Pediatric emergency medicine trisk 3475 3475
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Plastic deformations are more common in the ulna, and are difficult to
identify without comparison films of the contralateral forearm.
Given the “ring” structure of the forearm and resulting transmission of
force, the presence of an apparent single-bone fracture should prompt
close inspection for possible dislocation at the proximal and distal
radioulnar joints.
The potential for remodeling decreases with increasing fracture
distance from the epiphysis and with the age of the child. As a result,
less angulation is acceptable in midshaft fractures than in more distal
injuries, and in adolescents relative to younger children.
The incidence of neurovascular complications from forearm and wrist
fractures is low.
Current Evidence. Forearm shaft fractures are the third most common fracture in
children, and many require sedated reduction in the ED to obtain anatomic or
near-anatomic alignment per guidelines of anticipated remodeling by age and
fracture location. Unfortunately, an estimated 39% to 64% of these reduced
complete shaft fractures of the ulna and radius remain unstable and will require
subsequent repeat manipulation or surgical stabilization ( Fig. 111.25 ). While
closed reduction and casting remains the standard of care, a primary surgical
approach may be preferential for certain patients and fracture types. This
consideration is based on the potential for failed reduction and/or increased risk
of permanent loss of motion secondary to waning remodeling potential of certain
patients due to age or unstable fracture location. Commonly unstable fracture
patterns at higher risk for failed closed reduction include proximal third fractures,
ulna fractures with angulation greater than 15 degrees, comminuted patterns,
Monteggia fractures, and fractures in older children. For these patients,
orthopedics should be consulted. While the standard of care has not changed,
emergency clinicians should be aware of these potential options to guide their
discussions with patients.
