Forearm Fractures

kid bbff 1kid bbff 2





- 8 / 52 gestation radius & ulna



- distal radius age 1

- proximal radius 4

- distal ulna age 5




Majority from distal physis

- 75% radius

- 80% ulna






Buckle / torus

Single or both bone

Galeazzi / Monteggia


Non Operative Management


BBFF accept 1BBFF 2


Acceptable Position


< 10 years old:  < 15 degrees malalignment

> 10 years old:  < 10 degrees malalignment


< 1 - 2 years of growth remaining: Anatomic alignment required


Operative Management




Outside parameters for non-operative treatment (see above)

Loss of reduction


Options for displaced fractures


1.  MUA



- young patients < 10

- greenstick fractures


2.  Compression Plating



- rigid, anatomical fixation



- increased scarring

- risk of complications with plate removal including refracture

- increased risk of infection and nerve injury


3.  Intramedullary elastic nail



- smaller scars with insertion

- easier to remove than plates



- generally immobilized

- must be removed

- non anatomical reduction compared with plates with theoretical risk of loss supination / pronation

- risk of extensor tendon rupture due to prominence of nails at insertion sites




Intramedullary nail v plate


Zhao et al World J Surg 2017

- meta-analysis of 13 RCTS

- IM nailing reduced operative time and complications compared to plate

- no difference in time to union, union rate, or loss of forearm rotation


Shah et al J Orthop Trauma 2010

- comparison of plate (46) v nail (15) for 61 adolescents average age 14

- 83% in both groups obtained full rotation

- no major complications in nail group

- 5 major complications in plate group


Manipulation under anaesthesia


Post reduction Positioning / Rule of Thirds 


1.  Fracture proximal to the insertion of Pronator Teres


Proximal fragment supinated by biceps

- supinate the forearm

- match proximal fragment 


Prox 1Prox 2Dist 3Prox 4


2. Fracture in the middle third 


Midposition / neutral

- biceps / pronator teres balanced


Midshaft 1Midshaft 2Mid 3Mid 4


3. Fracture in the distal third


Proximal fragment pronated by pronator teres

- pronation is the position of choice


Prox fore 1Prox fore 2


TENS technique


Tens 1tens 2


Synthes titanium elastic nail techique PDF


AO Surgery Radius Tens

AO Surgery Ulna Tens


Vumedi technique




Radius (typically first as more difficult to reduce)


Entry point with awl 2 cm proximal to distal physis


1.  Radial styloid / distal lateral entry 

- ensure radial nerve / cephalic vein, 1st extensor compartment protected


2.  Listers tubercle / dorsal entry


Tens dorsoulnatens listersRadial awl


Elastic Nail size


60 - 70% of the intramedullary canal

Typically 1.5 - 2.5 mm


Fracture reduction


Avoid passing nails incorrectly multiple times as may cause compartment syndrome

Bend tip of elastic nail

May need small open reduction


Cut nail


Withdraw 1 cm, cut with endcutter, then advance


Ulna (usually reduced after radius fixation)


Entry point 2 cm distal to apophyseal plate


1.  Proximal lateral

- avoids ulna nerve


3.  Distal medial


tens prox ulna




Cast in supination to tighten interosseous membrane

Cast 6 weeks


Removal of TENS at 4 - 6 months once osseous union established


Single v Double Elastic Nail


Dietz et al. J Pediatr Orthop 2010

- retrospective review of 38 children with both bone forearm fractures

- treated only with ulna elastic nail

- all patients had union with restoration of rotation

- two patients had angulation of the radius > 20 degrees that underwent surgical intervention


ORIF with plates


Plates 1Plates 2Plates 3Plates 4


AO surgery Henry approach to radius


AO surgery approach to ulna


AO surgery compression plating technique


Single versus Double plate


Khaled et al Int Orthop 2022

- RCT of 100 patients with both bone forearm fractures

- ulna plating versus ulna & radius plating

- no difference in outcome, range of motion or union rates

- some loss of position in radius when not plated




Compartment syndrome


Martus et al J Paediatr Orthop 2013

- 205 fractures treated with elastic nail

- 3/205 (1.5%) compartment syndrome




Forearm nonunion TENS 1Forearm TENS nonunion 2


Fernandez et al J Paediatr Orthop 2009

- 592 patients treated with elastic nail

- 6/592 (1%) nonunion / pseudoarthrosis

- all in ulna, 5/6 opened in surgery to facilitate nail passage




Makki et al J Paediatr Orthop B 2014

- plate removal refracture rate 8.5% if removed within 12 months of implantation

- nail removal refracture rate 17% if nail removed within 6 months of implantation


Clement et al JBJS Br 2012

- 82 children with retained forearm plates followed for 8 years

- 7% incidence of implant related fractures


Extensor tendon injuries with elastic nails


Kruppa et al Medicine 2017

- 202 elastic nails

- 3/202 (1.5%) EPL ruptures


Murphy et al J Pediatr Orthop 2019

- systematic review of 33 EPL ruptures post elastic nail

- all with dorsal approach to the radius

- average 10 weeks post surgery

- treated with repair, EIP to EPL transfer, or graft reconstruction with palmeris longus