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Distal forearm fractures in children: Initial management

Distal forearm fractures in children: Initial management
Literature review current through: Jan 2024.
This topic last updated: Jul 27, 2022.

INTRODUCTION — The initial management of distal forearm fractures in children will be reviewed here. The diagnosis, assessment, fracture reduction, and casting of distal forearm fractures in children and the care of pediatric proximal or midshaft forearm fractures are discussed separately:

(See "Distal forearm fractures in children: Diagnosis and assessment".)

(See "Closed reduction and casting of distal forearm fractures in children".)

(See "Midshaft forearm fractures in children".)

(See "Proximal fractures of the forearm in children".)

DIAGNOSIS — The assessment and diagnosis of distal forearm fractures in children is discussed separately. (See "Distal forearm fractures in children: Diagnosis and assessment".)

EMERGENCY TREATMENT — The goals for initial care of children with a suspected distal forearm fracture are the following (algorithm 1):

Identify and treat vascular compromise

Identify open fractures

Provide analgesia and immobilization

Absent pulse — The emergency clinician should promptly identify children with vascular insufficiency and obtain emergency consultation with 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.

Open fracture — All pediatric patients with open fractures of the forearm warrant prompt consultation with an orthopedic surgeon. Patients with type II or higher open fractures (table 1) 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 as needed (table 2)

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. These fractures have low infection rates (table 1). 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 [1-3]. 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.

Predebridement wound cultures do not correlate with infectious pathogens in patients with open fractures and are not recommended [4,5].

Analgesia and immobilization — For children with no signs of vascular compromise, initial therapy consists of pain control and immobilization prior to radiographic evaluation [5]:

Mild to moderate pain – For patients with mild to moderate pain (eg, nondisplaced or minimally displaced fracture), oral nonopioid analgesia (eg, ibuprofen alone or in combination with acetaminophen) may suffice. In most circumstances, pain relief will result in an improved ability to assess neurovascular status in the apprehensive child. For persistent moderate pain, a single dose of an oral opioid medications (eg, oxycodone or hydromorphone) may be added.

Severe pain – Initial pain control in patients with severe pain (eg, obviously deformed fracture) can be achieved expeditiously with intranasal fentanyl delivered by an atomizer (2 mcg/kg; maximum single dose 100 mcg) while establishing intravenous (IV) access. Once an IV line is established, further opioid analgesia (eg, fentanyl, morphine, or hydromorphone) can be given IV as needed. Pain should be controlled prior to radiographic evaluation. (See "Pediatric procedural sedation: Pharmacologic agents", section on 'Fentanyl'.)

In patients with significant deformity, immobilizing the injured arm prior to taking radiographs also promotes pain relief and avoids additional soft tissue injury from inadvertent arm movement. In this situation, the arm should be splinted "as it lies" (typically a volar splint using prefabricated splinting material or eight layers of plaster with under cast padding [eg, Webril] and loosely applied elastic bandages [eg, Ace wrap]) (figure 1). 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 'Sugar tong splints'.)

Patients without obvious deformity may be initially managed with a splint and sling or a sling alone for additional pain relief during radiographic assessment.

After immobilization, patients without vascular compromise should elevate the distal forearm above the level of the heart and should have a cold pack applied while awaiting definitive treatment.

INDICATIONS FOR ORTHOPEDIC CONSULTATION OR REFERRAL — Prompt orthopedic consultation should be obtained for children with any of the following distal forearm fractures:

Open fractures

Fractures with neurovascular compromise

Salter-Harris III, IV, or V physeal fractures (figure 2 and image 1 and image 2)

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

Forearm fractures complicated by wrist or elbow dislocation or supracondylar fracture

Displaced Salter-Harris I or II physeal fractures (figure 2 and image 3A)

Angulated and/or complete fractures (if the clinician is not experienced in fracture reduction, splinting or casting) (image 4)

Galeazzi fractures (oblique or transverse radial fracture with dislocation of the distal ulna)

Evidence suggests that clinicians who are experienced in pediatric fracture reduction and cast or splint immobilization of the reduced fracture can provide this care for displaced Salter-Harris I or II, greenstick, or complete distal forearm fractures with good outcomes. As an example, fractures reduced and casted by trained pediatric emergency physicians had a similar healing, shorter emergency department stays, lower facility charges, and no increased short-term cast problems when compared with reduction by orthopedic residents [6-8]. In one study, the need for remanipulation was greater for fractures reduced by pediatric emergency medicine providers [8].

INITIAL FRACTURE MANAGEMENT — The initial management of distal forearm fractures in children is determined by the type of fracture, degree of displacement, and age of the child (algorithm 1).

Physeal fracture — Injury to the growth plate may be apparent on plain radiographs or, in patients with nondisplaced Salter-Harris I fractures, inferred by localized tenderness over the physis. The type of fracture, based upon the Salter-Harris classification (figure 2), and the degree of displacement determine the treatment. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Physeal fractures'.)

Nondisplaced Salter-Harris I fractures — Presumed Salter-Harris I fractures occur when there is localized tenderness over the physis in the absence of any radiographic findings. If there is concern for a Salter-Harris I fracture without radiographic findings, it can be treated with a removable volar splint and re-evaluated by the primary care provider after 7 to 10 days to determine if further immobilization or imaging is required [9]. If there is still concern, then an orthopedist should be consulted.

Nondisplaced Salter-Harris II fractures — Patients with nondisplaced Salter-Harris II fractures should receive immobilization with a sling and a short arm splint or short arm cast for three to four weeks [10]. A volar splint is typically adequate. (See "Basic techniques for splinting of musculoskeletal injuries", section on 'Upper extremity splints' and "Closed reduction and casting of distal forearm fractures in children", section on 'Immobilization'.)

Management should include evaluation by an orthopedic surgeon with appropriate pediatric expertise within seven days.

Displaced Salter-Harris I or II fractures — Treatment of these fractures focuses on reducing the fracture and maintaining arm support during the healing period. The reduction should be performed as soon as possible (within a week), because the growth plate heals quickly and closed reduction after seven days is associated with injury to the growth plate and a higher risk of growth arrest (image 3A-B) [11]. (See "Closed reduction and casting of distal forearm fractures in children", section on 'Salter I or II fracture reduction' and 'Complications' below.)

Follow-up with an orthopedic surgeon with appropriate pediatric expertise should occur within seven days. Displaced Salter-Harris I or II fractures typically require immobilization with a splint or cast for three to four weeks. Because these fractures do not involve the joint, they have an excellent prognosis.

Salter-Harris III, IV, and V fractures — These fractures warrant prompt consultation with an orthopedist with appropriate pediatric expertise. Salter-Harris type III fractures involve the joint surface (image 1). They commonly need open reduction to obtain a stable joint.

Salter-Harris type IV and V fractures also typically require open reduction with internal fixation [12]. Salter-Harris IV fractures are unstable, and perfect reduction is necessary for a good outcome (image 2). These fractures usually heal in four to six weeks. Salter-Harris type V fractures are frequently difficult to identify at initial evaluation and are followed by premature growth plate closure and growth arrest several months later. (See 'Complications' below.)

After healing, follow-up for all growth plate fractures is recommended at four to six months and again at a year, in order to detect any growth arrest [10,12,13]. If the radial growth plate closes and the ulna continues to grow, a wrist deformity will occur (picture 1). (See 'Complications' below.)

Torus (buckle) fracture — Torus fractures are stable compression fractures that are located at the distal metaphysis where the bone is most porous (image 5). They may be associated with distal ulna buckle (image 6) or distal ulna styloid fractures. Treatment is aimed at pain relief and comfort with a return to activities as guided by patient symptoms [12,14]. Before treatment, the clinician should be certain that the child does not have a greenstick (image 7) or Salter-Harris II distal radius fracture because these fractures are often mistaken for torus fractures. In contrast with torus fractures of the distal radius, greenstick and Salter-Harris II fractures of the distal radius have a greater tendency to displace, warrant closer follow-up, and require prolonged immobilization to ensure proper healing and recovery [15-17]. (See "Distal forearm fractures in children: Diagnosis and assessment" and 'Nondisplaced and mild displacement' below and 'Nondisplaced Salter-Harris II fractures' above.)

For children with a torus (buckle fracture), we recommend treatment with either a soft elastic bandage or a removable short arm splint (eg, soft Velcro splint or a well-padded and molded fiberglass or plaster volar splint) rather than a circumferential cast [18]. The choice of a soft elastic bandage versus a short-arm splint is determined by the parent's/primary caregiver's management preferences after an informed discussion of treatment options. This discussion should emphasize the evidence that pain control and recovery are similar regardless of which treatment is provided. It should also include detailed pain management instructions with the expected time of recovery [14]. Home management with follow-up with a physician as needed is sufficient for the vast majority of patients with torus fractures. (See 'Torus fractures' below.)

Use of a soft elastic bandage instead of splint immobilization (mostly removable splints) for torus fractures has been examined in a large multicenter randomized trial performed in nearly 1000 children 4 to 15 years old [18]. The primary outcome of pain at three days measured with the Wong-Backer Faces pain rating scale was similar in the two groups (adjusted difference -0.1 [95% CI -0.4 to 0.2]) and pain scores remained equivalent at all other follow-up time points (day 7, 21, and 42). Patient or caregiver reported functional recovery was also similar in the two groups. Of the 458 children assigned to treatment with a soft bandage, 11 percent returned for medical care to change treatment to splint immobilization. Approximately 1 percent of patients were found to have an alternative diagnosis (eg, greenstick or complete fracture) that required a revisit and casting. Parent/caregiver satisfaction was higher for the splinted group on day 1 but was equivalent between the two groups on day 42.

Systematic reviews demonstrate that splinting of torus fractures is similar to casting with respect to pain, return to normal function, treatment failure, or risk for refracture while having the advantage of lower burden of treatment, greater comfort, and lower cost [19-21]. Although there is heterogeneity among the trials, they do demonstrate that, regardless of the treatment, children with torus fractures have a full return to prior function with no serious adverse events or refracture and indicate that below-elbow casting for torus fractures is unnecessary [18,19].

Greenstick fracture — Children with greenstick fractures have 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 (image 7 and image 8) [16,17]. (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Greenstick fractures'.)

These patients typically require immobilization in a short arm cast or splint (depending on degree of angulation and displacement) for approximately four to six weeks, depending on the speed of radiographic healing and patient symptoms. Unlike buckle fractures, greenstick fractures are unstable and may continue to displace after casting [15]. Thus, these patients should see an orthopedist on a regular basis while casted.

Nondisplaced and mild displacement — Children with nondisplaced and mild displacement greenstick fractures should undergo splinting with reevaluation and casting by an orthopedic surgeon in three to five days [10,13,16,22,23].

The following are general guidelines for degree of angulation that can be treated without reduction [24]:

Children under 5 years of age – 10 to 30 degrees of angulation on lateral plain radiograph and up to 10 degrees of angulation on the anterior posterior (AP) view

Children 5 to under 10 years of age – 10 to 20 degrees of angulation on lateral plain radiograph and up to 10 degrees of angulation on the AP view

Children over 10 years of age – 5 to 15 degrees of angulation on lateral plain radiograph and 0 degrees of angulation on the AP view

Alternatively, these mildly angulated greenstick fractures can be casted without previous reduction and then gently reduced while the cast materials are setting (image 9). The reduction is held in place with a three-point smoothly molded cast (figure 3). (See "Closed reduction and casting of distal forearm fractures in children", section on 'Immobilization'.)

The degree of angulation that is allowed without reduction depends on the patient's age and type of deformity. Additionally, the more distal the fracture, the more angulation is tolerated without need for reduction. The actual angle should be measured on the radiograph. When questions about the need for reduction arise in children with greenstick distal forearm fractures, discussion with an orthopedic surgeon is warranted.

Moderate to severe displacement — Prompt reduction by an experienced clinician or orthopedic surgeon is indicated for fractures with greater angulation than described above, or in cases where the arm looks angulated on visual inspection [25]. (See 'Nondisplaced and mild displacement' above and "Closed reduction and casting of distal forearm fractures in children", section on 'Greenstick fracture reduction'.)

Complete fracture — A fracture is considered complete when it passes through both cortices of the distal radius and/or ulna, often with displacement (image 4). (See "Distal forearm fractures in children: Diagnosis and assessment", section on 'Complete fractures'.)

Treatment of complete distal forearm fractures is highly dependent upon the age of the child; the involved area of the bone(s); and the degree of angulation, displacement, and malrotation. If a metaphyseal fracture is isolated to the distal radius, it is not uncommon for it to be nondisplaced (image 10) [25]. When questions about the need for reduction arise in children with complete distal forearm fractures, discussion with an orthopedic surgeon is warranted.

Management by type of fracture is as follows:

Nondisplaced or minimally displaced metaphyseal fractures (one or both bones) have a great potential for remodeling because of the proximity to the distal growth plate. Nondisplaced isolated radial metaphyseal fractures with up to 15 to 20 degrees angulation can be splinted in a sugar tong splint or casted without reduction in children under 10 years of age (image 10) [10,11,26]. As an example, a trial of splinting versus casting of minimally displaced (5 mm or less) or minimally angulated (15 degrees or less) transverse fractures of the distal radius in 96 children between 5 and 12 years of age found that the use of a fabricated splint was as effective as a short arm cast in terms of physical function at six weeks with no refracture seen in either group [16].

Isolated distal radius diaphyseal fractures with minimal lateral shift (<2 mm), dorsal angulation of less than 10 degrees, and shortening of <2 mm minimal angulation or minimal displacement can be casted without reduction [27]. Although some investigators have reported casting duration for as short as one week [28], most orthopedists would cast for three weeks. Similarly, bayonet apposition will heal well with casting alone in children under 10 years old as long as there is no rotational deformity and no angulation [29]. Bayonet apposition does not limit rotation [11]. (See "Closed reduction and casting of distal forearm fractures in children", section on 'Complete fracture reduction' and "Closed reduction and casting of distal forearm fractures in children", section on 'Immobilization'.)

Displaced fractures and those with greater than 20 degrees angulation require closed reduction (image 11 and image 12). If adequate closed reduction is not achieved or cannot be maintained, distal complete fractures may ultimately need operative treatment, particularly if the child is over 10 years of age (image 13). (See "Closed reduction and casting of distal forearm fractures in children", section on 'Complete fracture reduction'.)

All complete fractures warrant follow-up with an orthopedic surgeon with pediatric expertise within seven days after splinting or casting.

Ulnar styloid fracture — This distal avulsion fracture typically occurs at the ulnar attachment site of the triangular fibrocartilage complex (TFCC) or the ulnocarpal ligament in conjunction with a radial fracture. In most instances, fracture management based upon the type of radial fracture with one rare 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 14) [30,31].

Galeazzi fracture — 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 15). This injury typically occurs after a fall onto an outstretched hand, and is very rare in children. These fractures warrant urgent consultation with an orthopedic surgeon with pediatric expertise for closed reduction followed by casting (skeletally immature children) or internal fixation (skeletally mature adolescents) [10].

FRACTURE REDUCTION AND CASTING — The methods for reduction and casting of distal forearm fractures in children are discussed in detail separately. (See "Closed reduction and casting of distal forearm fractures in children".)

HOME CARE

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

For children who are splinted and require fracture follow-up, caregivers should be instructed to not remove the splint before the next follow-up appointment and to keep it dry.

For children with torus fractures who do not require routine follow-up evaluation, caregivers should be advised to have the child wear the splint for three weeks, but the splint may be removed for bathing and sleeping. If there is no pain after three weeks, the child needs no further follow-up.

Pain control — 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.

For pain control, the area can be iced by placing a thin cloth over the cast or splint and applying an ice pack or bag of frozen vegetables for 15 to 20 minutes at a time for the first 24 to 48 hours.

In addition, for patients without contraindications to nonsteroidal antiinflammatory agents, we suggest pain control with oral ibuprofen. Some clinicians may choose to provide a prescription for a limited amount of opioid pain medication (eg, oxycodone 0.1 to 0.2 mg/kg every four to six hours as needed; maximum 5 mg per dose for a maximum duration of two to three days) to be used as a rescue medication in patients whose pain is not adequately controlled within one hour of ibuprofen administration. At 72 hours, continued pain requiring opioid analgesia is an indication for reevaluation.

The recommendation for ibuprofen is based upon a randomized trial of 336 children with arm fractures (majority with forearm fractures) in which patients who initially received home pain therapy with oral ibuprofen were appeared to be more likely to achieve adequate analgesia during the first three days after fracture reduction and immobilization than those who received acetaminophen with codeine although the difference was not statistically significant (80 percent versus 69 percent; 95% CI for the difference -0.2 to 22.0 percent) [32]. Patients receiving ibuprofen also had significantly fewer adverse effects (30 versus 51 percent) with drowsiness, nausea, and vomiting comprising the adverse effects most prevalent in children receiving acetaminophen with codeine. Limitations of this small trial include a high loss to follow-up and use of acetaminophen with codeine as the opioid analgesic, which has largely been replaced by other opioid formulations with fewer side effects for the treatment of pain in children.

FOLLOW-UP

Torus fractures — Children with low-risk torus (buckle) fractures treated with removable volar splints of soft elastic bandages do not require routine primary care provider or orthopedic follow-up [18,33-37].

However, an interval visit with a primary care provider, as needed, to reassess the child and provide anticipatory guidance about splint or bandage use may be reassuring to some caregivers and help guide recovery and return to sports [33]. Because these fractures do not displace during healing [15], additional routine radiographs at this follow-up visit are unnecessary for children with normal recovery [22,23,38]. Radiographs and orthopedic evaluation are reasonable for selected children diagnosed with torus fractures who are not recovering as expected and demonstrate diminished range of motion or continued pain, which suggests a more severe fracture [22,36,38,39].

Support for home management of torus fractures is provided by several trials [18,35-37]. For example, in a randomized, blinded trial of 133 children diagnosed with torus fractures in a pediatric emergency department, functional recovery and caregiver satisfaction at three weeks was at least as good for children who were assigned home management compared with routine primary care provider follow-up (mean performance score 95.4 versus 95.9 percent [95 percent score on the modified Activities Scale for Kids-38 question performance version indicates no disability]) [37]. None of the caregivers of children assigned to the home management group reported complications (eg, reinjury or pain and swelling more than four weeks after injury). In a large multicenter randomized trial of nearly 1000 children 4 to 15 years of age with torus fractures, a change in treatment because of persistent pain requiring a repeat hospital visit occurred in 11 percent of patients who received an elastic bandage and 5 percent of those who were splinted [18]. Health care costs were significantly lower for children who received home management.

Although, in the vast majority of children with low-risk torus (buckle) fractures managed with splinting, the removable device can be discontinued by three to four weeks [33], duration of splinting should be guided by the child's activity level and degree of discomfort [40]. An observational study of 39 children with buckle fractures found that children often stop using their splints after two weeks with no negative consequences [39]. In another study, a soft bandage was used in 14 children and most had removed the bandage by one week's time, allowing more comfort and early range of motion [36]. Finally, in an observational study that included 180 children with buckle fractures treated with a premolded commercial splint, most parents reported regular splint usage until three weeks [33].

Other distal forearm fractures — After initial care, children with distal forearm fractures, other than torus fractures, warrant follow-up with an orthopedic surgeon with pediatric expertise. Close follow-up with an orthopedic surgeon is necessary for those fractures that are prone to growth arrest (eg, Salter-Harris III, IV, and V fractures and displaced Salter-Harris fractures), refracture (greenstick fractures and angulated complete fractures), or loss of reduction (complete fractures). Specific timing depends upon the type of fracture and treatment as summarized here and discussed in greater detail above (see 'Initial fracture management' above):

Splinted or casted physeal fractures – Within one week

Splinted greenstick or complete fractures – 3 to 5 days

Casted greenstick or complete fractures – 7 to 10 days

Children who have received operative care may 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.

RETURN TO ACTIVITY — Return to activity varies by fracture type. For patients who have undergone casting, the orthopedist provides approval for full return to activity based upon radiographic assessments of fracture healing during follow-up care.

The following provides a general estimate of expected return to full activity by fracture type:

Displaced fractures – Most displaced fractures require at least three months of healing before return to full activity. Proper healing of displaced distal forearm fractures often requires a short or long arm cast for four to six weeks, depending upon the specific type of fracture (eg, physeal, greenstick or complete fracture) followed by placement in a removable splint for an additional four to six weeks. High-risk activities (eg, skateboarding, all-terrain vehicle riding) should be restricted until solid radiographic union is achieved to reduce the chance of a refracture [41].

Nondisplaced fractures – Nondisplaced Salter Harris I or II and greenstick fractures are often fully healed by four to six weeks. At that point, the child may participate in sports while wearing a splint if allowable (eg, soccer) for two more weeks or until the forearm is fully recovered. If the child cannot wear the splint during sports, then they should refrain from team sports until the wrist is back to full function without pain (typically a total of six to eight weeks).

Torus fractures – For torus (buckle) fractures, children may be treated with a soft elastic bandage or removable splint and typically heal within two to four weeks. During this time period, it may be prudent to avoid activities that may reinjure the wrist and potentially result in a more significant fracture. Alternatively, a removable splint may be applied for additional protection during sports.

COMPLICATIONS — The prognosis for full healing and recovery of arm function following distal forearm fractures is very good with proper diagnosis and treatment.

Up to 5 percent of children who undergo forearm fracture reduction and casting may require a second emergency department visit for pain and swelling [42,43]. Compartment syndrome or neurovascular compromise are rare.

Potential long-term complications of distal forearm fractures vary depending upon the type of fracture:

Physeal fractures – Malunion represents the most common problem with these fractures [10]. However, if the fracture occurs in a child with extensive growth remaining, then remodeling usually results in adequate healing and good wrist function. Because of the higher risk of damage to the growth plate with ensuing growth arrest, patients with displaced Salter-Harris I and II fractures require orthopedic referral within seven days of the injury [10,44].

The risk of growth arrest increases significantly for Salter-Harris III, IV, or V fractures. Growth arrest in a skeletally immature child can lead to growth disparity between the radius and ulna that can cause ulnocarpal impaction syndrome (pain and clicking with wrist extension, ulnar deviation, or repetitive wrist loading), triangular fibrocartilage complex tear, and limitation of wrist motion and function (picture 1) [10].

Median neuropathy may also occur after a radial and/or ulnar distal physeal fracture as a result of direct trauma or a secondary carpal tunnel syndrome. Fracture reduction or release of the carpal tunnel compression typically results in return of nerve function.

Torus (buckle) fractures – The lack of anatomic disruption makes neurovascular injury or long-term functional complications extremely unlikely.

Greenstick fractures — Refracture may occur in children with poorly healed greenstick fractures. For this reason, these fractures need to be adequately immobilized until radiographic and clinical healing are evident. In addition, activities should be restricted for additional time (one to six weeks) so that full recovery of arm movement and strength can occur [41]. (See "General principles of fracture management: Fracture patterns and description in children", section on 'Greenstick'.)

Rarely, malunion or cross union between the radius and ulna may cause significant functional limitation.

Complete fractures – Up to 25 percent of complete fractures displace during follow-up despite adequate initial closed reduction and casting [25]. These fractures require repeat closed reduction or surgical intervention. In most instances, the deformity will remodel over time.

Refracture is another common complication. Complete diaphyseal fractures are eight times more likely to refracture than complete metaphyseal fractures, with the rate of refracture highest in patients with the shortest duration of casting [29].

Adverse functional or cosmetic outcomes may also occur with forearm rotation being the motion most frequently affected [13,29]. Poor outcomes are less common in younger children because of their extensive ability to remodel. For example, if the growth plates are open, about 50 percent of the remodeling will occur in the first six months. The remaining portion will occur in the next 18 months with no clinical deformity [12]. Typically, remodeling can correct about 10 degrees of apex-volar angulation for each year of growth remaining [11,45,46].

Growth arrest and neurovascular injuries may occur but are much less common than in patients with physeal fractures.

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

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

SUMMARY AND RECOMMENDATIONS

Emergency treatment – The emergency clinician should promptly identify children with vascular insufficiency and emergently involve an orthopedic surgeon with appropriate pediatric expertise. 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 or pale hand despite reduction attempts require emergency operative exploration and vascular repair. (See 'Absent pulse' above.)

For children with adequate distal circulation, initial therapy consists of (see 'Analgesia and immobilization' above and 'Open fracture' above):

Identification and initiation of care for open fractures

Pain management

Immobilization to prevent further displacement of the fracture

Specialty consultation – Emergency orthopedic consultation is indicated for children with (see 'Indications for orthopedic consultation or referral' above):

An open fracture

Neurovascular compromise

Forearm fracture complicated by joint dislocation or supracondylar elbow fracture

Initial fracture management – The initial management of distal forearm fractures in children is determined by the type of fracture, degree of displacement, and age of the child (algorithm 1):

Displaced or angulated fractures; high-grade Salter Harris fractures – Prompt involvement of an orthopedic surgeon is appropriate for children with displaced or angulated distal forearm fractures or Salter-Harris III, IV, or V fractures. (See 'Initial fracture management' above.)

Some clinicians, who are experienced in fracture reduction and cast or splint immobilization of the reduced fracture, may choose to provide this care for displaced greenstick, complete, and displaced Salter-Harris I or II physeal fractures. Proper cast technique is essential to the overall success of the procedure. (See "Closed reduction and casting of distal forearm fractures in children" and "Closed reduction and casting of distal forearm fractures in children", section on 'Immobilization' and "Closed reduction and casting of distal forearm fractures in children", section on 'Indications'.)

Nondisplaced or mildly displaced fractures – Patients with nondisplaced or mildly displaced physeal, greenstick, or complete fractures may receive immobilization with a short arm splint or cast and a sling in the emergency department. (See 'Physeal fracture' above and 'Greenstick fracture' above and 'Complete fracture' above.)

Torus or buckle fractures – For children with a torus (buckle fracture) (image 5 and image 6), we recommend treatment with either a soft elastic bandage or a removable short arm splint (eg, soft Velcro splint or a well-padded and molded fiberglass or plaster volar splint) in accordance with the primary caregiver's preference rather than a below-elbow cast (Grade 1B). For these patients, the clinician should be certain that the child does not have a greenstick (image 7) or Salter-Harris II distal radius fracture. (See 'Torus (buckle) fracture' above.)

Home care – Proper home care of distal forearm fractures is supported by cast or splint care instructions and advice on pain control. Elevation of the fracture above the level of the heart and cold therapy are helpful adjuncts for pain control during the first 48 hours. (See 'Home care' above.)

For patients with distal forearm fractures and no contraindications to nonsteroidal antiinflammatory agents, we suggest pain control with oral ibuprofen (Grade 2B). Some clinicians may choose to provide a prescription for a limited amount of opioid pain medication (eg, oxycodone 0.1 to 0.2 mg/kg every four to six hours as needed; maximum 5 mg per dose for a maximum duration of two to three days) to be used as a rescue medication in patients whose pain is not adequately controlled within one hour of ibuprofen administration. At 72 hours, continued pain requiring opioid analgesia is an indication for re-evaluation. (See 'Pain control' above.)

Follow-up – Following definitive care, children with distal forearm fractures, other than splinted torus fractures, should follow up with an orthopedic surgeon. Timing depends on the type of fracture and treatment provided. (See 'Other distal forearm fractures' above.)

Children with low-risk torus (buckle) fractures treated with a soft bandage or removable volar splints do not routinely require medical follow-up or repeat radiographs. (See 'Torus fractures' above.)

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Topic 6543 Version 39.0

References

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