Buckled, Bent Or Broken?

Home , Buckling, Greenstick fracture, Ulna fracture

CLINICAL

Buckled, bent or broken?

Gajan Selvakumaran, Nicole Williams THE RADIUS AND ULNA are the long bones ‘scissors’ adducts the thumb, abducts the fractured most commonly in school-aged index and middle fingers, and flexes the children, accounting for 40% of fractures.1,2 ring and small fingers to test the ulnar Background The radius and ulna are the most Forearm fractures occur at a rate of 1.5 nerve supply to the intrinsic hand muscles, commonly fractured long bones in the per child, with the ratio of affected boys and the ‘okay’ position isolates the anterior school-aged population, accounting for to girls increasing to 5.5:1 at adolescence. interosseous branch of the median nerve 40% of all fractures. Management of For children over the age of eight years, with flexion of the thumb and index finger individual fractures depends on the the distal radius is the site of 25% of to form a circle. Sensation is examined on fracture pattern and age of the child. all fractures.2 the first webspace dorsally (radial nerve), Objective Fracture management is guided by the and the pads of the index finger (median The aim of this article is to provide an fracture pattern and remodelling potential. nerve) and small finger (ulnar nerve). overview of the management concepts The aim of this article is to provide an Demonstrating with the uninjured hand for specific fracture patterns and support overview of management concepts and first can build trust. general practitioners to confidently support general practitioners to confidently The pain felt by most patients presenting manage these fractures and refer to manage these fractures and refer to to general practice with a fracture can orthopaedic services when required. orthopaedic services when required. be relieved with oral paracetamol and Discussion nonsteroidal anti-inflammatory drugs, with Orthopaedic advice and/or referral are a small sip of water if fasting for potential recommended for unstable fracture Initial assessment surgery. Nitrous oxide or intranasal or types (greenstick and complete oral opioids may facilitate splinting and fractures), particularly in older children The mechanism of injury may suggest where remodelling potential is minimal. the likelihood of fracture as well as type transport in more severe cases. Early referral for growth plate injuries of fracture sustained. It is important and suspected Monteggia and Galeazzi to remember that wrist sprains are injuries is warranted to minimise uncommon in children.3 Additional Fracture types long‑term complications. injuries should be sought, such as a distal Torus (buckle) fractures humerus fracture in association with a The anatomical term ‘torus’ refers to fracture at the wrist. Past history may a rounded protuberance.5 Also called provide insight into pathological fractures. a ‘buckle’ fracture, torus fractures are The possibility of non-accidental injury characterised by buckling of one or should be considered. more cortices of the bone as a result of a Documentation of neurovascular compressive force, typically a fall from status is essential before and after any standing height onto the outstretched intervention, including cast or splint hand. These fractures usually occur in application. A simple screening aid for children <10 years, and the distal radius neurovascular injury in children is to play and/or ulna metaphysis is the most ‘rock, paper, scissors, okay?’4 ‘Rock’ tests common site. The majority of the cortex the median nerve supply to the finger remains intact, and torus fractures are flexors, ‘paper’ tests the radial nerve therefore inherently stable. They can be supply to wrist and finger extensors, managed appropriately with a range of

740 | REPRINTED FROM AJGP VOL. 49, NO. 11, NOVEMBER 2020 © The Royal Australian College of General Practitioners 2020 A GUIDE TO PAEDIATRIC FOREARM FRACTURES CLINICAL

immobilisation methods from casts to those aged <8–10 years, and those aged with immobilisation that does not extend removable splints,6,7 balancing adequate ≥10 years. Fifteen-degree angulation and above the elbow. In young children, immobilisation for pain relief against 45° malrotation are considered acceptable extending the splint or cast above the compliance, convenience and costs in children aged <10 years, while 10° elbow may assist to prevent slippage of related to follow-up. A removable splint angulation and 30° malrotation should the immobilisation device on the chubby provides adequate protection while being be applied for those aged ≥10 years forearm (Figure 1B). Acute fractures can easily removed by parents at home after (Table 1).12–14 be managed safely in volar and dorsal a 3–4-week treatment period without Malrotation can be difficult to assess. (sandwich-style) slabs that extend up to further clinical or radiographic follow- As a guide, the radial styloid should face the metacarpophalangeal joints but leave up.6,7 Sports, high impact and loading opposite the bicipital tuberosity of the them free to move. Midshaft and proximal should be avoided for a further four weeks. radius, and the ulnar styloid should face third fractures require immobilisation of opposite the coronoid process of the the elbow joint. Greenstick fractures and ulna.15 The majority of forearm growth Plastic deformity refers to increased plastic deformity occurs at the wrist; therefore, a greater bowing to the radius or ulna without an Greenstick fractures are incomplete degree of angulation can be accepted for obvious fracture line due to multiple fractures involving disruption of 1–3 sides of distal forearm fractures when compared microfractures along the length of the the bone with bending of the others, akin to with more proximal fractures as the deformity.9 Management is similar to bending and splintering a tongue depressor remodelling potential is higher.16 Radial greenstick fractures, and reduction is without snapping it clean in two. Both the and ulnar deviation have less potential indicated on the basis of the degree of radius and ulna are commonly affected, to remodel, and rotational deformities deformity. Follow-up can be simplified as and these fractures commonly occur with have no potential to remodel.14 Clinical for greenstick fractures.17 Plastic deformity falls from a height or during recreational deformity often provides a clue that and isolated greenstick fractures of the activities as a result of combined bending orthopaedic intervention is required. ulna can be associated with radial head and twisting forces.8 A fracture of both Greenstick fractures are inherently dislocation (Monteggia injury), and it is bones at the same level of the forearm unstable and will continue to angulate critical that this is not missed. suggests a bending force was applied, while if not adequately splinted (Figure 1). fractures at different levels suggest that a With an appropriately moulded cast or Complete fractures rotational force has spiralled through both ‘front and backslab’ application, the A complete fracture disrupts the entire bones and the intervening interosseous intact cortex will maintain a degree of cortex, with resultant deformity and membrane.9 Greenstick fractures can affect stability. Aftercare includes one X-ray angulation. These are often found in any region of the forearm, and clinical immediately after cast application if higher-energy injuries, such as falls deformity is common.9,10 fracture manipulation was required, from a height, sports and road traffic Acceptable fracture angulation is that and one follow-up X-ray after 7–10 days accidents.18 Complete fractures may occur which does not require manipulation and to document maintenance of position. in any location and commonly affect is dependent on the capacity to remodel If reduction is maintained, one further both the radius and ulna. The lack of any and restore normal alignment. The most clinic visit at 5–6 weeks post-fracture for cortical continuity allows for complete important determinant is the time until removal of the cast is all that remains.17 displacement as well as shortening, which skeletal maturity, which, as a general X-rays to check union are not required in may appear as ‘bayonet’ deformity on the rule of thumb, occurs at 14 years of age the majority of cases.17 lateral X-ray. Despite complete fracture of for girls and 16 years of age for boys.11 Distal third radius and ulna fractures the bones, the thick periosteal sleeve often Many guidelines stratify angulation for in older children are suitably managed remains intact, providing some stability.

Table 1. Acceptable displacement guidelines

Fracture type Age <10 years Age ≥10 years Notes

Buckle fractures <25° angulation <15° angulation

Distal third greenstick or <15° angulation <15° angulation Beware of distal radioulnar joint complete fractures <1 cm shortening <1 cm shortening dislocation

Middle and proximal third <15° angulation <10° angulation Beware of radial head dislocations with greenstick or complete fractures <1 cm shortening <1 cm shortening ulnar fractures and plastic deformity

Physeal fractures <50% displacement <25% displacement Avoid delayed referrals <30° angulation <25o angulation

Parents and clinicians alike are often difference in skeletal maturity, girls and dislocation of the distal radioulnar surprised to learn that 100% displacement present on average 1.5 years earlier than joint at the wrist.22 These account for 3% and bayonet apposition of the distal boys for similar fracture locations.21 of paediatric distal radius fractures.23 radius and ulna will completely remodel The risk of growth plate damage with Monteggia fracture-dislocations, first as long as the angulation remains within fracture increases with increasing Salter- described in 1844, involve a fracture of acceptable limits, and at least two years Harris grade.10 The distal radius physis the ulna associated with dislocation of of growth remain.14,19 Acute orthopaedic contributes 75% of forearm length, and the proximal radius (radial head).24 They advice or emergency department review damage to this growth plate can cause typically occur in children aged between is warranted for displaced greenstick or significant disability. Delayed manipulation four and 10 years22,24 as a result of a fall complete fractures. of fractures or remanipulation of fractures onto an outstretched hand. The elbow is that have lost position beyond seven days forced into hyperextension, the forward Growth plate injuries is ill-advised because of the risk of further momentum dislocates the radial head, and Salter-Harris fractures involve the growth disrupting the physeal blood supply and the ulna, burdened with the full force of plate. The classification system, first high rates of growth arrest.9,16 Acute referral the fall, fails in tension. proposed in 1963, grades fractures from and close review is warranted, particularly Fracture-dislocations should be splinted I to V.20 It is remembered with the ‘SALTR’ for high-energy injuries. to include the elbow and wrist to prevent acronym: Straight across the physis, Above forearm rotation. Urgent referral is warranted the physis extending into the metaphysis, Fracture-dislocation as rapid healing in children will make delayed Low to the physis extending into the In cases of isolated radius or ulna fracture, reduction of the dislocation difficult. epiphysis and articular surface, Through particularly with significant angulation the physis going above and below, and or displacement, it is important to check cRushed. Growth plate fractures account the elbow and wrist joints to rule out an Principles of management, for 30% of all long bone fractures.21 Their associated dislocation. referral and follow-up incidence peaks during the pre-adolescent Galeazzi fracture-dislocations involve Individual management is influenced growth spurt and, given the relative a fracture of the distal third of the radius by local resources, and knowledge of

Figure 1. Anteroposterior and lateral X-rays of the forearm and wrist showing a greenstick fracture of the distal radius in a child aged three years

A. X-rays at initial presentation; B. The short, volar splint has slipped at follow-up and provided inadequate immobilisation. The fracture has displaced. Extending immobilisation above the elbow in young children and applying volar and dorsal slabs provides better fracture stability. B

742 | REPRINTED FROM AJGP VOL. 49, NO. 11, NOVEMBER 2020 © The Royal Australian College of General Practitioners 2020 A GUIDE TO PAEDIATRIC FOREARM FRACTURES CLINICAL

local referral pathways is helpful. GP Key points 3. Spain D. Early management of upper limb fractures in general practice. Aust Fam Physician management of a child with no appreciable • True torus (buckle) fractures of the 2004;33(3):105–09. clinical deformity may include pre-emptive distal radius and ulna are inherently 4. Davidson AW. Rock–Paper–Scissors. Injury immobilisation and outpatient radiology, stable and may be managed with 2003;34(1):61–63. doi: 10.1016/s0020- 1383(02)00102-x. followed by telephone advice or orthopaedic 3–4 weeks of immobilisation in 5. Merriam-Webster. Torus. Springfield, MA: surgeon/fracture clinic referral as a splint, or a soft cast that can be Merriam-Webster, 2020. Available at www. required, avoiding unnecessary trips to the removed by parents. More complex merriam-webster.com/dictionary/torus [Accessed 20 May 2020]. emergency department. Communication fracture patterns should be discussed 6. The Royal Children’s Hospital Melbourne. Clinical with radiology departments can help direct with an acute orthopaedic service via practice guidelines: Distal radius and or ulna patients appropriately following X-ray the local emergency department or metaphyseal fracture – Emergency department. Parkville, Vic: RCH, 2020. Available at www.rch. confirmation of a fracture. Advising the referral to hospital. org.au/clinicalguide/guideline_index/fractures/ referral hospital whether your practice Greenstick fractures and plastic Distal_radius_and_or_ulna_metaphyseal_fractures_ • Emergency_Department_setting [Accessed has cast-removal facilities can help with deformity are common in the midshaft 20 May 2020]. planning follow-up, particularly for patients of the forearm. The degree of 7. Hamilton TW, Hutchings L, Alsousou J, et al. The in rural and remote areas. angulation dictates whether reduction treatment of stable paediatric forearm fractures using a cast that may be removed at home: Injuries with clinical deformity, is necessary. Fracture reduction may be Comparison with traditional management in a neurovascular compromise or a concerning required for fracture angulation >15° randomised controlled trial. Bone Joint J 2013;95- B(12):1714–20. radiology report should be referred to the in children aged <10 years and >10° in 8. Atanelov Z, Bentley TP. Greenstick fracture. local acute orthopaedic service or emergency children aged ≥10 years. Discussion Treasure Island, FL: Stat Pearls Publishing, 2020. department. A telephone call prior to patient with an acute orthopaedic service or 9. Flynn JM, Skaggs DL, Waters PM. Rockwood transfer can expedite management. Growth referral to the emergency department is and Wilkins’ fractures in children. 8th edn. Philadelphia, PA: Wolters Kluwer, 2015. plate injuries require early review. Online recommended for these fracture types. 10. Flynn JM, Weinstein S. Lovell and Winter’s resources provide general guidance as to • Complete fractures, fractures involving pediatric orthopaedics. 7th edn. Philadelphia, PA: when referral is required.6,16,25 the growth plate and any fracture with Lippincott Williams & Wilkins, 2014. 11. Menelaus MB. Correction of leg length As a general rule, forearm fractures and clinical deformity should be referred to discrepancy by epiphysial arrest. J Bone Joint Surg suspected fractures in children require an orthopaedic service or emergency Br 1966;48(2):336–39. early follow-up and formal follow-up after department acutely. 12. Asadollahi S, Pourali M, Heidari K. Predictive factors for re-displacement in diaphyseal forearm healing until normal range of motion • It is important to be wary of isolated fractures in children – Role of radiographic is restored. This will minimise cases complete radius or ulna shaft fractures/ indices. Acta Orthop 2017;88(1):101–08. of missed injuries and unanticipated plastic deformation and always look doi: 10.1080/17453674.2016.1255784. 13. Bowman EN, Mehlman CT, Lindsell CJ, outcomes. It is important to remember that for a concomitant dislocation of the Tamai J. Nonoperative treatment of both- wrist sprains are uncommon in children.3 proximal radio-capitellar or distal bone forearm shaft fractures in children: Appropriate follow-up depends on the radioulnar joints. Predictors of early radiographic failure. J Pediatr Orthop 2011;31(1):23–32. doi: 10.1097/ fracture type and local circumstances • Follow-up until the child’s usual BPO.0b013e318203205b. and may include a fracture clinic, virtual range of motion has returned is a safe 14. Noonan KJ, Price CT. Forearm and distal radius fracture clinic, private orthopaedic clinic, fractures in children. J Am Acad Orthop Surg approach to minimise missed injuries 1998;6(3):146–56. doi: 10.5435/00124635- general practice or a combination. True and unanticipated outcomes. 199805000-00002. torus (buckle) fractures are stable injuries. 15. Wenger DR, Pring ME, Pennock AT, Upasani VV. Some hospitals may choose to apply a Rang’s children’s fractures. 4th edn. Philadelphia, Authors PA: Wolters Kluwer, 2018. removable immobilisation device, provide Gajan Selvakumaran BMed, MTrauma, Orthopaedic 16. The Royal Children’s Hospital Melbourne. written information to parents and forego Registrar, John Hunter Hospital, NSW Fracture education: Physeal (growth plate) formal follow-up for these fractures.6 This Nicole Williams FRACS, BMed, BMedSc (Hons), injuries. Parkville, Vic: RCH, 2020. Available at Orthopaedic Surgeon, Women’s and Children’s www.rch.org.au/fracture-education/growth_ is appropriate, as long as the diagnosis Hospital, SA; Associate Professor, Discipline of plate_injuries/Physeal_growth_plate_injuries is correct and the injury is not in fact an Orthopaedics and Trauma, University of Adelaide, SA. [Accessed 20 May 2020]. [email protected] unstable greenstick fracture (Figure 1A). 17. Ting BL, Kalish LA, Waters PM, Bae DS. Reducing Competing interests: None. cost and radiation exposure during the treatment Funding: None. of pediatric greenstick fractures of the forearm. J Pediatr Orthop 2016;36(8):816–20. doi: 10.1097/ Provenance and peer review: Not commissioned, BPO.0000000000000560. Summary externally peer reviewed. 18. Rennie L, Court-Brown CM, Mok JYQ, Beattie TF. The wide spectrum of forearm fractures References The epidemiology of fractures in children. Injury 2007;38(8):913–22. doi: 10.1016/j. and differences in age can create a 1. Chung KC, Spilson SV. The frequency and injury.2007.01.036. daunting management matrix. Confident epidemiology of hand and forearm fractures in the United States. J Hand Surg Am 2001;26(5):908–15. 19. Price CT, Scott DS, Kurzner ME, Flynn JC. management of simple fractures by the doi: 10.1053/jhsu.2001.26322. Malunited forearm fractures in children. J Pediatr GP, as well as appropriate referral, allows 2. Cheng JC, Shen WY. Limb fracture pattern in Orthop 1990;10(6):705–12. doi: 10.1097/01241398- different pediatric age groups: A study of 3,350 199011000-00001. for an efficient healthcare system and children. J Orthop Trauma 1993;7(1):15–22. 20. Salter R, Harris W. Injuries involving the epiphyseal optimal outcomes. doi: 10.1097/00005131-199302000-00004. plate. J Bone Joint Surg Am 1963;45(3):587–622.

21. Mann DC, Rajmaira S. Distribution of physeal and nonphyseal fractures in 2,650 long-bone fractures in children aged 0–16 years. J Pediatr Orthop 1990;10(6):713–16. doi: 10.1097/01241398- 199011000-00002. 22. Giannoulis FS, Sotereanos DG. Galeazzi fractures and dislocations. Hand Clin 2007;23(2):153–63. doi: 10.1016/j.hcl.2007.03.004. 23. Walsh HP, McLaren CA, Owen R. Galeazzi fractures in children. J Bone Joint Surg Br 1987;69(5):730–33. 24. Hastings H 2nd, Simmons BP. Hand fractures in children. A statistical analysis. Clin Orthop Relat Res 1984(188):120–30. 25. The Royal Children’s Hospital Melbourne. Clinical practice guidelines: Forearm fractures. Parkville, Vic: RCH, 2020. Available at www.rch.org.au/ clinicalguide/guideline_index/forearm_fractures [Accessed 20 May 2020]. correspondence [email protected]