Forearm fractures are common injuries in pediatric patients, and the vast majority are managed successfully with closed reduction and external immobilization.1,2 Multiple methods of external immobilization have been recommended, including long-arm casting, short-arm casting, and a variety of splinting techniques.2
Recently, the authors reviewed 2 cohorts of pediatric patients with forearm fractures. These groups included patients with fractures of the proximal, middle, and distal thirds of the radius and ulna that were managed with closed reduction and immobilization in either a single sugar-tong splint (SSTS) or a long-arm cast (LAC). No difference in the need for repeat intervention was revealed between the 2 groups.3
Fractures involving the proximal or middle third of the forearm may be more unstable and have less remodeling potential than those involving the distal forearm.4,5 Traditional teaching and pediatric orthopedic texts generally recommend use of LAC in such patients.6–8 To the authors' knowledge, no study has compared the efficacy of SSTS vs LAC for definitive treatment after closed reduction of displaced midshaft or proximal pediatric forearm fractures. This study compared maintenance of alignment and the rate of secondary intervention in pediatric patients with displaced midshaft or proximal forearm fractures managed with SSTS or LAC.
Materials and Methods
After receiving institutional review board approval, a retrospective chart and radiographic review was performed of all pediatric patients with a forearm fracture treated between January 2011 and June 2016 at a single level 1 academic medical center. Inclusion criteria for this cohort included children ages 3 through 15 years who presented with a midshaft or proximal shaft forearm fracture of the radius, ulna, or both and underwent closed reduction and external immobilization in the emergency department under conscious sedation.
Exclusion criteria were patients younger than 3 years or older than 15 years at the time of injury, fractures that did not require or undergo reduction, fractures that involved the distal third of the forearm, open fractures, and Monteggia fracture or dislocations. Patients without a minimum of 4 weeks of radiographic follow-up after reduction, those who presented with a refracture, or those who underwent index reduction at another facility also were excluded.
Orthopedic residents performed the fracture reduction and splint or cast application in an emergency department setting using conscious sedation techniques. The decision to use either a LAC or SSTS was at the discretion of the orthopedic team on call. Most LACs were bivalved to accommodate future swelling.
Patients were examined at 1, 2, and 4 weeks after injury, and anteroposterior and lateral radiographs were obtained at each visit. At the 1-week follow-up visit, all bivalved LAC and all SSTS were over-wrapped. Residual fracture alignment at 4-week follow-up and any repeat intervention events were recorded. Four weeks after reduction was chosen as the final data point, as this was thought to represent the time point after which there would be minimal risk of further change in fracture alignment.9 Data analysis was conducted using the Statistical Package for the Social Sciences (SPSS Statistics, version 23; IBM Corporation). Chi-square, Fisher exact test, and independent and dependent t tests were used as appropriate to compare the LAC and SSTS groups.
Several of the patients in the current cohort were included in a prior study3 that compared the efficacy of SSTS with LAC for maintenance of reduction in a nonconsecutive cohort of pediatric forearm fractures of all locations (proximal, midshaft, and distal). In contrast, the current study was a consecutive investigation of all patients during a 6-year period exclusively with a midshaft or proximal third fracture location.
A total of 121 patients (83 males and 38 females) with a midshaft or proximal forearm fracture were evaluated (70 LAC, 51 SSTS). There were no statistical differences between the groups regarding age (LAC, 7.3±2.8 years; SSTS, 7.4±2.7 years; P=.95), sex (P=.41), or body mass index (LAC, 16.5±2.5 kg/m2; SSTS, 17.6±4.6 kg/m2; P=.12).
Fracture location was midshaft in 114 (94%) of the patients, and proximal fractures were essentially equivalent in the 2 cohorts (4 of 70 LAC and 3 of 51 SSTS; P=.16). For all 121 patients, the mean initial injury sagittal angulation was 25°±11°, and the mean initial injury coronal angulation was 13°±11°.
Some of these patients were included in a prior study that used data from a similar time period at the same institution.3 In that study, 100 pediatric forearm fractures at all anatomic levels were reviewed. There were 57 distal forearm fractures in that group, and the remaining 43 midshaft or proximal forearm fractures were included in the current cohort.
For all patients, there was a significant improvement in alignment from pre-reduction to initial reduction in the sagittal (25° to 8°, P=.001) and coronal (13° to 5°, P=.001) planes. At 4-week follow-up, there were no statistically significant differences between the 2 groups in the mean sagittal (10° for LAC vs 8° for SSTS; P=.5) or coronal (6° for both LAC and SSTS; P=.68) planes. Mean coronal and sagittal angular deformities at the 3 time points, stratified by LAC or SSTS, are compared in Table 1.
Radiographic Measurements at Injury, After Reduction, and at 4-Week Follow-up
Nine patients underwent secondary intervention after the index reduction (LAC, 7 of 70; SSTS, 2 of 51), with no statistical difference between groups regarding the need for repeat intervention (P=.30). Details of the 9 cases that required secondary intervention are provided in Table 2.
Clinical Details of Patients Who Underwent Repeat Manipulation
Forearm fractures are common injuries in pediatric patients, and unlike similar fractures in adults, the majority are treated successfully with closed reduction and immobilization.10 Restoration and maintenance of precise anatomic alignment of these fractures in children are not necessary due to the known remodeling potential of the immature skeleton, with greater remodeling expected in younger patients. Some amount of residual angulation in both the coronal and sagittal planes can be accepted while still achieving excellent clinical and functional results.4
The literature demonstrates the majority of pediatric forearm fractures that undergo closed management achieve satisfactory results.4,6,7,10 Immobilization with a LAC has been recommended most frequently for pediatric forearm fractures, particularly those involving the midshaft or proximal shaft, which are considered to be more unstable and at potentially greater risk of redisplacement.7 Other options include a short-arm cast11 or double sugar-tong12 or single sugar-tong13 splints.
There are multiple studies comparing the use of LAC vs different splinting methods in the management of pediatric forearm fractures. However, the vast majority of the studies within the English literature have included either fractures at all anatomic levels (distal, middle, and proximal) or have focused exclusively on distal forearm fractures, as in the reports of Webb et al,14 Bohm et al,11 Acree et al,15 and Denes et al.13
The current authors recently reported a series comparing patients with forearm fractures involving all anatomic locations that were managed with either LAC or SSTS.3 The findings of the study demonstrated equivalent maintenance of reduction and rate of secondary intervention between the 2 types of immobilization for pediatric forearm fractures. The clinical equipoise between treatment methods renders the use of an SSTS as a valid treatment option. These findings are supported by recent work from Dittmer et al,9 who reported on the efficacy of SSTS for maintenance of reduction in 293 forearm fractures. They concluded an SSTS was an acceptable method of immobilization, reporting a rate of radiographic loss of reduction of 38% and a need for secondary intervention of 17.8%. Radiographic loss of reduction in that series was associated most commonly with distal radius fractures.
In the current study, the authors did not quantify explicit parameters for radiographic loss of reduction. Instead, the incidence of secondary intervention was used as a surrogate for clinically significant loss of reduction. They found the incidence of secondary intervention of SSTS patients was markedly lower than that reported by Dittmer et al,9 occurring in 6% of patients in the authors' earlier study3 and 4% in the current cohort.
Use of an SSTS, rather than a LAC, for immobilization of pediatric forearm fractures after closed reduction poses multiple potential advantages. These include greater ease and teaching of SSTS vs LAC application and removal, better use of the involved hand by the patient for activities of daily living, and less of a tendency for fracture sag along the ulnar border, as well as limiting the risks inherent in the use of a circumferential cast in patients with an acute fracture. Anecdotally, residents at the authors' institution prefer SSTS due to ease of application. Although some literature supports cost savings with initial short arm cast application over SSTS with later overwrapping,15 those findings were derived only from management of distal radius fractures.
Review of the current patient cohorts (LAC and SSTS) included only those with middle and proximal third fractures. The patient groups were well matched in both coronal and sagittal plane alignment before and after reduction. In addition, the 2 groups showed no statistically significant differences in initial postreduction angulation in either plane, and both groups were matched statistically for age, sex, body mass index, and mechanism of injury. There were no significant differences at the 4-week postinjury mark in coronal or sagittal alignment between patients managed with either a LAC or SSTS. Most importantly, there was no statistical difference between the 2 cohorts regarding the incidence of secondary intervention. Given these findings, it appears that pediatric fractures involving the middle and proximal third of the forearm can be managed effectively and equivalently with immobilization using either a LAC or SSTS after closed reduction.
Four-week follow-up was chosen as the endpoint of this study because it appears to be the time after which further change in fracture alignment is unlikely to occur in pediatric patients. Dittmer et al9 confirmed this assumption when they demonstrated that 90% of the patients who had loss of reduction in their review of pediatric forearm fractures did so in the first 2 weeks after initial injury. The majority of patients who underwent secondary intervention in the current series did so at approximately 2½ weeks or less. The only outlier was patient 7, who underwent open treatment of his fracture 40 days following initial reduction. This was a skeletally mature male who expressed a desire to return to contact sports more quickly. Internal fixation was performed with the goal of expediting his time to stability and possible return to activity.
This study had several limitations. As noted previously, several patients in this cohort were included in a prior evaluation of these treatment options for all anatomic regions of pediatric forearm fractures.3 The authors do not believe the inclusion of these patients compromised the validity or integrity of the comparison currently reported. Only patients with middle and proximal third fractures from the earlier study were part of the current cohort, which was expanded by the addition of a consecutive list of patients managed during an expanded data collection period.
Other concerns include those inherent to the retrospective nature of the study, as well as the potential for missing patients and incomplete records. Furthermore, although guidelines for acceptable alignment of pediatric forearm fractures are well described in the literature,4,5,7,16 the diversity of tolerance of acceptable radiographic parameters by the multiple clinicians in this study may have influenced the decision to proceed with repeat manipulation.11,17 The authors acknowledge this lack of standardization in decision-making as a potential limitation.
There were no statistically significant differences in loss of reduction or the incidence of repeat manipulation between patients with displaced pediatric middle and proximal third forearm fractures managed with either LAC or SSTS after closed reduction. Both SSTS and LAC appear to be equivalent and acceptable methods of immobilization for these fractures after nonoperative reduction.
- Chung KC, Spilson SV. The frequency and epidemiology of hand and forearm fractures in the United States. J Hand Surg Am. 2001;26(5):908–915. doi:10.1053/jhsu.2001.26322 [CrossRef] PMID:11561245
- Cheng JC, Ng BK, Ying SY, Lam PK. A 10-year study of the changes in the pattern and treatment of 6,493 fractures. J Pediatr Orthop. 1999;19(3):344–350. doi:10.1097/01241398-199905000-00011 [CrossRef] PMID:10344317
- Murphy RF, Plumblee L, Sleasman B, Barfield W, Dow MA, Mooney JF III, . Clinical and radiographic comparison of single-sugar-tong splint to long-arm cast immobilization for pediatric forearm fractures. J Pediatr Orthop B. 2019;28(6):549–552. doi:10.1097/BPB.0000000000000572 [CrossRef] PMID:30531491
- Noonan KJ, Price CT. Forearm and distal radius fractures in children. J Am Acad Orthop Surg. 1998;6(3):146–156. doi:10.5435/00124635-199805000-00002 [CrossRef] PMID:9689186
- Price CT. Surgical management of forearm and distal radius fractures in children and adolescents. Instr Course Lect. 2008;57:509–514. PMID:18399605
- Lovell WW, Weinstein SL, Flynn JM. Lovell and Winter's Pediatric Orthopaedics. 7th ed. Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014.
- Flynn JM, Skaggs DL, Waters PM. Rockwood & Wilkins' Fractures in Children. 8th ed. Wolters Kluwer Health; 2014.
- Runyon RS, Doyle SM. When is it ok to use a splint versus cast and what remodeling can one expect for common pediatric forearm fractures. Curr Opin Pediatr. 2017;29(1):46–54. doi:10.1097/MOP.0000000000000435 [CrossRef] PMID:27870687
- Dittmer AJ, Molina DT IV, Jacobs CA, Walker J, Muchow RD. Pediatric forearm fractures are effectively immobilized with a sugar-tong splint following closed reduction. J Pediatr Orthop. 2019;39(4):e245–e247. doi:10.1097/BPO.0000000000001291 [CrossRef] PMID:30839473
- Jones K, Weiner DS. The management of forearm fractures in children: a plea for conservatism. J Pediatr Orthop. 1999;19(6):811–815. doi:10.1097/01241398-199911000-00021 [CrossRef] PMID:10573354
- Bohm ER, Bubbar V, Yong Hing K, Dzus A. Above and below-the-elbow plaster casts for distal forearm fractures in children: a randomized controlled trial. J Bone Joint Surg Am. 2006;88(1):1–8. doi:10.2106/JBJS.E.00320 [CrossRef] PMID:16391243
- Levy J, Ernat J, Song D, Cook JB, Judd D, Shaha S. Outcomes of long-arm casting versus double-sugar-tong splinting of acute pediatric distal forearm fractures. J Pediatr Orthop. 2015;35(1):11–17. doi:10.1097/BPO.0000000000000196 [CrossRef] PMID:24787302
- Denes AE Jr, Goding R, Tamborlane J, Schwartz E. Maintenance of reduction of pediatric distal radius fractures with a sugar-tong splint. Am J Orthop (Belle Mead NJ). 2007;36(2):68–70. PMID:17405634
- Webb GR, Galpin RD, Armstrong DG. Comparison of short and long arm plaster casts for displaced fractures in the distal third of the forearm in children. J Bone Joint Surg Am. 2006;88(1):9–17. PMID:16391244
- Acree JS, Schlechter J, Buzin S. Cost analysis and performance in distal pediatric forearm fractures: is a short-arm cast superior to a sugar-tong splint?J Pediatr Orthop B. 2017;26(5):424–428. doi:10.1097/BPB.0000000000000382 [CrossRef] PMID:27602915
- Zionts LE, Zalavras CG, Gerhardt MB. Closed treatment of displaced diaphyseal both-bone forearm fractures in older children and adolescents. J Pediatr Orthop. 2005;25(4):507–512. doi:10.1097/01.bpo.0000158005.53671.c4 [CrossRef] PMID:15958905
- Boyer BA, Overton B, Schrader W, Riley P, Fleissner P. Position of immobilization for pediatric forearm fractures. J Pediatr Orthop. 2002;22(2):185–187. doi:10.1097/01241398-200203000-00010 [CrossRef] PMID:11856927
Radiographic Measurements at Injury, After Reduction, and at 4-Week Follow-up
|At 4 weeks|
Clinical Details of Patients Who Underwent Repeat Manipulation
|Patient no./age, y/sex||Immobilization||Location||Intervention||Time from reduction to intervention, d|
|1/8/M||Cast||Midshaft both bones||In office cast wedge||11|
|2/10/F||Cast||Midshaft both bones||In OR repeat manipulation||4|
|3/13/M||Cast||Midshaft both bones||ORIF||7|
|4/13/M||Cast||Midshaft both bones||Flex nail||8|
|5/14/M||Cast||Midshaft both bones||ORIF||40|
|6/6/F||Cast||Proximal both bones||Flex nail||18|
|7/9/M||Cast||Proximal both bones||Manipulation in OR||1|
|8/10/F||Splint||Midshaft both bones||ORIF||11|
|9/8/M||Splint||Midshaft both bones||In office cast wedge||18|