200 Review article
The shaft fractures of the radius and ulna in children: current
concepts
Juha-Jaakko Sinikumpu and Willy Serlo
The incidence of forearm shaft fractures in children has
increased in recent years. They are challenging to treat and
they can result in several long-lasting complications. The
treatment of children’s fractures needs to be individualized
to their needs. Nonoperative care will be satisfactory for
young, preschool children and it is primarily treatment in
stable fractures of children at every age. Injury mechanism
must be understood to perform appropriate closed
reduction. Immobilization using a long-arm cast needs to be
focused against the deforming muscle forces – in particular
those that rotate – in the forearm, keeping the bones in
alignment until bone healing. Operative stabilization by
elastic stable intramedullary nailing is the primarily method
of treatment in cases of unstable fractures, in particular, in
children between preschool age and adolescence. For older
children near to skeletal maturity, a rigid plate and screw
fixation will be justified. The most common complication
after closed treatment is worsening of the alignment and
Introduction
The shaft fractures of the radius and ulna cover 5–10% of
all bone fractures in children [1,2]. Their incidence has
increased markedly in recent years [3,4]. The fractures are
most common in the summer months. A wide majority
(90%) of the fractures occur outdoors and dry weather
increases the risk of fractures by 50% compared with rainy
days [5]. The surgical treatment of forearm shaft fractures
in children has also increased [6]: the incidence of elastic
stable intramedullary nailing (ESIN) increased from 13 to
53% in 2000–2009 [4]. There is no doubt that forearm
shaft fractures are potentially harmful and challenging to
manage [7]. They are unique and they differ from frac-
tures of any other long bones [8]. They are one of the few
paediatric fractures that show a real risk of complications
and prolonged morbidity [9].
The goal of this review article was to comprehensively
clarify the shaft fractures of the radius and ulna in a
population with growing bones, focusing on the recent
published evidence of treatment and outcome of these
fractures, still complemented by authors’ preferred
methods of diagnosis and treatment. For this purpose, a
computerized literature search was performed using
‘forearm’, ‘shaft’, ‘fracture’, ‘children’ and ‘adolescents’ as
the keywords in PubMed and OvidMedline databases
covering English publications. The reference lists of the
identified articles were reviewed for any valid articles not
found in the search.
1060-152X Copyright © 2015 Wolters Kluwer Health, Inc. All rights reserved.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
need for repetitive interventions. elastic stable
intramedullary nailing results usually in good outcome, and
range of forearm rotation is the main feature determining
the clinical result. In this article, we report the current
concept of paediatric shaft fractures in the radius
and ulna. J Pediatr Orthop B 24:200–206 Copyright © 2015
Wolters Kluwer Health, Inc. All rights reserved.
Journal of Pediatric Orthopaedics B 2015, 24:200–206
Keywords: children and adolescents, forearm shaft, fracture, radius and ulna,
treatment
Department of Paediatric Surgery and Orthopaedics, Oulu University Hospital,
Oulu, Finland
Correspondence to Juha-Jaakko Sinikumpu, MD, PhD, Department of Paediatric
Surgery and Orthopaedics, Oulu University Hospital, FIN-90029 OYS Oulu,
Finland
Tel: + 358 8 3155835; fax: + 358 8 315 4499;
e-mail: juha-jaakko.sinikumpu@ppshp.fi
Functional anatomy of the forearm
Forearm is an essential shank that improves the extent of
the upper extremity, allowing one to bring the hand towards
the trunk. Further, it is a nonsynovial joint with a wide range
of motion (∼170°) [10]. Rotational movement is based on
a defined geography of both forearm bones; the ulna is near
to the straight axle around which the curved radius swings
[11,12]. The hand moves in connection with the radius
because of the radiocarpal joint between the radius and
carpal bones. The muscles responsible for forearm move-
ments are located in the forearm, except from the brachialis
muscle, which is a strong supinator. Another purpose of the
forearm is to transmit load from the hand upwards to the
humerus. This occurs by a peculiar mechanism, in which
most load (60–95%) transmits from the radius to the ulna
along the central band of the interosseus membrane [13,14].
Injury mechanism and the types of the fractures
Forearm shaft fractures usually occur because of indirect
trauma. The shaft consists mostly of the cortical bone,
which means that it is strong and requires great trauma
energy to damage compared with the metaphysis [15].
Typically, a child protects himself/herself by an out-
stretched upper extremity when falling [16]. In that
moment, the hand is usually pronated, which leads to rapid
supination of the forearm during landing. The radius
absorbs the highest load and most usually breaks first,
resulting in dorsal bending. The distal fracture part then
DOI: 10.1097/BPB.0000000000000162

Fig. 1
The most typical mechanism of injury resulting in children’s forearm shaft
fractures is falling down while a child protects himself or herself with an
outstretched, pronated upper arm. At the time of crash, the pronated
forearm will absorb the trauma energy (arrow) and suddenly fracture to a
supination position and bend dorsally.
turns to supination (Fig. 1) [17]. A fracture with opposite
pronation deformation and volar angular deformation may
follow an injury in which a child falls over his/her supinated
forearm. Forearm shaft fractures involve both the radius
and the ulna in most cases. A direct blow, for example, in
connection with traffic injury may lead to an isolated
single-bone fracture [16]. A typical type of the forearm
fracture is greenstick among younger children and com-
pleted or short oblique fractures in older children [16].
Comminuted fractures or bowing fractures are unusual.
Findings and investigations
Visible deformity, tenderness and decreased range of
movements are the best clinical signs of forearm shaft
fractures [18]. A slightly deformed forearm fracture may
be less easy to investigate in younger, nonverbal chil-
dren, who present only discomfort with motions and
limited activity [16]. Diagnosis is always made on the
basis of radiographs. Anteroposterior and lateral projec-
tions are to be obtained and both the wrist and the elbow
joints should be captured in the plain films [15]. It must
be kept in mind that maximum angulation of the fracture
may exceed the angulation seen on two separate radio-
graphic views [19]. A mismatch of the cortices on both
sides of the fractured bone is indicative of rotational
deformity (Fig. 2). Also, rotation is evaluated by com-
paring the bicipital tuberosity and the radial styloid,
which normally lie 180° from each other [20]. Disruption
of radial bowing is radiographically determined by ante-
roposterior projection [21]. For differential diagnosis, not
only two-bone fractures but also possible fracture dis-
locations can be identified in the plain radiographs:
Monteggia fracture dislocation includes a dislocation of
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
The shaft fractures of radius and ulna Sinikumpu and Serlo 201
Fig. 2
Bicipital
tuberosity
Radial
styloid
process Rotation
Radiography
Rotational deformity of the forearm shaft fracture may be evaluated in
radiographs by recognizing a possible mismatch of cortices’ diameters
in the fracture parts, a ‘wedge’ in the normally smooth silhouettes of the
bones and changed directions of the bicipital tuberosity and the radial
styloid process that normally lie 180° from each other. The illustration
was first published in the series Acta ([20]) and reproduced by
permission of the publisher (University of Oulu, Finland).
the radial head accompanied by a fracture or plastic
deformation of the ulna. Galeazzi fracture dislocation
consists of a radius fracture with a concominant disloca-
tion at the distal radioulnar joint [22].
Aims of treatment
The most important clinical aim is to restore the rotational
range of motion in the forearm in the long term, while
minimizing complications [23,24]. In practice, the primary
aim is to secure ossification of the fractures in good
alignment. Spontaneous remodelling of the long bones
can be considered as a part of treatment: however, the
capacity of remodelling should not be overestimated as
the angular deformation will correct spontaneously not
more than 1° in a year until skeletal maturity [25].
Accepted alignment in children’s forearm shaft fractures is
therefore related to the age of the patient. Not more than
10°–15° of angulation or 5°–10° of angulation should be
accepted in children less than 8 years of age or of 8 years
of age or more, respectively [26,27]. Displacement should
be accepted not more than that of bone diameter and
rotational malformation under 45° and 30° in children less
than 9 years and more than 9 years of age [28]. If full
displacement is accepted, no more than 10 mm shortening
should be accepted. The more proximal the shaft fracture,
the closer the anatomic reduction required. (Table 1).
202 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 3

Table 1 Acceptable alignment and displacement of forearm shaft treatment’ [2]. Complete diaphyseal fractures, especially
fractures in children according to patients’ age
those that are oblique, occur on the same level or show
< 8 years of age ≥ 8 years of age huge displacement (>10 mm), as well as greenstick frac-
Angular deformitya (deg.) < 10–15 < 5–10 tures with a large (>45°) angular curve may justify primarily
Rotational deformity (deg.) < 45 < 30 surgical osteosynthesis [2,7,36,37]. The latter use to change
Translation (%) ≤ 100 < 100
Shorteningb (mm) <10 – from semistable to unstable beyond appropriate alignment,
because of a relatively violent reduction is usually neces-
a
In any direction.
b
In case total displacement of the fracture is accepted.
sary. Instability of the bones justifying internal fixation
should be determined in every case not earlier than during
the treatment because stability of fractures can only be
The principle of fracture reduction assessed intraoperatively as radiographs are a poor guide for
In children, fracture reduction is usually performed under this [2]. Evidently clear indications for operative treatment
general anaesthesia. Incomplete greenstick and bowing are open fractures, segmental (comminuted) fractures,
fractures will be reduced closed without traction [29]. concominant dislocation, floating elbow and fractures with
During reduction, the physician has to understand the severe soft-tissue complications.
injury mechanism: the reduction is performed by
Patients’ age affects the treatment strategy; children of pre-
‘reversing’ the bones to their anatomic form following the
school age are not usually treated by any osteosynthesis [38].
opposite course than the previous injury. Therefore, for
School-age children are most commonly operated by ESIN,
supination fractures, the distal part needs to be pronated,
which is the primary method for osteosynthesis in children’s
which usually also corrects dorsal angular deformity [30].
forearm shaft fractures in that age group [16,39–41].
In pronation fractures, the distal part is reduced by
Complications of ESIN are more frequent in children older
supinating it. A proper angular deformity of the bones is
than 10 years of age compared with younger children [42]. At
straightened using a three-point manoeuvre. There are
least 80% of all forearm fractures requiring operative stabili-
opposite recommendations for the completion of a
zation are treated by ESIN nowadays [43]. In practice, the
greenstick fracture: some suggest completion to avoid
nails are chosen to be about 40% in diameter compared with
further deformation as a result of the inherent spring,
the smallest diameter of the intramedullary canal. Thin nails
whereas others advise maintaining it intact to increase
by themselves confer unsatisfactory stability for the fractured
stability, as do the authors, too [16,28]. Complete frac-
bone [25,44]. However, satisfactory stability is based on
tures require sustained traction to overcome muscle
bending of the nails; bent thin nails in both bones together
spasm and to correct possible shortening. In the unstable
establish a tension frame around the fracture in the entire
fractures, traction itself may also result in spontaneous
forearm [7] (Fig. 3). ESIN still allow a micromovement over
reduction of possible rotational malformation [31].
the fracture that may contribute towards ossification [45].
After achieving good alignment, a long-arm cast over ESIN is usually made of titanium or stainless steel. There is a
elbow-in-flexion is recommended [27,30]. Elbow in new innovative technique, BESIN (biodegradable-elastic-
extension can yield a good outcome, but it is impractical stable-intramedullary-nailing), under on-going clinical eva-
[30]. Plaster of Paris is the most universal material widely luations [46].
available, but modern synthetic casts are also available.
Adolescents nearing skeletal maturity will be treated like
The cast should be a wide enough splint to cover both
adults with a rigid plate and screw fixation to achieve
volar and dorsal sides of the forearm and applying
a hairline reduction using a suitable surgical approach
appropriate corrective pressure against malalignment [20,
[47,48]. The functional outcome of the plate fixation is as
32]. The cast should also take control of separation of the
good as that of ESIN [49,50]. The risk of complications
radius and ulna to maintain tension on the interosseus
after plating has been reported to be similar to that after
membrane and to protect the interosseus space from
ESIN [51,52]. However, the aesthetic result used to be
collapse [16]. Casting is aimed at neutralizing deforming
worse after plating as a result of generally longer incisions
muscle forces, in particular, supinator and pronation
with plating compared with more mini-invasive techni-
muscles around the fracture until it has healed [11,33,34].
ques. Irrespective of satisfactory results, only 5% of the
Usually, all the fractures in the proximal third can be
fractures have been stabilized by plate and screw fixation
immobilized in the supination position, those in the
in the past few years [43]. Plating is a suitable procedure
middle third in the neutral position and fractures in the
in particular in refractures as the intramedullary canal
distal third in pronation [16,32,35]. Finally, the best
may be obstructed and more rigidity may be required.
position for immobilization is still recognized periopera-
External fixation may be needed in segmental fractures
tively using the fluoroscopy [17].
and in the fractures with severe soft-tissue damage.

Operative treatment Other treatment

Evidently unstable fractures should be fixed operatively If treated nonoperatively, radiographic follow-up is
according to the principle of ‘primarily definitive recommended in 1, 2 and 3 weeks postoperatively to

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 The shaft fractures of radius and ulna Sinikumpu and Serlo 203

Fig. 3

(a) (b) (c) (d)

S

SIN

L
L

An unstable forearm shaft fracture in a school-age child (a, b) has been operatively treated and stabilized by ESIN. The diameter of thin nails (c, d)
covers just 40% of the smallest diameter of the intramedullary canals, but the osteosynthesis still achieves satisfactory stability because of bending of
the nails. ESIN, elastic stable intramedullary nailing.

prevent malunion [4,16,29,36]. After 3 weeks, the above-
elbow cast may be converted into a below-elbow cast to
improve cast comfort in cases with nonreduced fractures
without increasing the risk of redisplacement [53].
However, further radiographs will not yield any additional
information beyond removal of the cast in about 4–6 weeks
after trauma if no complication has occurred until that time
point [54,55]. Healing by satisfactory callus admits of light
mobilization, but heavy sports should not be allowed for
several months because the risk of refractures is increased
during the next 4–6 months [56]. Physiotherapy has not
traditionally been used for this purpose after treatment, but
recent evidence suggests the benefits of physiotherapy in
treating the contractures resulting in limitation of range of
motion [57]. Some authors recommend a late follow-up
visit to ensure that satisfactory range of motion of 0°–100°
is achieved [58].
Fractures that are stabilized by operative means should
be investigated by radiographs in 4–6 weeks once the
immobilization is relaxed. Some surgeons do not prefer
immobilization in forearm fractures with ESIN. ESIN are
recommended to be removed not earlier than 6 months
postoperatively because of the risk of refractures [41] and
plates not earlier than 12 months postoperatively for the
same reason [59]. In older children in whom the anatomy
of the radius and ulna will no longer change, the intra-
medullary implants may be left permanently [20,60].
However, there is no evidence from clinical trials on the
removal of the ESIN in children.

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204 Journal of Pediatric Orthopaedics B 2015, Vol 24 No 3
Complications and outcome
Nearly two-thirds (60%) of children with a middle-third
forearm fracture show residual loss of motion in the
forearm [61]. This complication is related to length dis-
crepancy, residual malangulation, malrotation deformity,
interosseal contracture and narrowing of the interosseus
space [62]. Angular deformation of 20° in the radius or the
ulna resulted in 30% or more decrease in pronation and/or
supination in cadaver studies [63,64]. Malunion is a
common complication because reduction can easily
fail [29].
The forearm shaft shows complete callus over the frac-
ture site in four cortices at least by 2–3 months [61,65].
However, delayed ossification is common in forearm
shaft fractures compared with most paediatric fractures.
Nonunion is more common in the ulna than the radius
[66]. However, just a small incidence of nonunion (3%)
with connection to plate and screw fixation has been
reported [28]. Refractures occur more often after forearm
shaft fracture than after any other paediatric fracture [9].
The incidence is about 6–10% [25]. Patient can develop
refracture even a year after the primary fracture [62].
Compartment syndrome is a rare complication, the risk of
which increases with multiple attempts at closed reduc-
tion and prolonged operation time [58,67]. Vascular
damages are rare. Being usually a traction-based neuro-
praxia, watchful waiting is recommended for 3 months in
injury-related nerve disturbances. Otherwise, further
nerve investigation is indicated [28]. Other nerve dama-
ges are usually connected to hardware removal, the
median nerve being damaged most commonly [29].
Cross-union is a rare but severe complication ruling out
rotational movement. Two separate exposures are nee-
ded to prevent cross-union in case of open reduction
primarily [68]. Cross-union needs to be excised
6–12 months after injury [28].
The ESIN is a minimally invasive technique of fixation
and the functional outcome has been reported to be good
or excellent [69]. Irrespective of the relatively high fre-
quency of immediate complications (30%), the short-
term problems are very minor [37,70]. The complications
are usually related to inexperience of the operator or poor
understanding of the technique [25,71,72]. Nonunion or
severe neurovascular problems are rare (0.5–2%) [2,73].
Controversies and conclusion
In conclusion, it has to be recognized that clinicians
treating the potentially harmful forearm shaft fractures
should be familiarized not only with the nonoperative
treatment and surgical procedures but also with the
functional forearm anatomy and injury mechanisms. The
most important prevailing controversy is the indication
for a nonoperative or an operative treatment. It is widely
accepted that nonoperative treatment is still the primary
treatment in most forearm shaft fractures in children.
Copyright © 2015 Wolters Kluwer Health, Inc. Unauthorized reproduction of the article is prohibited.
However, the incidence of ESIN has increased four-fold
during the last decade as an alternative to nonoperative
treatment [4], which is mysterious. It is known that there
is a high risk of redisplacement (30%) after nonoperative
treatment in the short term [74], which could justify the
increasing tendency against the use of primary surgical
fixation [37]. Nevertheless, according to the latest lit-
erature, the performance of nonoperatively treated fore-
arms is still good or excellent in a huge majority of
patients after long-term follow-up compared with the
matched controls [75], which again supports nonoperative
treatment as a primary method of care.
As another controversy, good results of single-bone nail-
ing have recently been published, despite the prevailing
consensus of unsatisfactory stability of single-bone nail-
ing [76,77]. Furthermore, no evidence-based consensus
exists on one technique over another in the treatment of
forearm diaphyseal fractures in older children [78].
Recently, ESIN has been suggested to be advantageous
for adolescents as long as the physes of the forearm bones
are not closed [79]. Anymore, no consensus of the type
and duration of immobilization in operatively treated
fractures has been reached. Insufficient evidence is
available concerning the removal of the implants after
children’s forearm shaft fractures.
The recommendations of treatment and postoperative
follow-up were presented here on the basis of the fact
that the current studies typically lack randomization,
comparators, prospective designs or independent eva-
luations; thus, strong evidence-based clinical conclusions
cannot be arrived at [32,80]. Until the results of highly
warranted prospective trials are available in the future,
the current concepts are based on both existing studies
with their limitations and expert opinion of the author-
ized authors.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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