Displaced diaphyseal both bone forearm fractures are common in older children and adolescents. There is no agreement regarding the amount of angulation, displacement or rotation that is acceptable. There is a current trend towards operative management of forearm fractures in children to maintain bony alignment and restore forearm integrity. Despite this trend, there have been no outcome studies supporting this treatment. The authors reviewed their treatment of completely displaced fractures of the forearm in skeletally immature patients. Older children (adolescents) were considered as boys older than 10 years of age and girls older than 8 years of age. Twenty-five patients met the inclusion criteria. All fractures were reduced in the emergency room under regional intravenous block. Radiographs were obtained weekly for the first three weeks and repeat manipulation was performed if unacceptable loss of reduction was observed. Mean follow-up was almost a year, although the range was from 13 to 135 weeks. Angulation was defined as the maximum angulation of each bone present on either the frontal or lateral view. A result was considered excellent if there were no complaints and a loss of forearm rotation less than or equal to 10º.
In summary, all of the fractures healed with a varying amount of angulation. Twelve patients showed 10º of angulation of both the radius and ulna. Eight patients had 11º to 15º of angulation of either the radius or ulna, and five patients had more than 15º of angulation of either bone. On the follow-up films, angulation diminished as remodeling occurred. Clinical evaluation showed equal forearm rotation in 11 of the 25 patients. Fourteen patients exhibited some loss of motion. Loss of forearm rotation correlated with angulation of the radius more so than angulation of the ulna. According to the grading criteria established, there were 16 excellent results, 6 good results, 3 fair results and no poor results. A higher proportion of excellent results was seen in patients whose x-rays at follow up showed angulation of up to 15º compared to those that showed greater than 15º.
The authors question how much residual deformity and loss of motion correlates with decreased function. This remains extremely variable as some children are able to adapt to small loss of rotation using compensatory movement. The authors conclude that up to 15º of angulation should be accepted rather than resorting to operative treatment. However, the conclusions have to be taken with caution, especially in older individuals with unstable injuries. Initial operative correction in some cases may be the only way to recover full upper extremity function, as reconstruction of established forearm malunions is extremely difficult and in no way predictable.
J Pediatr Orthop