Proximal fractures of the forearm in children

INTRODUCTION — This topic will discuss the evaluation and management of proximal fractures of the forearm in children.

Other forearm or elbow fractures are discussed separately:

●(See "Midshaft forearm fractures in children" and "Distal forearm fractures in children: Initial management".)

●(See "Evaluation and management of condylar elbow fractures in children" and "Epicondylar and transphyseal elbow fractures in children" and "Supracondylar humeral fractures in children".)

TERMINOLOGY — Proximal forearm fractures are a subset of elbow fractures. They include radial head and neck fractures, ulnar olecranon, ulnar coronoid process fractures, and Monteggia fractures.

EPIDEMIOLOGY — Proximal forearm fractures, also considered a type of elbow fracture, include radial head and neck fractures as well as ulnar olecranon and coronoid process fractures. These are the least common type of forearm fracture in children. However, with the popularity of football and basketball and an increase in extreme sports, there has been an accompanying increase in elbow injuries, including proximal forearm fractures [1-3]. Radial head and neck fractures in particular, previously rare in pediatrics, have increased dramatically in teenagers with the increased popularity of extreme skateboarding, ATV riding, and other high-risk sports. There is a high risk of complication in these children, including loss of forearm rotation [4].

Proximal radial fractures account for approximately 5 to 8 percent of elbow fractures in children [5-8]. The most common age group is 9- to 12-year-olds, and most of these fractures involve the radial neck (metaphysis and physis) rather than the radial head. This is because the radial head is mostly cartilage in this age group [2,5,8-13]. For example, in a review of nearly 500 proximal radius fractures, a radial neck fracture was the most common finding (89 percent); associated elbow fractures were found on 39 percent of images, most commonly at the olecranon [14].

Olecranon fractures are uncommon in children, accounting for about 5 percent of elbow fractures [2,5-7,15-17]. In children, the olecranon is comprised of thicker bone than the distal humerus, and therefore, supracondylar fractures of the humerus are more common than olecranon fractures.

Coronoid fractures are uncommon pediatric fractures and are usually associated with an elbow dislocation or other elbow fracture [1,18].

PERTINENT ANATOMY — The anatomy of the pediatric forearm determines the types and extent of the common fractures and the healing process. The bones, muscles, ligaments, and tendons all work together in stabilizing the forearm. The motions of the elbow are flexion, extension, pronation and supination. These require maintenance of the stability of the three articulations: radio humeral (radiocapitellar), proximal radioulnar, and ulnohumeral (figure 1) [1,5,15].

The anatomy of the radius and ulna are shown in the picture (figure 2). The radial head is the epiphysis at the proximal end of the radius. The radial head articulates with the capitellum, which is located on the distal lateral humerus. The radial neck is just distal to the radial head, and then the radius expands into the radial tuberosity and the diaphysis. The proximal ulna forms a groove into which the trochlea of the distal humerus rests. The bounds of this recess are the coronoid process on the volar aspect and the olecranon process on the dorsal aspect.

The elbow does not have bony stability; the radial and ulnar collateral ligaments and capsule are the principle joint stabilizers (figure 3) [1,15]. The radial and ulnar collateral ligaments connect the distal humerus to the proximal radius and ulna, and the annular ligament and interosseous membrane maintain the radioulnar joint [1,15,19]. Because of the complex structure of the elbow, even minor abnormalities can cause significant pain and disability.

The arteries and nerves coursing through the elbow are at risk when there is an elbow injury. The brachial artery, and median and radial nerves run anterior to the elbow joint and can be stretched or disrupted by proximal forearm fractures, especially with valgus displacement (figure 4) [1]. The ulnar nerve courses medially through the elbow and can be stretched, torn, or entrapped, especially with posterior injuries [1].

PHYSICAL FINDINGS — History should include the age of the child, mechanism of the injury, when it occurred, and the position of the hand or forearm during impact, if known [1,15]. In a young child with a swollen or sore elbow, it may be difficult to distinguish between infection and trauma. Even with a nonspecific history of minor trauma, such as "fell down", the source of pain and swelling may be infectious. A history of a witnessed fall with immediate pain and decreased use of the arm makes trauma the most likely cause. The evaluation of children with osteomyelitis or bacterial arthritis is discussed separately. (See "Hematogenous osteomyelitis in children: Evaluation and diagnosis", section on 'Initial evaluation' and "Bacterial arthritis: Clinical features and diagnosis in infants and children", section on 'Evaluation'.)

After a fall on an outstretched arm, there is often swelling, pain, and deformity with markedly limited range of motion of the hand, wrist, forearm, and elbow. Patients who have sustained major trauma (table 1) are at risk for multiple traumas and warrant a complete physical examination and appropriate ancillary studies. (See "Approach to the initially stable child with blunt or penetrating injury", section on 'Blunt trauma' and "Trauma management: Approach to the unstable child", section on 'Initial approach'.)

Once other injuries are excluded, the examination can focus on the forearm and elbow. In a patient with severe pain, analgesia should be initiated to facilitate the child's comfort. Initial pain control in patients with moderate to severe pain can be achieved within 10 minutes with intranasal fentanyl delivered by an atomizer. Once an intravenous line is established, morphine can be given as needed. Pain should be controlled prior to radiographic evaluation. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Fentanyl'.)

Inspection and palpation — The clinician should examine the arm from the clavicle down, noting the following:

●Arm position

●Any obvious deformity, tenderness, or swelling around the elbow – The proximal radius and ulna should be palpated. It is important to also examine the entire upper extremity, especially the joint above and below the injured area. For example, bilateral proximal radial fractures with associated scaphoid fractures have been described [20], and proximal radial fractures are frequently associated with a second elbow injury such as a ligament rupture, a medial epicondyle fracture, or an olecranon or other ulnar fracture [1,2,6,11].

●Skin wounds – Careful inspection of the entire forearm is necessary to detect an open fracture. Signs of an open fracture may be subtle because the bone often pokes through the skin and then retracts, leaving only a small puncture. In contrast to an abrasion or puncture from the outside of the arm overlying the fracture site, a small puncture resulting from an open fracture tends to ooze blood. If no active bleeding is noted, the clinician should attempt to express blood through the wound site as circumferential pressure will bring blood to the surface from a small open fracture.

●Range of motion of all joints in the affected arm – The patient should perform active range of motion of all joints that can safely be moved without exacerbating the injury (eg, supination, pronation, flexion, and extension of the elbow; abduction, adduction, internal and external rotation of the shoulder). The clinician should not perform passive range of motion in patients with suspected fractures. Normal range of motion for the elbow includes flexion to at least 135 degrees (typical normal elbow flexion 150 degrees), extension to 0 degrees, and supination and pronation each to 90 degrees [15]. The clinician should compare mobility with the unaffected elbow in children whose range of motion appears limited [1].

Neurovascular examination — A complete neurovascular evaluation includes an assessment of radial and brachial pulses and the sensory and motor function of the median, radial, and ulnar nerves (table 2). Patients with normal initial neurovascular examinations warrant regular repeated evaluation, especially immediately following fracture manipulation or movement of the affected extremity.

Pulse — The clinician should compare the radial and brachial pulse with the opposite limb. Initially symmetric and equal pulses with normal perfusion and skin warmth are reassuring but do not entirely exclude vascular injury. However, patients who maintain normal pulses and perfusion over time are unlikely to have brachial artery injuries.

If a radial or brachial pulse is not palpable, a Doppler ultrasound should be used to determine the presence of distal perfusion. Pulse oximetry may also provide evidence of pulsatile flow as well as degree of oxygenation distal to the injury. If the pulse oximetry provides a wave form and oxygen saturation, then it can be used to provide continuous information on distal extremity perfusion.

Perfusion — Brisk capillary refill, normal color, and a warm hand indicate the presence of some distal perfusion, even when distal pulses are diminished or absent. Maintenance of perfusion despite abnormal pulses often arises from brachial artery spasm that typically resolves after urgent closed reduction and percutaneous pinning.

However, diminished or absent pulses in association with poor distal perfusion, pallor, and a cool hand are concerning signs of ischemia, especially in association with pain upon passive extension of the fingers. Patients with these findings warrant emergency intervention to reestablish limb perfusion.

Neurologic function — The following tests establish motor function of the major nerves while minimizing extremity movements:

●"OK" sign (alternatively, ask the patient to pinch your hand): anterior interosseous nerve (branch of median nerve) and posterior interosseous nerve (branch of radial nerve) (picture 1)

●Two fingers spread against resistance (eg, pointer or middle finger) or holding a piece of paper firmly between the middle and ring fingers: ulnar nerve (figure 5)

●Thumbs up sign: radial nerve (figure 6)

The clinician should perform testing of two-point discrimination in children over five years of age to assess sensory function. Using a folded paper clip, the clinician assesses the ability to recognize two points, 5 mm apart, applied simultaneously to the skin as distinct from a single point in the following areas on the hand:

●Dorsal web space – Innervated by the radial nerve

●Index (pointer) finger – Innervated by the median nerve

●Pinky (or little finger) – Innervated by the ulnar nerve

Compartment syndrome — The following findings suggest a developing compartment syndrome [2,21,22]:

●Excessive swelling and ecchymosis at the elbow

●Increasing forearm pain

●Increased pain upon passive extension of the fingers

●Cold hand with poor perfusion, pallor, and diminished or absent pulse (late finding)

Compartment syndrome may occur prior to or after definitive orthopedic care. It is more common in children with proximal forearm fractures who also have a supracondylar fracture. Once the clinician suspects an acute compartment syndrome, compartment pressures must be measured to determine whether they are elevated, or a clinical decision to perform a fasciotomy is needed. (See "Acute compartment syndrome of the extremities", section on 'Management'.)

RADIOGRAPHIC ASSESSMENT — Children with suspected proximal forearm fractures should undergo plain radiographs of the elbow and forearm (including anteroposterior [AP] and lateral views of the elbow, forearm, and wrist). All of these views can be obtained on two plain radiographs by an experienced radiology technician. Much of the pediatric elbow is composed of cartilage, and fractures can be very subtle on radiographs [2]. The anatomic landmarks as seen in a normal radiograph of the elbow are shown in the figure (image 1). The radial head and neck are demonstrated on both AP and lateral views of the elbow. The olecranon process of the ulna is best seen on the lateral view. The radial head often is superimposed over the coronoid process of the ulna on the lateral view. The normal appearance of the radial head and olecranon varies significantly with age (figure 7). Oblique views of the elbow may be needed to evaluate for specific types of proximal forearm fractures (eg, radial neck or coronoid fractures) (image 2).

A disciplined approach to examining pediatric elbow radiographs helps to ensure that important findings are not missed. In addition to noting obvious fractures, this approach includes examining the ossification centers, looking for anterior and posterior fat pads, checking the anterior humeral line, and evaluating the radial-capitellar relationship. The interpretation of elbow radiographs in children is discussed in detail separately. (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Plain radiograph interpretation'.)

Classification of specific proximal forearm fractures in children is discussed separately (See 'Presentation of proximal radial fractures' below and 'Presentation of olecranon fractures' below and 'Presentation of coronoid fractures' below.)

INITIAL TREATMENT — The goals for initial care of proximal forearm fractures in children are to reverse vascular compromise, treat acute compartment syndrome, provide analgesia, and immobilize the fracture.

Absent pulse — The emergency clinician should promptly identify children with vascular insufficiency and emergently involve an orthopedic surgeon with appropriate pediatric expertise. Rarely, these children may require partial closed reduction in the emergency department in an attempt to restore distal circulation. Patients who display a cold, white, or cyanotic hand despite reduction attempts require operative exploration and vascular repair. In most instances, children with proximal forearm fractures and vascular compromise also have either a supracondylar fracture or an elbow dislocation.

Acute compartment syndrome — Compartment syndrome may occur prior to or after definitive orthopedic care. It is more common in children with a proximal forearm fracture who also have a supracondylar fracture. Suspected compartment syndrome should prompt measurement of compartment pressure and/or emergency consultation with an orthopedic surgeon with pediatric expertise. (See "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures' and "Supracondylar humeral fractures in children", section on 'Upper extremity examination'.)

Once confirmed by compartment pressure measurement or by clinical examination by an orthopedic surgeon, immediate management of suspected acute compartment syndrome includes relieving all external pressure on the compartment. Any dressing, splint, cast, or other restrictive covering should be removed. The limb should NOT be elevated. Elevation can diminish arterial inflow and exacerbate ischemia. Analgesics should be given. Definitive treatment consists of fasciotomy to decompress all involved compartments. (See "Acute compartment syndrome of the extremities", section on 'Management'.)

Analgesia and immobilization — For children with no signs of vascular compromise or compartment syndrome, initial therapy consists of pain management and immobilization.

●Intranasal fentanyl or parenteral analgesia (eg, intravenous morphine) is most appropriate for initial pain control in patients with moderate to severe pain and should be given prior to radiographic evaluation. Oral analgesia (eg, ibuprofen) may suffice for patients who have suffered a nondisplaced proximal forearm fracture. In most circumstances, pain relief will result in an improved ability to assess neurovascular status in the apprehensive child.

●Patients without severe deformity may be initially managed with a sling for comfort during radiographic assessment.

In patients with significant deformity, immobilizing the injured arm prior to taking radiographs promotes pain relief and avoids additional soft tissue injury from inadvertent arm movement. In this situation, the arm should be splinted "as it lies" with a long arm splint (figure 8). Neurovascular status should be checked before and after splinting. If any further compromise is found after immobilization, then the splinting material should be removed, and the arm position should be adjusted. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Long arm splint'.)

Patients with obvious elbow deformities are likely to need sedation for reduction or may undergo operative reduction and stabilization. Thus, these patients should have nothing by mouth.

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — An orthopedist with pediatric expertise should be consulted by phone for all proximal radial and ulnar fractures in children. Emergency evaluation by an orthopedist is necessary in the following situations:

●Severe elbow swelling with suspected early acute compartment syndrome

●Open fracture

●Fracture with neurovascular injury

●Fracture with elbow joint instability

Urgent orthopedic consultation is warranted for the following proximal radial and/or ulnar fractures in children:

●Radial head or neck fracture with more than 30 degrees of angulation

●Olecranon fractures with a step off of over 2 mm, significant displacement, or comminution, or with an accompanying radial head or neck fracture

●Coronoid fracture

●Monteggia fracture (proximal ulnar fracture accompanied by a radial head dislocation)

EVALUATION AND TREATMENT OF SPECIFIC FRACTURES

Occult fractures of the elbow

Presentation — An occult fracture is suggested by pain, swelling, and tenderness over the radial head or proximal ulna and the presence of a posterior fat pad on lateral radiographs of the elbow (image 3 and figure 9). Among proximal forearm injuries, radial neck and olecranon fractures are the most likely to present with this finding, especially in older, more skeletally mature children [1,15]. (See "Elbow anatomy and radiographic diagnosis of elbow fracture in children", section on 'Fat pads'.)

Management — Most of these fractures can be initially managed by the experienced clinician without orthopedic consultation. Presumptive treatment consists of application of a posterior long arm splint with adequate (not tight) bandaging and a sling (figure 8). (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Long arm splint'.)

The splint should prevent movement at the elbow and allow room for further swelling. The elbow typically is flexed to 90 degrees, and the forearm is kept in neutral position with respect to supination and pronation. If swelling is significant, the elbow should be straighter than 90 degrees in the splint to permit better venous return and decrease the possibility of the development of an acute compartment syndrome. If the elbow is very swollen, an orthopedist should be consulted at the time of initial evaluation to assess for an associated injury or early compartment syndrome. (See "Epicondylar and transphyseal elbow fractures in children", section on 'Diagnosis and imaging'.)

Children with a positive fat pad sign on radiograph should be seen by an orthopedist approximately 7 to 10 days after the injury. Callus formation or periosteal elevation on a repeat plain radiograph indicates that a fracture is present. In one study of 45 children (average age four and a half years) with posterior fat pad signs, but no obvious fracture on the initial radiographs, 34 (76 percent) had evidence of a fracture on follow-up radiographs [23].

Radial head and neck fractures

Injury mechanism — There are two mechanisms that can result in fracture of the radial neck. Most commonly, a fall on the outstretched hand (FOOSH) with the elbow extended transmits a valgus force to the neck of the radius, pushing the radial head onto the capitellum [5-8,13,15,24]. A proximal radial fracture, usually through the physis, may also accompany a posterior dislocation of the elbow (image 4). The fracture occurs either with the dislocation, or when the elbow dislocation spontaneously reduces, and the radial head (epiphysis) is displaced either anteriorly or posteriorly [7].

Presentation of proximal radial fractures — The clinician should suspect a proximal radial fracture if there is tenderness over the radial head, and supination and pronation of the forearm produces pain on the lateral side of the elbow [1,2,7,8].

Plain radiographs most commonly show a Salter Harris II fracture through the physis with a metaphyseal fragment (figure 10 and image 5); a radial neck fracture can also be more distal through the metaphysis. Radial head fractures, which are intraarticular, occur in skeletally mature adolescents and adults [2,6,7,15,24]. The proximal end of the radius normally angulates (near the radial head) about 15 degrees on the AP view and about 5 degrees on the lateral view [7,9,25]. When examining radiographs of radial neck fractures, there are multiple methods to measure this angulation, but the measurements have low inter-rater reliability [25]. This situation adds confusion to the diagnosis and treatment of radial neck fractures. Whenever possible, angulation should be determined by a person with expertise (eg, pediatric radiologist or orthopedic surgeon). In addition, the curve of the radial shaft should be smooth; a sharp angle indicates a fracture [2].

Approximately half of children with proximal radial fractures will have a second elbow injury such as a ligament rupture, a medial epicondyle fracture, or an olecranon or other ulnar fracture [1,2,6,11]. In patients with nondisplaced or minimally displaced fractures, additional or comparison views may be necessary as minimally displaced fractures of the radial neck are easily overlooked [2,5]. A subtle radial neck fracture may be present with or without a posterior fat pad sign, as part of the radial neck is extraarticular. A subtle displacement of the radial head or neck may be implied by checking the radiocapitellar line; the line drawn down the middle of the radius should bisect the capitellum in all views, in both flexion and extension [1,5,23,26].

Management — Because of the potential for missing radial head and/or neck fractures and because treatment of displaced radial head and neck fractures is controversial, these injuries should be discussed with an orthopedist with pediatric expertise at the time of the initial emergency department visit to determine the appropriate management and follow-up.

The indications for reduction of an angulated radial neck fracture vary by degrees of fracture angulation (figure 11) [1,6,7,11]. Due to the ability for remodeling to result in adequate healing without limitation of the range of motion [7], most experts accept up to 30 degrees of angulation without reduction in pediatric patients with proximal radial fractures if sufficient growth remains [1,2,6,10,11,15]. In these patients, a cast or posterior long arm splint (figure 8) is placed with the elbow at 90 degrees, and the forearm maintained in neutral position with respect to supination and pronation. If no reduction is necessary, early mobilization at 7 to 10 days is recommended to avoid stiffness and loss of motion [7,15] and duration of immobilization varies from five days up to three weeks [1,9,11,27].

The management of radial neck fracture with 30 to 60 degrees of angulation (image 6) is controversial:

●A case series of 38 children under 10 years old with up to 50 degrees of radial neck angulation and older children with up to 20 degrees angulation, all treated without reduction, found excellent results after a mean follow-up time of 11 years [27].

●In contrast, another study with long-term follow-up (mean 19 years) of isolated radial head or neck fractures in 24 children, 16 years of age or younger, showed excellent outcome if those fractures with angulation over 30 degrees were reduced by closed or open reduction [10].

●Another case series of 42 children with radial neck fracture found that fractures with less than 60 degrees of angulation and displacement of the radial head of less than 50 percent had similar outcomes with operative or nonoperative treatment in the same study [11].

In the authors' experience, closed reduction is typically attempted by the orthopedist in these patients. This procedure can usually be accomplished under sedation in the emergency department. After closed reduction, immobilization (in 90 degrees of flexion) is typically followed by active range of motion beginning 14 to 21 days after the injury [1,7]. If closed reduction is not successful, the orthopedist often proceeds to operative reduction and fixation [1,2,6,11].

Angulation of over 60 degrees often needs operative treatment [1,11]. For example, open reduction had significantly better results than closed reduction if the angulation was over 60 degrees, and the radial head was displaced over 50 percent in a case series of 42 children with radial neck fractures (image 7) [8,11].

Because of the relationship of the radial head to the capitellum, it is important that the radial head is in proper position on the radial shaft; if not, supination and pronation will be limited after healing [1]. If there is displacement of the epiphysis (radial head), there is an increased chance of premature physeal closure, nonunion, and avascular necrosis [1,8]. Lateral displacement of the proximal radius does not remodel well [1,27]. The length of immobilization time will depend on the fracture and type of operative repair. If there is an open reduction involving the epiphysis, there is an increased incidence of stiffness and avascular necrosis [1,6,7]. (See 'Outcomes' below.) These fractures are followed closely to make sure the reduction is maintained.

Olecranon fractures

Injury mechanism — The olecranon can fracture when a child falls directly onto a flexed or extended elbow, commonly from a fall on the playground or during sports (figure 12 and figure 13) [6,15,16,28]. It can also occur if the child falls onto an outstretched hand with valgus stress on the forearm (figure 14) [6,16].

Presentation of olecranon fractures — Pain, tenderness, and/or swelling are noted over the olecranon area. Fractures of the olecranon are most commonly greenstick or stress fractures of the metaphysis with minimal or no displacement (image 8) [1,5,23]. One classification system also divides the fractures into intraarticular versus extraarticular [2,29]. The intraarticular fractures are then classified by the size of the fracture and the amount of displacement of the proximal fragment (figure 15). The extraarticular fractures are usually greenstick and may not have a fat pad sign. Several radiographic features make the diagnosis of an olecranon fracture challenging:

●The olecranon is not visualized on the AP view of elbow radiographs.

●The olecranon ossification center is an epiphysis and normally may appear separated or irregular. Thus, differentiating a normal center from a fracture may be difficult.

●Multiple ossification centers on the lateral view may be misinterpreted as fractures [2,6].

Comparison views of the other elbow can help to distinguish between fractures and ossification center irregularities when the diagnosis is in doubt [5,6].

Up to one third of olecranon fractures are associated with fractures or dislocations of the radial neck, medial epicondyle or coronoid process (image 9 and image 10) [7-9,12,30,31].

Management — These injuries should be discussed with an orthopedist with pediatric expertise at the time of the initial emergency department visit to determine the appropriate management and follow-up.

Greenstick or stress fractures with minimal or no displacement may be treated with casting [6,7]. However, if the periosteum is torn, the fragments may be pulled apart [1]. A cast with about 20 degrees of flexion at the elbow will reduce the distracting pull of the triceps muscle and permits proper healing [1,15]. Typically, these fractures are followed with weekly plain radiographs for two or three weeks, and most of these injuries have very good functional outcome [16,17,28].

Olecranon fractures with a step off of over 2 mm, displacement, or comminution, with an accompanying radial head or neck fracture, frequently warrant open reduction and fixation to realign the fragments and address the associated radial injuries [1,2,6,7,15,28].

Coronoid fractures

Injury mechanism — Coronoid fractures may occur from a fall on an outstretched hand or a direct fall onto the elbow, often in association with an elbow dislocation [18].

Presentation of coronoid fractures — Patients with coronoid fractures have pain, swelling, tenderness, and decreased range of motion of the elbow. On plain radiographs, the coronoid process ossifies around age six. Coronoid fractures are classified by the size of the fragment and the degree of displacement. Type I involves the tip of the coronoid process, Type II involves more of the coronoid but less than 50 percent, and Type III involves more than 50 percent (figure 16) [18]. The "B" subtype of each Type indicates dislocation of the fragment [18]. Small fractures of the coronoid may be difficult to identify on plain radiographs. Oblique views, computed tomography, or magnetic resonance imaging of the elbow may be employed to better characterize the injury (image 2). Consultation with a pediatric radiologist or orthopedic surgeon with pediatric expertise may help determine the need for further studies and the most appropriate modality [18].

Management — These fractures warrant urgent consultation with an orthopedic surgeon with pediatric expertise. If a coronoid fracture is associated with an elbow dislocation, the dislocation should first be reduced, usually by closed reduction [18]. Subsequent treatment of the coronoid fracture is dependent on the size of the fragment, displacement, and any resultant instability of the elbow [18].

Patients with a small coronoid avulsion or a fracture fragment <50 percent of the coronoid process, no other elbow injuries, and a stable joint typically receive a long arm cast (90 degrees of elbow flexion with the forearm in supination) for three weeks. Early use of the affected elbow is encouraged to preserve range of motion [1,32]. Potential indications for operative repair and fixation include elbow joint instability and/or large coronoid fracture fragments [18].

Monteggia fractures — A Monteggia fracture is a proximal ulnar fracture accompanied by a radial head dislocation (image 11). This fracture results from falling on an outstretched arm with the arm in pronation and is rare in children. There is tenderness and swelling at the fracture site and decreased range of motion at the elbow. Identification of Monteggia fractures requires recognition of the proximal ulnar fracture and a true lateral view of the elbow that shows lack of radiocapitellar alignment. These fractures warrant urgent consultation with an orthopedic surgeon with pediatric expertise. Definitive management typically consists of closed reduction. Open reduction and internal fixation is reserved for fractures that cannot be reduced [33].

DISPOSITION — Following definitive care, children with proximal forearm fractures should follow-up with an orthopedic surgeon. Timing depends on the type of fracture and treatment provided:

●Occult fractures and nondisplaced fractures – 7 to 10 days

●Radial neck fractures with <30 degrees of displacement – 5 to 7 days

●Fractures treated with closed reduction alone by the orthopedist – 5 to 7 days

All patients should receive a sling and should keep the fracture site elevated above the level of the heart as much as possible for the first 48 hours after injury.

Caretakers of children who undergo casting should receive detailed instructions. (See "Patient education: Cast and splint care (Beyond the Basics)".)

Children who have received operative care should be admitted for 24-to-48-hour observation of neurovascular status and soft tissue compartments. Once discharged, these patients are followed closely and may require weekly orthopedic evaluation with radiographs to determine the optimal timing for subsequent hardware removal.

Home pain management — We suggest that children with nonoperatively reduced and immobilized proximal forearm fractures receive ibuprofen for home pain management. Limited evidence suggests that ibuprofen is better for initial pain management of upper extremity fractures than the use of opioid pain medications [34].

Some clinicians may choose to provide a prescription for a limited amount of opioid pain medication (eg, oxycodone for two to three days) to be used as a rescue medication in patients whose pain is not adequately controlled by ibuprofen. At 72 hours, continued pain requiring opioid analgesia is an indication for reevaluation.

Immobilization and return to activity — Proper healing of proximal forearm fractures often require a long arm cast for six to eight weeks followed by splinting for an additional 8 to 12 weeks. High-risk activities (eg, skateboarding, all-terrain vehicle riding) should be restricted until solid radiographic union is achieved in order to reduce the chance of a refracture [35].

OUTCOMES — Most children recover fully after proximal forearm fractures without sequelae as long as immobilization is maintained, and high-risk activities (eg, skateboarding) are restricted until strong radiographic union is achieved. (See 'Immobilization and return to activity' above.)

●Radial head and neck fractures – It is not uncommon to have some loss of pronation and supination of the forearm after radial head or neck fractures, especially if open reduction was necessary. Fracture angulation and displacement also predict long-term motion [2]. Flexion and extension are usually preserved [1]. There is occasionally residual pain. There is often deformity of the radial head or enlargement of the proximal end of the radius on future radiographs, but these do not result in functional disability [11,27].

The functional results of open or closed reduction at six months follow-up are usually predictive of final outcome [10,11,27]. More serious complications, such as avascular necrosis of the radial head, premature closure of the growth plate, synostosis, or valgus elbow deformity, are associated with the following risk factors [1,2,6,12,13,27,30]:

•Child >10 years of age at time of injury

•Angulation over 30 degrees

•Delayed reduction

•Open reduction

•Associated injuries (eg, elbow dislocation)

●Olecranon fractures – Most of these fractures heal fully with good functional outcomes [6]. However, if a displaced or comminuted olecranon fracture is not reduced or fixated properly, there can be poor function or early arthritis. Rare complications of olecranon fractures in children include growth arrest, arthritis from poor reduction, peripheral nerve injury, flexion contracture, and nonunion [1,15-17,28].

•In a follow-up study of 39 pediatric patients with olecranon fractures (average follow-up of 23.8 years), 34 of the patients were treated with casting, and five required surgery [16]; 41 percent had an associated fracture or dislocation. Of the 39 patients, 34 had a good result, two had a fair result, and three had a poor result. The patients with associated elbow injuries were more likely to have a poor long-term result.

•In another study with follow-up of 26 pediatric olecranon fractures (mean follow-up of five years), three patients who also had radial head fractures and required surgery had a growth disturbance [28]. Clinical results were generally excellent in the remaining patients.

●Coronoid fractures – These fractures typically heal well with good functional outcome. The most common complications are loss of motion and stiffness at the elbow [18].

ADDITIONAL INFORMATION — Several UpToDate topics provide additional information about fractures, including the physiology of fracture healing, how to describe radiographs of fractures to consultants, acute and definitive fracture care (including how to make a cast), and the complications associated with fractures. These topics can be accessed using the links below:

●(See "General principles of fracture management: Bone healing and fracture description".)

●(See "General principles of fracture management: Fracture patterns and description in children".)

●(See "General principles of acute fracture management".)

●(See "General principles of definitive fracture management".)

●(See "General principles of fracture management: Early and late complications".)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: General management of pediatric fractures" and "Society guideline links: Upper extremity, thoracic, and facial fractures in children" and "Society guideline links: Acute pain management".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topics (see "Patient education: How to care for your child's cast (The Basics)" and "Patient education: Elbow fracture (The Basics)")

●Beyond the Basics topic (see "Patient education: Cast and splint care (Beyond the Basics)")

SUMMARY AND RECOMMENDATIONS

●Terminology – Proximal forearm fractures, also considered a type of elbow fracture, include radial head and neck fractures, ulnar olecranon and coronoid process fractures, and Monteggia fractures (image 1). (See 'Terminology' above.)

●Mechanism of injury – The child with a proximal forearm fracture typically has a history of a fall onto an outstretched arm with valgus or varus stress on the forearm (figure 14) or onto a flexed elbow (figure 12). (See 'Injury mechanism' above and 'Injury mechanism' above and 'Injury mechanism' above.)

●Imaging – Patients with forearm fractures require a true AP and lateral plain radiograph of the injured forearm that includes the wrist, forearm, and distal humerus. Oblique views of the elbow may be needed to evaluate for specific types of proximal forearm fractures (eg, radial neck or coronoid fractures) (image 2). Many children with a fracture of the proximal radius or ulna will have another fracture in the elbow or wrist. (See 'Radiographic assessment' above.)

In patients with an obvious deformity or high suspicion for a displaced fracture, analgesia (eg, intranasal fentanyl delivered by an atomizer, or intravenous morphine) and splinting is advisable prior to obtaining radiographs. Otherwise, a sling typically provides adequate support of nondisplaced fractures and permits radiographs to be obtained more easily. (See "Distal forearm fractures in children: Initial management", section on 'Analgesia and immobilization'.)

●Initial treatment – For children with adequate distal circulation, initial therapy consists of pain management and immobilization to prevent further displacement of the fracture. (See 'Analgesia and immobilization' above.)

●Orthopedic surgery consultation – Emergency orthopedic surgery consultation is indicated for children with proximal forearm fractures complicated by (see 'Indications for orthopedic consultation or referral' above):

•Vascular insufficiency – Rarely, these children will require partial closed reduction in the emergency department in an attempt to restore distal circulation. Patients who display a cold, cyanotic hand despite reduction attempts require emergency operative exploration and vascular repair. (See 'Absent pulse' above.)

•Compartment syndrome – Once confirmed by compartment pressure measurement, immediate management of suspected acute compartment syndrome includes relieving all external pressure on the compartment. Definitive treatment consists of fasciotomy to decompress all involved compartments. (See 'Compartment syndrome' above.)

•Open fracture.

•Forearm fracture with joint dislocation.

An orthopedist with pediatric expertise should be consulted, at a minimum, by phone for all proximal radial and ulnar fractures in children. Prompt involvement of an orthopedic surgeon during emergency department care is appropriate for the following proximal forearm fractures (see 'Indications for orthopedic consultation or referral' above):

•Radial head or neck fracture with more than 30 degrees of angulation (see 'Management' above)

•Olecranon fractures with a step off of over 2 mm, significant displacement, or comminution, or with an accompanying radial head or neck fracture (see 'Management' above)

•Coronoid fracture (see 'Management' above)

•Monteggia fracture (see 'Monteggia fractures' above)

●Aftercare – Following definitive care in the emergency department, children with proximal forearm fractures should follow-up with an orthopedic surgeon. Timing depends on the type of fracture and treatment provided. (See 'Disposition' above.)

We suggest that children with nonoperatively reduced and immobilized proximal forearm fractures receive ibuprofen instead of oral opioid medications for initial home pain management (Grade 2B). Some clinicians may choose to provide a prescription for a limited amount of opioid pain medication (eg, oxycodone for two to three days) to be used as a rescue medication in patients whose pain is not adequately controlled by ibuprofen. At 72 hours, continued pain requiring opioid analgesia is an indication for reevaluation. (See 'Home pain management' above.)