1. General considerations

Plating is the standard technique for treating forearm fractures in adults and is therefore best considered for skeletally mature or nearly mature children.

Children with open physes have thick active periosteum favoring stability and rapid healing with the ESIN method. Where such techniques are unavailable plating may be used in younger children.

If technically possible, ESIN is biologically favored. If plating is used, soft-tissue and periosteal stripping of the bone should be minimized.

2. Principles

Introduction

Plating of pediatric forearm shaft fractures follows the technique for plate fixation in adults.

Both bones need to be fixed according to their fracture pattern.

Order of reduction and fixation

The order of fixation is a matter of surgeon preference.

Combination with other treatment options

Plating one bone can be combined with ESIN or external fixation of the other bone where clinically indicated.

This may be useful in open fractures, with unstable segmental fractures, or in situations where closed reduction cannot be obtained.

Choice of approach

The bones should be approached through separate incisions to prevent cross-union.

For proximal radial shaft fractures, the anterior approach (Henry) is most often used to minimize the risk of damage to the posterior interosseous nerve, which crosses the proximal radius within the supinator.

In mid and distal radial shaft fractures, either the anterior approach (Henry) or posterolateral approach (Thompson) can be used, depending on surgeon’s preference.

The ulna is exposed by the direct approach between the flexor and extensor muscle compartments.

3. Patient preparation

This procedure is normally performed with the patient in a supine position .

4. Reduction and fixation of the radius

The steps for radial fracture fixation are described in the relevant plating procedure for each fracture type:

• Plating for simple transverse fracture (22r-D/4.1)
• Plate and screw fixation for oblique or spiral fracture (22r-D/5.1 + 5.2)
• Bridge plating for unstable multifragmentary fracture (22r-D/4.2 + 5.2)

5. Reduction and fixation of the ulna

The steps for ulnar fracture fixation are described in the relevant plating procedure for each fracture type:

• Plating for simple transverse fracture (22u-D/4.1)
• Plate and screw fixation for oblique or spiral fracture (22u-D/5.1 + 5.2)
• Bridge plating for unstable multifragmentary fracture (22u-D/4.2 + 5.2)

6. Final assessment

Check the completed osteosynthesis with image intensification. These images should be retained for documentation or alternatively an x-ray should be obtained before discharge.

Make sure that the plate is at the correct location, the screws are of appropriate length and the desired reduction has been achieved.

Stabilize the elbow at the epicondyles and check the forearm rotation.