Discovery Diary: Unlocking Success in Treating Kids’ Forearm Fractures: What Can We Improve?

Published in Journal of Children’s Orthopaedics
Unlocking Success in Treating Kids’ Forearm Fractures:
What Can We Improve?
from the Desks of Rachel Thompson,
MD and Mauricio Silva, MD

Distal third forearm fractures are common in children and are typically treated with closed reduction and casting. Unfortunately, some patients fail initial non-operative management of these fractures, necessitating further intervention. This study’s aim was to identify independent risk factors associated with subsequent loss of reduction following successful initial closed management in children with distal third forearm fractures.

This study was a retrospective review of 207 children treated with closed reduction and casting for distal third forearm fractures at a dedicated children’s hospital between 2019 and 2021. Patients were divided into two groups: those who were successfully managed with closed reduction, and those who ultimately failed non-operative management.

Eight percent of subjects experienced a loss of reduction in this study. After multivariate analysis including demographic characteristics, cast type, cast index, radiographic fracture, soft tissue characteristics, and quality of reduction-the study identified two independent risk factors for closed reduction failure: larger soft tissue envelope at the fracture site and immobilization with a long arm (vs forearm) cast immobilization.

A larger soft tissue envelope at the fracture site can make it more difficult to achieve and maintain a good reduction because the soft tissue may make it difficult to successfully manipulate the fracture through the surrounding soft tissue. Additionally, a larger soft tissue envelope my represent transient swelling that, once resolved, results in a loose-fitting cast, which may lead to loss of reduction. Long arm casts restrict the range of motion of the forearm, which can lead to muscle atrophy and weakening, making it potentially more difficult for the muscles to maintain the reduction.

The findings of this study are significant and should lead to a higher rate of success when it comes to closed reduction and casting for children experiencing distal forearm fractures. Clinicians will be able to look to this study and mitigate future failures by choosing to use short arm casts whenever possible and closely studying the soft tissue enveloping a fracture.

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