Management of Pediatric Forearm Fractures After Failed Closed Reduction

Pediatric and adolescent forearm fractures account for nearly 40% of all fractures in childhood. The incidence of these fractures has increased over the past decade with a 10-fold increase in surgical intervention. A thorough physical examination of the upper extremity, with plain radiographs of the forearm, should be obtained to make the diagnosis. The primary modality of management for closed both-bone forearm fractures is a closed reduction if needed and long arm immobilization. Patients should be followed up weekly, for at least 3 weeks, to ensure maintenance of fracture alignment. Failure of closed management is a known complication of nonsurgical management, and providers should have a management algorithm to treat these patients. Re-manipulation and casting, or cast wedging, is warranted if the loss of reduction is noted early in the postreduction period. If closed reduction cannot be achieved, elastic stable intramedullary nailing is the management of choice with either single- or both-bone fixation. Potential complications of elastic stable intramedullary nailing include acute compartment syndrome, nonunion, dorsal radial sensory nerve neuritis, and extensor pollicis longus tendon rupture. In older children and adolescents with less remodeling potential, osteosynthesis with plate-and-screw fixation or hybrid fixation should be used.