FOREARM FRACTURE IN

CHILDREN
 DEFINITION
 Fracture is the discontinuation of continuity of bone tissue
due to cracks, drops or rupture of the cortex layer so that bone
stretches well in complete and there is a shift from bone
fragments
 a closed fracture is the skin above the fracture is intact
 an open fracture is a fracture with the skin connected to the
outside world
 An antebrachi fracture is the breaking of the ulna radius
continuity

•Rasjad,C. Trauma pada tulang in: Pengantar Ilmu Bedah ortopedi, BAB 14. Jakarta: PT. Yarsif Watampone.2012
 ANATOMY
 Osteology

•Russel T A. Rockwood and Green’s Fracture in Adults. 8th Edition. Wolters Kluwer Health. 2015.
•Standring S, Ellis H, Healy JC, Johnson D, Williams A, et al. Gray’s Anatomy: The Anatomical Basis of Clinical Practice. 39th Edition. [textbook
of Anatomy]. Elsevier Churchill Livingstone: 2008.
  Muscle
Anterior compartment

Anterior Compartment superficial layer

•Russel T A. Rockwood and Green’s Fracture in Adults. 8th Edition. Wolters Kluwer Health. 2015
•Thompson Jon C. Netter’s Concise Orthopaedic Anatomy. 2nd Edition. Saunders, Elsevier. Philadelphia, USA; 2010.
 Anterior Compartment Medial Layer Anterior Compartment Profunda Layer

•Russel T A. Rockwood and Green’s Fracture in Adults. 8th Edition. Wolters Kluwer Health. 2015
•Thompson Jon C. Netter’s Concise Orthopaedic Anatomy. 2nd Edition. Saunders, Elsevier. Philadelphia, USA; 2010.
 Posterior Compartment

Posterior Compartment superficial layer Posterior Compartment Profunda Layer

•Russel T A. Rockwood and Green’s Fracture in Adults.8th
Edition. Wolters Kluwer Health. 2015
•Thompson Jon C. Netter’s Concise Orthopaedic Anatomy. 2nd Edition. Saunders, Elsevier. Philadelphia, USA; 2010.
  Nerves

N. Medianus
•Russel T A. Rockwood and Green’s Fracture in Adults.8th
Edition. Wolters Kluwer Health. 2015
•Thompson Jon C. Netter’s Concise Orthopaedic Anatomy. 2nd Edition. Saunders, Elsevier. Philadelphia, USA; 2010.
 N. Radialis N. Ulnar

•Russel T A. Rockwood and Green’s Fracture in Adults. 8th Edition. Wolters Kluwer Health. 2015
•Thompson Jon C. Netter’s Concise Orthopaedic Anatomy. 2nd Edition. Saunders, Elsevier. Philadelphia, USA; 2010.
  Arteries

•Russel T A. Rockwood and Green’s Fracture in Adults. 8th Edition. Wolters Kluwer Health. 2015
 ETIOLOGY

directly
severe
trauma
indirectly
spontaneous
fracture
/ pathologic

stress /
fatigue

•Goh Lesley A., Peh Wilfred C. G., Fraktur-klasifikasi,penyatuan, dan komplikasi dalam : Corr Peter. Mengenali Pola Foto-Foto Diagnostik. Penerbit
Buku Kedokteran EGC. Jakarta. 2011. Hal 112-121.
•Ekayuda Iwan, Trauma Skelet (Rudapaksa Skelet) dalam: Rasad Sjahriar, Radiologi Diagnostik. Edisi kedua, cetakan ke-6. Penerbit Buku
BalaiPenerbitan FKUI. Jakarta. 2009. Hal 31-43.
Pathomechanism
Epiphyseal Growth and Closure
 Fractures of the Distal Radius and
Ulna Injury Mechanisms
• Fall on an outstretched hand.
• Extended position of the wrist at the time of
loading leads to tensile failure on the volar
side of the distal forearm. (Fig. 11-1).
• Axial loading on the flexed wrist will produce a
volarly displaced fracture with apex dorsal
angulation (Fig. 11-2).

Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Mechanism of Injury
• Indirect : fall onto an outstretched hand
– Pronation  flexion injury (apex in dorsal)
– Supination  extension injury (apex in volar)
• Direct trauma
 Fractures of the Distal Radius and
Ulna Injury Mechanisms
• A direct blow sustained to the distal forearm
may result in fracture and displacement.
• In addition to the angular deformity caused by
axial and bending loads applied to the distal
forearm, rotational displacement may also
occur, based upon the position of the forearm
and torsional forces sustained at the time of
injury.

Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Fractures of the Distal Radius and
Ulna Injury Mechanisms
• Fracture type and degree of displacement is also
dependent on the height and velocity of the fall
or injury mechanism.
• Prepubescent boys and girls were found to have
lower estimates of bone strength compared to
same sex postpubertal peers. Fractures of the
distal forearm in children typically occur when
the radius and/or ulna are more susceptible to
fracture secondary to biomechanical changes
during skeletal development.
Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Fractures of the Distal Radius and
Ulna Injury Mechanisms
• Fractures occur at the biomechanically
weakest anatomic location of bone, which also
varies over time. As the metaphyseal cortex of
the radius is relatively thin and porous
fractures in this region are most common,
followed by physeal.

Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Fractures of the Distal Radius and
Ulna Injury Mechanisms
• Children who are overweight, have poor postural
balance, ligamentous laxity, or less bone
mineralization are at increased risk for distal
radial fractures.
• Although bone quality measures predict that
boys had lower risk of fracture than girls at every
stage except during early puberty, these fractures
have been reported to be three times more
common in boys.
• However, the increased participation in athletics
by girls at a young age may be changing this ratio.
Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Injuries Associated with Fractures of
the Distal Radius and Ulna
• With marked radial or ulnar
fracture displacement,
neurovascular compromise can
occur.
• Median neuropathy may be seen
in severely displaced distal radius
fractures, due to direct nerve
contusion sustained at the time of
fracture displacement, persistent
pressure or traction from an
unreduced fracture, or an acute
compartment syndrome.
• Ulnar neuropathy with similar
mechanisms, entrapment or
incarceration of the ulnar nerve
within the fracture site.

Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
 Injuries Associated with Fractures of
the Distal Radius and Ulna
• Wrist ligamentous and articular cartilage injuries
have been described in association with distal
radial and ulnar fractures in adults and less
commonly in children.
• Concomitant scaphoid fractures have occurred.
• More than 50% of distal radial physeal fractures
have an associated ulnar fracture. This usually is
an ulnar styloid fracture, but can be a distal ulnar
plastic deformation, greenstick, or complete
fracture.
Flynn, John M., Skaggs, David L., Waters, David L. Rockwood and Wilkins’ Fractures in Children
8th Ed. Wolters Kluwer. 2015.
• Pediatric bone has a higher water content and
lower mineral content per unit volume than adult
bone.
– pediatric bone has a lower modulus of elasticity (less
brittle)
– higher ultimate strain-to-failure than adult bone.
– relatively stronger in tension than compression,
• The periosteum in a child is a thick fibrous
structure (up to several millimeters) that
encompasses the entire bone except the articular
ends
• ligaments in children are functionally stronger
than the physis
• The blood supply to the growing bone includes a
rich metaphyseal circulation with fine capillary
loops ending at the physis
Rockwood and Wilkins Fractures in Children, 7th Edition, Physeal Injuries and Growth Disturbances
Rockwood and Wilkins Fractures in Children, 7th Edition, Physeal Injuries and Growth Disturbances
Classification Fractures of the
Distal Radius and Ulna
Physeal Injury
 Salter-Harris
classification of
physeal fractures
• Salter-Harris type I fractures, the fracture line is entirely within
the physis, referred to by Poland as type I.
• Salter-Harris type II fractures, the fracture line extends from the
physis into the metaphysis; described by Poland as type II and
Aitken as type I.
• Salter-Harris type III fractures, the fracture enters the epiphysis
from the physis and almost always exits the articular surface.
Poland described this injury as type III and Aitken as type II.
• Salter-Harris type IV, the fracture extends across the physis from
the articular surface and epiphysis, to exit in the margin of the
metaphysis. Aitken described this as a type III injury in his
classification.
• Salter-Harris type V fractures: crush injury to the physis with
initially normal radiographs with late identification of premature
physeal closure.
Rockwood and Wilkins Fractures in Children, 7th Edition, Physeal Injuries and Growth Disturbances
Miller's Review of Orthopaedics, 6th ed
 AO classification

AO Pediatric Comprehensive Classifi cation of Long-Bone Fractures (PCCF)

AO Pediatric Comprehensive Classifi cation of Long-Bone Fractures (PCCF)
 SIGN AND SYMPTOM
• Symptoms
– Forearm pain and deformity
• Physical Examination
– Swelling and focal tenderness
– Should assess for neurovascular injury
– Should rule out compartment syndrome
 RADIOLOGY
Plain radiograph (X-Ray) :
- Anteroposterior (AP)
- Lateral
• The extended position of the wrist at the time
of loading leads to tensile failure on the volar
side of the distal forearm
• Axial loading on the flexed wrist will produce a
volarly displaced fracture with apex dorsal
angulation
 TREATMENT

NON OPERATIVE

OPERATIVE
• NON OPERATIVE
 - Techniques :
1. Splint Immobilization of Torus Fractures
2.Cast Immobilization of Nondisplaced or Minimally
Displaced Distal Radial Metaphyseal and Physeal
Fractures
3.Reduction and Immobilization of Incomplete
Fractures of the Distal Radius and Ulna
4.Closed Reduction and Cast Immobilization of
Displaced Distal Radial Metaphyseal Fractures
• OPERATIVE
- Indication :
1). Unstable fracture after closed reduction
2). Open fracture
3). Compartement syndrome
4). Floating elbow
- Surgical Procedure:
1). Closed Reduction and Pin Fixation of Displaced Distal
Radial Fractures
2). Open Reduction and Fixation
3). Reduction and Fixation of Distal Ulnar Fractures
4). External Fixation
 Complication
• Loss of reduction
• Malunion
• Nonunion
• Cross-union
• Refracture
• Distal and ulna growth disruption
• Ulnocarpal impaction sydnrome
• Triangular Fibrocartlage tear
• Neuropathy
• Infection
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