INTRODUCTION — The diagnosis of distal forearm fractures in children will be reviewed here. Management, fracture reduction, and casting of distal forearm fractures and the care of pediatric midshaft forearm fractures is discussed separately:
EPIDEMIOLOGY — Forearm fractures are the most common fractures in children, representing 40 to 50 percent of all childhood fractures [1,2]. The distal third of the forearm, involving the radius and/or ulna, is the most common location, accounting for about 75 percent of forearm fractures and 20 to 25 percent of all pediatric fractures [3,4]. This high incidence can be explained by increased body mass in relation to an overall decreased bone mineral content during growth and development [2,5]. Most of these fractures will occur in children older than five years (peak age 10 to 14) [5,6].
The type and location of fracture varies by age (see 'Specific radiographic findings' below):
●Torus (buckle) and greenstick fractures occur most frequently in children younger than 10 years of age [1-3,7].
●Physeal separations (ie, fractures involving the growth plate) are more likely in patients older than 10 years [1,8].
●In adolescents, distal forearm fractures often accompany a growth spurt [1,5,6].
●The location of fractures has also been noted to advance distally with an increase in age [2,7,8].
Body weight may also be a modifying factor for forearm fractures. For example, in a retrospective observational study that compared characteristics of forearm fractures in 403 normal-weight children versus 162 overweight/obese children, normal-weight children were more likely than overweight/obese children to have an open fracture, possibly because thicker soft tissues may be protective against an open fracture . The overweight/obese group had more distal forearm fractures than proximal fractures, and more isolated radial shaft fractures, while the normal-weight children had more isolated ulnar shaft fractures. The two groups did not have a different rate of complications or failure of treatment.
PERTINENT ANATOMY — 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) [1,3,7,10,11].
The two areas where the radius and ulna meet, at the elbow and the wrist, are called the radioulnar articulations. The distal radial-ulnar joint (DRUJ) is stabilized by the triangular fibrocartilage complex (TFCC) (figure 3). Because of the interosseous membrane and these articulations, any disruption or distal fracture of one bone is usually accompanied by fracture to the other (image 1) and may cause a tear in the TFCC [1,7,11]. Thus, 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.
The articular surface of both the radius and ulna is initially formed by the epiphysis, which is separated from the metaphysis by the physis or the cartilaginous growth plate (figure 4) . The physeal area, where longitudinal growth occurs, is firmly connected to the metaphysis by periosteum, and is difficult to separate by injury . The distal radial and ulnar physes account for 75 to 80 percent of forearm growth and almost half of upper extremity growth .
The porous nature of bones in children makes them more flexible than in adults, and thus, they are able to tolerate more bending and deformation before a fracture occurs. The periosteum around the bones in children is thick and strong and provides some mechanical stability after fracture. It is less readily torn than periosteum in adults, but when it is torn, a fracture becomes displaced. Rapid growth in children and abundant blood supply to the distal radius and ulna permits excellent healing and remodeling of forearm fractures [7,10,14]. The site of the injury and age of the child determine to what extent the deformity can remodel [4,10]:
●Fractures near the growth plate remodel best in the plane of motion of the joint (flexion and extension).
●Small deformities from fractures without reduction or after incomplete reduction are corrected by growth of the physis and periosteum. Bone is resorbed on the convex side and formed on the concave side [7,14]. Even malaligned physeal fractures may have excellent results over time, especially in young children (image 2).
MECHANISM OF INJURY — A fall onto an outstretched hand (FOOSH) accounts for most forearm fractures in children [2,7,10,15,16]. When falling, a child usually braces against the fall with the arm while extending the wrist. This arm position puts maximum axial force onto the forearm.
Common high-risk activities include snowboarding, skateboarding, skim-boarding, soccer goalkeeping, and horseback riding, although any activity that results in a fall with sufficient force can cause a distal forearm fracture [16-20]. Wrist guards have been shown to reduce the risk of fracture associated with snowboarding by 71 percent (95% CI: 13-90 percent) and are also recommended for inline skating .
Most forearm fractures are not associated with multiple trauma. However, children who fall from a height greater than three times their standing height or sustain a distal forearm fracture as a result of another major trauma mechanism (table 1) are at risk for multiple trauma 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'.)
A distal forearm fracture without a history or a plausible mechanism warrants careful examination and potential further evaluation for child abuse (table 2) (see "Physical child abuse: Recognition"). However, distal forearm fractures, in general, are not specific findings for abusive injury compared with other fractures. (See "Orthopedic aspects of child abuse", section on 'Fracture patterns'.)
CLINICAL FEATURES — The child with a distal forearm fracture typically has a history of a fall on an outstretched hand with swelling, bony pain, and/or deformity of the distal forearm. (See 'Mechanism of injury' above and 'Physical examination' below.)
PHYSICAL EXAMINATION — Patients with distal forearm fractures usually have a history of a fall on an outstretched arm with swelling, bony pain, and/or deformity accompanied by limited range of motion of the hand, wrist, and forearm. In most instances, plain radiographs provide the diagnosis. (See 'Clinical features' above and 'Diagnosis' below.)
Patients who have sustained major trauma (table 1) are at risk for multiple trauma 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. In a patient with severe pain, analgesia (eg, intranasal or intravenous fentanyl or intravenous morphine) prior to examination is often necessary to facilitate the child's cooperation.
●Inspection and palpation – The clinician should examine the arm from the clavicle down, noting the following:
•Obvious deformity – The arm may be difficult to examine if there is severe deformity or if the child is already splinted. A dorsal deformity may represent a physeal fracture (image 3) or a displaced metaphyseal or diaphyseal fracture resulting from a fall on an extended hand (eg, "dinner fork" or "bayonet" deformity) (image 4 and figure 5). A fall on a flexed hand results in a volar deformity (image 5).
•Neurovascular status – A complete neurovascular evaluation includes an assessment of radial and brachial pulses and the motor and sensory function of the median, radial, and ulnar nerves (table 3). Patients with a normal initial neurovascular examination warrant regular repeated evaluation, especially immediately following fracture manipulation or movement of the affected extremity.
Although nerve injuries may rarely be associated with long-term sequelae, the majority are neurapraxias, such as, temporary loss of nerve function (especially motor function) without anatomical nerve disruption [14,15].
Blood vessel injuries are rare with distal forearm fractures but occur more commonly with supracondylar fractures that may accompany a forearm fracture. (See "Supracondylar humeral fractures in children", section on 'Pertinent anatomy'.)
•Open 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 wound (picture 1). 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.
•Presence and location of tenderness or swelling – When there is no obvious deformity, tenderness over the distal radius or ulna and/or decreased grip strength indicates an increased likelihood of a fracture being present . In particular, nondisplaced Salter I physeal fractures may be very subtle on examination because of a relatively intact range of motion (figure 6). However, the clinician will find localized tenderness over the distal physis in these patients. (See 'Nondisplaced Salter I fracture' below.)
•Injury to the joint above and below the injured area – Careful evaluation of the elbow and wrist is warranted in patients with a suspected forearm fracture because of the occasional association of forearm fractures with supracondylar elbow and scaphoid bone fractures [23-26].
•Range of motion of all joints in the affected arm – The clinician should not perform passive range of motion in patients with a suspected fracture. 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 or the elbow; abduction, adduction, internal and external rotation of the shoulder).
•Associated injuries – When there is an isolated fracture evident in the radius or ulna, the clinician should check the joints above and below the fracture site for other injuries. Supracondylar fractures occasionally complicate forearm fractures in children. Patients with a forearm fracture and a supracondylar elbow fracture ("floating elbow") are at increased risk of an acute compartment syndrome [24,25]. Thus, the elbow warrants careful inspection for swelling and/or deformity and palpation for bony tenderness. Forearm radiographs should routinely include the distal humerus in children with forearm fractures. (See 'Imaging' below.)
In addition, hand, wrist, shoulder, and clavicle injuries may occur and any deformity, swelling, or bony tenderness in these areas warrants radiographic investigation.
●Motor examination – Assessment of neurologic status is particularly important as nerve deficits, especially median nerve injury, are found in up to 8 percent of patients with deformed distal forearm fractures .
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) (picture 2)
•Finger spread against resistance or holding a piece of paper firmly between the middle and ring fingers: ulnar nerve (figure 7)
•Thumb's up sign: radial nerve (figure 8)
●Sensory examination – The clinician should perform testing using light touch. The patient's thumb web space and pointer and pinky fingers are lightly stroked on the affected and unaffected sides, and the patient is asked if there is a difference in sensation.
In children over five years of age, two point is an alternative means 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 of the thumb – Innervated by the radial nerve
•Index (pointer) finger – Innervated by the median nerve
•Pinky (or little finger) – Innervated by the ulnar nerve
DIAGNOSIS — With the exception of nondisplaced Salter I physeal (growth plate) fractures, plain radiographs of the forearm provide the diagnosis and are warranted in children with bony tenderness or deformity. Point-of-care ultrasonography (POCUS) by a trained examiner can detect distal forearm fractures in children with a relatively high sensitivity and specificity and is an alternative for initial imaging in children with distal forearm injuries without visible deformity or can be used if radiography is not available. Children whose POCUS findings indicate cortical breaks or displacement necessitating reduction and/or casting and follow-up should also undergo radiography. (See 'Plain radiographs' below and 'Point-of-care ultrasonography' below.)
Plain radiographs — Plain radiographs are the traditional modality for identifying distal forearm fractures and, whenever available, are recommended for children who present with obvious deformities of the distal forearm that will require reduction and casting. For children 6 to 15 years old without a visible deformity, POCUS has good diagnostic accuracy and is a reasonable alternative for initial imaging studies. (See 'Point-of-care ultrasonography' below.)
When obtaining radiographs in the child with a suspected distal forearm fracture, the necessary films should be taken with minimal movement of the extremity. In patients with an obvious deformity or where high suspicion for a displaced fracture exists, analgesia (eg, intranasal fentanyl or intravenous morphine) and splinting is advisable prior to obtaining radiographs. Otherwise, a sling typically provides adequate support of nondisplaced fractures and allows for radiographs to be obtained more easily. (See "Distal forearm fractures in children: Initial management", section on 'Analgesia and immobilization'.)
●Radiographic views – All patients with suspected forearm fractures who undergo radiography should have a true anteroposterior (AP) and lateral view of the injured forearm that includes the wrist and distal humerus. A good AP view of the forearm will have minimal superimposition of the radial tuberosity (located at the proximal radius) over the proximal ulna, and similar radiographic density for the proximal and distal forearm (image 6 and picture 3) . A true lateral view of the forearm has superimposition of the radial head upon the ulnar coronoid process at the proximal end, superimposition of the radius and ulna at the distal end, a view of the soft tissues around both bones, and an elbow position that is 90 degrees of flexion (image 7) .
If there is concern about a wrist and/or elbow fracture or dislocation based upon physical findings and/or initial forearm radiographs, the clinician should order separate wrist and/or elbow radiographs [7,10]. In addition, supracondylar fractures may complicate forearm fractures and cause an associated compartment syndrome. For this reason, anteroposterior and lateral radiographs of the forearm should include the distal humerus in all patients with forearm fractures.
●Classification – Additional radiographic findings and examples of each type of distal forearm fracture are described below by fracture type. (See 'Specific radiographic findings' below.)
When describing and documenting a distal forearm fracture, the key elements include whether the fracture is open or closed; the presence of physeal involvement, angulation, displacement; and the presence of bony rotation .
•A closed fracture has no connection between the fracture site and any adjacent skin wounds whereas an open (compound) fracture has obvious bony protrusion through the skin or a contiguous open wound. (See 'Physical examination' above.)
•Physeal fractures are commonly described by using the Salter-Harris classification system and indicating whether the radius, ulna, or both bones are injured (figure 6). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal fracture description'.)
•Distal metaphyseal fractures of the radius and/or ulna are described as torus (or buckle), greenstick, or complete fractures based upon the radiographic findings. (See 'Specific radiographic findings' below.)
•Fracture displacement is defined on the lateral view by the displacement of the distal fragment (dorsal or volar).
•Most displacements are also rotated. Rotation of the fracture is judged by a break in the smooth curve of the bone, or change in the diameter of the bone or width of the cortex of the two fragments [7,10].
•If there is displacement or angulation on the AP view, descriptions are similar, but in the radial or ulnar direction. (See "General principles of fracture management: Bone healing and fracture description", section on 'Fracture description' and "General principles of fracture management: Fracture patterns and description in children", section on 'Fracture description in children'.)
●Clinical decision rules – The Amsterdam wrist rules have been prospectively derived in 408 children and validated in 379 children in the Netherlands . During validation, the Amsterdam wrist rules had a sensitivity of 96 percent and specificity of 37 percent for fracture, and application of the rules reduced the number of children undergoing radiographs by 22 percent. Four fractures, all torus fractures, were missed. In an implementation study of 408 children with wrist injuries, the Amsterdam rules had similar sensitivity and specificity and reduced radiographic examinations by 19 percent . A total of eight fractures were missed, including four fractures that warranted casting and close follow-up to ensure that displacement did not worsen. However, radiographs were recommended in three of these four patients, but the recommendation was not followed by the treating physician. These studies suggest that the Amsterdam wrist rules have the potential for detecting most clinically important wrist fractures while permitting a significant decrease in the use of plain radiographs. However, more evidence from larger cohort studies is needed before they can be routinely recommended.
Point-of-care ultrasonography — When performed by a properly trained provider, point-of-care ultrasonography (POCUS) has good diagnostic accuracy for detecting or excluding distal forearm fractures [30,31]. Also, when used as the initial imaging modality in children 5 to 15 years old with forearm injury and no visible deformity, it results in similar clinical outcomes compared with radiography . In addition, POCUS causes less pain than radiography, takes less time, and has the potential to avoid radiation, especially in children with suspicion for fracture but no visible deformity [32-35]. If POCUS is performed and demonstrates a cortical break or displaced fracture requiring reduction and/or casting, then we recommend plain radiographs to further characterize the injury whenever possible.
Based upon a meta-analysis of 12 studies with a total enrollment of 951 children (18 years of age and younger), ultrasound detects distal forearm fractures with a pooled sensitivity of 98 percent and a specificity of 96 percent using plain radiographs as the gold standard . These findings correspond to an estimated 3 out of 100 distal forearm fractures missed by ultrasound. In most included studies, the ultrasound was performed at bedside by the managing physician rather than by a radiologist. Thus, ultrasound by a trained and experienced physician is a viable alternative to plain radiographs for the diagnosis of distal forearm fractures . Six-view ultrasound technique is associated with the best sensitivity and specificity (figure 9). Furthermore, in three studies not included in the aforementioned meta-analysis, ultrasound was less painful than plain radiographs [33-35]. In one of these studies, the median time to perform the ultrasound examination was 1.5 minutes .
In a nonblinded trial of 270 children 5 to15 years old with an isolated distal forearm injury and no visible deformity, patients who had initial imaging with POCUS in the emergency department rather than radiography had similar physical function four weeks after injury . Of the patients who initially underwent POCUS, 40 patients also had radiography because ultrasound identified that a fracture other than a buckle fracture was present and would require casting and follow-up.
POCUS has also been used successfully to guide distal forearm fracture reductions and determine when the fracture has been adequately reduced [36-39]. For example, in one prospective observational study of almost 60 children who underwent reduction of forearm fractures, most of which were distal radius and/or ulnar fractures, POCUS identified inadequate reductions with a sensitivity of 100 percent and specificity of 92 to 93 percent compared with fluoroscopy . Thus, ultrasound, when performed by an experienced and properly trained provider, POCUS may be an alternative means of assessing closed reduction when fluoroscopy is not available.
Specific radiographic findings
Nondisplaced Salter I fracture — Patients with a nondisplaced Salter I physeal fracture of the distal radius or ulna (figure 6) usually have normal plain radiographs at initial presentation. However, bony tenderness is present over the physis in these patients and helps to differentiate this injury from a bruise or ligamentous strain or sprain . Other radiographic findings that may be present soon after injury include a volar fat pad on the lateral view and epiphyseal widening on stress views. However, stress views are painful for the patient and usually unnecessary. Plain radiographs obtained at least seven days after injury will show healing bone in children with nondisplaced Salter I fractures and also provides a definitive diagnosis.
Physeal fractures — Physeal separations or fractures occur across the growth plate of the bone. Until fused, the physes (growth plates) are a site of relative weakness and are therefore prone to fracture. When there is a fracture at the physis, it usually occurs between the calcified and uncalcified layers of cartilage corresponding to the hypertrophic zone (figure 4). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal (growth plate)'.)
Physeal injuries of the distal radius are the most common sites of growth plate injury . Ulnar physeal injuries are much less common and typically occur in conjunction with radial fractures. When there is injury to the radial or ulnar physis, circulation typically remains unaffected, and growth is usually not disturbed .
The Salter-Harris system is the most commonly used classification scheme for describing these fractures (figure 6). The Salter-Harris levels progress from type I to type V. Salter-Harris types I and II comprise the majority of distal physeal forearm injuries (image 3). The higher levels (type III or higher) correspond to an increased need for surgical intervention and a greater risk for growth arrest after fracture healing (image 8 and image 9). (See "General principles of fracture management: Fracture patterns and description in children", section on 'Physeal fracture description' and "Distal forearm fractures in children: Initial management", section on 'Physeal fracture'.)
In infants and very young children, who have minimal or no ossification of the epiphysis, the fracture may be difficult to appreciate on plain radiographs. If there is no deformity, then immobilization and follow-up with a primary care provider in seven to 10 days is warranted. (See "Distal forearm fractures in children: Initial management", section on 'Nondisplaced Salter-Harris I fractures'.)
Bone bruise — A subset of children with presumed nondisplaced Salter-Harris distal forearm fractures may have normal acute and follow-up radiographs but exhibit persistent bony pain despite immobilization for four to five weeks . Magnetic resonance imaging with fat suppression may detect microfractures, termed "bone bruises" in such patients.
Torus (buckle) fractures — A buckle fracture occurs at the distal metaphysis, where the bone is most porous, usually in younger children (image 10). This injury is caused by buckling of the cortex due to compression failure. On clinical presentation there is tenderness over the bone, but other symptoms (eg, swelling, decreased range of motion) may be minimal and not highly suggestive of a fracture.
The most common buckle fracture involves the dorsal surface of the distal radius (image 10), but may involve both radius and ulna bones (image 11). It is important to look at all views for a disruption of the smooth contour of the metaphysis, since the buckle may be very subtle (image 12).
Greenstick fractures — A greenstick fracture is a complete fracture of the tension side of the cortex of the radius or ulna and a plastic deformation, or buckling, of the compression side. On radiograph, the fracture will be seen as a complete disruption on one side of the bone with a buckle on the opposite side (image 13 and image 14). Commonly a complete or buckle fracture of one bone accompanies a greenstick fracture of the other.
Complete fractures — A fracture is considered complete when it passes through both cortices of the distal metaphysis (distal third) of the radius and/or ulna, often with displacement (image 4). They are usually caused by a high energy fall onto the hand with the wrist in a pronated and extended position [1,23]. These fractures do not affect the growth plate. If the fracture extends completely through the distal radius and ulna, the extension of the hand during these falls gives a characteristic deformity to these fractures sometimes referred to as the dinner fork deformity (figure 5). A fall on a flexed hand results in the opposite deformity (image 5). Slight variations in mechanism can produce different injuries.
Because children's bones are more flexible than those of adults, these pediatric fractures are rarely comminuted. The bony segments assume the position that is dictated by the muscle forces exerted on the bone [1,10]. In particular, the brachioradialis muscle exerts a volar deforming force with the hand in pronation (figure 10) and with total bony displacement, shortening of the forearm with overlapping fracture fragments .
Ulnar styloid fractures — This fracture a distal avulsion fracture at the site of the triangular fibrocartilage complex (TFCC) or the ulnocarpal ligament attachment (figure 3). It typically occurs in conjunction with a radial fracture. In most instances, fracture care is determined by the type of radial fracture with one exception; a displaced fracture that occurs at the base of the ulnar styloid may indicate a disruption of the TFCC and may warrant surgical intervention (image 15) [44,45].
Galeazzi fractures — A Galeazzi fracture is a fracture of the distal third of the radius along with dislocation of the distal radioulnar joint or ulnar physeal separation (Galeazzi-equivalent fracture) (image 16). This injury typically occurs after a fall onto an outstretched hand and is very rare in children.
Associated fractures — Forearm fractures are associated with supracondylar fractures in up to 5 percent of cases . The combination of supracondylar and forearm fractures is termed the "floating elbow" and increases the possibility of compartment syndrome . For this reason, anteroposterior and lateral radiographs of the forearm should include the distal humerus in all patients with forearm fractures.
Proximal humerus, clavicle, wrist, and hand fractures may also occur with a distal forearm fracture. Deformity and/or bony tenderness during physical examination dictate appropriate radiographic assessment of these areas in selected patients.
DIFFERENTIAL DIAGNOSIS — In children with radiographic evidence of fracture, the diagnosis is straightforward. Compared to patients with nondisplaced Salter-Harris I fractures, children with soft tissue injuries and no fracture often have diffuse tenderness rather than tenderness over the physis and show significant improvement in pain and swelling within a few days after injury. (See 'Nondisplaced Salter I fracture' above.)
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:
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 5th to 6th 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 10th to 12th 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 topic (see "Patient education: Common wrist injuries (The Basics)")
SUMMARY AND RECOMMENDATIONS
●Epidemiology – Distal forearm fractures are the most common fractures in children. The type and location of fracture varies by age with torus (buckle) and greenstick fractures most frequently occurring in children under 10 years of age, physeal (growth plate) fractures more likely in patients over 10 years of age, and complete fractures most common in adolescents. Older children tend to have more distal fracture location when compared to younger children. (See 'Epidemiology' above.)
●Clinical features – The child with a distal forearm fracture typically has a history of a fall on an outstretched hand with swelling, bony pain, and deformity. (See 'Clinical features' above.)
●Physical examination – Physical examination of children with distal forearm fractures should focus on the presence of open wounds near the fracture site, careful neurovascular assessment, and identification of any injury to the wrist or elbow joints. Because of the anatomy of the interosseous membrane and the radioulnar articulations, any disruption or distal fracture of one bone is usually accompanied by fracture to the other (image 1) and may cause a tear in the triangular fibrocartilage complex (figure 3). Thus, 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. (See 'Pertinent anatomy' above and 'Physical examination' above.)
●Imaging and diagnosis – In patients with an obvious deformity or high suspicion for a displaced fracture, analgesia (eg, intranasal fentanyl or intravenous morphine) and splinting is advisable prior to obtaining radiographs. Otherwise, a sling typically provides adequate support of nondisplaced fractures and allows for radiographs to be obtained more easily. Adequate analgesia also facilitates a better assessment of sensory and motor function during physical examination. (See 'Imaging' above and 'Physical examination' above.)
With the exception of nondisplaced Salter I physeal (growth plate) fractures or physeal microfractures (or "bone bruises"), plain radiographs of the forearm (image 6 and picture 3 and image 7) or point-of-care ultrasonography by a trained clinician can provide the diagnosis. Plain radiographs are recommended for children who present with obvious deformities of the distal forearm that will require reduction and casting. If POCUS is performed instead of radiography and demonstrates a cortical break or displaced fracture requiring reduction and/or casting, then we recommend plain radiographs to further characterize the injury whenever possible. (See 'Plain radiographs' above and 'Point-of-care ultrasonography' above.)
Children with a nondisplaced Salter I physeal fracture of the distal radius or ulna (figure 6) usually have normal anteroposterior and lateral plain radiographs at initial presentation. However, bony tenderness is present over the physis in these patients, and this finding helps to differentiate this injury from a bruise or ligamentous strain or sprain. Plain radiographs obtained at least seven days after injury usually will show healing bone in children with nondisplaced Salter I fractures and also provides a definitive diagnosis. However, microfractures or a "bone bruise" of the physis may only be apparent upon magnetic resonance imaging with fat suppression. (See 'Nondisplaced Salter I fracture' above and 'Bone bruise' above.)
●Specific radiographic findings – Specific types of distal forearm fractures include (see 'Specific radiographic findings' above):
•Physeal fractures (image 3)
•Torus (buckle) fractures (image 10)
•Greenstick fractures (image 14)
•Complete fractures (image 4)
•Ulnar styloid fractures (image 15)
●Associated fractures – Forearm fractures are associated with supracondylar fractures in up to 5 percent of cases. The combination of supracondylar and forearm fractures is termed the "floating elbow" and increases the possibility of compartment syndrome. For this reason, anteroposterior and lateral radiographs of the forearm should include the distal humerus in all patients with forearm fractures. (See 'Specific radiographic findings' above and 'Associated fractures' above.)
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