A both bone forearm fracture is a fracture of both the radius and ulna bones, the two bones that make up the forearm. These fractures occur in the diaphysis, or mid portion of the bones. These are typically high energy injuries sustained by children when a fall from height occurs such as a fall from a trampoline, swing or other high energy impact. There is typically deformity of the forearm with significant bruising and pain.
Diaphyseal radius and ulna fractures are typically obvious injuries first noticed by the resultant deformity of the extremity. X-rays confirm the diagnosis and are crucial to understand the morphology of the fractures in question. Usually, advanced imaging such as a CT or MRI are not needed. However, if other injuries are suspected these advanced imaging modalities may be needed to further classify these other injuries.
Some both bone forearm fractures only require closed reduction and casting under anesthesia. This will require a visit to the OR for treatment and a long arm cast for imobilization. Other more difficult fractures will require surgically implanted hardware to ensure stable fixation. With the development of flexible intramedullary nails many times these fractures can be treated with rods placed inside the bone through small incisions. In older children who are closer to skeletal maturity, standard techniques may be needed, such as plate and screw fixation through standard incisions made in the forearm.
If closed reduction and casting is all that is required, patients can expect to be placed in a long arm cast which is left in place approximately 6 weeks. If flexible intramedullary nails are used, they are placed in the OR and left in place for approximately 8 weeks. After this period of time, they are removed. This requires a second visit to the OR where the rods are removed through the same incisions through which they were placed. If plates and screws are used, they are usually left in place for no longer than a year. Depending on the patient’s age and skeletal maturity they may be left in place forever.
If closed reduction and casting is used, the cast will stay in place for 6 weeks on average. The patient will be instructed to be non-weight bearing during the healing process and can expect to have some degree of stiffness once the cast is removed. This stiffness typically is self-remitting but may require the help of an occupational therapist for complete recovery. Typically, full activity is allowed once the patient is pain free and complete healing is seen on x-rays. This usually occurs at 8 – 10 weeks after the initial cast was placed.
If flexible intramedullary nailing is employed, the patient will be placed in a splint at the time of the first surgery that will be removed at 2 weeks after surgery. The patient is allowed to perform range of motion exercises but is not allowed to bear weight until approximately 6 weeks. The rods will be removed around 8 weeks post insertion and a second splint worn for an additional 2 weeks. At this point the patient will again start with range of motion and progress to gradual weight bearing. Typically, the patient will be allowed to return to full activity 4 weeks after the rods are removed.
If plates and screws are used the patient can expect to be placed in a postoperative splint that will be exchanged for a thermoplastic splint molded to the patient by an occupational therapist. The patient will begin with a restricted range of motion protocol allowing only flexion and extension of the wrist and elbow. Rotation is limited for the first 4 weeks. The splint is used for a total of 6 weeks in most cases. During this time the patient is to be non-weightbearing. Weight bearing is typically initiated at 6 weeks and full activity if allowed once the patient is pain free and has healing shown on x-ray. This typically occurs around 8-10 weeks.