Open reduction; plate fixation

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.

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.

The order of fixation is a matter of surgeon preference.

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.

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.

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

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)

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)

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.

Whilst the child remains in bed, the forearm should be elevated on pillows to reduce swelling and pain.

Plate fixation of forearm fractures is intrinsically stable and supplementary casting or splinting is therefore not required.

Some surgeons prefer a long or short splint for 2-3 weeks postoperatively for comfort.

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.

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.

See also the additional material on postoperative infection.

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:

1. If the child is in a cast, 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 from hospital follows local practice and is usually possible after 1-3 days.

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

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

The arm can be placed in a sling for a few days until the patient is pain free. Many children are more comfortable without support.

Early movement of the forearm should be encouraged as soon as the patient is pain free.

Formal physiotherapy is normally not indicated, but children should have a sheet of exercises to stimulate mobilization.

The first clinical and radiological follow-up depends on the age of the child and is usually undertaken 4 weeks postoperatively.

At this point, the child should be able to move the forearm almost fully.

AP and lateral x-rays are required.

See also the additional material on healing times.

Plate removal is delayed for at least 6 months.

An asymptomatic plate that does not interfere with forearm rotation can be left in place minimizing complications associated with implant removal.