be immobilized in pronation. ➢ Above or below elbow cast: Children younger than about 4 years should have an above elbow cast for
Shaft fractures10 1. Angulation Under 10 years: more than 15 degrees Over 10 years: more than 10 degrees 2. Translation More than 50% 3. Rotation Any detectable Further indications for reduction are clinically obvious deformity and decreased rotational ability in children of school going age.
Surgical anatomy The distal radial epiphysis appears on radiographs by the age of 2, perhaps slightly later in boys, and fuses between the ages of 16 and 17 in girls with boys being about a year later.11 The distal ulna epiphysis appears around the age of 7 and fuses about six months before the distal radius.11 The distal radius and ulna physes contribute more than three quarters of forearm growth.4 The distal radio-ulnar joint (DRUJ) is stabilized by the triangular fibrocartilage complex (TFCC), whilst the proximal radioulnar joint is stabilized by the annular ligament. The interosseous membrane or ligament stabilizes the radius and ulna along their shafts. It is described as being made up of up to 5 ligaments: the central band (which is the key component), the accessory band, proximal oblique cord, distal oblique bundle and the dorsal oblique accessory cord. The radius rotates around a relatively immobile ulna. The radius bows laterally causing the
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CHILDREN’S ORTHOPAEDICS
Figure 4 (a and b): Measured at the fracture site. The width inside the cast in the sagittal plane (a) divided by the width inside the cast in the coronal plane (b) should be <0.7.
fractures, where a closed reduction was not possible or could not be maintained. They only performed an open reduction and internal fixation of the radius and they achieved excellent anatomical and functional results. ➢ Tourniquets for surgical intervention: When used, tourniquets should be inflated to a pressure 50 e100 mmHg above systolic blood pressure. Inflation time should be minimized so as to decrease compartment syndrome risk.
distal fractures to prevent the cast sliding off. Most surgeons would advocate an above elbow cast for shaft fractures as well as unstable distal both bone fractures in all age groups. Two randomized control trials have shown that distal third forearm fractures in children over the age of 4 may be successfully treated with below elbow casts.14,15 These studies do mention that both bone distal forearm fractures were at a high risk of loss of reduction. Operative 0 Closed reduction and percutaneous Kirschner (K) wires ➢ Distal radius fractures shown to be unstable, following reduction, by image intensifier screening in theatre. ➢ Failed non operative management of distal radius fractures. 0 Closed reduction and flexible intramedullary nailing ➢ Shaft fractures with the following indications: failed non operative treatment, unstable fracture patterns, irreducible fractures, open fractures and refractures. ➢ Good to excellent outcomes are reported in approximately 85% of patients with an overall complication rate of 14%.16 Wound related problems account for the majority of complications and there is a 2% risk of superficial radial nerve injury. These reported complications all resolved with no negative effect on the final functional outcome.16 Open reduction and stabilization with K wires or flexible nails ➢ Although mentioned in the literature for fractures with interposed periosteum, open reduction and Kwiring would have very limited indications. In contrast, open reduction and flexible nailing is commonly indicated. 0 Open reduction and internal fixation (ORIF) with a plate and screws. For both bone diaphyseal forearm fractures that require ORIF, most surgeons would advocate fixing both the radius and the ulna. Kirkos et al.17 reported a series of 50 children with both bone diaphyseal forearm
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Open fractures The British Orthopaedic Association, together with the British Association of Plastic, Reconstructive and Aesthetic Surgeons developed a protocol for the management of open fractures (Standards for Trauma) in 2009. Although specifically relating to severe open lower limb fractures, the principles should be applied to all open fractures. Derived from this protocol, open fractures should be managed as follows: Intravenous antibiotics according to local policies as soon as possible, and tetanus toxoid booster if indicated. Intravenous antibiotics are repeated in theatre at initial debridement and stopped following wound closure or 72 h, whichever is earlier. Vascular and neurological examination of the limb, repeated regularly and in particular following any reduction attempt or splinting. Vascular compromise requires immediate vascular surgical consultation to determine the need for intervention. In some hospitals the plastic surgery team manage paediatric limb vascular injuries. Only remove gross contamination to allow wound photography. Saline soaked gauze covered by impermeable dressings to prevent desiccation. Plaster slab to splint limb. Surgical debridement and irrigation e wound should always be extended to expose bone ends. The most important factor in optimizing outcomes for open fractures is to have combined senior orthopaedic and plastic surgery involvement from the outset. Surgery is performed in a
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CHILDREN’S ORTHOPAEDICS
timely fashion (within 24 h) except where there is heavy contamination by marine, agricultural or sewage matter in which the need is emergent. Immediate surgery may also be indicated in multiply injured patients. Reduction and stabilization. The majority of open paediatric forearm fractures will be suitable for primary definitive stabilization. Soft tissue coverage e if primary closure is not possible, consider a vacuum dressing and plan for definitive soft tissue cover within 72 h.
Surgical technique There is a strong likelihood that fractures in the distal 2 cm of the radius will be amenable to non-operative techniques whereas in the case of shaft fractures there should be a low threshold for surgical stabilization. Closed reduction, K-wire fixation and casting Incomplete fractures are usually reduced by gradually increasing a sustained force directed opposite to the displacement. There is often an element of plastic deformation, which can only be corrected by a sustained, sometimes considerable, force applied over a few minutes. Patience is the key ingredient in closed reductions. Fracturing the intact cortex is not a problem and some authors advocate this. Tearing intact periosteum should be avoided however, as this will destabilize the fracture. Once the fracture is reduced, a below elbow, full plaster of Paris cast is moulded with a curve opposing the original displacement (Sir John Charnley’s statement: “A curved plaster is necessary in order to make a straight limb.”). Good 3 point moulding, aiming for a cast index of <0.7, is the target. When the cast has set, final image intensifier views are obtained to confirm satisfactory reduction and correct cast application before the cast is completed to an above elbow cast. A below elbow cast may be adequate for stable distal physeal fractures. The child should return for weekly check radiographs for 2e3 weeks and then at 4 weeks the cast may be reduced to a below elbow cast for a further 2 weeks. At 6 weeks, the cast is removed and radiographs are obtained. All being well, the child is allowed to mobilize (Figures 5 and 6). For displaced physeal and metaphyseal fractures, reduction is achieved with axial traction to disimpact the fracture followed by manipulation, increasing the deformity to align and engage the cortices on the concave side of the fracture, reducing the translation, and then correcting the angulation. Once reduced, these fractures should be screened for stability using the image intensifier to view the fracture with maximal flexion and extension of the wrist. Physeal fractures are often stable but metaphyseal fractures are usually unstable. If unstable, a single K-wire is inserted from the radial styloid and accurately passed, avoiding multiple attempts which may compromise the physis, to engage the cortex of the proximal fragment. Further image intensifier screening takes place to confirm stability. For metaphyseal fractures, a second K-wire may be used from the radial side, proximal to the physis. Rarely, it may be necessary to insert a dorsal K-wire to achieve stability but this should be avoided in growth plate injuries. The wires are then bent and cut outside the skin, which is released if needed, dressed with iodine dressings and a piece of sponge before a plaster slab or full cast is applied.
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Figure 5 Flexion type distal radius fracture: (a) Pre reduction. (b) Post closed reduction and casting. Note the molded cast in extension.
Follow up is at one week with check radiographs and a cast change if needed. All being well, further follow up is at 6 weeks with cast off, wires out in clinic, radiographs and mobilization. All children are reluctant to mobilize immediately when the cast is removed but almost without exception they will mobilize on their own in the days following cast removal. Physiotherapy is very seldom required and long term stiffness is extremely rare (Figures 7e9). Intramedullary titanium elastic nails (flexible nails) This should be a core technique for all orthopaedic trainees, as it is the preferred surgical treatment option for the majority of forearm shaft fractures, and many other long bone fractures, in children. It can be technically difficult in very young children (under 5 years of age). The objectives of this technique are to reduce the fractures, avoid damaging the growth plates, stabilize the fractures and leave the nails prominent enough to facilitate later removal but buried sufficiently so as not to cause irritation or skin compromise.
Figure 6 Incomplete both bone forearm shaft fracture. (a) Pre reduction. (b) Post reduction and molded cast application.
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Figure 8 Physeal fracture (Salter-Harris II) e Intraoperative closed reduction and K-wire to show wire position.
the nail is established teaching.16 The diameter of the nail should be a maximum of two thirds of the diameter of the medullary canal at the isthmus.18 It is then introduced and manoeuvred through the fracture site, using a combination of manipulation and utilizing the prebent end of the nail to steer with image intensifier control. It is essential to have an assistant hold the reduction to facilitate passage of the nail across the fracture. Having exhausted closed reduction techniques, there should be a low threshold for performing an open reduction. As a general rule, if a skilled surgeon cannot achieve a closed reduction in approximately 15 min, conversion to open reduction should take
Figure 7 Distal radius fracture reduction e three steps: (a) Axial traction to disimpact the fracture. (b) Reduce the translation. (c) Correct the angulation.
With the patient appropriately prepared in theatre, positioned supine with the arm on a side table and a tourniquet on but not inflated, the procedure may begin. Usually the fracture which is most displaced should be nailed first, as doing it the other way around restricts the ability to manipulate a displaced fracture with the other fracture stabilized. For the radius, a short incision is made over the radial side of the metaphysis, avoiding the superficial branch of the radial nerve by staying slightly on the volar aspect of the axis. Using an image intensifier, the entry point is identified and opened under direct vision using a sharp awl. The correct entry point should be 1e2 cm from the physis. The awl is then advanced in a cranial direction within the medullary canal and removed. A titanium elastic nail with a precontoured end is then pre-bent with a gentle curve along a length equal to that of the radius, with the apex matching the position of fracture site along the length of the bone being nailed. There is evidence to support excellent outcomes without contouring the nails but the technique of precontouring
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Figure 9 Intraoperative closed reduction and K-wire for metaphyseal fracture. The fracture is stable on image intensifier screening.
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place. Kang et al., in a study of 90 children who had flexible nails inserted for forearm fractures, showed that irrespective of the grade of surgeon, approximately 44% of fractures required an open reduction.16 After successful negotiation across the fracture site the nail is then rotated to bring the apex of the pre-bent curve away from the interosseous membrane, restoring the radial bow, before advancing it to within 20 mm of the proximal radial physis. It is cut and a 10e15 mm punch is used to seat the nail with 10e15 mm protruding at the entry site. As long as the skin covers the prominent point of the nail without being stretched, it can then be closed. Leaving the nail prominent facilitates removal but it should not compromise the skin as this will lead to skin breakdown and an exposed nail. The ulna is entered on the radial side of the proximal ulna, 15 e20 mm distal to the physis. An alternative entry point is straight through the olecranon but care should be taken to bend the end of the nail in such a way that it points towards the triceps and it is not too prominent. A similar procedure is then performed and the nail should be rotated with the apex of its long curve away from the interosseous membrane prior to final seating of the nail. When placed with opposing curves, the two nails keep the interosseous membrane under tension, which improves the stability of the reduction. Although there is evidence to suggest that postoperative immobilization is unnecessary, the author’s preferred method is to apply an above elbow backslab in theatre with the forearm in a neutral to supinated position. This is changed at 2 weeks to a below elbow cast for a further 4 weeks. In patients over 10 years
of age, an above elbow cast will be applied at 2 weeks for a further 2e4 weeks depending on the patient’s expected level of activity. It is standard procedure for radius and ulna flexible nails to be removed after six months. Sinikumpu et al. has reported a new technique of using bioabsorbable intramedullary nails, avoiding skin irritation from prominent nails and negating the need for implant removal. Results from this study are awaited (Figures 10e13). Open reduction and internal fixation This follows the established principles of anatomic reduction, absolute stability and early mobilization. The indications include distal shaft fractures, shaft fractures in older children, established malunion or non-union. Further indications may include the surgeon’s preference and the unavailability of flexible nailing kits. Disadvantages of this technique are wider surgical exposure and very visible surgical scars. The surgical approach to the radius is the well known Henry’s approach to the radial shaft, with a modification of this approach (between the radial artery and flexor carpi radialis) being used for distal shaft and metaphyseal fractures. The ulna is approached directly between flexor carpi radialis and extensor carpi radialis. An appropriate plate should be used, which is not bigger in diameter than the bone it is being applied to. It is also acceptable to use two bicortical screws either side of the fracture. Generally, for children over the age of 11, standard small fragment dynamic compression plates are appropriate and for shaft fractures in children over the age of
Figure 10 Complete mid to distal radial shaft fracture. (a and b) Pre operative views. (c and d) Intraoperative views. This is near the distal limit for fractures amenable to flexible nail fixation. (e) United and remodelled fracture at 6 months prior to removal of nails.
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Figure 11 Midshaft forearm fracture treated with one Flexible Nail.
12, three bicortical screws should be inserted either side of the fracture (Figure 14). If stable fixation is achieved, these patients are normally placed in a below elbow backslab for 2 weeks and then gently mobilized as long as the wounds are healing well. Plates and screws are usually not removed. Occasionally metal implants may cause symptoms or patients and their parents may be adamant that these should be removed. It is reasonable to remove plates and screws, however, both the risks of this surgery and the fact that symptoms may not be relieved should be emphasized.
Monteggia and Galeazzi fractures It is essential to obtain a complete set of radiographs, including the wrist and elbow, to actively look for radioulnar and radiocapitellar joint disruption associated with forearm fractures, as many of these injuries are not recognized initially. In both these fractures, the affected joint normally reduces when the long bone fracture is reduced and stabilized. Often these fractures are managed by closed methods, as the long bone fracture is incomplete. The joint is then examined for stability.
Figure 13 Midshaft forearm fracture in a child approaching skeletal maturity treated by flexible nails.
joint, a long arm cast is applied in a position of stability with the elbow flexed to 100 degrees or more. Image intensifier images to confirm reduction are obtained in cast prior to the patient waking from anaesthesia. The child is followed up at 1 and 2 weeks with radiographs and the cast is kept in place for 6 weeks. Monteggia fractures diagnosed late can be treated successfully up to 6 months or occasionally longer following the injury, but invariably require a corrective osteotomy of the ulna and an open reduction of the radial head, with or without annular ligament reconstruction. Senior surgeons have advocated surgery for all missed Monteggia fractures at any age and with any dislocation. The ulna osteotomy should always be an opening wedge in order to regain length. In Galeazzi fractures, with the distal radius stabilized between 2 fingers, the distal ulnar is manipulated in an anterior and posterior direction. There should be a definite end point to the movement indicating an intact DRUJ. If the DRUJ is disrupted and unstable, an open reduction should be performed to remove interposed tissue. The DRUJ may then be stabilized with a smooth K-wire from the ulna into the radius with the forearm in midrotation. This wire is removed at 4 weeks in the clinic. Either way, an above elbow cast with the forearm in midrotation is applied for 6 weeks with check radiographs at 1 and 2 weeks to ensure reduction is maintained.
Monteggia fractures If the radiocapitellar joint is irreducible there should be a low threshold for opening it, as the annular ligament may be interposed and the joint will only reduce once this is cleared. If repair of the annular ligament is possible once the joint has been openly reduced, this should be done. With a reduced radiocapitellar
Complications 1. Compartment syndrome 0 Rare but potentially catastrophic complication. 0 Pain not responding to opioid analgesia is highly suggestive
Figure 12 Typical Midshaft forearm fracture. Extension type.
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CHILDREN’S ORTHOPAEDICS
pressure). If clinically obvious compartment syndrome, do not delay fasciotomies to measure pressures. Emergent surgical release is achieved by full decompression of both flexor (first) and then extensor compartments. The author’s preferred method is a standard Henry’s approach to decompress the flexor compartment (both superficial and deep) and the mobile wad. The carpal tunnel may be decompressed through a separate incision. A midline dorsal approach is used to decompress the less affected extensor compartment. There are different approaches described but a standard Henry’s approach allows exposure of the radius for fixation if needed and does not compromise future access to the radius. 2. Nerve injury This may occur either as part of the injury or following surgery. It is imperative to document neurological findings before and after any intervention. The incidence ranges from 4% in patients who do not have surgery to 7% in patients who undergo surgery.19 Fortunately, the vast majority of nerve injuries are neuropraxias, which will recover fully. However, if a significant nerve injury is identified, early plastic surgery consultation is paramount to establish whether surgical exploration is indicated. 3. Carpal tunnel syndrome This is rare in children but if symptoms persist despite reduction of the fracture, surgical decompression should be performed. 4. Infection Despite it being a rare complication in childrens fractures, all precautions to minimize the risk should be adhered to and vigilance maintained following surgery. 5. Loss of reduction 0 Reports in the literature suggest that the risk for loss of reduction in forearm fractures ranges from 7% to as high as 91% in distal metaphyseal fractures and from 7% to 27% in fractures of the diaphysis.10 A prospective study of 247 children in the Netherlands with both bone forearm fractures showed a loss of reduction rate of 33% for metaphyseal and 27% for diaphyseal fractures.10 High risk factors for loss of reduction10 were shown to be ➢ Non dominant hand ➢ Severity of fracture Complete fractures Translation of the ulna on lateral view radiographs Shortening 6. Malunion Significant malunion leads to loss of pronation and supination. Angulation in the frontal plane leads to a greater rotational deficit than angulation in a sagittal plane. Angulation at the fracture site leads to a loss of forearm rotation at a ratio of 1:2 whereas rotation at the fracture site causes a loss of forearm rotation at a ratio of 1:1.20 Shoulder movement compensates better for a loss of pronation than supination. Early paediatric orthopaedic consultation is advised. 7. Delayed union A rate of 7% has been reported.19 No apparent difference between operative and non-operative groups. 8. Non union Factors which may contribute to non-union are high energy injuries, open fractures and pre-existing disease which should
Figure 14 Completely translated distal radius and ulna shaft fracture. (a) Pre-operative views. (b and c) Intra operative views following open reduction and internal fixation.
0 Pain on passive stretching of forearm muscles e flexion and extension of fingers 0 Cast should be split immediately down to skin and patient reassessed. 0 Deep flexor compartment most commonly affected 0 Compartment pressure measurement: usually in theatre. Absolute value of >30e45 mmHg or delta P < 30mmHg (Delta P ¼ diastolic blood pressure e compartment ORTHOPAEDICS AND TRAUMA --:-
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Good casting techniques are required to treat these fractures, probably more so than in any other fractures. Though it can be intimidating to operate on children, this should not be a deterrent to surgery if the indications are correct. Due to the high incidence of loss of reduction during the course of treatment of these fractures, the high risk nonoperatively treated fractures should be followed up with weekly radiographs for the first 2e3 weeks, but physeal fractures should not be manipulated more than 7 days post injury. A
always be considered. May occur in about 1% of forearm fractures.19 9. Growth arrest This may occur in as many as 7% of displaced radial physeal fractures. Rang advocated that repeated attempts at manipulation and manipulation after 7 days should be avoided. Radiographic follow up of these fractures at 1 year is indicated. However, this is not always possible within the limitation of certain healthcare systems. 10. Synostosis (Vince and Miller classification) Type 1 e intra-articular in distal third (not seen) Type 2 e middle or distal third (after severe trauma) Type 3 e proximal third (most common, even with mild trauma) A rare complication in children’s forearm fractures but more likely to follow high energy trauma, surgical intervention, repeated manipulations and fractures associated with a head injury.21 11 .Refracture A reported refracture rate of approximately 7% seems to be constant irrespective of whether the fracture is treated operatively or non-operatively.19 Removing an implant may temporarily increase the risk of refracture and patients should avoid high impact activities and contact sports for about 6 weeks. 12. Prominent scar Rarely patients may develop scars which are cosmetically unacceptable and may need revision.
REFERENCES 1 Rennie Louise, Court-Brown Charles M, Moka Jacqueline YQ, Beattie Thomas F. The epidemiology of fractures in children. Inj Int J Care Inj 2007; 38: 913e22. 2 Brown Rick, Eastwood Deborah. Skeletal embryology and limb growth. Basic orthopaedic sciences e the Stanmore guide. Chapter 2007; 3: 24e5. 3 Calmar Elizabeth A, Vinci Robert J. The anatomy and physiology of bone fracture and healing. Clin Pediatr Emerg Med June 2002; 3: 85e93. 4 Ogden JA, Beall JK, Conlogue GJ, et al. Radiology of postnatal skeletal development. IV. Distal radius and ulna. Skelet Radiol 1981; 6: 255e66. 5 David Warwick. Injuries of the forearm and wrist. Apley’ system of orthopaedics and fractures. 9th edn. [Chapter 25]. 768e776. 6 Armstrong PF, Joughin VE, Clarke HM. Pediatric fractures of the forearm, wrist, and hand. In: Green NE, Swiontkowski MF, eds. Skeletal trauma in children. 2nd edn. Philadelphia: WB Saunders, 1998; 161e70. 7 Price Charles T, Scott Donald S, Kurzner Mitchell E, Flynn Joseph C. Malunited forearm fractures in children. J Pediatr Orthop November/December 1990; 10: 705e12. 8 De Courtivron B. Spontaneous Correction of the Distal Forearm Fractures in Children. European Pediatric Orthopaedic Society Annual Meeting. Brussels: Belgium, 1995. 9 Wood Alexander M, Robertson Greg A, Rennie Louise, Caesar Benjamin C, Court-Brown Charles M. The epidemiology of sports-related fractures in adolescents. Inj Int J Care Inj 2010; 41: 834e8. 10 Colaris JW, Allema JH, Reijman M, et al. Risk factors for the displacement of fractures of both bones of the forearm in children. Bone Jt J May 2013; 95-B: 689e93. 11 Greulich W, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. Stanford: Stanford University Press, 1959. 12 Hamilton TW, Hutchings L, Alsousou J, et al. The treatment of stable paediatric forearm fractures using a cast that may be removed at home: comparison with traditional management in a randomised controlled trial. Bone Joint J December 2013; 95-B: 1714e20. 13 Kamat AS, Pierse N, Devane P, et al. Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures. J Pediatr Orthop 2012; 32: 787e91. 14 Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below-theelbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Jt Surg Am 2006 Jan; 88: 1e8. 15 Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Jt Surg Am 2006 Jan; 88: 9e17.
Special considerations Non accidental injury (NAI) 22 Suspicion should be raised in children younger than 2 years with a significant injury without a satisfactory explanation. It is best to consult the designated child protection officer or team within the hospital for advice if there is a concern, but admitting the child until a satisfactory outcome has been established is safe practice. Involving the authorities and a skeletal survey may be indicated. Factors linked to NAI Fractures in various stages of healing Bruises of different colours indicating different ages Long bone fractures before walking age, especially distal femur Metaphyseal corner fractures Rib fractures Pathological fractures Fractures through existing lesions or abnormal bone are not uncommon. Consulting a radiologist to discuss lesions in bone prior to fixation is always indicated to establish a diagnosis and determine the correct management. Involving a paediatrician is essential in managing metabolic bone disease and conditions such as osteogenesis imperfecta.
Summary Almost every orthopaedic surgeon will be expected to manage paediatric forearm fractures through most of their career. A sound understanding of the injury and remodelling potential will allow correct management decisions to be made. It is true to say that most distal radius fractures can be managed non operatively but complete shaft fractures, due to their inherent instability, are more commonly managed operatively.
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16 Kang S-N, Mangwani J, Ramachandran M, Paterson JMH, Barry M. Elastic intramedullary nailing of paediatric fractures of the forearm: a decade of experience in a teaching hospital in the United Kingdom. J Bone Jt Surg Br February 2011; 93-B: 262e5. 17 Kirkos John M, Beslikas Theodore, Kapras Euripides A, Papavasiliou Vasilios A. Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius. Inj Int J Care Inj 2000; 31: 591e6. 18 Brian W. Scott. Flexible intramedullary nailing for children’s forearm fractures. Practical procedures in orthopaedic trauma surgery. 2nd edn. [Chapter 5], 130e133.
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19 Sinikumpu Juha-Jaakko, Lautamo Anu, Pokka Tytti, Serlo Willy. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Inj Int J Care Inj 2013; 44: 431e6. 20 Rang M. Children’s fractures. Philadelphia: JB Lippincott, 1983. 21 Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part II: children. J Bone Joint Surg Am. 1987; 69: 640. 22 S. Terry Canale, James H. Beaty. Fractures and dislocations in children. Campbell’s operative orthopaedics, 12th edn, Volume Twovol. 2. [Chapter 36], 1376e1386.
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Children’s forearm fractures
This article will encompass forearm fractures in children distal to the elbow region as well as Monteggia fractures, which are forearm fractures with associated elbow involvement. Primary injuries of the elbow region in children are outside the scope of this article.
Michael Mokawem Brian Scott
Principles of management
Abstract Forearm fractures in children are commonly encountered by orthopaedic surgeons, who are expected to manage these fractures with a thorough understanding of the nature of fracture, the acceptable displacement which will remodel and the appropriate treatment modalities available should intervention be indicated. The incidence of these fractures remains high, as children are prone to participation in high-risk activities on a regular basis. Activities such as trampolining, ice skating, cycling and the use of climbing frames will ensure that these fractures continue to present in large numbers. Treatment modalities are well established but not universally well followed. Distal fractures are most commonly amenable to closed treatment methods. In contrast, there should be a low threshold for surgical stabilization in shaft fractures. Flexible intramedullary nailing has contributed significantly to the better management of shaft fractures, which can be very difficult to treat successfully with other methods. An increased awareness of those fractures that have a high risk of displacement following reduction will lead to better selection of fractures likely to benefit from early surgical stabilization. Overall, excellent outcomes can be expected if care is taken to treat these fractures appropriately.
Epidemiology Numerous epidemiological studies have shown the incidence of fractures in the paediatric population to be in the region of 20/ 1000/year. This is almost twice the incidence seen in adults and it is thought to be increasing due to increased participation in high risk sporting activities as well as increased levels of obesity. It is estimated that nearly one third of all children will, at some time, experience a fracture. Forearm fractures account for about 40 percent of all paediatric fractures and distal radius fractures make up three quarters or more of these. There is a predominance in males seen in both distal (55%) and shaft (66%) fractures. Distal radius fracture incidence shows a unimodal pattern with a steady increase in both sexes through early childhood, peaking at the age of 12e14 and then decreasing. The incidence of shaft fractures differs between boys and girls. Girls have a unimodal distribution peaking at around 6 years of age but boys have a bimodal distribution with a peak at around 6e7 and then a large spike in the teenage years, highest at 14 years of age.1
Keywords forearm fractures; flexible nailing; growth plate; Monteggia; redisplacement
Children’s bone
Michael Mokawem MB ChB MRCS Specialty Registrar in Trauma and Orthopaedic Surgery, Leeds General Infirmary, Leeds, West Yorkshire, UK. Conflicts of interest: none declared.
Enchondral ossification at the physis leads to bone lengthening, while peripheral growth at the physis takes place in the zone of Ranvier. Peripheral growth along the diaphysis is due to deposition of bone beneath the periosteum, referred to as appositional ossification.2 Compared with adults, the periosteum in a child is an enormously strong, thick structure. Even in complete fractures, the periosteum is often intact. This allows most paediatric fractures to be treated non-operatively, as it will aid reduction and then assist in controlling the reduction. When the periosteum is disrupted, fractures are much more difficult to reduce and a low threshold for surgical stabilization should exist. Paediatric bone is less dense than adult bone due to a lower mineral content. It has a lower bending strength but also a lower modulus of elasticity which allows it to absorb more energy before it fractures.3 Three unique incomplete fracture patterns are seen in paediatric bones: Buckle or Torus fractures Metaphyseal fractures. The bone fails in compression. Plastic deformation Angulation exceeds the elastic limit, leading to microscopic failure of the tension side which does not propagate to the compression side. Greenstick fractures A continuum of plastic deformation in which an increased bending force causes the tension side to fracture but the fracture does not propagate to the compression side.3
Brian Scott MB BS FRCS (Orth) Consultant Trauma and Orthopaedic Surgeon, Department of Trauma and Orthopaedics, Leeds General Infirmary, Leeds, West Yorkshire, UK. Conflicts of interest: none declared.
Physeal micro-anatomy A well organised process of chondrocyte maturation takes place at the physis through four layers arranged perpendicular to the long axis of the bone (Figure 1). As the chondrocytes mature through the
Introduction Children’s forearm fractures present a challenge to trauma and orthopaedic surgeons throughout their career. These fractures make up a significant portion of the work in both major trauma centres and smaller units. Correct management of these injuries relies upon a sound understanding of the specific injury, as well as an ability to accurately predict the remaining growth and remodelling potential of the developing skeleton. Trauma and orthopaedic surgeons need to be proficient in closed reduction and casting techniques, which lay a strong foundation for the competent management of these fractures. Vitally, they need to be skilled in the art of open reduction and surgical stabilization to confidently intervene surgically when the correct indications are present. Furthermore, being adept at the outpatient management of these fractures requires an ability to accurately assess the fracture as well as effectively communicate with the child and the parents, often reassuring parents regarding remodelling potential, stiffness and the risk of refracture.
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Figure 1 Physeal microanatomy with growth plate layers.
1 m (þ-25%).1 Sports (football and gymnastics) related injuries and falls from bicycles are commonly seen. Trampolines and monkey bars are frequently implicated, while activities such as ice skating and skiing also contribute significantly to the genesis of these fractures.9
layers, they progressively hypertrophy, resulting in less space for the strong surrounding extracellular matrix. This is most evident in the hypertrophic layer where the physis is most susceptible to fractures. In the final layer (Zone of calcification) metaphyseal vascularization leads to programmed cell death of chondrocytes, calcification of the extracellular matrix and formation of osteoblasts and osteoclasts which produce primary bone and are involved in remodelling. The ring of La Croix is a strong, fibrous structure which stabilizes the epiphysis on the metaphysis.2
Presentation The mechanism of injury often dictates the presentation and any patient who presents following a high energy mechanism should be managed according to Advanced Trauma Life Support principles. Children usually present with pain shortly after the incident, although with less severe injuries such as torus fractures the presentation may be delayed, as the symptoms will be mild. An obvious deformity may be present and the child or accompanying adult may be cradling or supporting the limb. It is important to give the child appropriate analgesia as soon as possible once it has been established that there are no contraindications such as head injury or allergy. This settles the child to allow a full history, examination, imaging and initial splinting. As soon as the child has settled sufficiently to allow examination, this should take place along the established formula of ‘look, feel and move’. Be sure to get a circumferential view of the arm so as not to miss a wound or open fracture. The examination should include the whole of the ipsilateral limb because simultaneous injuries may occur. No more than gentle palpation should be attempted at the site of injury. The entire forearm should be carefully examined to include the wrist and elbow joints, as well as the distal radio-ulna joint. A careful neurovascular examination is then carried out to specifically establish whether this is intact. A radial pulse is identified and capillary refill time is tested: the findings are documented. Sensation is tested by light touch over the ulna side of the little finger (ulna nerve), palmar side of the index finger and thumb (median nerve) and dorsum of first web space (radial nerve). Motor function is tested by asking the patient to give a “thumbs up” (extensor pollicis longus
Remodelling potential Although there is great scope for remodelling in the plane of joint movement, rotation will not remodel. Angulation will remodel more in distal fractures due to approximately 75% of radial growth taking place at the distal physis.4 The following is a guide as to how much angulation can be expected to remodel satisfactorily.5 Distal 0 Under 10 years of age: up to 30 degrees 0 Over 10 years of age: up to 15 degrees Shaft 0 Under 6 years of age: up to 15 degrees 0 6e12 years of age: up to 10 degrees 0 Over 12 years of age: minimal These figures are supported in the literature: Armstrong et al.6 and Price et al.7 have shown that distal fractures remodel in the sagittal plane at þ- 0.9 degrees per month and in the frontal plane at þ- 0.8 degrees per month. Only minimal remodelling takes place after the age of 12 years and only very limited remodelling of angular deformities in the frontal plane will take place after the age of 9 years.8
Mechanism of injury Falls from a height of less than 1 m (þ-50%) are responsible for nearly twice as many fractures as fall from a height of more than
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innervated by the posterior interosseous nerve e branch of radial nerve), make an “O” sign, observing for flexion at the thumb interphalangeal joint (flexor pollicis longus innervated by anterior interosseous nerve e branch of median nerve), resisted thumb abduction (abductor pollicis brevis e median nerve), crossing index over middle fingers (first palmar and second dorsal interosseous muscles e ulnar nerve) and flexing the little finger distal interphalangeal joint (flexor digitorum profundus e ulnar nerve). These findings must be clearly documented prior to any attempt at manipulation and casting. A thorough examination may be difficult due to the child’s anxiety and level of pain.
Type of fracture Incomplete: 0 Torus/buckle 0 Plastic deformation 0 Greenstick Complete Associated injury Open fracture Joint disruption: Monteggia (radiocapitellar) and Galeazzi (DRUJ) fractures 0 Monteggia (Bado classification) ➢ Type 1 e Anterior radial head dislocation with apex anterior proximal ulna fracture (most common) ➢ Type 2 e Posterior radial head dislocation with apex posterior proximal ulna fracture ➢ Type 3 e Lateral radial head dislocation with apex lateral proximal ulna fracture ➢ Type 4 e Proximal radius and ulna fractures with dislocation of radial head 0 Galeazzi (rare in children) Interosseous membrane disrupted (Essex Lopresti) e possibly not seen in children
Imaging Standard anteroposterior and lateral radiographs of the whole forearm including the wrist and elbow are obtained. These are usually adequate for diagnosis. Be vigilant for disruptions of either the radiocapitellar or distal radioulnar (DRUJ) joints. A line drawn along the axis of the medullary cavity of the radius directed proximally should bisect the capitellum in any view. Discrepancy in the cortical widths either side of the fracture site is a good indicator of rotation. Further imaging is rarely needed but occasionally computed tomography (CT) scans are obtained for intraarticular distal radius or proximal ulna fractures. With a markedly deformed fracture, it is not necessary to repeat the radiographs if splinting alone has been applied. However, if any manipulation has been attempted, or the original images showed an unstable fracture in a good position, repeat radiography after splinting or casting is essential.
Displacement This can be broken down further into angulation, translation, rotation and shortening, with bayonetting being an independent consideration. Although there is literature to support treating bayonetting non-operatively as it will remodel, it is rare in modern practice for this not to be reduced and stabilized.
Classification Physeal fractures are classified separately (Salter e Harris) (Figure 2): Type 1 e usually displace dorsally Type 2 (most common) e usually displace dorsally (Figure 3) Type 3 (rare in forearm fractures) Type 4 (rare in forearm fractures) Type 5 (usually identified retrospectively)
Forearm fractures may be classified by four descriptors, namely: 1. Anatomical location 2. Type of fracture 3. Associated injury 4. Displacement Anatomical location Distal radius and or ulna fractures: physeal (Salter-Harris classification) or metaphyseal Shaft/diaphyseal fractures: proximal third, middle third or distal third. Proximal radius and or ulna fractures
Criteria for reduction Distal fractures 1. Angulation
Figure 2 Salter-Harris classification of physeal fractures.
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Figure 3 Salter-Harris II distal radius fracture.
Under 10 years of age: more than 30 degrees Over 10 years of age: more than 15 degrees 2. Translation More than 50% 3. Intra-articular displacement Most surgeons would have a lower threshold for reducing distal radius fractures, as they normally only require closed reduction and angulation of 30 would otherwise take approximately 30 months to remodel.
separation distance between the radius and ulna to be greater distally. In full supination the radial styloid should be seen laterally and the radial tuberosity should be medial, indicating the correct rotational alignment of the radius.
Treatment options Non-operative 0 Splinting for comfort in stable fractures ➢ These include minimally displaced physeal injuries (Salter-Harris 1 and 2 with less than 5 mm translation), torus fractures and minimally displaced greensick fractures (less than 15 degrees angulation). It has been shown in a randomized controlled trial that these fractures may be treated satisfactorily with a flexible cast, removed at home after 3 weeks.12 Many centres treat torus fractures satisfactorily with a removable wrist splint, patient advice leaflet for the parents and discharge from further follow up. 0 Moulded cast immobilization in the plaster room when the fracture is in a satisfactory position 0 Closed reduction and application of a moulded cast (usually in theatre under general anaesthetic) ➢ Applying a well moulded plaster cast is a vital skill when managing forearm fractures. A cast index diameter of <0.7e0.8 has been shown to be a factor in preventing loss of reduction when this was revisited by Kamat et al. in 2012.13 Cast index diameter (Figure 4) is measured at the fracture site and is the sagittal width inside the cast divided by the coronal width inside the cast. Although only validated for distal fractures, the same principles apply to shaft fractures. ➢ Pronated or supinated: Proximal fractures should be immobilized in supination and distal fractures should be immobilized in pronation. ➢ Above or below elbow cast: Children younger than about 4 years should have an above elbow cast for
Shaft fractures10 1. Angulation Under 10 years: more than 15 degrees Over 10 years: more than 10 degrees 2. Translation More than 50% 3. Rotation Any detectable Further indications for reduction are clinically obvious deformity and decreased rotational ability in children of school going age.
Surgical anatomy The distal radial epiphysis appears on radiographs by the age of 2, perhaps slightly later in boys, and fuses between the ages of 16 and 17 in girls with boys being about a year later.11 The distal ulna epiphysis appears around the age of 7 and fuses about six months before the distal radius.11 The distal radius and ulna physes contribute more than three quarters of forearm growth.4 The distal radio-ulnar joint (DRUJ) is stabilized by the triangular fibrocartilage complex (TFCC), whilst the proximal radioulnar joint is stabilized by the annular ligament. The interosseous membrane or ligament stabilizes the radius and ulna along their shafts. It is described as being made up of up to 5 ligaments: the central band (which is the key component), the accessory band, proximal oblique cord, distal oblique bundle and the dorsal oblique accessory cord. The radius rotates around a relatively immobile ulna. The radius bows laterally causing the
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Figure 4 (a and b): Measured at the fracture site. The width inside the cast in the sagittal plane (a) divided by the width inside the cast in the coronal plane (b) should be <0.7.
fractures, where a closed reduction was not possible or could not be maintained. They only performed an open reduction and internal fixation of the radius and they achieved excellent anatomical and functional results. ➢ Tourniquets for surgical intervention: When used, tourniquets should be inflated to a pressure 50 e100 mmHg above systolic blood pressure. Inflation time should be minimized so as to decrease compartment syndrome risk.
distal fractures to prevent the cast sliding off. Most surgeons would advocate an above elbow cast for shaft fractures as well as unstable distal both bone fractures in all age groups. Two randomized control trials have shown that distal third forearm fractures in children over the age of 4 may be successfully treated with below elbow casts.14,15 These studies do mention that both bone distal forearm fractures were at a high risk of loss of reduction. Operative 0 Closed reduction and percutaneous Kirschner (K) wires ➢ Distal radius fractures shown to be unstable, following reduction, by image intensifier screening in theatre. ➢ Failed non operative management of distal radius fractures. 0 Closed reduction and flexible intramedullary nailing ➢ Shaft fractures with the following indications: failed non operative treatment, unstable fracture patterns, irreducible fractures, open fractures and refractures. ➢ Good to excellent outcomes are reported in approximately 85% of patients with an overall complication rate of 14%.16 Wound related problems account for the majority of complications and there is a 2% risk of superficial radial nerve injury. These reported complications all resolved with no negative effect on the final functional outcome.16 Open reduction and stabilization with K wires or flexible nails ➢ Although mentioned in the literature for fractures with interposed periosteum, open reduction and Kwiring would have very limited indications. In contrast, open reduction and flexible nailing is commonly indicated. 0 Open reduction and internal fixation (ORIF) with a plate and screws. For both bone diaphyseal forearm fractures that require ORIF, most surgeons would advocate fixing both the radius and the ulna. Kirkos et al.17 reported a series of 50 children with both bone diaphyseal forearm
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Open fractures The British Orthopaedic Association, together with the British Association of Plastic, Reconstructive and Aesthetic Surgeons developed a protocol for the management of open fractures (Standards for Trauma) in 2009. Although specifically relating to severe open lower limb fractures, the principles should be applied to all open fractures. Derived from this protocol, open fractures should be managed as follows: Intravenous antibiotics according to local policies as soon as possible, and tetanus toxoid booster if indicated. Intravenous antibiotics are repeated in theatre at initial debridement and stopped following wound closure or 72 h, whichever is earlier. Vascular and neurological examination of the limb, repeated regularly and in particular following any reduction attempt or splinting. Vascular compromise requires immediate vascular surgical consultation to determine the need for intervention. In some hospitals the plastic surgery team manage paediatric limb vascular injuries. Only remove gross contamination to allow wound photography. Saline soaked gauze covered by impermeable dressings to prevent desiccation. Plaster slab to splint limb. Surgical debridement and irrigation e wound should always be extended to expose bone ends. The most important factor in optimizing outcomes for open fractures is to have combined senior orthopaedic and plastic surgery involvement from the outset. Surgery is performed in a
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timely fashion (within 24 h) except where there is heavy contamination by marine, agricultural or sewage matter in which the need is emergent. Immediate surgery may also be indicated in multiply injured patients. Reduction and stabilization. The majority of open paediatric forearm fractures will be suitable for primary definitive stabilization. Soft tissue coverage e if primary closure is not possible, consider a vacuum dressing and plan for definitive soft tissue cover within 72 h.
Surgical technique There is a strong likelihood that fractures in the distal 2 cm of the radius will be amenable to non-operative techniques whereas in the case of shaft fractures there should be a low threshold for surgical stabilization. Closed reduction, K-wire fixation and casting Incomplete fractures are usually reduced by gradually increasing a sustained force directed opposite to the displacement. There is often an element of plastic deformation, which can only be corrected by a sustained, sometimes considerable, force applied over a few minutes. Patience is the key ingredient in closed reductions. Fracturing the intact cortex is not a problem and some authors advocate this. Tearing intact periosteum should be avoided however, as this will destabilize the fracture. Once the fracture is reduced, a below elbow, full plaster of Paris cast is moulded with a curve opposing the original displacement (Sir John Charnley’s statement: “A curved plaster is necessary in order to make a straight limb.”). Good 3 point moulding, aiming for a cast index of <0.7, is the target. When the cast has set, final image intensifier views are obtained to confirm satisfactory reduction and correct cast application before the cast is completed to an above elbow cast. A below elbow cast may be adequate for stable distal physeal fractures. The child should return for weekly check radiographs for 2e3 weeks and then at 4 weeks the cast may be reduced to a below elbow cast for a further 2 weeks. At 6 weeks, the cast is removed and radiographs are obtained. All being well, the child is allowed to mobilize (Figures 5 and 6). For displaced physeal and metaphyseal fractures, reduction is achieved with axial traction to disimpact the fracture followed by manipulation, increasing the deformity to align and engage the cortices on the concave side of the fracture, reducing the translation, and then correcting the angulation. Once reduced, these fractures should be screened for stability using the image intensifier to view the fracture with maximal flexion and extension of the wrist. Physeal fractures are often stable but metaphyseal fractures are usually unstable. If unstable, a single K-wire is inserted from the radial styloid and accurately passed, avoiding multiple attempts which may compromise the physis, to engage the cortex of the proximal fragment. Further image intensifier screening takes place to confirm stability. For metaphyseal fractures, a second K-wire may be used from the radial side, proximal to the physis. Rarely, it may be necessary to insert a dorsal K-wire to achieve stability but this should be avoided in growth plate injuries. The wires are then bent and cut outside the skin, which is released if needed, dressed with iodine dressings and a piece of sponge before a plaster slab or full cast is applied.
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Figure 5 Flexion type distal radius fracture: (a) Pre reduction. (b) Post closed reduction and casting. Note the molded cast in extension.
Follow up is at one week with check radiographs and a cast change if needed. All being well, further follow up is at 6 weeks with cast off, wires out in clinic, radiographs and mobilization. All children are reluctant to mobilize immediately when the cast is removed but almost without exception they will mobilize on their own in the days following cast removal. Physiotherapy is very seldom required and long term stiffness is extremely rare (Figures 7e9). Intramedullary titanium elastic nails (flexible nails) This should be a core technique for all orthopaedic trainees, as it is the preferred surgical treatment option for the majority of forearm shaft fractures, and many other long bone fractures, in children. It can be technically difficult in very young children (under 5 years of age). The objectives of this technique are to reduce the fractures, avoid damaging the growth plates, stabilize the fractures and leave the nails prominent enough to facilitate later removal but buried sufficiently so as not to cause irritation or skin compromise.
Figure 6 Incomplete both bone forearm shaft fracture. (a) Pre reduction. (b) Post reduction and molded cast application.
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CHILDREN’S ORTHOPAEDICS
Figure 8 Physeal fracture (Salter-Harris II) e Intraoperative closed reduction and K-wire to show wire position.
the nail is established teaching.16 The diameter of the nail should be a maximum of two thirds of the diameter of the medullary canal at the isthmus.18 It is then introduced and manoeuvred through the fracture site, using a combination of manipulation and utilizing the prebent end of the nail to steer with image intensifier control. It is essential to have an assistant hold the reduction to facilitate passage of the nail across the fracture. Having exhausted closed reduction techniques, there should be a low threshold for performing an open reduction. As a general rule, if a skilled surgeon cannot achieve a closed reduction in approximately 15 min, conversion to open reduction should take
Figure 7 Distal radius fracture reduction e three steps: (a) Axial traction to disimpact the fracture. (b) Reduce the translation. (c) Correct the angulation.
With the patient appropriately prepared in theatre, positioned supine with the arm on a side table and a tourniquet on but not inflated, the procedure may begin. Usually the fracture which is most displaced should be nailed first, as doing it the other way around restricts the ability to manipulate a displaced fracture with the other fracture stabilized. For the radius, a short incision is made over the radial side of the metaphysis, avoiding the superficial branch of the radial nerve by staying slightly on the volar aspect of the axis. Using an image intensifier, the entry point is identified and opened under direct vision using a sharp awl. The correct entry point should be 1e2 cm from the physis. The awl is then advanced in a cranial direction within the medullary canal and removed. A titanium elastic nail with a precontoured end is then pre-bent with a gentle curve along a length equal to that of the radius, with the apex matching the position of fracture site along the length of the bone being nailed. There is evidence to support excellent outcomes without contouring the nails but the technique of precontouring
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Figure 9 Intraoperative closed reduction and K-wire for metaphyseal fracture. The fracture is stable on image intensifier screening.
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CHILDREN’S ORTHOPAEDICS
place. Kang et al., in a study of 90 children who had flexible nails inserted for forearm fractures, showed that irrespective of the grade of surgeon, approximately 44% of fractures required an open reduction.16 After successful negotiation across the fracture site the nail is then rotated to bring the apex of the pre-bent curve away from the interosseous membrane, restoring the radial bow, before advancing it to within 20 mm of the proximal radial physis. It is cut and a 10e15 mm punch is used to seat the nail with 10e15 mm protruding at the entry site. As long as the skin covers the prominent point of the nail without being stretched, it can then be closed. Leaving the nail prominent facilitates removal but it should not compromise the skin as this will lead to skin breakdown and an exposed nail. The ulna is entered on the radial side of the proximal ulna, 15 e20 mm distal to the physis. An alternative entry point is straight through the olecranon but care should be taken to bend the end of the nail in such a way that it points towards the triceps and it is not too prominent. A similar procedure is then performed and the nail should be rotated with the apex of its long curve away from the interosseous membrane prior to final seating of the nail. When placed with opposing curves, the two nails keep the interosseous membrane under tension, which improves the stability of the reduction. Although there is evidence to suggest that postoperative immobilization is unnecessary, the author’s preferred method is to apply an above elbow backslab in theatre with the forearm in a neutral to supinated position. This is changed at 2 weeks to a below elbow cast for a further 4 weeks. In patients over 10 years
of age, an above elbow cast will be applied at 2 weeks for a further 2e4 weeks depending on the patient’s expected level of activity. It is standard procedure for radius and ulna flexible nails to be removed after six months. Sinikumpu et al. has reported a new technique of using bioabsorbable intramedullary nails, avoiding skin irritation from prominent nails and negating the need for implant removal. Results from this study are awaited (Figures 10e13). Open reduction and internal fixation This follows the established principles of anatomic reduction, absolute stability and early mobilization. The indications include distal shaft fractures, shaft fractures in older children, established malunion or non-union. Further indications may include the surgeon’s preference and the unavailability of flexible nailing kits. Disadvantages of this technique are wider surgical exposure and very visible surgical scars. The surgical approach to the radius is the well known Henry’s approach to the radial shaft, with a modification of this approach (between the radial artery and flexor carpi radialis) being used for distal shaft and metaphyseal fractures. The ulna is approached directly between flexor carpi radialis and extensor carpi radialis. An appropriate plate should be used, which is not bigger in diameter than the bone it is being applied to. It is also acceptable to use two bicortical screws either side of the fracture. Generally, for children over the age of 11, standard small fragment dynamic compression plates are appropriate and for shaft fractures in children over the age of
Figure 10 Complete mid to distal radial shaft fracture. (a and b) Pre operative views. (c and d) Intraoperative views. This is near the distal limit for fractures amenable to flexible nail fixation. (e) United and remodelled fracture at 6 months prior to removal of nails.
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CHILDREN’S ORTHOPAEDICS
Figure 11 Midshaft forearm fracture treated with one Flexible Nail.
12, three bicortical screws should be inserted either side of the fracture (Figure 14). If stable fixation is achieved, these patients are normally placed in a below elbow backslab for 2 weeks and then gently mobilized as long as the wounds are healing well. Plates and screws are usually not removed. Occasionally metal implants may cause symptoms or patients and their parents may be adamant that these should be removed. It is reasonable to remove plates and screws, however, both the risks of this surgery and the fact that symptoms may not be relieved should be emphasized.
Monteggia and Galeazzi fractures It is essential to obtain a complete set of radiographs, including the wrist and elbow, to actively look for radioulnar and radiocapitellar joint disruption associated with forearm fractures, as many of these injuries are not recognized initially. In both these fractures, the affected joint normally reduces when the long bone fracture is reduced and stabilized. Often these fractures are managed by closed methods, as the long bone fracture is incomplete. The joint is then examined for stability.
Figure 13 Midshaft forearm fracture in a child approaching skeletal maturity treated by flexible nails.
joint, a long arm cast is applied in a position of stability with the elbow flexed to 100 degrees or more. Image intensifier images to confirm reduction are obtained in cast prior to the patient waking from anaesthesia. The child is followed up at 1 and 2 weeks with radiographs and the cast is kept in place for 6 weeks. Monteggia fractures diagnosed late can be treated successfully up to 6 months or occasionally longer following the injury, but invariably require a corrective osteotomy of the ulna and an open reduction of the radial head, with or without annular ligament reconstruction. Senior surgeons have advocated surgery for all missed Monteggia fractures at any age and with any dislocation. The ulna osteotomy should always be an opening wedge in order to regain length. In Galeazzi fractures, with the distal radius stabilized between 2 fingers, the distal ulnar is manipulated in an anterior and posterior direction. There should be a definite end point to the movement indicating an intact DRUJ. If the DRUJ is disrupted and unstable, an open reduction should be performed to remove interposed tissue. The DRUJ may then be stabilized with a smooth K-wire from the ulna into the radius with the forearm in midrotation. This wire is removed at 4 weeks in the clinic. Either way, an above elbow cast with the forearm in midrotation is applied for 6 weeks with check radiographs at 1 and 2 weeks to ensure reduction is maintained.
Monteggia fractures If the radiocapitellar joint is irreducible there should be a low threshold for opening it, as the annular ligament may be interposed and the joint will only reduce once this is cleared. If repair of the annular ligament is possible once the joint has been openly reduced, this should be done. With a reduced radiocapitellar
Complications 1. Compartment syndrome 0 Rare but potentially catastrophic complication. 0 Pain not responding to opioid analgesia is highly suggestive
Figure 12 Typical Midshaft forearm fracture. Extension type.
ORTHOPAEDICS AND TRAUMA --:-
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CHILDREN’S ORTHOPAEDICS
pressure). If clinically obvious compartment syndrome, do not delay fasciotomies to measure pressures. Emergent surgical release is achieved by full decompression of both flexor (first) and then extensor compartments. The author’s preferred method is a standard Henry’s approach to decompress the flexor compartment (both superficial and deep) and the mobile wad. The carpal tunnel may be decompressed through a separate incision. A midline dorsal approach is used to decompress the less affected extensor compartment. There are different approaches described but a standard Henry’s approach allows exposure of the radius for fixation if needed and does not compromise future access to the radius. 2. Nerve injury This may occur either as part of the injury or following surgery. It is imperative to document neurological findings before and after any intervention. The incidence ranges from 4% in patients who do not have surgery to 7% in patients who undergo surgery.19 Fortunately, the vast majority of nerve injuries are neuropraxias, which will recover fully. However, if a significant nerve injury is identified, early plastic surgery consultation is paramount to establish whether surgical exploration is indicated. 3. Carpal tunnel syndrome This is rare in children but if symptoms persist despite reduction of the fracture, surgical decompression should be performed. 4. Infection Despite it being a rare complication in childrens fractures, all precautions to minimize the risk should be adhered to and vigilance maintained following surgery. 5. Loss of reduction 0 Reports in the literature suggest that the risk for loss of reduction in forearm fractures ranges from 7% to as high as 91% in distal metaphyseal fractures and from 7% to 27% in fractures of the diaphysis.10 A prospective study of 247 children in the Netherlands with both bone forearm fractures showed a loss of reduction rate of 33% for metaphyseal and 27% for diaphyseal fractures.10 High risk factors for loss of reduction10 were shown to be ➢ Non dominant hand ➢ Severity of fracture Complete fractures Translation of the ulna on lateral view radiographs Shortening 6. Malunion Significant malunion leads to loss of pronation and supination. Angulation in the frontal plane leads to a greater rotational deficit than angulation in a sagittal plane. Angulation at the fracture site leads to a loss of forearm rotation at a ratio of 1:2 whereas rotation at the fracture site causes a loss of forearm rotation at a ratio of 1:1.20 Shoulder movement compensates better for a loss of pronation than supination. Early paediatric orthopaedic consultation is advised. 7. Delayed union A rate of 7% has been reported.19 No apparent difference between operative and non-operative groups. 8. Non union Factors which may contribute to non-union are high energy injuries, open fractures and pre-existing disease which should
Figure 14 Completely translated distal radius and ulna shaft fracture. (a) Pre-operative views. (b and c) Intra operative views following open reduction and internal fixation.
0 Pain on passive stretching of forearm muscles e flexion and extension of fingers 0 Cast should be split immediately down to skin and patient reassessed. 0 Deep flexor compartment most commonly affected 0 Compartment pressure measurement: usually in theatre. Absolute value of >30e45 mmHg or delta P < 30mmHg (Delta P ¼ diastolic blood pressure e compartment ORTHOPAEDICS AND TRAUMA --:-
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CHILDREN’S ORTHOPAEDICS
Good casting techniques are required to treat these fractures, probably more so than in any other fractures. Though it can be intimidating to operate on children, this should not be a deterrent to surgery if the indications are correct. Due to the high incidence of loss of reduction during the course of treatment of these fractures, the high risk nonoperatively treated fractures should be followed up with weekly radiographs for the first 2e3 weeks, but physeal fractures should not be manipulated more than 7 days post injury. A
always be considered. May occur in about 1% of forearm fractures.19 9. Growth arrest This may occur in as many as 7% of displaced radial physeal fractures. Rang advocated that repeated attempts at manipulation and manipulation after 7 days should be avoided. Radiographic follow up of these fractures at 1 year is indicated. However, this is not always possible within the limitation of certain healthcare systems. 10. Synostosis (Vince and Miller classification) Type 1 e intra-articular in distal third (not seen) Type 2 e middle or distal third (after severe trauma) Type 3 e proximal third (most common, even with mild trauma) A rare complication in children’s forearm fractures but more likely to follow high energy trauma, surgical intervention, repeated manipulations and fractures associated with a head injury.21 11 .Refracture A reported refracture rate of approximately 7% seems to be constant irrespective of whether the fracture is treated operatively or non-operatively.19 Removing an implant may temporarily increase the risk of refracture and patients should avoid high impact activities and contact sports for about 6 weeks. 12. Prominent scar Rarely patients may develop scars which are cosmetically unacceptable and may need revision.
REFERENCES 1 Rennie Louise, Court-Brown Charles M, Moka Jacqueline YQ, Beattie Thomas F. The epidemiology of fractures in children. Inj Int J Care Inj 2007; 38: 913e22. 2 Brown Rick, Eastwood Deborah. Skeletal embryology and limb growth. Basic orthopaedic sciences e the Stanmore guide. Chapter 2007; 3: 24e5. 3 Calmar Elizabeth A, Vinci Robert J. The anatomy and physiology of bone fracture and healing. Clin Pediatr Emerg Med June 2002; 3: 85e93. 4 Ogden JA, Beall JK, Conlogue GJ, et al. Radiology of postnatal skeletal development. IV. Distal radius and ulna. Skelet Radiol 1981; 6: 255e66. 5 David Warwick. Injuries of the forearm and wrist. Apley’ system of orthopaedics and fractures. 9th edn. [Chapter 25]. 768e776. 6 Armstrong PF, Joughin VE, Clarke HM. Pediatric fractures of the forearm, wrist, and hand. In: Green NE, Swiontkowski MF, eds. Skeletal trauma in children. 2nd edn. Philadelphia: WB Saunders, 1998; 161e70. 7 Price Charles T, Scott Donald S, Kurzner Mitchell E, Flynn Joseph C. Malunited forearm fractures in children. J Pediatr Orthop November/December 1990; 10: 705e12. 8 De Courtivron B. Spontaneous Correction of the Distal Forearm Fractures in Children. European Pediatric Orthopaedic Society Annual Meeting. Brussels: Belgium, 1995. 9 Wood Alexander M, Robertson Greg A, Rennie Louise, Caesar Benjamin C, Court-Brown Charles M. The epidemiology of sports-related fractures in adolescents. Inj Int J Care Inj 2010; 41: 834e8. 10 Colaris JW, Allema JH, Reijman M, et al. Risk factors for the displacement of fractures of both bones of the forearm in children. Bone Jt J May 2013; 95-B: 689e93. 11 Greulich W, Pyle SI. Radiographic atlas of skeletal development of the hand and wrist. Stanford: Stanford University Press, 1959. 12 Hamilton TW, Hutchings L, Alsousou J, et al. The treatment of stable paediatric forearm fractures using a cast that may be removed at home: comparison with traditional management in a randomised controlled trial. Bone Joint J December 2013; 95-B: 1714e20. 13 Kamat AS, Pierse N, Devane P, et al. Redefining the cast index: the optimum technique to reduce redisplacement in pediatric distal forearm fractures. J Pediatr Orthop 2012; 32: 787e91. 14 Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below-theelbow plaster casts for distal forearm fractures in children. A randomized controlled trial. J Bone Jt Surg Am 2006 Jan; 88: 1e8. 15 Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Jt Surg Am 2006 Jan; 88: 9e17.
Special considerations Non accidental injury (NAI) 22 Suspicion should be raised in children younger than 2 years with a significant injury without a satisfactory explanation. It is best to consult the designated child protection officer or team within the hospital for advice if there is a concern, but admitting the child until a satisfactory outcome has been established is safe practice. Involving the authorities and a skeletal survey may be indicated. Factors linked to NAI Fractures in various stages of healing Bruises of different colours indicating different ages Long bone fractures before walking age, especially distal femur Metaphyseal corner fractures Rib fractures Pathological fractures Fractures through existing lesions or abnormal bone are not uncommon. Consulting a radiologist to discuss lesions in bone prior to fixation is always indicated to establish a diagnosis and determine the correct management. Involving a paediatrician is essential in managing metabolic bone disease and conditions such as osteogenesis imperfecta.
Summary Almost every orthopaedic surgeon will be expected to manage paediatric forearm fractures through most of their career. A sound understanding of the injury and remodelling potential will allow correct management decisions to be made. It is true to say that most distal radius fractures can be managed non operatively but complete shaft fractures, due to their inherent instability, are more commonly managed operatively.
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16 Kang S-N, Mangwani J, Ramachandran M, Paterson JMH, Barry M. Elastic intramedullary nailing of paediatric fractures of the forearm: a decade of experience in a teaching hospital in the United Kingdom. J Bone Jt Surg Br February 2011; 93-B: 262e5. 17 Kirkos John M, Beslikas Theodore, Kapras Euripides A, Papavasiliou Vasilios A. Surgical treatment of unstable diaphyseal both-bone forearm fractures in children with single fixation of the radius. Inj Int J Care Inj 2000; 31: 591e6. 18 Brian W. Scott. Flexible intramedullary nailing for children’s forearm fractures. Practical procedures in orthopaedic trauma surgery. 2nd edn. [Chapter 5], 130e133.
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19 Sinikumpu Juha-Jaakko, Lautamo Anu, Pokka Tytti, Serlo Willy. Complications and radiographic outcome of children’s both-bone diaphyseal forearm fractures after invasive and non-invasive treatment. Inj Int J Care Inj 2013; 44: 431e6. 20 Rang M. Children’s fractures. Philadelphia: JB Lippincott, 1983. 21 Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part II: children. J Bone Joint Surg Am. 1987; 69: 640. 22 S. Terry Canale, James H. Beaty. Fractures and dislocations in children. Campbell’s operative orthopaedics, 12th edn, Volume Twovol. 2. [Chapter 36], 1376e1386.
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