What is the management of a both-bone forearm fracture with initial 20-degree angulation that has been reduced to an acceptable position?

From the Guidelines

Immobilization with a long arm cast is the recommended management approach for a both bone forearm fracture that has been reduced from a 20-degree angulation to an acceptable position, as it allows for proper healing and preservation of forearm rotation and function. The management of such fractures involves immobilizing the forearm in neutral rotation to prevent malunion and preserve pronation-supination function, as noted in general fracture management principles 1. Key considerations in the management of this type of fracture include:

• Immobilization: A long arm cast is typically used for 6-8 weeks to maintain the forearm in the correct position.
• Pain management: Acetaminophen 650-1000mg every 6 hours or ibuprofen 400-600mg every 6-8 hours can be used as needed for the first 1-2 weeks.
• Rehabilitation: After cast removal, a progressive rehabilitation program should be initiated, including range of motion exercises and gradual strengthening.
• Follow-up: Regular follow-up radiographs at 1-2 weeks, 4-6 weeks, and 3 months are essential to monitor healing and alignment. The principle of immobilization is supported by the idea that fracture immobilization is an essential part of definitive fracture treatment, although the specific benefits of splinting in the prehospital setting are not clearly established 1. In the context of a reduced fracture, the focus shifts to maintaining the reduction and allowing the fracture to heal, which can be achieved through immobilization and appropriate follow-up care. It is also important for patients to be advised to elevate the limb above heart level for the first few days to reduce swelling and to immediately report increased pain, numbness, or color changes in the fingers, as these could indicate complications such as poor perfusion to the extremity 1.

From the Research

Management of Both-Bone Forearm Fracture

• The management of both-bone forearm fractures with 20 degree angulation that has been reduced to an acceptable position can be approached through nonoperative treatment, such as closed reduction and casting 2.
• According to a study published in the Journal of Pediatric Orthopedics, the thresholds for maximum acceptable angulation for pediatric patients are as follows: 10 degrees for proximal-third, 15 degrees for middle-third, and 20 degrees for distal-third fractures 2.
• The use of casts and splints is generally limited to the short term to minimize complications such as chronic pain, joint stiffness, and muscle atrophy 3.
• It is essential to monitor patients carefully to ensure proper recovery and to avoid complications such as forearm compartment syndrome, which can have devastating consequences 4.

Treatment Options

• Closed reduction and casting is a common treatment option for pediatric forearm fractures, but the outcomes can be variable 2.
• Operative fixation, such as intramedullary nailing or plating, is also an option, but it comes with a significantly increased complication rate 5.
• The ideal treatment approach would depend on various factors, including the patient's age, fracture location, and degree of angulation 2, 5.

Complications and Monitoring

• Complications such as forearm compartment syndrome can occur, and early diagnosis and decompressive fasciotomy are essential for treatment 4.
• Patients who are placed in a splint or cast require careful monitoring to ensure proper recovery and to minimize complications 3.
• The use of validated functional outcome tools can help define the complications from each treatment and guide evidence-based decision-making 5.