What is the diagnosis?

This is a fracture of both the ulna and the radius of the arm, referred to as a both bone forearm fracture.

• Pearl: This fracture is one of the most common pediatric fractures, estimated to be approximately 40% of fractures [1].

• Pearl: Make sure to assess for “floating elbow” or supracondylar fracture. This occurs approximately 15% of the time.

What is the mechanism of injury?

This injury requires a moderate amount of force and usually occurs secondary to a fall from height such as monkey bars or a sports injury.

What physical exam findings are expected?

Likely ecchymosis and swelling, with likely deformity. Be sure to assess neurovascular status and look for evidence of compartment syndrome as well.

• Pearl: Be sure to assess for signs of an open fracture. This can present as small poke holes.

Which imaging modalities can be used?

X-rays are the way to go. You need to obtain AP/Lateral views of the forearm while also obtaining orthogonal views of the elbow and wrist to assess for other injuries. 

What is the management in the ED?

Remember to control your patient's pain. Management of these fractures can typically be done non-operatively when there is a greenstick deformity or the deformation is not greater than 20 degrees. It is important to reduce the fracture! The goal of reduction is angulation less than 15 degrees and rotation less than 45 degree in children younger than 10 years old. For children older than 10 years old the goal for reduction is angulation less than 10 degrees and rotation less than 30 degrees. Post reduction, patients should be placed in a sugar tong splint. Patient’s should follow up with orthopedics in approximately one week.

• Pearl: Reduction and casting without subsequent operative management have been shown to have high functional outcomes in the pediatric population [2].

• Pearl: In the adult world, non-operative management of both forearm bone fractures is rare [3].

When do you consult Orthopedics?

Orthopedics should be consulted whenever there is concern for open fracture or neurovascular compromise. Orthopedics should also be consulted if there is rotational deformity, greater than 10 degrees of angulation in pediatric patients older than 8 years old, or greater than 15 degrees of angulation in pediatric patients younger than 8 years old.