You’ve heard it here before: guidelines for treatment of any problem are just that: guidelines. Each and every patient must still be considered individually. Treatment should be customized based on patient factors and surgeon opinion.
In this article on forearm fractures in children, these same principles are applied. The authors provide best-practice ideas for the problem of forearm shaft fractures in children. They offer their opinions as well and point out “operative pearls and pitfalls” when treatment requires surgery.
A forearm shaft fracture is a break in the middle of the two long bones in the forearm (radius and ulna). A simple fracture without displacement (separation of the bones) can be successfully treated with cast immobilization. But displacement and angulation (bones shift and are no longer straight but instead form a V- or angular-shape) may be severe enough to require surgery.
The decision between cast immobilization and surgical reduction and fixation depends on a number of factors. First, there are guidelines for what is acceptable versus unacceptable angulation and displacement. For example, children under the age of nine can still be treated with cast immobilization when there is complete displacement but only up to 15 degrees of angulation and 45 degrees of malrotation.
The guidelines for casting children with forearm shaft fractures who are nine and older are 10 degrees of angulation and 15 degrees of malrotation. The reason children with these changes in alignment can still be treated conservatively (nonoperative care) is that they are still growing and the bones will reform, reshape, and realign on their own.
Surgery to realign (reduce) the bones and hold them together with hardware (fixation) is recommended when it would be difficult to keep the fractured bones lined up and held in place with a simple cast. This is often the case when the bones are in a severe V- or angular position referred to as bayonet apposition. Surgery is also required anytime the fracture site is unstable or an acceptable reduction position cannot be reached.
Making the decision to perform surgery is just the beginning of the process. Now the surgeon must decide whether to use fixation on one or both bones and what type of fixation to use. The two most commonly considered options are a metal plate or a long nail down the shaft of the bone (called intramedullary fixation or IM).
Choice of fixation device goes hand-in-hand with type of procedure: open or closed reduction. As the names suggest, an open reduction means the surgeon makes an incision to open the arm. A closed procedure is done through the skin (percutaneously) or other minimally invasive approach.
Follow-up treatment involves post-operative care selecting either a long or short arm case, length of time in the cast, and if/when to remove the hardware after healing is complete. Removing fixation devices too soon can cause failure to heal and even loss of reduction and reangulation.
Surgeons are encouraged to reduce the bone that is easiest first. If it looks like a toss-up between the two bones, then the straighter bone (the ulna) is reduced first. The authors discuss how and where to insert the nail for best results when intramedullary nailing is the treatment choice.
Failure to gain access down the middle of the bone with the nail is a possibility. Repeated efforts to accomplish the task can result in significant soft tissue damage. At that point, the surgeon should switch to an open reduction procedure.
The authors summarize their comments by saying that using fixation for forearm shaft fractures in children does improve results. Not all children need fixation so the challenge becomes the ability to evaluate each child and make the best decision for that patient. Suggestions and guidelines provided in this article may help when there are complex considerations.