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Our 12-year-old son broke his forearm during a particularly spectacular tackle in junior league football. The surgeon decided not to operate and just put a cast on his arm. Three weeks later and the broken ends of the bone had separated again. Then he did have to have surgery. Shouldn't they just have pinned it in the first place?
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In the last 10 years, surgeons have revisited the question of whether or not casting is sufficient for these types of fractures. There's been some suggestion that surgery to pin the healing bones might be a better option than just cast immobilization. The thinking behind this has come as a result of the many cases where the fracture reduction was lost with casting.
Loss of fracture reduction is so common, it appears that at least one-third of all forearm fractures (and as many as 90 per cent of cases) are affected. The first step in understanding how to keep this from happening is to look for risk factors.
Some of the factors that have been shown to increase the risk of loss of fracture reduction include: 1) type of fracture displacement, 2) amount of displacement (more than 50 per cent), 3) location of the fracture (closer to the wrist), 3) increased angle of the bone, and 4) fracture of both bones in the forearm bone (radius and ulna).
Other factors that may contribute to the loss of fracture reduction have been suggested. Muscle atrophy (wasting) and decreased swelling while in the cast can make a difference. The arm moves around too much inside the loose cast to keep the fracture firmly in place while healing. Movement of the arm can cause the fractured ends of the bones to separate again.
There's been some question as to whether a short-arm (below the elbow) versus long-arm (above the elbow) cast makes a difference. Studies show that even more important than the type of maneuver used to reduce the fracture or the type of cast (short versus long) is the casting technique used. Serial X-rays taken once a week can help identify when a problem with reduction is occurring.
At the same time, there were some studies done to look at the outcomes when using surgery to pin the fracture sites. The final results showed that patients didn't fare any better after surgical fixation than they did with nonoperative casting. So the conclusion was to continue using short-arm casts applied with good technique and follow the patient with serial (weekly) X-rays until complete healing occurs.
If these steps are not enough to prevent loss of reduction, then surgery is advised. Reduction with pin fixation is also considered appropriate when there is a fracture through the metaphysis (growth plate), but it's not recommended for every fracture. Other reasons open surgery might be done include open fractures (bone pokes through the skin), fractures that overlap and can't be reduced, and fractures that are pressing on nerves or blood vessels.
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