Both Bone Forearm Fracture (Paediatric)

1. Clinical Overview

Summary

Both bone forearm fractures (BBFF) represent one of the most common fracture patterns in the paediatric population, accounting for approximately 5-6% of all childhood fractures. [1] These injuries involve simultaneous fractures of both the radius and ulna shafts, typically occurring through a fall onto an outstretched hand (FOOSH) mechanism. The management of these fractures in children differs fundamentally from adults due to the remarkable remodeling capacity of the immature skeleton, the presence of open physes, and the thick osteogenic periosteum that provides inherent stability. [2]

The paediatric forearm serves as the anatomical and functional link between hand and elbow, permitting the crucial movements of pronation and supination. These movements rely on the precise anatomical relationship between the radius and ulna, including the maintenance of the radial bow (maximum in the middle third) and the integrity of the interosseous membrane. Any malunion, particularly rotational deformity, can significantly impair forearm rotation and functional outcomes. [3]

The cornerstone of treatment for most paediatric both bone forearm fractures remains closed reduction and above-elbow casting, with excellent outcomes expected due to the child's remodeling potential. However, unstable fracture patterns, older children approaching skeletal maturity, and cases of failed closed reduction require surgical stabilisation, most commonly with flexible intramedullary nailing (Titanium Elastic Nails - TENS) or percutaneous Kirschner wires. [4]

Key Clinical Facts

Clinical Pearls

The Rule of Tens: In a child under 10 years, up to 10 degrees of angulation in the sagittal plane at the distal third can be accepted because it will remodel. However, rotational malunion does NOT remodel and must be corrected. [8]

Greenstick Paradox: The intact periosteum and cortex provide stability but also cause springback. Consider completing the fracture to achieve stable reduction, then apply a well-moulded cast. [9]

Pronation-Supination Arc: Loss of even 10 degrees of forearm rotation is clinically significant and may impair activities of daily living. Anatomic reduction is crucial in older children. [3]

The Three-Point Mould: A properly applied above-elbow cast must include three-point moulding and an interosseous mould (oval cross-section) to prevent re-displacement. [10]

Why This Matters

Paediatric forearm fractures are among the most common injuries presenting to emergency departments and fracture clinics. Understanding the unique properties of children's bones, appropriate acceptance criteria for residual angulation, indications for surgical intervention, and the recognition of limb-threatening complications (compartment syndrome) is essential for every orthopaedic trainee, emergency physician, and paediatrician.

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2. Epidemiology

Incidence and Prevalence

Forearm fractures are the most common paediatric long bone injuries, with both bone fractures representing the more severe spectrum of diaphyseal involvement. [1]

Risk Factors

Intrinsic Factors:

• Age 8-14 years (growth spurt, cortical thinning)
• Male sex (more risk-taking behaviour)
• Previous forearm fracture (structural weakness)
• Vitamin D deficiency
• Obesity (higher energy falls)
• Osteogenesis imperfecta and other metabolic bone diseases

Extrinsic Factors:

• Trampolines (significant contributor - up to 15% of paediatric fractures) [11]
• Playground equipment (monkey bars, climbing frames)
• Sporting activities (skateboarding, cycling, contact sports)
• Road traffic accidents (high-energy mechanism)

Mechanism of Injury

Exam Detail: Epidemiological Trends: The incidence of paediatric forearm fractures has increased over recent decades, attributed to changes in physical activity patterns and the proliferation of trampolines. A Swedish study demonstrated a 30% increase in forearm fracture incidence between 1998 and 2007. [1] The American Academy of Pediatrics and British Orthopaedic Association have both issued position statements regarding trampoline safety due to the high incidence of upper extremity injuries. [11]

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3. Anatomy and Biomechanics

Forearm Osseous Anatomy

The forearm consists of two parallel long bones - the radius (lateral) and ulna (medial) - connected by the interosseous membrane (IOM). Understanding this anatomy is crucial for fracture management.

Radius:

• Articulates proximally with the capitellum (radiocapitellar joint) and radial notch of ulna (PRUJ)
• Distally articulates with carpal bones and ulna (DRUJ)
• Maximum radial bow located at junction of proximal and middle thirds
• Critical for pronation-supination (rotates around ulna)

Ulna:

• Articulates proximally with trochlea (ulnohumeral joint)
• Relatively straight bone serving as axis for forearm rotation
• Subcutaneous border allows direct palpation

Interosseous Membrane:

• Dense fibrous tissue connecting radius to ulna
• Fibres run obliquely (distal radius to proximal ulna direction)
• Transmits forces between bones
• Creates distinct volar and dorsal compartments
• Critical for forearm stability

Muscle Forces and Fracture Deformity

Understanding muscle attachments predicts fracture displacement and guides reduction and immobilisation position.

Exam Detail: Key Muscle Attachments:

Supinators:

• Biceps Brachii - inserts on radial tuberosity
• Supinator - wraps around proximal radius

Pronators:

• Pronator Teres - inserts on lateral radius (mid-shaft)
• Pronator Quadratus - inserts on distal radius

In proximal third fractures, the proximal fragment is supinated by biceps and supinator, while the distal fragment is pronated by pronator teres and pronator quadratus. The forearm must be casted in supination to bring the distal fragment into alignment with the proximal fragment. [3]

Paediatric Bone Properties

Children's bones possess unique properties that influence fracture patterns and healing.

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4. Pathophysiology

Fracture Pattern Classification

Paediatric forearm fractures demonstrate characteristic patterns distinct from adults due to the unique bone properties.

Greenstick Fracture Biomechanics

Greenstick fractures represent a partial failure of the bone in tension with the compression side cortex remaining intact but plastically deformed. The intact periosteum on the concave (compression) side acts as a hinge. [9]

Key Considerations:

• The intact periosteum provides stability but causes springback
• Reduction is achieved by increasing the deformity to unlock the fragments, then correcting
• May need to "complete" the fracture by breaking the intact cortex to achieve stable reduction
• The intact periosteum can be used as a tension band to maintain reduction

Plastic Deformation

Unique to paediatric bone, plastic deformation occurs when the bone is bent beyond its elastic limit but not to the point of creating a discrete fracture line. The bone sustains microfractures along its length. [12]

Clinical Significance:

• No visible fracture line on radiographs
• Bone appears bowed compared to contralateral side
• May prevent reduction of an adjacent complete fracture
• May require osteoclasis or gradual correction under anaesthesia
• Less remodeling potential than other fracture types

Remodeling: The Paediatric Advantage

Remodeling is the capacity of the immature skeleton to correct residual angular deformity through asymmetric physeal growth and periosteal remodeling. [8]

Factors Affecting Remodeling Potential:

Exam Detail: Quantifying Remodeling:

The Neer-Horowitz principle and subsequent studies have established approximate limits for acceptable angulation based on age and fracture location: [8]

Critical Point: Rotational deformity does NOT remodel. Even 10-15 degrees of malrotation can cause clinically significant loss of pronation-supination. [3]

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5. Clinical Presentation

History

Mechanism Details to Elicit:

• Exact mechanism (FOOSH, direct blow, twisting)
• Height of fall
• Hand dominance
• Time since injury
• Previous fractures at same site (refracture risk)
• Activity at time of injury (safeguarding consideration)

Red Flag History:

• Mechanism inconsistent with injury pattern (NAI)
• Delay in presentation
• Multiple fractures of different ages
• History of previous fractures

Symptoms

Signs

Inspection:

• Swelling and ecchymosis
• Angular deformity (apex volar or dorsal)
• Skin integrity (open fracture assessment)
• Comparison with contralateral limb
• Evidence of other injuries

Palpation:

• Point tenderness over fracture site
• Crepitus (do not actively elicit - painful)
• Compartment tension assessment
• Distal pulse assessment (radial, ulnar)

Movement:

• Active movement contraindicated
• Pain on passive stretch of fingers (compartment syndrome)
• Avoid manipulation until imaging obtained

Neurovascular Examination

A thorough neurovascular assessment must be documented before and after any intervention. [13]

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6. Compartment Syndrome

Critical Emergency Recognition

Compartment syndrome is a limb-threatening emergency that must be recognised and treated urgently. The forearm has three compartments: volar (flexor), dorsal (extensor), and mobile wad. [14]

The 6 Ps - Clinical Signs

CRITICAL: Do NOT wait for all 6 Ps. Pain on passive stretch of fingers (especially passive extension) is the earliest and most reliable sign. A palpable pulse does NOT exclude compartment syndrome. [14]

Management of Suspected Compartment Syndrome

Immediate Actions:

1. Remove all constricting dressings, casts (split to skin), bandages
2. Position limb at heart level (not elevated)
3. Measure compartment pressures if available (delta P less than 30 mmHg is concerning)
4. Urgent orthopaedic review
5. Prepare for emergency fasciotomy if clinical suspicion high

Fasciotomy Timing:

• Irreversible muscle necrosis begins at 4-6 hours of ischaemia
• Nerve damage at 4 hours
• Target fasciotomy within 6 hours of onset

Henry (Volar) Approach for Forearm Fasciotomy

Incision:

• Curvilinear incision from medial epicondyle to thenar crease
• Release carpal tunnel
• Decompress superficial and deep volar compartments
• Leave wounds open, delayed primary closure or skin grafting at 48-72 hours

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7. Investigations

Imaging

First-Line: Plain Radiographs

Radiographic Assessment

Systematic Evaluation:

1. Fracture Identification

   • Location: Proximal, middle, or distal third
   • Pattern: Buckle, greenstick, complete, plastic deformation
   • Number: Isolated vs both bone

2. Angulation Measurement

   • Measure angle between proximal and distal fragments
   • Record in both AP (coronal) and lateral (sagittal) views
   • Angulation in sagittal plane remodels better than coronal

3. Displacement Assessment

   • Percentage of cortical contact
   • Translation direction (volar, dorsal, radial, ulnar)
   • Bayonet apposition (overriding with shortening)

4. Rotation Assessment

   • Difficult on plain films
   • Compare width of bone at fracture site
   • Asymmetry suggests rotational malalignment

5. Associated Injuries

   • ALWAYS check proximal and distal joints
   • Monteggia: Ulna fracture + radial head dislocation
   • Galeazzi: Radius fracture + DRUJ disruption

Monteggia vs Galeazzi

Radiocapitellar Line: On all views, a line drawn through the centre of the radial head and neck should pass through the centre of the capitellum. Failure to align indicates radial head dislocation. [15]

Advanced Imaging

CT Scan:

• Rarely required for acute fractures
• Useful for complex intra-articular extension
• Assessment of malunion for corrective osteotomy planning

MRI:

• Not typically indicated acutely
• May assess interosseous membrane injury
• Physeal bar assessment if growth disturbance suspected

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8. Classification

AO Paediatric Long Bone Fracture Classification

The AO Foundation provides a comprehensive classification for paediatric long bone fractures. [16]

Forearm = Segment 2

Diaphyseal Subtypes:

Bado Classification (Monteggia)

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9. Management

Initial Management (Emergency Department)

Immediate Priorities:

┌─────────────────────────────────────────────────────────────────────────────┐
│                    INITIAL ASSESSMENT - BBFF (CHILD)                        │
├─────────────────────────────────────────────────────────────────────────────┤
│                                                                             │
│  1. PRIMARY SURVEY (if high-energy mechanism)                              │
│     └── ATLS principles. Exclude life-threatening injuries.                │
│                                                                             │
│  2. ANALGESIA                                                               │
│     ├── Paracetamol 15 mg/kg (max 1g) PO/IV                                │
│     ├── Ibuprofen 10 mg/kg (max 400mg) PO                                  │
│     ├── Intranasal Diamorphine 0.1 mg/kg (if severe pain)                 │
│     └── Consider procedural sedation if manipulation required              │
│                                                                             │
│  3. SPLINTING                                                               │
│     ├── Above-elbow backslab in position of comfort                        │
│     ├── Elbow at 90 degrees                                                │
│     └── Elevate in broad arm sling                                         │
│                                                                             │
│  4. NEUROVASCULAR EXAMINATION                                               │
│     ├── Document motor/sensory/vascular status                             │
│     ├── Check radial and ulnar pulses                                      │
│     └── Assess compartments (firmness, pain on passive stretch)            │
│                                                                             │
│  5. IMAGING                                                                 │
│     ├── AP and Lateral forearm X-rays                                      │
│     └── Include wrist AND elbow joints                                     │
│                                                                             │
│  6. OPEN FRACTURE ASSESSMENT                                                │
│     ├── If open: IV antibiotics (Co-amoxiclav + Gentamicin)               │
│     ├── Tetanus status                                                     │
│     ├── Photograph wound, apply saline-soaked dressing                     │
│     └── Urgent orthopaedic referral                                        │
│                                                                             │
└─────────────────────────────────────────────────────────────────────────────┘

Acceptable Alignment Parameters

The following parameters guide decision-making regarding need for reduction. [8,17]

KEY POINT: Rotational malunion does NOT remodel and has the greatest functional impact on pronation-supination. It is the most important parameter to correct. [3]

Decision Algorithm

┌─────────────────────────────────────────────────────────────────────────────┐
│                    MANAGEMENT DECISION ALGORITHM                            │
├─────────────────────────────────────────────────────────────────────────────┤
│                                                                             │
│  FRACTURE PATTERN ASSESSMENT                                               │
│                                                                             │
│  ┌─────────────────────┐                                                   │
│  │ Buckle (Torus)       │──────► Removable splint or below-elbow cast      │
│  │ fracture             │         3-4 weeks. Fracture clinic follow-up.    │
│  └─────────────────────┘                                                   │
│                                                                             │
│  ┌─────────────────────┐                                                   │
│  │ Greenstick or        │                                                  │
│  │ Complete fracture    │                                                  │
│  └──────────┬──────────┘                                                   │
│             │                                                              │
│             ▼                                                              │
│  ┌─────────────────────────────────────────────────────────────────────┐   │
│  │ IS ALIGNMENT ACCEPTABLE FOR AGE?                                     │   │
│  │ (See acceptable parameters table above)                              │   │
│  └──────────┬──────────────────────────────────────────────┬───────────┘   │
│             │                                              │               │
│         YES ▼                                          NO  ▼               │
│  ┌─────────────────────┐                      ┌─────────────────────┐     │
│  │ Above-elbow cast     │                      │ CLOSED REDUCTION     │     │
│  │ Position per level   │                      │ Under sedation or GA │     │
│  │ 4-6 weeks            │                      └──────────┬──────────┘     │
│  └─────────────────────┘                                  │               │
│                                                           ▼               │
│                              ┌─────────────────────────────────────────┐   │
│                              │ POST-REDUCTION: ACCEPTABLE ALIGNMENT?    │   │
│                              └──────────┬────────────────────┬─────────┘   │
│                                         │                    │             │
│                                     YES ▼                NO  ▼             │
│                              ┌─────────────────┐  ┌─────────────────────┐  │
│                              │ Above-elbow cast │  │ SURGICAL FIXATION   │  │
│                              │ 4-6 weeks        │  │ TENS or K-wires     │  │
│                              └─────────────────┘  └─────────────────────┘  │
│                                                                             │
└─────────────────────────────────────────────────────────────────────────────┘

Closed Reduction Technique

Preparation:

• Appropriate analgesia and sedation (Ketamine or General Anaesthesia)
• C-arm fluoroscopy available
• Reduction performed by experienced operator
• Assistant for counter-traction

Reduction Steps:

1. Traction: Apply longitudinal traction to distal forearm
2. Disimpaction: Exaggerate the deformity to unlock fragments
3. Correction: For greenstick - consider completing the fracture for stability
4. Alignment: Apply pressure over the apex to correct angulation
5. Rotation: Rotate forearm to position dictated by fracture level:
   • Proximal: Full supination
   • Middle: Neutral
   • Distal: Neutral to slight pronation
6. Assessment: Check alignment under fluoroscopy - AP and lateral views

Post-Reduction:

• Repeat neurovascular examination
• Apply well-moulded above-elbow cast
• Post-reduction radiographs

Cast Application: Above-Elbow Cast

Technique Principles: [10]

Three-Point Moulding: Apply pressure at the apex of deformity while applying counter-pressure proximal and distal to the fracture. The cast should be moulded while still wet and malleable. [10]

Casting Position by Fracture Level

Follow-Up Protocol

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10. Surgical Management

Indications for Operative Fixation

Absolute Indications: [4,18]

• Open fracture (after debridement)
• Irreducible fracture (soft tissue interposition)
• Unstable fracture pattern after closed reduction
• Compartment syndrome (after fasciotomy)
• Floating elbow (ipsilateral supracondylar + forearm fracture)
• Polytrauma patient

Relative Indications:

• Older child/adolescent approaching skeletal maturity (limited remodeling)
• Unacceptable alignment after MUA
• Re-displacement after casting
• Refracture
• Metabolic bone disease
• Obesity (difficult casting)

Flexible Intramedullary Nailing (TENS)

Titanium Elastic Nails (TENS) have become the preferred surgical fixation method for unstable paediatric forearm fractures. [4,18]

Principles:

Surgical Technique - Radius:

1. Small incision over lateral distal radius, proximal to physis
2. Create cortical window with awl
3. Insert pre-bent nail, advance to fracture site
4. Reduce fracture under fluoroscopy
5. Advance nail across fracture into proximal fragment
6. Confirm position on AP and lateral views
7. Cut nail leaving 5-10 mm proud for later removal

Surgical Technique - Ulna:

1. Incision at olecranon or distal ulna
2. Entry point in metaphyseal bone
3. Insert pre-bent nail, cross fracture site
4. Confirm reduction and position

Post-Operative Care:

• Above-elbow cast for 4 weeks (protection)
• Range of motion exercises at 4-6 weeks
• Nail removal at 6-12 months (once remodeling complete)

Kirschner Wire Fixation

Indications:

• Younger children with smaller bones
• Simpler fracture patterns
• When TENS not available or appropriate

Technique:

• Percutaneous or mini-open insertion
• Cross the fracture site
• May use single or multiple wires
• Leave wires proud for removal at 4-6 weeks
• Requires cast immobilisation

Open Reduction and Internal Fixation (ORIF)

Indications:

• Adolescents near skeletal maturity
• Adult-pattern fractures
• Segmental fractures
• Delayed presentation with malunion

Technique:

• Henry (volar) approach to radius
• Direct subcutaneous approach to ulna
• Low-profile compression plates (3.5mm LC-DCP or LCP)
• Plate on tension side (volar radius, posterior ulna)

Complications of Plating:

• Larger incisions, more soft tissue stripping
• Higher refracture rate after plate removal
• Potential for plate removal surgery

TENS vs K-wires vs Plating

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11. Complications

Acute Complications

Delayed Complications

Refracture Prevention [7]

Risk Factors for Refracture:

• Peak risk at 3-6 months post-cast removal
• Same-level radius and ulna fractures
• Early return to contact sports
• Complete fractures (vs greenstick)
• Adolescents

Prevention Strategies:

• Advise no contact sports, trampolines, climbing for 3 months post-cast removal
• Consider protective splint for sports during at-risk period
• Longer cast immobilisation if concern for refracture
• Early surgical fixation in high-risk patterns

Synostosis [19]

Definition: Abnormal bony bridge between radius and ulna, causing loss of pronation-supination.

Risk Factors:

• High-energy trauma
• Same-level fractures (both bones fractured at same level)
• Crush injuries
• Delayed surgery (> 2 weeks)
• Extensive surgical dissection
• Open fractures

Prevention:

• Avoid extensive periosteal stripping
• Early stable fixation if surgery required
• Avoid drilling/plating at same level

Treatment:

• Observation initially (may resolve)
• Excision of synostosis if mature and functionally limiting
• Interposition of fat, silicone, or fascia
• High recurrence rate (up to 30%)

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12. Prognosis and Outcomes

Expected Outcomes

Functional Outcomes

ROM Recovery:

• Most children regain full pronation-supination
• Stiffness usually resolves spontaneously with return to normal activities
• Formal physiotherapy rarely required in children

Return to Activity:

• Light activities: After cast removal
• Non-contact sports: 6 weeks post-cast removal
• Contact sports: Minimum 3 months post-cast removal (refracture prevention)

Prognostic Factors

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13. Special Populations

Non-Accidental Injury (NAI)

Red Flags:

• Mechanism inconsistent with injury pattern
• Delay in presentation
• Multiple injuries of different ages
• Spiral fractures in non-ambulatory children
• Inconsistent history between caregivers
• Previous unexplained injuries

Action:

• Document concerns meticulously
• Skeletal survey
• Ophthalmology assessment (retinal haemorrhages)
• Senior paediatric review
• Safeguarding referral
• Do NOT confront parents

Osteogenesis Imperfecta

Considerations:

• Multiple fractures with minimal trauma
• Blue sclerae, hearing loss, dental abnormalities
• Wormian bones on skull X-ray
• Genetic testing for confirmation
• Bisphosphonate therapy
• Involve metabolic bone team
• May require internal fixation more readily

Pathological Fracture

Suspect if:

• Fracture with minimal trauma
• Abnormal bone appearance on X-ray (lucency, periosteal reaction)
• Previous malignancy
• Systemic symptoms

Investigation:

• Full-length limb X-rays
• Blood tests (calcium, ALP, inflammatory markers)
• Further imaging (CT, MRI, bone scan) as indicated
• Biopsy if lesion identified

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14. Exam Focus: FRCS Viva Preparation

Opening Statement

"Paediatric both bone forearm fractures are common injuries, typically occurring through a FOOSH mechanism. Management differs from adults due to the excellent remodeling potential of the immature skeleton. Most can be managed with closed reduction and above-elbow casting, though unstable patterns or older children may require flexible intramedullary nailing."

Key Points to Memorise

1. Acceptable Angulation: "10 degrees in under 10 years"

• but rotation NEVER acceptable

2. Cast Position: Proximal = supination, Middle = neutral, Distal = neutral/pronation
3. Remodeling Factors: Age, proximity to physis, plane of motion, NOT rotation
4. Greenstick Management: May need to complete the fracture for stable reduction
5. Compartment Syndrome: Pain on passive stretch is earliest sign; pulses present does NOT exclude it
6. Refracture Prevention: No contact sports for 3 months post-cast removal

Common Examiner Questions

Q1: "What are the acceptable limits of angulation in a paediatric forearm fracture?"

A: "The acceptable limits depend on the child's age, fracture location, and plane of deformity. In a child under 8 years, I would accept up to 15-20 degrees of angulation in the sagittal plane at the distal third. This decreases with age - in a 10-year-old, I would accept 10-15 degrees, and in an adolescent approaching skeletal maturity, less than 5-10 degrees. Coronal plane deformity remodels less well, and rotational malunion does NOT remodel and must be corrected. The proximity to the physis is also important - distal fractures remodel better than mid-diaphyseal fractures."

Q2: "Describe your technique for reducing a greenstick forearm fracture."

A: "I would perform this under appropriate anaesthesia - either procedural sedation with ketamine or general anaesthesia. With an assistant providing counter-traction at the elbow, I would apply longitudinal traction to the distal fragment. For a greenstick fracture, I would first exaggerate the deformity to unlock the fragments and may need to complete the fracture by breaking the intact cortex to achieve a stable reduction. I would then correct the angulation by applying pressure over the apex while maintaining traction. The forearm position depends on fracture level - proximal third in supination, middle third in neutral. I would confirm reduction with fluoroscopy in AP and lateral views, then apply a well-moulded above-elbow cast with three-point moulding and an interosseous mould."

Q3: "What are the indications for operative fixation?"

A: "Absolute indications include: open fractures after debridement, irreducible fractures due to soft tissue interposition, fractures unstable after closed reduction, compartment syndrome after fasciotomy, floating elbow, and polytrauma. Relative indications include: older children or adolescents with limited remodeling potential, unacceptable alignment after MUA, re-displacement after casting, refracture, and metabolic bone disease. My preferred method is Titanium Elastic Nails, using two pre-bent nails per bone to create stable three-point fixation."

Q4: "How would you manage a child with a suspected compartment syndrome?"

A: "Compartment syndrome is a limb-threatening emergency requiring immediate action. If I suspect compartment syndrome - based on pain out of proportion to injury, pain on passive stretch of fingers, and tense compartments - I would immediately remove all constricting dressings and split the cast to skin. I would position the limb at heart level, not elevate it. If there is no rapid improvement or if clinical suspicion remains high, I would proceed to emergency fasciotomy. The forearm has three compartments that need decompression. I would use a volar Henry approach extended to include carpal tunnel release, with a separate dorsal incision if needed. Wounds are left open for delayed closure at 48-72 hours."

What Gets You Failed

• Missing compartment syndrome
• Not checking for associated injuries (Monteggia/Galeazzi)
• Accepting rotational malunion
• Not understanding remodeling principles
• Inappropriate treatment for age (e.g., conservative management of displaced fracture in adolescent)
• Poor cast technique knowledge
• Not knowing TENS technique

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15. Patient Information

What Is a Both Bone Forearm Fracture?

Your child has broken both of the bones in their forearm - the radius and the ulna. This is a common injury in children, usually happening after a fall onto an outstretched hand.

How Is It Treated?

Most children are treated with a plaster cast:

• The doctor may need to straighten the bones first (called a "reduction") while your child is given medicine to make them sleepy or asleep
• A full arm cast (from above the elbow to the hand) is applied for 4-6 weeks
• Children's bones heal very well and even if the bones are not perfectly straight, they will often straighten as your child grows

Some children need an operation:

• If the break is very unstable, your child may need metal rods (called "nails") or wires to hold the bones in place
• These are usually removed later (after 3-12 months)

Recovery Timeline

When to Seek Urgent Help

Bring your child back immediately if:

• Severe pain that is getting worse, not better
• Fingers turn white, blue, or cold
• Fingers become very swollen or cannot move
• Numbness or tingling in the fingers
• The cast feels very tight
• Bad smell or discharge from under the cast
• The cast gets wet or damaged

Cast Care

Refracture Prevention

The bone is weakest for about 3 months after the cast comes off. During this time:

• No trampolines
• No climbing frames or monkey bars
• No contact sports (football, rugby, martial arts)
• No skateboarding or scooters
• Gradually return to normal activities after 3 months

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16. Quality Standards and Audit

Recommended Audit Standards

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17. Summary Algorithm

┌───────────────────────────────────────────────────────────────────────────────┐
│                 BOTH BONE FOREARM FRACTURE (PAEDIATRIC)                       │
│                        COMPLETE MANAGEMENT ALGORITHM                           │
├───────────────────────────────────────────────────────────────────────────────┤
│                                                                               │
│  PRESENTATION                                                                 │
│  ├── History: FOOSH, direct blow, mechanism details                          │
│  ├── Examination: Deformity, swelling, skin, NV status                       │
│  ├── Splint and analgesia                                                    │
│  └── X-ray: AP and Lateral including wrist AND elbow                         │
│                                                                               │
│  EXCLUDE EMERGENCIES                                                          │
│  ├── Compartment syndrome → Split cast → Fasciotomy if needed                │
│  ├── Open fracture → IV antibiotics → Theatre for debridement               │
│  ├── NV compromise → Urgent reduction → Explore if persistent                │
│  └── Floating elbow → Combined injury management                              │
│                                                                               │
│  FRACTURE CLASSIFICATION                                                      │
│  ├── Buckle → Splint/cast 3-4 weeks → Routine follow-up                      │
│  ├── Greenstick → Assess alignment → MUA if needed                           │
│  ├── Complete → Assess alignment → MUA +/- fixation                          │
│  └── Plastic deformation → Assess for adjacent fracture reduction            │
│                                                                               │
│  ALIGNMENT DECISION (Age-Specific)                                           │
│  ├── Acceptable → Above-elbow cast 4-6 weeks                                 │
│  │   └── Position: Proximal=supination, Mid=neutral, Distal=pronation        │
│  └── Unacceptable → Closed reduction under sedation/GA                       │
│      ├── Acceptable post-reduction → Cast 4-6 weeks                          │
│      └── Unacceptable/Unstable → Surgical fixation (TENS/K-wires)            │
│                                                                               │
│  FOLLOW-UP                                                                    │
│  ├── Week 1-2: X-ray in cast (check for loss of reduction)                   │
│  ├── Week 4-6: Union assessment, cast removal                                │
│  ├── Month 3: ROM assessment, clear for contact sports                       │
│  └── Hardware removal: K-wires 4-6 weeks, TENS 6-12 months                   │
│                                                                               │
│  COUNSELLING                                                                  │
│  ├── Remodeling expectations (age-appropriate)                               │
│  ├── Cast care instructions                                                  │
│  ├── Red flag symptoms (compartment syndrome warning)                        │
│  └── Activity restriction: NO contact sports/trampolines × 3 months          │
│                                                                               │
└───────────────────────────────────────────────────────────────────────────────┘

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18. Key Evidence and Landmark Studies

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19. Guidelines Reference

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20. References

1. Hedstrom EM, Svensson O, Bergstrom U, Michno P. Epidemiology of fractures in children and adolescents: Increased incidence over the past decade: a population-based study from northern Sweden. Acta Orthop. 2010;81(1):148-153. doi:10.3109/17453671003628780

2. Landin LA. Fracture patterns in children: Analysis of 8,682 fractures with special reference to incidence, etiology and secular changes in a Swedish urban population 1950-1979. Acta Orthop Scand Suppl. 1983;202:1-109. doi:10.3109/17453678309155630

3. Matthews LS, Kaufer H, Garver DF, Sonstegard DA. The effect on supination-pronation of angular malalignment of fractures of both bones of the forearm. J Bone Joint Surg Am. 1982;64(1):14-17. doi:10.2106/00004623-198264010-00003

4. Fernandez FF, Eberhardt O, Langendorfer M, Wirth T. Treatment of severely displaced radial neck fractures in children with flexible titanium elastic nails. J Pediatr Orthop. 2010;30(1):45-50. doi:10.1097/BPO.0b013e3181c6b5a1

5. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15-22. doi:10.1097/00005131-199302000-00004

6. Brudvik C, Hove LM. Childhood fractures in Bergen, Norway: identifying high-risk groups and activities. J Pediatr Orthop. 2003;23(5):629-634. doi:10.1097/01241398-200309000-00010

7. Bould M, Bannister GC. Refractures of the radius and ulna in children. Injury. 1999;30(9):583-586. doi:10.1016/s0020-1383(99)00147-4

8. Daruwalla JS. A study of radioulnar movements following fractures of the forearm in children. Clin Orthop Relat Res. 1979;(139):114-120. PMID: 455827

9. Green NE. Greenstick fractures of the forearm in children. Clin Orthop Relat Res. 1983;(178):227-230. PMID: 6883851

10. Chess DG, Leahey JL, Hyndman JC. Computed tomography and the three-point moulding technique in the management of forearm fractures in children. J Pediatr Orthop. 1994;14(5):604-606. doi:10.1097/01241398-199409000-00009

11. American Academy of Pediatrics Committee on Injury and Poison Prevention and Committee on Sports Medicine and Fitness. Trampolines at home, school, and recreational centers. Pediatrics. 1999;103(5 Pt 1):1053-1056. doi:10.1542/peds.103.5.1053

12. Chamay A. Mechanical and morphological aspects of experimental overload and fatigue in bone. J Biomech. 1970;3(3):263-270. doi:10.1016/0021-9290(70)90028-x

13. Bae DS, Kadiyala RK, Waters PM. Acute compartment syndrome in children: contemporary diagnosis, treatment, and outcome. J Pediatr Orthop. 2001;21(5):680-688. doi:10.1097/01241398-200109000-00024

14. Matsen FA 3rd. Compartmental syndrome: A unified concept. Clin Orthop Relat Res. 1975;(113):8-14. doi:10.1097/00003086-197511000-00003

15. Storen G. Traumatic dislocation of the radial head as an isolated lesion in children; report of one case with special regard to roentgen diagnosis. Acta Chir Scand. 1959;116(2):144-147. PMID: 13626488

16. Slongo T, Audige L, AO Pediatric Classification Group. Fracture and dislocation classification compendium for children: the AO pediatric comprehensive classification of long bone fractures (PCCF). J Orthop Trauma. 2007;21(10 Suppl):S135-S160. doi:10.1097/00005131-200711101-00020

17. Price CT, Scott DS, Kurzner ME, Flynn JC. Malunited forearm fractures in children. J Pediatr Orthop. 1990;10(6):705-712. doi:10.1097/01241398-199011000-00001

18. Lascombes P, Prevot J, Ligier JN, Metaizeau JP, Poncelet T. Elastic stable intramedullary nailing in forearm shaft fractures in children: 85 cases. J Pediatr Orthop. 1990;10(2):167-171. doi:10.1097/01241398-199003000-00005

19. Vince KG, Miller JE. Cross-union complicating fracture of the forearm. Part I: Adults. J Bone Joint Surg Am. 1987;69(5):640-653. doi:10.2106/00004623-198769050-00003

20. Flynn JM, Jones KJ, Garner MR, Goebel J. Eleven years experience in the operative management of pediatric forearm fractures. J Pediatr Orthop. 2010;30(4):313-319. doi:10.1097/BPO.0b013e3181d98f2c

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Medical Disclaimer: MedVellum content is for educational purposes and clinical reference. Always apply clinical judgement appropriate to individual patient circumstances. If your child has a suspected fracture, seek medical attention promptly.