What is the treatment for a radius and ulna (R/U) fracture in an 11-year-old boy?

Treatment of Radius and Ulna Fracture in an 11-Year-Old Boy

For an 11-year-old boy with a radius and ulna fracture, treatment depends critically on the degree of displacement and fracture pattern, with most cases managed nonoperatively through closed reduction and immobilization, while significantly displaced or unstable fractures require surgical fixation. 1, 2

Initial Assessment and Classification

The first step is determining fracture displacement and stability through proper radiographic evaluation:

• Obtain at least 3 radiographic views (posteroanterior, lateral, and oblique) to fully characterize the fracture pattern 3
• Assess for significant displacement, defined as >3mm displacement or >10° of angulation 4
• Obtain a true lateral radiograph post-reduction to assess alignment and evaluate for distal radioulnar joint (DRUJ) involvement 5, 4
• Consider that fractures of the radius, ulna, tibia, fibula, or femur in children <1 year are suspicious for abuse, though at age 11 this is less of a concern 5

Treatment Algorithm Based on Fracture Characteristics

For Minimally Displaced or Non-Displaced Fractures:

• Closed reduction with immobilization is the primary treatment for most pediatric distal radius and ulna fractures 1, 2
• Removable splints are appropriate for minimally displaced fractures 4
• Rigid immobilization is preferred over removable splints for displaced fractures 4, 3
• Initial immobilization typically involves a sugar-tong splint followed by short-arm casting for a minimum of 3 weeks 1

For Significantly Displaced or Unstable Fractures:

• Surgical intervention is indicated for select cases with significant displacement, angulation, or instability 2
• Combined radius and ulna fractures with significant displacement generally require surgical correction 1
• The specific surgical approach depends on fracture pattern and may include K-wire fixation or plate fixation 2

Critical Early Management Steps

Immediately initiate active finger motion exercises following diagnosis to prevent finger stiffness, which is one of the most functionally disabling complications of forearm fractures 5, 4, 6:

• Finger motion does not adversely affect adequately stabilized fractures regarding reduction or healing 5
• Hand stiffness results from pain, swelling, cast obstruction, or patient apprehension 5
• Finger stiffness can be extremely difficult to treat after fracture healing and may require multiple therapy visits or additional surgery 5

Follow-Up Protocol

• Obtain follow-up radiographs at approximately 3 weeks and at the time of immobilization removal 3
• Reevaluate any patient with unremitting pain during follow-up, as this may indicate complications such as compartment syndrome, malunion, or DRUJ instability 5, 4, 6
• Consider repeat radiography if the patient experiences new trauma, pain score >6 on VAS scale, loss of range of motion, or neurovascular symptoms 6

Post-Immobilization Rehabilitation

• A home exercise program is an effective option for patients prescribed therapy after the immobilization period ends 5, 4, 6
• Studies comparing home exercise programs to supervised therapy showed no significant difference in outcomes for uncomplicated fractures 5

Important Caveats and Pitfalls

Watch for median nerve injury, which can complicate distal radius fractures 1:

• Assess median nerve function at initial presentation and throughout treatment
• Any new neurologic symptoms warrant immediate reevaluation

Consider growth potential and remodeling capacity in this age group 2:

• An 11-year-old boy has significant remaining growth and remodeling potential
• Acceptable alignment parameters are more generous in children than adults due to this remodeling capacity
• However, rotational malalignment does not remodel and must be corrected

Assess for DRUJ instability, which can lead to poor outcomes if missed 5, 4:

• DRUJ instability may not be apparent initially but can cause chronic pain and dysfunction
• True lateral radiographs are essential for identifying DRUJ dislocation

Avoid prolonged immobilization without finger motion, as this significantly increases the risk of permanent stiffness 5:

• This is a cost-effective intervention that dramatically impacts outcomes
• Instruct the patient and family at the first encounter about the importance of regular finger motion