Proximal forearm fractures require control of forearm rotation to increase fracture stability.
Lower risk of stiffness
Easy to remove and reapply
Earlier functional use of arm
2. Immobilization with a sling
The injured arm is supported with an arm sling.
Pitfall: The sling should go around the shoulder and not the neck to avoid neck pain.
Alternative types of sling
Alternatively a broad arm sling may be used.
Some surgeons prefer greater stabilization of the arm to the body. This can be achieved by wrapping the arm as illustrated or using commercially available devices.
3. 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.
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.
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 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:
Remove or split constrictive dressings or casts.
Elevate the limb.
Encourage active finger movement.
Reexamine the child after 30 min.
If a definitive diagnosis of compartment syndrome is made, then a fasciotomy should be performed without delay.
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
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.