Summary

Both Bone Forearm Fractures (BBFF) are extremely common in children, typically resulting from falls onto an outstretched hand (FOOSH) or direct trauma (playground, trampoline). The fractures involve both the radius and ulna shafts simultaneously. Children's fractures differ fundamentally from adults due to the growth plate (physis), periosteum (thicker and stronger), and remodelling potential. Most paediatric BBFFs can be treated with closed reduction and casting, as the thick periosteal sleeve provides stability and children's bones remodel. However, unstable, displaced, or older child fractures may require internal fixation (K-wires or Titanium Elastic Nails – TENS).

Key Facts

• Common Injury: Peak age 10-12 years (active, before skeletal maturity).
• Mechanism: FOOSH (Fall Onto Outstretched Hand), direct blow.
• Fracture Types: Greenstick, Buckle (Torus), Complete, Plastic Deformation.
• Treatment (Children): Closed Reduction + Full Arm Cast (majority). K-wires/TENS if unstable.
• Treatment (Adults): ORIF with compression plates is standard (limited remodelling).
• Key Complication: Compartment Syndrome. Refracture after removal of hardware.
• Remodelling: Excellent in young children; <10 degrees angulation at <10 years will remodel.

Clinical Pearls

"The 10-10 Rule": Up to 10 degrees of angulation can be accepted in a child under 10 years because it will remodel. Malrotation does NOT remodel well.

"Greenstick = Incomplete Fracture": The cortex is broken on the convex side but intact on the concave side. The intact periosteum acts as a hinge, providing stability but risking re-angulation if not corrected.

"Complete the Fracture": In a Greenstick fracture, you may need to complete the fracture (break the intact cortex) to allow proper reduction and prevent springback.

Beware Compartment Syndrome: Any child with severe pain out of proportion to injury, especially pain on passive finger extension, requires urgent fasciotomy. Do NOT dismiss as "normal post-fracture pain".

Why This Matters Clinically

Forearm fractures are bread-and-butter paediatrics. Knowing which fractures are stable (buckle) versus unstable (displaced/angulated), understanding acceptable alignment for age, and recognising the red flags (compartment syndrome, neurovascular injury) is essential for safe management.

Examination Steps

1. Look: Swelling, Deformity, Bruising, Skin integrity (Open fracture?).
2. Feel: Point tenderness. Compartments (Tense?). Pulses.
3. Move: Hold in position. Do NOT manipulate unnecessarily.
4. Neurovascular Status: Motor/Sensory/Vascular as above. Document before and after any intervention.

Compartment Syndrome: The 6 Ps

Prognosis

• Excellent in Children: Younger children have superb remodelling capacity.
• Functional Outcome: Almost all children regain full range of motion.
• Long-Term: No significant disability expected if properly managed.

Remodelling Potential

Key Guidelines

Evidence Levels

Scenario 1:

• Stem: 8-year-old falls from monkey bars. X-ray shows both bone forearm fracture with 15 degrees angulation at the radius mid-shaft. What is the plan?
• Answer: Acceptable angulation for age is ~10 degrees. 15 degrees may not fully remodel. MUA (Manipulation Under Anaesthesia) and full arm cast. Repeat X-ray post-reduction.

Scenario 2:

• Stem: A 7-year-old in cast for BBFF returns complaining of severe pain in the forearm, worse on passive finger extension. What is your concern and action?
• Answer: Compartment Syndrome until proven otherwise. Split cast immediately (all layers). Elevate. If no improvement – urgent fasciotomy.

Scenario 3:

• Stem: What is the "10-10 Rule"?
• Answer: Up to 10 degrees of angulation is acceptable in a child under 10 years old because the bone will remodel.

Scenario 4:

• Stem: What is a Monteggia fracture-dislocation?
• Answer: Fracture of the proximal ulna shaft with dislocation of the radial head. Must always check the radiocapitellar line (line through radius should pass through capitellum on all views).

Scenario 5:

• Stem: A child had a BBFF treated in cast. Now 3 months post-removal, they sustain another fall and refracture the same site. Comment on risk factors and management.
• Answer: Refracture is common (~10%), especially in the first 3-6 months when bone is weakened during remodelling. Management: Re-reduction and casting. Consider TENS nails if recurrent or unstable. Advise no contact sports for 3 months after healing.

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 from a fall.

How is it treated?

Most of these fractures can be treated with a plaster cast covering the arm from above the elbow to the hand. Sometimes the doctor needs to straighten the bone first (closed reduction) while your child is asleep or sedated.

If the break is unstable, your child may need a small operation to put in wires or flexible nails to hold the bones in place.

How long is recovery?

• Cast: Usually worn for 4-6 weeks.
• After cast removal: Avoid rough play, trampolines, and contact sports for at least 3 months to reduce the risk of re-breaking the bone.

When should I worry?

Bring your child back immediately if:

• Severe pain that is getting worse, not better.
• Fingers go pale, blue, numb, or cold.
• They cannot move their fingers properly.
• The cast feels very tight.

Key Counselling Points (For Parents)

1. Remodelling: "Children's bones are amazing at healing. Even if it doesn't look perfectly straight on the X-ray, the bone will often straighten itself as your child grows."
2. Keep Cast Dry: "No baths or swimming. Cover with a plastic bag in the shower."
3. Elevation: "Keep the arm raised above heart level to reduce swelling."
4. Activity Restriction: "After the cast comes off, no trampolines, climbing frames, or contact sports for 3 months."

Cast Care Instructions (Patient Handout Content)

Give written instructions to all families.

Physiotherapy (Post-Cast Removal)

Usually recovery is spontaneous – formal physio rarely needed.

Red Flags to Parents (Emergency Card)

Give this list to every family at discharge. 🚨 Bring your child 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 fingers.
• Foul smell or discharge from under cast.

Special Populations