Executive Editor: James Hunter

General Editor: Fergal Monsell

Authors: Andrew Howard, Peter Schmittenbecher, Theddy Slongo

Pediatric forearm shaft 22r-D/4.1 - Closed reduction; cast or splint fixation

Aftercare following closed management

Duration of immobilization

Diaphyseal fractures of the radius and ulna usually require 4-6 weeks of immobilization for adequate callus formation (see also the additional material on healing times ).

Analgesia

Ibuprofen and paracetamol should be administered regularly during the first 4-5 days of injury, with additional oral narcotic medication for breakthrough pain.

If the level of pain is increasing the child should be examined.

Neurovascular examination

The child should be examined regularly, 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 are 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. Split the cast, along its full length, down to skin level.
  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:

For the first few days, the elbow and forearm can be elevated on a pillow, until swelling decreases and comfort returns.

When the limb is comfortable, the child may use a sling but many children are more comfortable without support.

Follow-up x-rays

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 cast wedging, further manipulation or conversion to internal fixation.

Removal of cast or splint

Fractures treated by closed reduction should have the cast removed 4-6 weeks after the injury.

Clinical assessment and x-rays without the 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 forearm.

The majority of forearm motion is recovered rapidly and within two months of cast 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.

Shaft fractures treated closed are at risk of refracture for 6 months after injury.

 

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v1.0 2018-11-28