Our study seeks to determine whether characteristics of radiographs taken post-reduction of a forearm fracture can indicate future risk of refracture or loss of reduction. We hypothesize that reducing forearm fractures too precisely may be counterproductive and provide less benefit than reductions left slightly offset prior to cast immobilization.

We conducted a retrospective review of 1079 pediatric patients treated for forearm fractures between January 2014 and September 2021 in a 327 bed regional medical center. Percent fracture displacement, location, orientation, comminution, fracture line visibility and angle of angulation were determined by AP and lateral radiographs. Percent fracture displacement was derived by: (Displacement of Bone Shafts / Diameter) x 100% = %Fracture Displacement.

Patients treated with closed reduction were reduced from a mean displacement of 29.26±36.18% at an angulation of 22.67±16.57 degrees to 7.88±9.07% displacement and 3.89±6.68 degrees angulation post-reduction. Patients developing complications including a loss of reduction or refracture were found to have post-operative radiographs with a lower percent displacement (0.50±1.12) than those not developing complications (8.65±9.21)(p=0.0580). Post-reduction angulation (p=1.000), average reduction in angulation (p=1.000) and average reduction in displacement percent(p=0.2102) were not significantly associated with development of complications.

Percent displacement of radial shafts was seen to be the most important metric to monitor in post-operative radiographs for patients undergoing closed reduction of a forearm fracture. We theorize a slight displacement provides greater surface area for osteoblastic expansion and callus formation leading to a decreased risk of refracture or loss of reduction. While our sample size precludes our ability to measure the ideal amount of post-reduction displacement for optimal healing, our results demonstrate that some degree of shaft displacement is required for optimal healing conditions.

Aims. The aim of this study was to report a complete overview of both incidence, fracture distribution, mode of injury, and patient baseline demographics of paediatric distal forearm fractures to identify age of risk and types of activities leading to injury. Methods. Population-based cohort study with manual review of radiographs and charts. The primary outcome measure was incidence of paediatric distal forearm fractures. The study was based on an average at-risk population of 116,950. A total number of 4,316 patients sustained a distal forearm fracture in the study period. Females accounted for 1,910 of the fractures (44%) and males accounted for 2,406 (56%). Results. The overall incidence of paediatric distal forearm fractures was 738.1/100,000 persons/year (95% confidence interval (CI) 706/100,000 to 770/100,000). Female incidences peaked with an incidence of 1,578.3/100,000 persons/year at age ten years. Male incidence peaked at age 13 years, with an incidence of 1,704.3/100,000 persons/year. The most common fracture type was a greenstick fracture to the radius (48%), and the most common modes of injury were sports and falls from ≤ 1 m. A small year-to-year variation was reported during the five-year study period, but without any trends. Conclusion. Results show that paediatric distal forearm fractures are very common throughout childhood in both sexes, with almost 2% of males aged 13 years sustaining a forearm fracture each year. Cite this article: Bone Jt Open 2022;3(6):448–454

We investigated whether, in the management of stable paediatric fractures of the forearm, flexible casts that can be removed at home are as clinically effective, cost-effective and acceptable to both patient and parent as management using a cast conventionally removed in hospital. A single-centre randomised controlled trial was performed on 317 children with a mean age of 9.3 years (2 to 16). No significant differences were seen in the change in Childhood Health Assessment Questionnaire index score (p = 0.10) or EuroQol 5-Dimensions domain scores between the two groups one week after removal of the cast or the absolute scores at six months. There was a significantly lower overall median treatment cost in the group whose casts were removed at home (£150.88 (sem 1.90) vs £251.62 (sem 2.68); p <  0.001). No difference was seen in satisfaction between the two groups (p = 0.48).

Cite this article: Bone Joint J 2013;95-B:1714–20.

Introduction and aims. Cast immobilisation of paediatric forearm fractures has traditionally used plaster of Paris. Recently, synthetic casting materials have been used. There have been no studies comparing the efficacy of these two materials. The aim of this study is to investigate whether one material is superior for paediatric forearm fracture management. Methods. A single-centre prospective randomised trial of patients presenting to the Women's and Children's Hospital with acute fractures of the radius and/or ulna was undertaken. Patients were enrolled into the study on presentation to the Emergency Department and randomised by sealed envelope into either a fiberglass or plaster of Paris group. Patients then proceeded to a standardised method of closed reduction and cast immobilisation. Clinical follow-up occurred at one and six weeks post-immobilisation. A patient satisfaction questionnaire was completed following cast removal at six weeks. All clinical complications were recorded and cast indexes were calculated. Results. Initially 50 patients were recruited to the study, with equal randomisation. There were no significant differences between the patient demographics of the two groups. The results from this sample indicated an increase in clinical complications involving the plaster of Paris casting group. These complications included soft areas of plaster requiring revision, loss of reduction with some requiring re-manipulation and a high rate of cast spliting due to material swelling. The fractures that loss reduction had increased cast indices. Fibreglass casts were also preferred by patient and their families, with many observational comments regarding the light-weight and durable nature of the material. Conclusions. Cast immobilisation of paediatric forearm fractures is a common orthopaedic treatment. There is currently no evidence regarding the best material for casting. This study suggests that both clinical outcomes and patient satisfaction are superior with fiberglass casts, we are continuing this study to enable greater power with our results

The aims of this study were i) to see if there is an association between poorly applied plasters and redisplacement of paediatric forearm fractures, and ii) to define reliable radiographic measurements to predict redisplacement of these fractures. The two radiographic measurements which were assessed were Cast Index and Padding Index which are a guide to plaster moulding and padding respectively. The sum of these was termed as the Canterbury Index. Case records and radiographs of 142 children who underwent a manipulation for a displaced fracture of forearm were studied. Angulation, translation displacement, Cast index and Padding index were measured on radiographs. Redisplacement was seen in 44 cases (32.3%). The means and 95 % Confidence intervals for cast index and padding index were 0.87 (0.84, 0.90) and 0.42 (0.39, 0.62) in the redisplacement group whereas were 0.71 (0.69, 0.72) and 0.11 (0.09, 0.12) in the group with no redisplacement respectively. Initial displacement, Cast index, Padding index and Canterbury Index were significantly greater in the redisplacement group (p< 0.005). No statistically significant difference was seen for age, fracture location, initial angular deformity and seniority of the surgeon. We suggest that Cast Index > 0.8, Padding Index > 0.3 and Canterbury Index > 1.1 are significant risk factors for redisplacement of conservatively treated paediatric forearm fractures

The April 2014 Children’s orthopaedics Roundup. 360 . looks at: urgent supracondylar fractures; rotational osteotomy for synostosis; predicting slip in paediatric forearm fractures; progressive lengthening of the digit is possible; treatment of SUFE with the Dunn osteotomy; and the best way to apply the eight-plate?

The April 2024 Children’s orthopaedics Roundup. 360. looks at: Ultrasonography or radiography for suspected paediatric distal forearm fractures?; Implant density in scoliosis: an important variable?; Gait after paediatric femoral shaft fracture treated with intramedullary nail fixation: a longitudinal prospective study; The opioid dilemma: navigating pain management for children’s bone fractures; 12- to 20-year follow-up of Dega acetabuloplasty in patients with developmental dysplasia of the hip; Physeal fractures of the distal ulna: incidence and risk factors for premature growth arrest; Analysis of growth after transphyseal anterior cruciate ligament reconstruction in children; Management of lateral condyle humeral fracture associated with elbow dislocation in children: a retrospective international multicentre cohort study

The June 2014 Children’s orthopaedics Roundup. 360 . looks at: plaster wedging in paediatric forearm fractures; the medial approach for DDH; Ponseti – but not as he knew it?; Salter osteotomy more accurate than Pemberton in DDH; is the open paediatric fracture an emergency?; bang up-to-date with femoral external fixation; indomethacin, heterotopic ossification and cerebral palsy hips; lengthening nails for congenital femoral deformities, and is MRI the answer to imaging of the physis?

Introduction. Two randomised trials concluded cast type (above or below elbow) makes no significant difference in the re-displacement rate of paediatric forearm fractures involving the distal third of the radius. This has not, however, led to the universal use of below elbow casts. In particular we noted one trial reported significant re-displacement in 40% or more of cases, which was much higher than we would expect. To review the radiological outcomes and need for re-manipulation of paediatric distal forearm fractures treated with closed manipulation under anaesthesia in our institution, in part for subsequent comparison with published results. All forearm fractures treated at a specialist children's hospital in one year were reviewed retrospectively. Based on the methodology of one trial, we included all fractures involving the distal third of the radius, with or without an ulna fracture, which underwent closed manipulation. Outcomes were radiological alignment using existing radiographs and need for re-manipulation. Cast type was at the discretion of the treating surgeon. The radiological criteria for re-displacement were based on published methodology. 79 children underwent manipulation, 71 receiving above elbow casts and 8 below elbow casts. Radiologically 21% of injuries treated in an above elbow cast re-displaced (15/71) compared to 38% of those in below elbow plasters (3/8). In 2 cases the re-displacement was treated with re-manipulation. The preference in our institution was clearly for above elbow casts in this injury pattern. The small number of below elbow casts in our series limits any comparisons. Our rate of re-displacement using above elbow casts was half that of one of the published studies, so the existing literature is not consistent with our experience

Infection and re-fracture are well-described complications following open paediatric forearm fractures. The purpose of this paper is to determine if patient, injury, and treatment characteristics can be used to predict the occurrence of these complications following the surgical management of paediatric open forearm fractures. This is an IRB-approved retrospective review at a single-institution paediatric level 1 trauma centrefrom 2007–2013 of all open forearm fractures. Medical records were reviewed to determine the type of open fracture, time to administration of initial antibiotics, time from injury to surgery, type of fixation, length of immobilisation, and complications. Radiographs were studied to document fracture characteristics. 262 patients with an average age of 9.7 years were reviewed. There were 219 Gustillo-Anderson Type 1 open fractures, 39 Type 2 fractures, and 4 Type 3 fractures. There were 9 infections (3.4%) and 6 re-fractures (2.3%). Twenty-eight (10.7%) patients returned to the operating room for additional treatment; 21 of which were for removal of implants. Contaminated wounds, as documented within the medical record, had a greater chance of infection (21% vs 2.2%, p=0.002). No difference in infection rate was seen with regard to timing of antibiotics (p=0.87), timing to formal debridement (p=0.20), Type 1 versus Type 2 or 3 open fractures (3.4% vs 5.0%, p=0.64), 24 hours vs. 48 hours of post-operative IV antibiotics (5.2% vs 3.5%, p=0.53), or when comparing diaphyseal, distal, and Monteggia fracture patterns (3.6 vs 2.9% vs 5.9%, p=0.81). There was no difference in infection rate when comparing buried or exposed intramedullary implants (3.5% vs 4.2%, p>0.99). Rate of re-fracture was not increased based on type of open wound (p>0.99) or fracture type (0.4973), although 5 of the 6 re-fractures were in diaphyseal injuries. In this series of open paediatric both bone forearm fractures, initial wound contamination was a significant risk factor for subsequent infection. The rate of infection did not vary with timing of antibiotics or surgery, type of open fracture, or length of post-operative antibiotics. A trend to higher re-fracture rates in diaphyseal injuries was noted. Surgeons should consider planned repeat irrigation and debridement for open forearm fractures with obviously contaminated wounds to reduce the subsequent infection risk

Purpose. This study evaluated the acceptability of performing manipulations with intranasal diamorphine and inhaled Entonox to parents of children presenting to our Emergency Department. Method. 65 fractures were manipulated in the Emergency Department in a 4-month timespan. Parents were invited to complete a questionnaire to indicate their experience with the procedure. Fracture position post-reduction was calculated as well as conversion rate to surgery. 32 patients who were admitted and had their forearm fractures managed in theatre were also asked to complete the questionnaire as a comparison group. Results. Overall response rate was 82% . 100% of parents of children who had a manipulation in the emergency department would recommend the treatment to parents of children with similar injuries. Relative risk of perceived distress to parents was 2.42 (0.8–7.2) with manipulation in the emergency department compared to theatre management. Relative risk of distress to the child was 1.45 (0.7–3.3) with manipulation in the emergency department compared to theatre management. This was not statistically significant. Mean (S.D.) fracture displacement was 29.2 (13.0)° pre reduction and 5.8 (5.9)° post reduction. Mean (S.D.) length of stay was 5.5 (3.2) hours from time of injury to discharge for patients receiving manipulation in the Emergency Department and 27.9 (14.3) hours for patients receiving procedures in theatre (p< 0.001). Overall, parents and children were satisfied about manipulations in the Emergency Department. Operative re-intervention rate was 2% when protocol violations were excluded. Reduction was as effective as previous reports and within acceptable treatment limits. Conclusion. Manipulation of paediatric forearm fracture is an effective and acceptable technique when performed with a diamorphine and Entonox protocol

Distal radius and ulna fractures are a common paediatric injury. Displaced or angulated fractures require manipulation under anaesthetic (MUA) with or without Kirchner (K) wire fixation to improve alignment and avoid malunion. After treatment a proportion redisplace requiring further surgical management. This study aimed to investigate whether the risk of redisplacement could be reduced by introducing surgical treatment guidelines to ascertain whether MUA alone or the addition of K wire fixation was required. A cohort of 51 paediatric forearm fractures managed either with an MUA alone or MUA and K wire fixation was analysed to determine fracture redisplacement rates and factors which predisposed to displacement. Guidelines for optimal management were developed based on these findings and published literature and implemented for the management of 36 further children. A 16% post-operative redisplacement rate was observed within the first cohort. Redisplacement was predicted if an ‘optimal reduction’ of less than 5° of angulation and/or 10% of translation was not achieved and no K wire fixation utilised. Adoption of the new guidelines resulted in a significantly reduced redisplacement rate of 6%. Implementation of departmental guidelines have reduced redisplacement rates of children's forearm fractures at Great Western Hospital

Purpose:. Paediatric forearm fractures are commonly seen and treated by closed reduction and plaster cast application in theatre. Historically, cast application has been subjectively evaluated for its adequacy in maintaining fracture reduction. More recently emphasis has been placed on objectively evaluating the adequacy of cast application using indicators such as the Canterbury index (CI). The CI has been used in predicting post-reduction, re-displacement risk of patients by expressing the casting and padding indices as a ratio. The CI has been criticized for not including cast 3 point pressure, fracture personality and lack of standardization of X-ray views as well as practical requirement of physical measurement using rulers. The aim of this study was to determine whether subjective evaluation of these indices, on intra-operative fluoroscopy and the day 1 to 7 postoperative X-ray, was accurate in predicting a patient's ultimate risk of re-displacement, following reduction and casting. Materials and Methods:. In total, 22 X-rays from 11 patients were evaluated by 20 orthopaedic registrars and 8 consultants, before and after a tutorial on the Canterbury index. Results:. Formal tutorial did not show an increased subjective predictive accuracy. No clear correlation could be demonstrated between CI and the clinical outcome. Conclusion:. Value of the CI in clinical practice is doubtful due to various confounding factors. The CI has been used due to lack of other available systems, and ideally a system should be sought which incorporates fracture personality, cast 3 point pressure and standardisation of X-Rays

Aim: The literal knowledge about the configuration of the radial bone is rare. Radial bone is investigated anatomically by computerized tomographic methods in this study. Patients and Methods: Twenty-one cleaned and dried cadaveric bones were used for this investigation. The measurements were done on the diaphyseal, proximal and distal metaphyseal CT sections of the bone. A tortional angle was defined. The repetetive measurements were done by two different researchers on the same sections in different times. The interclass and intraclass correlation coefficients were analysed. Results: The mean measurement of the radial tortional angle was 73 degrees [between 59° to 86°]. The ICC value between the initial measurements of the observers was, 9990 and considered torsion to be significant. (p< 0.001). The ICC value between the secondary measurements of the observers was,9980 and considered torsion to be significant. (p< 0.0001). The ICC value between the both measurements of the first observer was,9975 and the found torsion to be significant. (p< 0.0001). The ICC value between the both measurements of the second observer was,9956 and the found torsion to be significant. (p< 0.0001). Conclusion: This method is useful for evaluating the rotational alignment of the radial bone and rotational motion restruction of the forearm after fracture healing. It can also be used to predict the potential of remodelling of the radial bone in pediatric forearm fractures

Forearm fractures are a common paediatric injury. This study was aimed to describe the epidemiological of paediatric forearm fractures in the urban population of Glasgow. We reviewed of all the forearm fracture treated by the orthopaedic service in Yorkhill Children's Hospital in 2008. Datum gathered from case notes and radiographs using the prospective orthopaedic database to identify patients with forearm fractures. The age, sex, side and type of fracture, the timing and mechanism of the injury and treatment were documented for the 436 fractures. Census data were used to derive absolute age-specific incidences. Distinction was made between torus and other types of fractures. Torus fractures require no specific orthopaedic treatment and were segregated out. For the remaining 314 fractures, the age and sex distribution, seasonal variation of fractures and treatments for each type of fracture were examined. The incidence of forearm fractures in our population is 411 fractures per 100,000 population per year. An increased number of fractures occurred during the months of May and August. A fall from less than one metre was the commonest mechanism of injury, sporting injuries were the second commonest with football the most common sport associated. This study identifies some features which are in good agreement with studies from elsewhere in Britain, such as incidence and seasonality. However, there are also interesting differences – such as the Glasgow peak incidence for forearm fractures being at age 8, with a marked decline by 12 years. Furthermore, our findings have been extended to consideration of type of intervention, and likelihood of successful treatment

The aim was to compare the efficacy and outcomes of reduction of closed forearm fractures in a paediatric population using Ketamine in the Emergency Department (ED) setting versus reduction under general anaesthesia (GA) in the operating theatre (OT). A prospective audit of children presenting to our institution with closed fractures of the radius and/or ulna was conducted. Patients presenting to ED were offered manipulation under GA or Ketamine, and then grouped accordingly. Children were followed up until full range of motion had recovered. Outcomes measured at follow up were 1) need for remanipulation, 2) position at union, 3) total hospital stay and 4) functional outcome. Forearm fractures account for 22% of acute paediatric orthopaedic admissions to our institution. 70% require manipulation and splintage. 221 forearm fractures required manipulation during the study period. 90 patients (41%) were manipulated under Ketamine in the ED, 131 patients (59%) were manipulated in the OT. There was no significant difference in mean angulation of fractures treated by either method (p=0.20). There was no significant difference between the two methods with respect to rates of remanipulation (p=0.73) or poor position at union (p=0.55). There was a significantly shorter hospital stay for those treated in the ED. Treatment of paediatric forearm fractures in the ED under Ketamine sedation offers an effective alternative for selected fractures. It also offers considerable financial savings and is less of a drain on valuable theatre and staff resources

Aim: To investigate the versatility of ßexible intramedullary nails (FIN) in the surgical treatment of forearm fractures in children. Methods: 28 children were treated using FIN for displaced forearm fractures over a period of 5 years. There were 18 boys and 10 girls. The mean age was 11.5 years and the mean follow up were 7.9 months. Two nails were used one each for radius and ulna. 12 children were operated for unstable displaced fractures, 14 were operated after failed initial reduction and 2 were operated for open fractures. 16 were nailed by closed method, 12 had mini open technique in cases of failed initial closed reduction. The nails were removed on an average of 6–8 months. Results: All the children achieved bony union in excellent position. The average time for union was 5.6 weeks. All but 2 patients had full range of movements and none had any functional difþculty. 3 children had transient hypo aesthesia in the area of superþcial radial nerve distribution and one child developed compartment syndrome which needed fasciotomy. There were no long term sequel. Conclusions: Use of FINs in paediatric forearm fractures should be encouraged when surgical intervention is needed. They are axially and rotationally stable. They are safe to introduce and remove at a later date. Their ßexibility allows remodelling of the fracture and growth of the long bones

Introduction: We aimed to assess a simple radiological method of predicting redisplacement of paediatric forearm fractures. The Cast Index (CI) is the ratio of sagittal to coronal width from the inside edges of the cast at the fracture site. A CI of > 0.7 was used as the standard in predicting fracture redisplacement. The cast index has previously been validated in an experimental study. Methods: Case records and radiographs of 1001 children who underwent a manipulation under general anaesthesia for a displaced fracture of the distal forearm were studied. Redisplacement was defined as more than 15 degrees of angulation and/or more than 80 percent of translational displacement on check radiographs at 2 weeks. Angulation (in degrees) and translation displacement (in percentage) were measured on the initial and check radiographs. The CI was measured on postoperative radiographs. Results: Fracture redisplacement was seen in 107 cases at 2 week follow up. Of the 752 patients (75%) with a CI of less than 0.7 the displacement rate was 5.58%. Of the 249 patients (25%) with a CI greater than 0.7 the redisplacement rate was 26%. The CI was significantly higher in the redisplacement group. No statistically significant difference was seen for age, sex or ethnicity. Nor were statistical differences noted in initial angular deformity, initial displacement and seniority of the surgeon. Good intra and inter observer reproducibility was observed. There was no statistical difference in patients with a cast index between 0.7 and 0.8. Conclusion: The cast index is a simple and reliable radiographic measurement to predict the redisplacement of forearm fractures in children. Previous studies have used a CI of > 0.7 as the predictor of redisplacement although this study suggests a plaster with a CI of < 0.81 is acceptable. A high cast index is associated with redisplacement of fractures and should therefore be considered when moulding casts in distal forearm fractures

We present an objective method for predicting the redisplacement of paediatric forearm and wrist fractures. Novel radiographic measurements were defined and their value assessed for clinical decision making. In Phase I of the study we defined the cast index and padding index and correlated these measurements with the incidence of fracture redisplacement. Phase II assessed these indices for their value in clinical decision making. Cast Index (a/b) is the ratio of cast width in lateral view (a) and the width of the cast in AP view (b). Padding Index (x/y) isthe ratio of padding thickness in the plane of maximum deformity correction (x) and the greatest interosseous distance (y) in AP view. The sum of cast index and padding index was defined as the Canterbury Index. In Phase I, 142 children's radiographs were analysed and a statistically significant difference was identified between redisplacement and initial complete off-ending of the bones, cast index > 0.8 and padding index of > 0.3. There was no significant association with age, fracture location, seniority of surgeon or angulation. In Phase II, radiographs of 5 randomly selected cases were presented to 40 surgeons (20 consultants & 20 registrars). Following an eyeball assessment they were asked to measure the cast index and padding index (after instruction). With eyeballing the consultants predicted 33% and registrars 25% of the cases that redisplaced. After learning to measure the indices the accuracy increased to 72% for consultants and 81% for registrars (p<0.001). We conclude that the cast index, padding index and Canterbury Index are validated tools to assess plaster cast quality and can be used to predict redisplacement of paediatric forearm fractures after manipulation. They can easily be taught to orthopaedic surgeons and are more accurate than eyeballing radiographs in the clinical setting. Redisplacement can be predicted if cast index > 0.8, padding index > 0.3 and Canterbury Index > 1.1

Aim: A retrospective study to analyse the treatment of paediatric diaphyseal forearm fractures over the preceding 6 years and to assess if there was any difference in outcome between plate and elastic stable intra-medullary nailing (ESIN). Material and Methods: Between January 1997 and December 2002, 144 unstable fractures required surgical fixation. 59 patients were treated with both-bone plate fixation, 55 patients were treated with single-bone plate fixation and 30 patients were treated with ESIN. The mean age of surgery was approximately 12 with peaks at age 8 and 13 years. In the plate group, 70% to 80% were undertaken by the SpRs and in the nailing group, approximately 50% were undertaken by staff grades; 30% by Consultants and 20% by SpRs. Results: Between each group there was no difference in time spent in plaster, clinic attendance, time to clinical union and time to restoration of normal movements. On radiographic reviews, single-bone plate fixation patients united quicker than the both-bone plate fixation or ESIN groups. Average anaesthetic times became more prolonged from single-bone to ESIN to both-bone plate fixation. Compound fractures were approximately 10% in both groups. There were hyper-trophic scars in approximately 10% in the plate group and 3% in the nail group. There were 3 compartment syndromes in the plate group and 2 compartment syndromes in the nail group. In the plating groups, there was a higher rate of peri-prosthetic fracture, mal-union, hyper-trophic scarring, infection and neuro-vascular complications. Conclusion: ESIN is superior to plating in relation to surgical complications. It is therefore recommended that elastic stable intra-medullary nailing should be used for displaced paediatric diaphyseal forearm fractures