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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
DISTAL FOREARM FRACTURES IN CHILDREN
The distal radius and ulna are among the commonest sites of childhood fractures. The
break may occur through the distal radial physis or in the metaphysis of one or both
bones.
Metaphyseal fractures are often incomplete or greenstick.
Mechanism of injury
The usual injury is a fall on the outstretched hand with the wrist in extension; the distal
fragment is forced posteriorly (this is often called a ‘juvenile Colles’ fracture’).
However, sometimes the wrist is in flexion and the fracture is angulated anteriorly.
Lesser force may do no more than buckle the metaphyseal cortex (a type of compression
fracture, or torus fracture).
Clinical features
There is usually a history of a fall, though this may be passed off as one of many
childhood spills.
The wrist is painful, and often quite swollen; sometimes there is an obvious ‘dinner-fork’
deformity.
X-ray The precise diagnosis is made on the x-ray appearances. Physeal fractures are
almost invariably Salter–Harris type I or II, with the epiphysis shifted and tilted
backwards and radially. Metaphyseal injuries may appear as mere buckling of the cortex
(easily missed unless appropriate views are obtained), as angulated greenstick fractures or
as complete fractures with displacement and shortening. If only the radius is fractured,
the ulna may be bent though not fractured.
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Treatment
Physeal fractures are reduced, under anaesthesia, by pressure on the distal fragment.
The arm is immobilized in a full-length cast with the wrist slightly flexed and ulnar
deviated, and the elbow at 90 degrees.
The cast is retained for 4 weeks.
These fractures very rarely interfere with growth. Even if reduction is not absolutely
perfect, further growth and modelling will obliterate any deformity.
Patients seen more than 2 weeks after injury are best left untreated.
Buckle fractures require no more than 2 weeks in plaster, followed by another 2 weeks of
restricted activity.
Greenstick fractures are usually easy to reduce – but apt to re-displace in the cast!
Some degree of angulation can be accepted: in children under 10, up to 30 degrees and in
children over 10, up 15 degrees.
If the deformity is greater, the fracture is reduced by thumb pressure and the arm is
immobilized with three-point fixation in a full-length cast with the wrist and forearm in
neutral and the elbow flexed 90 degrees.
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DR.JAMAL AL-SAIDY
M.B.CH.B…F.I.C.M.S
The cast is changed and the fracture re-x-rayed at 2 weeks; if it has re-displaced a further
manipulation can be carried out.
The cast is finally discarded after 6 weeks.
Complete fractures can be embarrassingly difficult to reduce – especially if the ulna is
intact. The fracture is manipulated in much the same way as a Colles’ fracture; the
reduction is checked by x-ray and a fulllength cast is applied with the wrist neutral and
the forearm supinated.
After 2 weeks, a check x-ray is obtained; the cast is kept on for 6 weeks.
If the fracture slips, especially if the ulna is intact, it should be stabilized with a
percutaneous K-wire.
Complications
EARLY
Forearm swelling and threatened compartment syndrome:This dire combination can
be prevented by avoiding over-forceful or repeated manipulations, splitting the
plaster, elevating the arm for the first 24–48 hours and encouraging exercises.
LATE
Malunion This late sequel is uncommon in children under 10 years of age. Deformity
of as much as 30 degrees will straighten out with further growth and remodelling over
the next 5 years. This should be carefully explained to the worried parents.
Radio-ulnar discrepancy Premature fusion of the radial epiphysis may result in bone
length disparity and subluxation of the radio-ulnar joint. If this is troublesome, the
radius can be lengthened and, if the child is near to skeletal maturity, the ulnar physis
fused surgically.
THANK YOU
DR.JAMAL AL-SAIDY
M.B.CH.B..…… F.I.C.M.S