Midshaft forearm fractures in children
- Paula Schweich, MD
Paula Schweich, MD
- Clinical Professor of Pediatrics
- University of Washington School of Medicine
- Section Editor
- Richard G Bachur, MD
Richard G Bachur, MD
- Section Editor — Pediatric Trauma
- Professor of Pediatrics and Emergency Medicine
- Harvard Medical School
- Deputy Editor
- James F Wiley, II, MD, MPH
James F Wiley, II, MD, MPH
- Senior Deputy Editor — UpToDate
- Deputy Editor — Adult and Pediatric Emergency Medicine
- Deputy Editor — Primary Care Sports Medicine (Adolescents and Adults)
- Clinical Professor of Pediatrics and Emergency Medicine/Traumatology
- University of Connecticut School of Medicine
Midshaft fractures of the forearm will be addressed here. The diagnosis and management of distal forearm fractures in children and other upper extremity fractures are discussed separately. (See "Distal forearm fractures in children: Initial management" and "Evaluation and management of supracondylar fractures in children" and "Midshaft humeral fractures in children".)
Forearm fractures are the most common fractures in children, representing 40 to 50 percent of all childhood fractures [1,2]. In one large series, forearm shaft fractures of the radius ranked as the third most common fracture after distal radial fractures and supracondylar humeral fractures . In addition, midshaft forearm fractures are the most common sites for refracture in children and among the most common sites of pediatric open fractures .
Forearm fractures have been associated with falls from playground equipment (eg, monkey bars) and from backyard trampolines [5,6]. However, any fall with adequate force may result in fracture.
The bones, muscles, ligaments, and tendons all work together in stabilizing the forearm. An interosseous membrane connects the radius and ulna, and the radius rotates around the ulna during supination and pronation of the forearm (figure 1 and figure 2) [1,7-10]. The two areas where the radius and ulna meet, at the elbow and the wrist, are called the radioulnar articulations. Because of the interosseous membrane and these articulations, any disruption or fracture of one bone is usually accompanied by fracture to the other (image 1) [1,4,9].
If only one bone appears to be fractured, the clinician should check the proximal and distal joints for injury to the other bone or the joint.
- Price CT, Flynn JM. Management of fractures. In: Lovell and Winter's Pediatric Orthopaedics, 6th, Morrissy RT, Weinstein SL. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.1463.
- Rodríguez-Merchán EC. Pediatric fractures of the forearm. Clin Orthop Relat Res 2005; :65.
- Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop 1999; 19:344.
- Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In: Rockwood and Wilkins' Fractures in Children, 6th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.400.
- Black GB, Amadeo R. Orthopedic injuries associated with backyard trampoline use in children. Can J Surg 2003; 46:199.
- Waltzman ML, Shannon M, Bowen AP, Bailey MC. Monkeybar injuries: complications of play. Pediatrics 1999; 103:e58.
- Pizzutillo PD. Pediatric orthopaedics. In: Essentials of Musculoskeletal Care, 3rd, Griffin LY. (Ed), American Academy of Orthopaedic Surgeons, Philadelphia 2005. p.863.
- Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg 1998; 6:146.
- Rang's Children's Fractures, 3rd, Rang M, Pring ME, Wenger DR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2005.
- Waters PM, Bae DS. Fractures of the distal radius and ulna. In: Rockwood and Wilkins' Fractures in Children, 7th, Beaty JH, Kasser JR. (Eds), Lippincott Williams & Wilkins, Philadelphia 2010. p.292.
- Roposch A, Reis M, Molina M, et al. Supracondylar fractures of the humerus associated with ipsilateral forearm fractures in children: a report of forty-seven cases. J Pediatr Orthop 2001; 21:307.
- Templeton PA, Graham HK. The 'floating elbow' in children. Simultaneous supracondylar fractures of the humerus and of the forearm in the same upper limb. J Bone Joint Surg Br 1995; 77:791.
- Carson S, Woolridge DP, Colletti J, Kilgore K. Pediatric upper extremity injuries. Pediatr Clin North Am 2006; 53:41.
- Kocher MS, Waters PM, Micheli LJ. Upper extremity injuries in the paediatric athlete. Sports Med 2000; 30:117.
- Merrill's Atlas of Radiographic Positions and Radiologic Procedures, 10th, Ballinger PW, Frank ED. (Eds), Mosby, St. Louis 2003. Vol 1.
- Flynn JM, Skaggs DL, Waters PM. Staying out of trouble while treating hand, wrist, and forearm injury. In: Staying Out of Trouble in Pediatric Orthopaedics, Skaggs DL, Flynn JM. (Eds), Lippincott Williams & Wilkins, Philadelphia 2006. p.85.
- Madhuri V, Dutt V, Gahukamble AD, Tharyan P. Conservative interventions for treating diaphyseal fractures of the forearm bones in children. Cochrane Database Syst Rev 2013; :CD008775.
- Mabrey JD, Fitch RD. Plastic deformation in pediatric fractures: mechanism and treatment. J Pediatr Orthop 1989; 9:310.
- Schwarz N, Pienaar S, Schwarz AF, et al. Refracture of the forearm in children. J Bone Joint Surg Br 1996; 78:740.
- Gruber R, von Laer LR. [The etiology of the refracture of the forearm in childhood (author's transl)]. Aktuelle Traumatol 1979; 9:251.
- Park HW, Yang IH, Joo SY, et al. Refractures of the upper extremity in children. Yonsei Med J 2007; 48:255.
- Davis DR, Green DP. Forearm fractures in children: pitfalls and complications. Clin Orthop Relat Res 1976; :172.
- Sharieff GQ, Kanegaye J, Wallace CD, et al. Can portable bedside fluoroscopy replace standard, postreduction radiographs in the management of pediatric fractures? Pediatr Emerg Care 1999; 15:249.
- Bazzi AA, Brooks JT, Jain A, et al. Is nonoperative treatment of pediatric type I open fractures safe and effective? J Child Orthop 2014; 8:467.
- Doak J, Ferrick M. Nonoperative management of pediatric grade 1 open fractures with less than a 24-hour admission. J Pediatr Orthop 2009; 29:49.
- Drendel AL, Gorelick MH, Weisman SJ, et al. A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain. Ann Emerg Med 2009; 54:553.
- Chess DG, Hyndman JC, Leahey JL, et al. Short arm plaster cast for distal pediatric forearm fractures. J Pediatr Orthop 1994; 14:211.
- Bould M, Bannister GC. Refractures of the radius and ulna in children. Injury 1999; 30:583.
- Deluca PA, Lindsey RW, Ruwe PA. Refracture of bones of the forearm after the removal of compression plates. J Bone Joint Surg Am 1988; 70:1372.
- Shoemaker SD, Comstock CP, Mubarak SJ, et al. Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children. J Pediatr Orthop 1999; 19:329.
- PERTINENT ANATOMY
- MECHANISM OF INJURY
- PHYSICAL FINDINGS
- Inspection and palpation
- Neurovascular examination
- Acute compartment syndrome
- Associated injuries
- RADIOGRAPHIC FINDINGS
- Radiographic technique
- Radiographic views and interpretation
- Specific fractures
- - Plastic deformations
- - Greenstick fractures
- - Complete fractures
- - Comminuted fractures
- Associated fractures
- INITIAL TREATMENT
- Absent pulse
- Compartment syndrome
- Analgesia and splinting
- INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL
- DEFINITIVE CARE
- Plastic deformation
- Greenstick fracture
- Complete fracture
- - Open fracture
- Comminuted fracture
- Immobilization and casting basics
- FOLLOW-UP CARE
- Home pain management
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS