What is the treatment for an ulnar fracture in a child?

Treatment of Pediatric Ulnar Fractures

The treatment of pediatric ulnar fractures should be based on fracture location, displacement, and stability, with most uncomplicated fractures managed effectively with closed reduction and immobilization, while unstable or significantly displaced fractures may require surgical fixation.

Assessment and Classification

• Determine fracture characteristics:
  • Location (proximal, midshaft, distal)
  • Displacement (none, minimal, significant)
  • Angulation (degree and direction)
  • Associated injuries (especially radius fractures)
  • Open vs. closed fracture

Treatment Algorithm

Isolated Ulnar Shaft Fractures

1. Minimally displaced or non-displaced fractures:

   • Initial immobilization with sugar-tong splint
   • Conversion to long-arm cast at first follow-up visit (typically 1 week)
   • Total immobilization period of 4-6 weeks 1
   • Sugar-tong splinting has shown excellent results in maintaining reduction while avoiding issues associated with circumferential casting 1

2. Displaced/unstable fractures:

   • Closed reduction under appropriate sedation/anesthesia
   • If reduction is stable: immobilization as above
   • If reduction is unstable: surgical fixation with flexible intramedullary nailing 2

Both-Bone Forearm Fractures (Radius and Ulna)

1. Closed reduction and casting for:

   • Minimally displaced fractures
   • Stable reductions
   • Acceptable alignment

2. Surgical fixation for:

   • Unstable fractures
   • Failed closed reduction
   • Significant displacement
   • Technique: Flexible intramedullary fixation with 1/8th inch Rush rod for ulna 2

Distal Ulnar Physeal Fractures

• Require special attention due to risk of growth disturbance
• Growth arrest occurs in approximately 20% of distal ulnar physeal fractures 3
• Higher risk factors for growth disturbance:
  • Displaced fractures (34.8% vs. 3.2% in non-displaced)
  • Salter-Harris type III/IV fractures (50% vs. 11.1% in type I/II)
  • Children with less than 2 years of skeletal growth remaining (46.2% vs. 9.5%) 3
• Treatment:
  • Anatomic reduction (open reduction if necessary)
  • Close follow-up for at least 6 months to monitor for growth disturbance

Follow-up Protocol

• Initial follow-up at 1 week to check for loss of reduction
• Subsequent follow-up at 2,4, and 6 weeks 1
• 90% of loss of reduction occurs within first 2 weeks 1
• For physeal fractures, extended follow-up (minimum 6 months) to monitor for growth disturbance 3

Complications to Monitor

• Loss of reduction (most common in first 2 weeks)
• Malunion
• Growth arrest (especially with physeal fractures)
• Decreased range of motion
• Compartment syndrome (rare)

Special Considerations

• Isolated ulnar shaft fractures in older children may heal more quickly with early mobilization rather than prolonged immobilization 4
• Distal ulnar physeal fractures require closer monitoring in:
  • Displaced fractures
  • Intra-articular fractures
  • Fractures requiring open reduction
  • Older children approaching skeletal maturity 3

The American Academy of Orthopaedic Surgeons provides guidelines primarily for supracondylar humerus fractures in children, but the principles of fracture management can be applied to ulnar fractures 5, 6. The evidence suggests that most pediatric ulnar fractures can be successfully managed with appropriate immobilization, with surgical intervention reserved for unstable or significantly displaced fractures.