Clinical and Radiographic Examination

If an injury to the forearm is suspected, the entire upper extremity should be assessed. The physical examination should begin with a visual inspection of the extremity to identify any lacerations, ecchymosis, edema, and/or obvious deformities. If possible, gentle active range of motion (AROM) testing should occur, although pain may limit this assessment. Neurovascular injury should then be assessed, considering the associated motor and sensory deficits that would be caused by an injury to the radial, ulnar, or median nerves. When assessing radiographs for a suspected both-bone forearm fracture, it is important to ensure that true orthogonal views are present, as well as radiographs of the elbow and wrist, to ensure the entire scope of the injury is noted.

Treatment

Both-bone fractures of the forearm in the pediatric population are largely treated nonoperatively with cast immobilization. Closed reductions may be required to obtain satisfactory alignment, followed by the application of a well-molded cast ( Fig. 18.1 ). Close follow-up with radiographs for the first 2–3 weeks following the injury is recommended to monitor for any loss of reduction. In children under 9 years old, up to 20 degrees of sagittal angulation is considered acceptable and capable of remodeling. The allowable angulation gradually decreases for children over the age of 9, as they approach skeletal maturity and the likelihood of remodeling diminishes.

Plain radiographs of a child with both-bone forearm fracture with apex volar deformity that was managed with successful closed reduction and long arm casting. (A) AP view prereduction. (B) Lateral view prereduction. (C) AP view postreduction. (D) Lateral view postreduction.

Courtesy of Joshua M. Abzug, MD.

In approximately 10% of pediatric both-bone forearm fractures, operative intervention is required. Flexible nailing, with or without open reduction techniques, is performed in younger patients and those with fracture patterns amenable to this technique, such as transverse and short oblique patterns ( Fig. 18.2 ). Open reduction with plate and screw fixation is performed in children/adolescents approaching skeletal maturity and in comminuted and long oblique fracture patterns. Postoperatively, patients are immobilized until definitive fracture healing has occurred. Flexible nails are typically scheduled for removal 3–4 months after the initial procedure, assuming complete healing has occurred, while plate and screw constructs are typically retained unless they are symptomatic.

Plain radiographs of a 10-year-old female with a both-bone forearm fracture that was treated with flexible nailing. (A) AP view preoperatively. (B) Lateral view preoperatively. (C) Postoperative AP view. (D) Postoperative lateral view.

Courtesy of Joshua M. Abzug, MD.

Outcomes and Therapeutic Management

Potential complications associated with pediatric and adolescent forearm fractures include compartment syndrome, decreased range of motion (ROM), particularly forearm rotation, skin breakdown, tendon and/or nerve injury, and refractures up to 6–12 months following the initial injury. The rotational deficits can lead to a functional impairment in activities of daily living (ADLs) such as self-feeding, washing, and grooming, as well as leisure activities. Although these limitations may be the result of bony malalignment, they may also occur due to soft-tissue contractures. Therefore, therapy may be prescribed to minimize any potential long-term deficits. In the pediatric population, the incorporation of play, along with functional exercises, can assist in regaining strength and mobility of the wrist and forearm and aid in building endurance. Example exercises that are wellreceived with this population include finger painting using an easel, playing card games that require forearm rotation, sporting activities such as dribbling a basketball, and other play activities such as tossing a beanbag. Throwing a ball overhead, crab walking, and playing the Wii or other computer games are excellent activities to focus on the restoration of forearm and wrist ROM.

Hand therapists are often incorporated in the treatment of patients with both-bone forearm fractures and concomitant nerve injuries. The hand therapists’ role is to assist in splinting to prevent joint contractures and to place the affected hand in the most optimal functional position, desensitization, and neuromuscular reeducation. Therapists also provide critical information to the patient and their caregivers about the key safety factors surrounding loss of protective sensation to the hand or affected digits.

Clinical and Radiographic Examination

The entire extremity should be inspected for wounds, deformity, ecchymosis, and/or edema. Palpation throughout the extremity is necessary to assess the extent of the injury and to identify any associated injuries, such as radial neck fractures, supracondylar humerus fractures, and Monteggia fracturedislocations. Posteroanterior (PA) and lateral plain radiographs are typically sufficient in diagnosing the injury.

Treatment

Fractures of the distal radius can often be treated nonoperatively in the pediatric population. Those fractures that are nondisplaced or have minimal displacement are typically treated with immobilization in a short arm cast or orthosis for 3–4 weeks. Fractures that have the potential for displacement due to their fracture pattern are commonly placed in a long arm cast and radiographs are obtained weekly for at least 2–3 weeks to ensure no loss of alignment. When there is displacement at the fracture site, a closed reduction can be attempted in the emergency department, outpatient office, or operating room before immobilization in a long arm cast ( Fig. 18.3 ). Close follow-up with weekly radiographs for at least 2–3 weeks must be performed. When casting, it is important to utilize optimal casting techniques, with an interosseous or three-point mold, to maximize the success in maintaining the reduction. Molding above the humeral condyles to prevent the cast from sliding down is also recommended when applying long arm casts.

Plain radiographs of a minimally displaced distal radius fracture after closed reduction in the emergency department in an 11-year-old female. (A) AP view. (B) Lateral view.

Courtesy of Joshua M. Abzug, MD.

Operative intervention is indicated for irreducible fractures, fractures with intraarticular involvement, open fractures, distal radius fractures with concurrent injuries, and fractures that have lost alignment following an initial reduction ( Fig. 18.4 ). The vast majority of pediatric and adolescent distal radius fractures can be treated with a closed reduction with percutaneous pinning. Open reduction with internal fixation (ORIF) is reserved for open fractures, nascent malunions that do not involve the physis, and fractures in skeletally mature individuals that are amenable to ORIF followed by early ROM ( Fig. 18.5 ). Following operative intervention, patients are commonly immobilized for 3–4 weeks and then early AROM is initiated.

PA and lateral radiographs of the wrist demonstrating a worsening displacement of a distal radius fracture: (A) Initial injury. (B) Worsening displacement 1 week after initial immobilization. (C) Final treatment utilizing closed reduction and percutaneous pinning.

Courtesy of Joshua M. Abzug, MD.

Preoperative (A) AP view and (B) lateral view and postoperative (C) AP view and (D) lateral view radiographs of a distal radius fracture treated with open reduction and internal fixation.

Courtesy of Joshua M. Abzug, MD.

Outcomes and Therapeutic Management

Distal radius fractures heal without complications in the vast majority of pediatric patients. Complication rates increase if there are multiple attempts to reduce a physeal fracture, as this has been shown to increase the risk of physeal damage and subsequent physeal arrest. The rate of physeal arrest associated with distal radius fractures is 4%–7%, and is seen more commonly in Salter–Harris III and IV fractures as well as in children approaching skeletal maturity. Nonunion, malunion, and radioulnarsynostosis are other potential complications following distal radius fractures in pediatric patients but are quite rare. Specific complications associated with operative intervention include pin tract infections, neurovascular damage, and painful hardware.

Therapy is typically not required for pediatric distal radius fractures whether they are treated with immobilization alone or with closed reduction and percutaneous pinning (CRPP). Patients that underwent ORIF procedures are typically treated following the same treatment algorithms as adults. These patients are often immobilized in a short arm cast for 3–4 weeks and then transitioned to a circumferential fracture brace for continued protection for a total of 6–8 weeks postoperatively. The goals of initial hand therapy following an ORIF procedure are edema control, orthosis fabrication, ROM of the uninvolved joints, and light activities of daily living within the orthosis ( Fig. 18.6 ) ( Fig. 18.7 ). Patients may experience extensor tendon irritation, swelling along the dorsum of the hand, and pain with composite extension during this phase, and ROM should be altered based on patient’s complaints and discomfort level. Caution with early AROM should be considered, as associated extensor tendon rupture has been reported during the early postoperative phase.

Clinical photograph of a custom-molded removable wrist splint to allow for light, active range of motion. (A) Top view. (B) Side view.

Courtesy of Joshua M. Abzug, MD.

Clinical photograph of an orthosis used in the immobilization of a pediatric distal radius fracture following removal of a pin utilized for stabilization.

Courtesy of Joshua M. Abzug, MD.

Once adequate bony healing has occurred, the initiation of active, active-assisted, and passive ROM to the wrist may be initiated. Now, the patient is allowed to increase the use of the effected extremity in daily activities and may be able to wean out of the orthosis use for functional tasks. For the athletic patient, return to full contact sports may be allowed 3–6 months postoperatively, once full ROM and strength are regained in the affected extremity.

Clinical and Radiographic Examination

When a patient presents with radial sided hand/wrist pain, the physical examination should cover the entirety of the hand and forearm to rule out any concurrent injuries. Any edema, ecchymosis, and abrasions should be noted. Patients with a scaphoid fracture often present with tenderness over the snuffbox region, or over the distal pole of the scaphoid. Studies have shown that pressure applied to the snuffbox region or scaphoid tubercle or axial pressure applied over the first metacarpal have high sensitivity but lesser specificity depending on the region where pressure is applied. Four radiographic views are recommended to identify a scaphoid fracture: posteroanterior, lateral, pronated oblique, and an ulnar-deviated posteroanterior view ( Fig. 18.8 ). CT and MRI can be used to obtain a definitive diagnosis if the initial plain radiographs are negative.

Plain radiographs of scaphoid fractures of the (A) proximal pole, (B) waist, and (C) distal pole.

Courtesy of Joshua M. Abzug, MD.

Treatment

Nondisplaced scaphoid fractures are typically treated nonoperatively, with 90% of nondisplaced pediatric scaphoid fractures healing successfully without complication. Operative indications include fractures presenting more than 6 weeks postinjury, displaced fractures, and those fractures that were unsuccessfully managed nonoperatively. Nondisplaced fractures are typically treated with percutaneous screw fixation; however, K-wires may be used in young children. ORIF is indicated for displaced fractures ( Fig. 18.9 ).

A scaphoid waist fracture nonunion in a skeletally immature child. (A) Preoperative AP and lateral radiographs demonstrate a displaced waist fracture with dorsal intercalated segment instability (DISI) deformity of the wrist. (B) Intraoperative photograph demonstrating the volar approach for open reduction and internal fixation using iliac crest bone graft and a compression screw. (C) Postoperative AP and lateral fluoroscopic images at final follow-up demonstrate restoration of scaphoid alignment with complete bony union.

Courtesy of Shriner’s Children Hospital, Philadelphia, PA.

Outcomes and Therapeutic Management

Patients who present with an acute injury and are treated with appropriate immobilization tend to have more favorable outcomes. Toh et al. reported in a study of 63 pediatric scaphoid fractures, the rate of successful healing upon initial treatment (operative or nonoperative) was 97% ( n = 58). The cases that did not immediately heal eventually went on to successful bony union after repeated intervention. Most pediatric scaphoid fractures are treated with cast immobilization, with a long arm thumb spica cast initially, transitioned to a short arm thumb spica cast at the 2-week follow-up appointment. Bae et al. reported a 90% rate of healing for acute, nonoperative scaphoid fractures in children, commenting that immobilization of at least 3 months may be required. However, for fractures requiring operative intervention, the same study reported a 97% rate of healing and a shorter time to union.

Pediatric patients typically experience excellent functional outcomes with cast immobilization alone, and most do not require formal hand therapy outside of the fabrication of an appropriate orthosis. Athletes and performing artists are an exception to this generalization, as their performance and return-to-sport may be optimized through the prescription of formal hand therapy given the required ROM, proprioception, and dexterity associated with such activities. In treating these patients, it may be beneficial to use static, progressive orthoses to target ROM lost during cast immobilization. Furthermore, the implementation of therapy protocols including exercises that concentrate on wrist/forearm proprioception, strength and endurance, and activity-specific activities is recommended. Exercises such as dart throwers movements and wrist gyroscopes can aid in achieving optimal results for rapid and complete return to the desired activities.

Bae et al. assessed 63 pediatric scaphoid fractures, treated both operatively and nonoperatively. In this study, all fractures were observed to heal successfully and 95% of patients reported Disability of the Arm, Hand, and Shoulder (DASH) scores at, or above, the level of the general pediatric population. Interestingly, when patients were given the sports/performing arts module of the DASH evaluation, 11% of the patients reported persistent functional limitations. This may be due to the more specific nature of recognizable functional limitations in the pediatric population. As a hand therapist, this outcome measure is an important tool in your evaluation that can allow you to tease out the functional limitations for your patient that can be targeted in therapy.