A 5-year-old boy fell off his bicycle and had immediate pain and swelling of his right wrist. He continued to complain of pain and could not use his right arm because of severe pain. In the emergency department a radiograph was obtained which showed a Buckle (Torus) right radius fracture (Figure 84-1). He was treated by immobilization with a short arm cast for 3 weeks and had an excellent recovery.

Distal radius and forearm fractures are common in children and adolescents. Patients typically present after falling on an outstretched arm. The diagnosis is confirmed by radiographs. Treatment in the pediatric population is usually non-operative with prolonged immobilization but can require operative care depending on the type of fracture, degree of displacement and the age of the patient.

Physeal fractures (growth plate injuries), Buckle (Torus), Greenstick fractures can occur in the forearm. Galeazzi and Monteggia fractures are more rare forearm fractures, but important to recognize.

• Radius/ulna fractures are the most common upper extremity fracture (37%) in children under the age of 6 years.¹

• Distal radial fractures (Figure 84-2) accounted for 25 to 30 percent of fractures in children ages 2 to 14.^2,3

• Incidence is 373/100,000 children.⁴

• Peak incidence is age 11 to 14 in boys and ages 8 to 11 in girls.⁴

• More common in boys across all ages.²

• Classic history is a fall from a height (bed or playground equipment), down stairs, or while running, biking, or skating on an outstretched arm.

• Increase in incidence of fractures during pubertal years is thought to be from increase physical activity concurrent with transient deficit in cortical bone mass and secondary to an increase in height that is not accompanied by an adequately increased accrual of bone mineralization.⁴

• Abuse: in infants (less than one year), should be considered especially if the history of injury is not plausible and inconsistent with injury pattern.⁵

• Male gender.

• Pubertal age.

• Previous history of fracture.

Diagnosis is suspected by a compatible history such as falling, physical findings of trauma and confirmed by radiographs (two or three views). In regard to radiographs, more than one view is essential to determine the degree of angulation and deformity. Typical radiographs include anterior posterior (AP), lateral and oblique films (Figure 84-3). For some specific injuries it is necessary to image the elbow because it can often have dislocation or other injuries associated with forearm fracture.

Clinical Features

Pain, obvious swelling, and/or deformity are usually present after accidental injury. External sign of injury and abnormal use of the arm is present in most cases. However, some children under the age of 6 years do not always manifest these signs. Fifteen percent of children will not have an external sign of injury and 16 percent may use a fractured arm normally.¹