What is the treatment for a midshaft radius fracture in a 9-year-old?

Treatment of Midshaft Radius Fracture in a 9-Year-Old Child

For a midshaft radius fracture in a 9-year-old child, closed reduction and cast immobilization is the recommended first-line treatment, with consideration of the Rang method (loop and sling proximal to the fracture site) to prevent redisplacement. 1

Initial Assessment and Management

• Obtain standard 3-view radiographs to evaluate the fracture pattern, displacement, and angulation 2
• Assess for associated ulnar fracture, as combined radius-ulna fractures are common in children
• Evaluate neurovascular status of the limb, particularly checking for median nerve injury which can complicate forearm fractures 3

Treatment Algorithm

For Minimally Displaced Fractures:

• Immobilize with a well-molded cast for 3-4 weeks
• Children under 10 years have excellent remodeling potential, allowing for acceptance of greater angulation (up to 15°) 1

For Completely Displaced Fractures:

1. Closed reduction and cast immobilization:

   • The Rang method (applying a loop and sling proximal to the fracture site) significantly reduces redisplacement rates (7% vs 63% with standard sling) 1
   • This technique is particularly valuable as traditional management of displaced midshaft fractures has redisplacement rates of 10-70%

2. Surgical options (if closed reduction fails or is unstable):

   • Percutaneous pinning with K-wires
   • Open reduction and internal fixation for unstable fractures or those with unacceptable alignment

Follow-up and Monitoring

• Obtain radiographs 7-10 days after initial treatment to ensure maintenance of reduction
• Monitor for loss of reduction, defined as >15° angulation in children under 10 years 1
• Progressive range of motion exercises should begin after the immobilization period 2
• Full recovery is typically expected within 6-8 weeks 2

Special Considerations

• Children have higher tolerance for immobilization and faster healing rates than adults, allowing for shorter immobilization periods 2
• Recent evidence suggests that even completely displaced distal radius fractures in children under 10 years can be treated without reduction with good functional outcomes 4
• The excellent remodeling potential in children under 10 years allows for acceptance of some displacement and angulation

Common Pitfalls to Avoid

• Failing to use the Rang method (loop and sling proximal to fracture) which significantly reduces redisplacement rates 1
• Unnecessary surgical intervention when closed management would suffice
• Inadequate immobilization leading to redisplacement
• Overlooking associated injuries, particularly ulnar fractures or nerve injuries
• Prolonged immobilization leading to stiffness - early active finger motion exercises should be encouraged 2

The evidence strongly supports that most pediatric midshaft radius fractures can be successfully managed with closed reduction and casting, with the Rang method offering superior outcomes in preventing redisplacement 1. Surgical intervention should be reserved for cases where acceptable alignment cannot be achieved or maintained through closed methods.