Executive Editor: James Hunter General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric proximal forearm 21r-E/2 - Cast immobilization

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Glossary

Aftercare following immobilization

Duration of immobilization

Metaphyseal and epiphyseal fractures of the proximal radius and ulna usually require 2-4 weeks of immobilization for adequate healing.

Analgesia

Ibuprofen and paracetamol should be administered regularly during the first 24-48 hours after surgery, with opiate analgesia for breakthrough pain.

Opiates should not be necessary after 48 hours and regular ibuprofen and paracetamol should be sufficient until 4-5 after injury or surgery.

The child should be examined if the level of pain is increasing or prolonged analgesia is needed.

Neurovascular examination

The child should be examined after casting, to ensure finger range of motion is comfortable and adequate.

Neurological and vascular examination should also be performed.

Compartment syndrome should be considered in the presence of increasing pain, especially pain on passive stretching of muscles, decreasing range of active finger motion or deteriorating neurovascular signs, which is a late phenomenon.

Compartment syndrome

Compartment syndrome is a possible early postoperative complication that may be difficult to diagnose in younger children.

The presence of full passive or active finger extension, without discomfort, excludes muscle compartment ischemia.

If there are signs of a compartment syndrome in a child in a cast or splint:

  1. Remove or split constrictive dressings or casts.
  2. Elevate the limb.
  3. Encourage active finger movement.
  4. Reexamine the child after 30 min.

If a definitive diagnosis of compartment syndrome is made, then a fasciotomy should be performed without delay.

Discharge care

When the child is discharged from the hospital, the parent/carer should be taught how to assess the limb.

They should also be advised to return if there is increased pain or decreased range of finger movement.

It is important to provide parents with the following additional information:

  • The warning signs of compartment syndrome, circulatory problems and neurological deterioration
  • Hospital telephone number
  • Information brochure

Follow-up

AP and lateral x-rays may be taken to assess fracture position at intervals decided by the fracture configuration and age of patient.

Loss of reduction can be treated by conversion to internal fixation.

See also the additional material on complications.

Removal of cast or splint

Fractures treated by immobilization should have the cast or splint removed 2-4 weeks after the injury.

Clinical assessment and x-rays without cast are used to judge adequate healing.

Recovery of motion

As symptoms recover, the child should be encouraged to remove the sling and begin active movements of the elbow and forearm rotation. See also the additional material on elbow stiffness.

The majority of motion is recovered rapidly and within two months of cast or splint removal.

The older child may take a little longer.

Once the child is comfortable, with a nearly complete range of motion, (s)he may incrementally resume noncontact sports.

Resumption of unrestricted physical activity is a matter for judgment by the treating surgeon.

v1.0 2019-08-28