Midshaft forearm fractures in children

INTRODUCTION — 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 "Supracondylar humeral fractures in children" and "Midshaft humeral fractures in children".)

EPIDEMIOLOGY — 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 [3]. In addition, midshaft forearm fractures are the most common sites for refracture in children and among the most common sites of pediatric open fractures [4].

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.

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) [1,7-10]. 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.

MECHANISM OF INJURY — Most both bone midshaft forearm fractures in children result from a fall onto an outstretched hand (FOOSH) [2,8,9]. A direct blow to the middle of the forearm may cause an isolated fracture of the midshaft ulna ("nightstick fracture") or, less commonly, the radius.

Midshaft forearm fractures are not typically associated with multiple trauma. However, children who fall from a height greater than three times their standing height or sustain a midshaft 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'.)

Intentional trauma should be suspected in a child with an isolated ulna fracture (nightstick fracture) or a complete midshaft radius and ulna fracture without a history of injury. (See "Orthopedic aspects of child abuse".)

PHYSICAL FINDINGS — The child with a midshaft forearm fracture typically has swelling, pain, and deformity at the middle forearm with limited range of motion of the hand, wrist, and elbow.

Once the clinician has performed a general physical examination to exclude other injuries, the examination can focus on the forearm. (See 'Associated injuries' below.)

In a patient with severe pain, analgesia prior to examination is necessary to enable the child to cooperate with the examination. Initial pain control in patients with moderate to severe pain can be achieved within 10 minutes with intranasal fentanyl delivered by an atomizer (2 mcg/kg once; maximum single dose 100 mcg). 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.

●Location of deformity.

●Skin wounds – Careful inspection of the entire forearm is necessary to detect an open fracture (image 2). The bone may have poked through the skin and then retracted, leaving a small puncture. In contrast to an abrasion or puncture from the outside of the arm overlying the fracture site, these small punctures resulting from the fracture tend to ooze blood. If blood can be expressed through the hole, it is an open fracture. This clinical tool can be used to detect even a small open fracture.

●Presence and location of tenderness and/or swelling.

●Evidence of injury in the wrist or elbow region.

Neurovascular examination — Assessment of neurovascular status is particularly important as nerve deficits, especially median nerve injury, are found in a significant number of children with midshaft forearm fractures.

The clinician should evaluate the sensory and motor function of the median, radial, and ulnar nerves (table 2).

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 radial nerve) (picture 1)

●Finger spread against resistance or holding a piece of paper firmly between the middle and ring fingers: ulnar nerve (figure 3)

●Thumb's up sign: radial nerve (figure 4)

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

Although nerve injuries may rarely be associated with long-term sequelae, the majority are neurapraxias (ie, temporary loss of nerve function, especially motor function) without anatomical nerve disruption [1].

●Radial and ulnar pulse – Blood vessel injuries are rare with forearm fractures, but occur commonly with supracondylar fractures that may accompany a forearm fracture. (See "Supracondylar humeral fractures in children", section on 'Pertinent anatomy'.)

●Range of motion of the arm (eg, supination, pronation, flexion, and extension) – The patient should be asked to perform active motion, if possible. The clinician should NOT perform passive range of motion if a fracture is suspected.

Acute compartment syndrome — Compartment syndrome may rarely occur prior to or after definitive orthopedic care of a midshaft forearm fracture. It is more common in children with forearm fracture who also have a supracondylar fracture [11,12]. The following findings suggest a developing compartment syndrome:

●Excessive swelling and ecchymosis at the elbow [13]

●Increasing forearm pain

●Increased pain upon passive extension of the fingers

●Tenseness of the affected muscle compartment

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

Once the clinician suspects an acute compartment syndrome, compartment pressures should be measured and emergent consultation with an orthopedic surgeon should occur. Fasciotomy constitutes definitive treatment. (See "Acute compartment syndrome of the extremities", section on 'Management'.)

Associated injuries — When there is an isolated fracture evident in the radius or ulna, the clinician should check the joints above and below for other injuries.

Up to 5 percent of forearm fractures in children are complicated by supracondylar fractures [14]. Thus, the elbow warrants careful inspection for swelling and/or deformity and palpation for bony tenderness. Radiographs of the forearm in children with fracture should visualize the wrist and the elbow. (See 'Radiographic views and interpretation' below.)

In addition, shoulder and clavicle injuries may occur, and any deformity, swelling, or bony tenderness in these areas warrants radiographic investigation.

RADIOGRAPHIC FINDINGS

Radiographic technique — When obtaining radiographs in the child with a suspected midshaft forearm fracture, the goal is to obtain the necessary films with minimal movement of the extremity. In patients with an obvious deformity or high suspicion for a displaced fracture, pain should be controlled prior to radiographic evaluation. Initial pain control can be achieved within 10 minutes with intranasal fentanyl delivered by an atomizer (2 mcg/kg once; maximum single dose 100 mcg). Once an intravenous line is established, morphine can be given, as needed. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Fentanyl'.)

For patients with an obvious deformity 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 'Analgesia and splinting' below.)

Radiographic views and interpretation — All patients with suspected forearm fractures need 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 should have minimal superimposition of the radial tuberosity (located on the proximal radius) over the proximal ulna, and similar radiographic density for the proximal and distal forearm (image 3) [15]. A true lateral view of the forearm has superimposition of the radial head and 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 the elbow flexed at 90 degrees (image 4) [15].

When describing and documenting a forearm fracture, the key elements include the location, angulation, displacement, and presence of bony rotation [1]:

●The forearm is divided into the proximal third, middle third, and distal third.

●On the lateral view, the displacement is defined by the displacement of the distal fragment (dorsal or volar).

●The angulation is described by the direction of the apex of the deformity (dorsal or volar) and the degree of angulation.

●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 [8,9]. Most displacements are also rotated.

If there is displacement or angulation on the AP view, descriptions are similar but in the radial or ulnar direction. If there is concern about an elbow fracture or dislocation, separate elbow radiographs should be obtained [8,9]. (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'.)

Classification — Forearm fractures are described using the following elements:

●Fracture type – Closed versus open

●Bone involvement – Single or both bone fracture

●Location – Distal, middle, or proximal third

●Fracture pattern – Plastic deformation, greenstick, complete, or comminuted

Specific fractures

Plastic deformations — If the bone (usually the diaphysis of the ulna) is bent on radiograph but not fractured, it may be bowed (image 5). The arm will typically look excessively curved as well.

Greenstick fractures — A greenstick fracture is a complete fracture of the tension side of the cortex and a plastic deformation, or buckling, of the compression side, most commonly in the diaphysis [1,2,7]. This type of injury is usually from a rotational force (figure 5 and image 6 and image 7) [8,16].

Complete fractures — A complete fracture is a fracture through both cortices of the radius and/or ulna, often with displacement (image 8). 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 [1,4,8].

Comminuted fractures — Midshaft fractures with multiple bony fragments are uncommon in children and typically arise from a high energy mechanism (eg, high speed motor vehicle collision).

Associated fractures — Forearm fractures are associated with supracondylar fractures in up to 5 percent of cases [11]. The combination of supracondylar and forearm fractures is termed the "floating elbow" and increases the possibility of compartment syndrome [12]. For this reason, AP 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 midshaft forearm fracture. Deformity and/or bony tenderness during physical examination dictate appropriate radiographic assessment of these areas in selected patients.

INITIAL TREATMENT — The goals for initial care of midshaft forearm fractures in children are to reverse vascular compromise or an 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.

Compartment syndrome — Compartment syndrome may rarely occur prior to or after definitive orthopedic care of a midshaft forearm fracture. It is more common in children with forearm fracture who also have a supracondylar fracture [11,12].

When compartment syndrome is suspected based on clinical findings, immediate management 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. Suspected compartment syndrome should prompt emergent compartment pressure measurement and orthopedic consultation. Definitive treatment consists of fasciotomy to decompress all involved compartments. (See "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures' and "Acute compartment syndrome of the extremities", section on 'Management'.)

Analgesia and splinting — For children with no sign of compartment syndrome, initial therapy consists of pain management and immobilization to prevent worsened alignment of the fracture.

●Parenteral analgesia (eg, intranasal fentanyl (2 mcg/kg once, maximum single dose100 mcg) and then intravenous morphine as needed) 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 forearm fracture. In most circumstances, pain relief will result in an improved ability to assess neurovascular status in the apprehensive child. (See "Pain in children: Approach to pain assessment and overview of management principles".)

●Immobilization of obviously deformed fractures prior to radiographs promotes pain relief and helps to prevent additional arm injury from inadvertent arm movement. In this situation, the arm should be splinted "as it lies" (typically a sugar tong splint using prefabricated splinting material or eight layers of plaster with cotton under cast padding and loosely applied elastic bandages) (figure 6). (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Sugar tong splints'.)

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 adjusted.

Patients with no or minimal deformity may be placed in a sling for comfort prior to radiographic assessment.

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Prompt orthopedic consultation should be obtained in any of the following midshaft forearm fractures:

●Open fractures

●Fractures with neurovascular compromise or compartment syndrome

●Complete both bones fractures (if the clinician is not experienced with reduction)

●Angulated fractures (if the clinician is not experienced with reduction)

●Single displaced radius fractures with intact ulna where a difficult reduction is anticipated

●Plastic deformation of one or both bones

●Forearm fractures with concomitant dislocations (eg, Monteggia or Galeazzi)

Clinicians who are experienced in closed fracture reduction and cast or splint immobilization of the reduced fracture may choose to provide this care for angulated or complete closed midshaft fractures.

DEFINITIVE CARE — Although high quality studies to guide management of pediatric midshaft forearm fractures are lacking [17], closed reduction followed by casting or splinting provides definitive treatment for most children [2,4]. The availability of safe pediatric sedation and analgesia outside of the operating room allows for many reductions to be performed in the emergency department. Clinicians who are experienced in fracture reduction and cast or splint immobilization of the reduced fracture may choose to provide this care for midshaft fractures and arrange for orthopedic follow-up. (See "Procedural sedation in children: Approach".)

If parents/caregivers choose to stay with the child during the procedure, they should be warned about the child's appearance during sedation, including the possibility that the child will cry out, vomit, or need airway support; the sound of moving bones during the reduction; and the possible need for multiple attempts and/or significant force to successfully reduce the fracture. In addition, they should be seated where they will be comfortable and out of the way.

Plastic deformation — If the deformation is less than 20 degrees or if the deformity occurs in a young child (<4 years of age), angulation is often corrected with immobilization alone [18]. If there is an associated angulated fracture of the radius, then closed reduction will typically straighten the bowed ulna, as well (image 9 and image 10).

However, more extensive plastic deformation can result in narrowing of the interosseous space, limiting future pronation and supination and requires prompt referral to an orthopedist (image 5 and figure 7) [1].

Greenstick fracture — If a reduction is necessary, it is done with the goal of reversing the mechanism of injury, including the angulation, displacement, and rotation. In most circumstances, rotating the palm of the hand toward the deformity while applying pressure just proximal to the apex of the deformity suffices (eg, pronation for apex-volar deformity and supination for an apex-dorsal deformity) (figure 5) [4].

To ensure complete reduction and healing, some experts recommend completion of the break through the non-fractured side [19-21]. However, observational studies have shown good healing without completion of the greenstick fracture [21,22]:

●Among 99 total children with forearm fractures, residual angulation was less in children with greenstick fractures than in those with complete fractures (5 versus 7 degrees, p = 0.02) [22].

●Reangulation during healing occurred less commonly for the 151 children with greenstick fractures than for the 47 children with complete fractures (10 versus 25 percent, p = 0.08) [21].

Once reduced, the arm should be immobilized in a sugar tong splint or long arm cast with molding that provides three-point fixation to hold the reduction in place (figure 8) [1,10]. (See 'Immobilization and casting basics' below.)

For very minimally angulated greenstick fractures, the fracture can be casted without previous reduction, and then gently reduced while the cast materials are setting. The reduction is held in place with a three-point smoothly molded cast (figure 8).

Even fractures with intact periosteum and no displacement can become malaligned during or after closed reduction and warrant orthopedic follow-up within 7 to 10 days to evaluate for redisplacement.

Complete fracture — The ability to adequately reduce these fractures in the emergency department depends on the degree of angulation, displacement, and overlapping of the fracture fragments:

●Very minimally angulated and displaced midshaft fractures can be casted without reduction and then gently reduced while the cast is on and setting. The reduction is held in place with a three-point mold (image 11).

●For significantly angulated and/or displaced fractures (image 8), traction may be applied prior to and during the reduction. Counter traction may be applied by slinging a sheet over the upper arm and stepping on the ends or by using weights slung over the distal humerus, or by hand. Adequate reduction of a complete fracture may take several attempts. Portable fluoroscopy is useful to check the adequacy of reduction during the procedure [23]. Malrotation of the radius and ulna must also be corrected by supination or pronation; rotational alignment of the radius is more important than that of the ulna. Maintaining reduction with good cast technique is essential. (See 'Immobilization and casting basics' below.)

●If both bones are significantly overlapping, the clinician should anticipate a very difficult reduction that will be unstable. In these instances, an orthopedic surgeon should be consulted for possible open reduction and internal fixation.

Midshaft complete fractures tend to be very unstable despite appropriate reduction and immobilization (image 8 and image 1). Midshaft complete fractures may require open reduction and internal fixation if adequate closed reduction is not achieved or cannot be maintained, especially in children over 10 years of age (image 12) [4].

Once a fracture reduction is performed, the child should follow up with an orthopedic surgeon within one week for radiographic assessment of fracture positioning. The patient should be seen on a regular basis for the first few weeks to monitor for any loss of reduction [1,4]. Up to 25 percent of complete forearm fractures displace during follow-up despite adequate initial closed reduction and casting and will require repeat closed reduction or surgical intervention [22].

Open fracture — All pediatric patients with open fractures of the forearm warrant emergency consultation with an orthopedic surgeon. Patients with type II or higher open fractures (table 3) have a substantial risk for infection and should receive surgical irrigation and debridement. Pending operative care, these patients should also undergo the following treatments (see "General principles of fracture management: Early and late complications", section on 'Open fractures'):

●Immobilization with a long arm splint (see "Basic techniques for splinting of musculoskeletal injuries", section on 'Long arm splint')

●Analgesia (eg, intravenous morphine)

●Intravenous antibiotics as determined by the prevalence of methicillin-resistant Staphylococcus aureus in the region (see "Hematogenous osteomyelitis in children: Management", section on 'Children three months and older')

●Tetanus prophylaxis (table 4)

Patients with type I open fractures of the forearm (ie, clean wound <1 cm in length) usually have minimal soft tissue injury and intact local perfusion. Preliminary evidence suggests that nonoperative treatment of these injuries with irrigation, one dose of intravenous antibiotics, and casting in the emergency department can have good results [24,25]. However, given the limited numbers of patients in these series, further study is needed before nonoperative treatment of these injuries becomes routine. An orthopedic consultation should always be obtained for these patients.

Comminuted fracture — These fractures are less common in children and are often associated with high energy mechanisms of injury or open fractures. Prompt orthopedic consultation for open reduction and internal fixation is typically necessary.

Immobilization and casting basics — Once reduced, the clinician may choose to immobilize the fracture using a combined sugar tong and long arm splint or a cast. If a splint is applied, the patient is typically referred for cast application by an orthopedic surgeon within two to five days. This approach allows time for the swelling to go down before the cast is placed but may risk loss of reduction [26]. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Upper extremity splints'.)

An overview of casting is provided separately. (See "General principles of definitive fracture management", section on 'Casting'.)

Key aspects of casting midshaft forearm fractures are as follows:

●Arm position – After a fracture reduction, the elbow should be placed at 90 degrees before ANY casting material is applied; if it is flexed after material is applied it causes bunching and irritation at the elbow. Typically, a second person is needed to hold the arm (by the fingers) in the proper position.

●Materials – The layers of the cast consist of stockinette next to the skin, cotton padding (eg, two-inch Webril) that is rolled with one half inch overlap, and two-inch fiberglass or plaster casting material. Compared with plaster, fiberglass is lighter, allows airflow, and is stronger. Extra padding should be applied to common pressure points at the wrist and elbow. It is important to ensure no major wrinkles exist in the stockinette and the padding before casting material is applied.

●Molding – Three-point molding of the forearm portion of the cast maintains the fracture reduction and allows the clinician to mold the cast without causing pressure points. The palm of one hand pushes gently distal to the fracture on the side of the intact periosteum, while the palm of the other hand pushes gently proximal to the fracture on the opposite side of the arm. An assistant's hand is placed more proximally on the arm (below the elbow) on the same side as the most distal hand. Once completed, the cast should be wider in the horizontal diameter than in the vertical diameter when viewed on end (vertical to horizontal diameter ratio 0.7) and the ulnar border should be straight (figure 8) [4].

●Forearm position in the cast – The cast should be in neutral position with respect to supination and pronation of the hand [2]. Although some orthopedists prefer the wrist to be casted in slight flexion with ulnar deviation to counteract opposing muscles, an observational study of 109 children with distal forearm fractures concluded that the position of immobilization (neutral, pronation, or supination) does not appear to affect maintenance of fracture reduction and residual angulation [3].

●Length of cast – A long arm cast should be placed on all reduced midshaft forearm fractures.

●Post-casting neurovascular assessment – The patient should have good perfusion of the fingers and be able to fully extend his or her fingers and thumb actively and passively after casting [8]. Poor perfusion, pain on finger extension, or limitation of finger or thumb motion suggests tendon and/or muscle entrapment or a tight cast.

●Assessment of reduction and casting – After closed reduction and casting, post-reduction radiographs are obtained in the radiology department or at the bedside using fluoroscopy [9]. Bedside fluoroscopy has the advantage of timeliness, continued ability to monitor the patient after sedation, and lower radiation exposure.

●Criteria for discharge – Once adequate fracture alignment and cast molding is documented radiographically, the child is fully recovered from sedation, and cast instructions have been provided, the child may be discharged home. (See 'Follow-up care' below.)

FOLLOW-UP CARE — All patients should be provided with a sling and instructed to keep the fracture site elevated above the level of the heart as much as possible for the first 48 hours after injury.

Caretakers and children who received a cast should be given detailed cast care instructions. (See "Patient education: Cast and splint care (Beyond the Basics)".)

Midshaft forearm fractures that undergo closed reduction should be evaluated by an orthopedic surgeon within a week. Subsequently, the patient is seen on a frequent basis for the first few weeks to monitor for any redisplacement or angulation [4,7]. Up to 25 percent of greenstick or complete fractures displace during follow-up despite adequate initial closed reduction and casting [22]. These fractures require repeat closed reduction or surgical intervention.

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 — A small trial found that after reduction and casting, approximately 80 percent of patients with arm fractures achieve adequate analgesia with nonsteroidal antiinflammatory medications (eg, ibuprofen) during the first three days after care [27]. However, up to 20 percent of patients may require oral opioid medication (eg, oxycodone) for adequate pain control during the first 72 hours. Thus, some clinicians may choose to provide a limited prescription to be used as needed. At 72 hours, continued pain requiring opioid analgesia is an indication for reevaluation.

COMPLICATIONS — Complications from midshaft forearm fractures are rare. Loss of alignment after reduction and refracture comprise the most common complications following midshaft forearm fracture care [2,4,22,28].

Refractures typically occur approximately six months after injury [29]. The risk of refracture is significantly higher in patients who sustained greenstick fractures or who had internal fixation with plates or intramedullary wires [19,29-31]. Splinting for up to two months after initial bone healing may decrease the frequency of refracture [22].

Delayed union or malunion occurs in less than 1 percent of midshaft fractures treated by closed reduction [4].

Although nerve injuries may be associated with long-term sequelae, the majority are neurapraxias that will resolve within two to three months. Surgical exploration may be needed for nerve deficits that persist beyond three months [4].

Complex regional pain syndromes may rarely follow a midshaft forearm fracture and are identified by marked pain with light touch to the skin (allodynia), swelling, and vasomotor changes. Splinting results in worsening symptoms. Multidisciplinary pain evaluation and treatment, including physical therapy, is typically helpful. (See "Complex regional pain syndrome in children".)

OUTCOMES — The prognosis for full healing and recovery of arm function following midshaft forearm fractures is very good with proper diagnosis and treatment, especially in children with nondisplaced fractures. Close follow-up with an orthopedic surgeon is necessary for these fractures because 10 to 25 percent of midshaft forearm fractures that undergo closed reduction will lose anatomic alignment during follow-up care despite appropriate initial care and casting [8,22].

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 topic (see "Patient education: How to care for your child's cast (The Basics)")

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

SUMMARY AND RECOMMENDATIONS

●The child with a midshaft forearm fracture typically has a history of a fall on an outstretched hand with swelling, pain, and deformity. (See 'Physical findings' above.)

●Patients with forearm fractures require a true anteroposterior (AP) and lateral plain radiograph of the injured forearm that includes the wrist and distal humerus. (See 'Radiographic views and interpretation' above.)

●In patients with an obvious deformity or high suspicion for a displaced fracture, analgesia (eg, 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 'Analgesia and splinting' above.)

●Specific types of midshaft forearm fractures include bowing fractures (plastic deformation) (image 5), greenstick fractures (image 6), complete fractures (image 8), and comminuted fractures. (See 'Specific fractures' above.)

●Emergency orthopedic consultation is indicated for children with an open fracture, neurovascular compromise, compartment syndrome, or forearm fracture complicated by wrist or elbow dislocation or supracondylar fracture. Prompt involvement of an orthopedic surgeon is appropriate for any patient with a displaced or angulated midshaft forearm fracture although the experienced clinician may perform the initial closed reduction. (See 'Indications for orthopedic consultation or referral' above and 'Definitive care' above.)

●Children with vascular insufficiency may 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 emergent operative exploration and vascular repair. (See 'Absent pulse' above.)

●Suspected compartment syndrome should prompt measurement of compartment pressure in addition to emergent consultation with an orthopedic surgeon with appropriate pediatric expertise. Once confirmed by compartment pressure measurement or clinical assessment, 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 and "Acute compartment syndrome of the extremities", section on 'Measurement of compartment pressures'.)

●Additional recommendations in children with open fractures include administration of intravenous antibiotics, tetanus prophylaxis, and emergency orthopedic consultation. (See 'Open fracture' above.)

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

●Patients with nondisplaced or minimally displaced midshaft fractures may receive immobilization with a long arm splint or cast and a sling in the emergency department and follow-up with an orthopedic surgeon with appropriate pediatric expertise within one week. (See 'Greenstick fracture' above and 'Plastic deformation' above.)