Pediatric Distal Forearm Fractures/Clinical Assessment

This module allows traditional bone setters, pre-hospital providers, clinical officers, nurses, nurse practitioners, and medical officers to become confident and competent in performing point-of-care ultrasound diagnostic imaging to rule out the presence of a pediatric distal forearm fracture and distinguish between buckle (torus) fractures and cortical break fractures to make appropriate referrals as part of the management of closed pediatric (< 16 years of age) distal forearm fractures in regions without access to X-ray imaging and orthopedic specialist coverage.^{[1][2][3][4][5][6][7][8][9]}

Clinical Evaluation[edit | edit source]

Learning Objectives[edit | edit source]

1. Conduct a comprehensive history and physical examination of a pediatric patient with a suspected distal forearm fracture
2. Know the clinical indications and contraindications for using ultrasound as the sole imaging modality in the diagnosis of pediatric distal forearm fractures
3. Know the indications for referral for pediatric distal forearm fractures

History[edit | edit source]

• Age
  • Children < 12 years of age are more likely to sustain buckle fractures of the distal radius metaphysis
  • Children > 12 years of age are more likely to sustain physeal fractures of the distal radius because the bone is stronger in comparison to the cartilaginous physis^[10]
• Hand preference
• Injured arm
• Mechanism of injury
  • Most are due to a fall on an outstretched hand (FOOSH).  The scaphoid bone in these patients should be carefully evaluated.
  • A direct strike to the forearm will inform the region of interest for scanning.
  • A twisting mechanism is more likely to result in a soft tissue injury.
• Time of injury
• Previous forearm injury or birth defect
• Analgesia received

Physical Examination[edit | edit source]

Look[edit | edit source]

• The hand, forearm and elbow of the injured arm should be inspected for signs of swelling, bruising or deformity.
• Patients with visible deformity must be referred for x-ray imaging.

Feel[edit | edit source]

• The bones of the injured arm should be systematically palpated for tenderness or crepitus, being careful to gently examine any region of interest last.
• The scaphoid bone should be evaluated in children > 10 years of age by palpating the anatomical snuffbox and tubercle.

Move[edit | edit source]

• The full range of movement of the wrist should be evaluated as tolerated by the patient, which includes: flexion, extension, lateral movements (radius and ulna deviation), supination, pronation.  Any pain or restriction of movement should be noted.
• Any significant pain or restriction of movement of the hand or elbow should prompt the patient being referred for x-ray imaging.

Neurovascular Exam[edit | edit source]

• Rock Paper Scissors OK exam^[11]

Clinical Indications for Ultrasound Scanning of a Pediatric Distal Forearm Injury[edit | edit source]

• Isolated, distal forearm injury with no visible deformity in a patient aged younger than 16 years^[12]

Contraindications for Ultrasound Scanning of a Pediatric Distal Forearm Injury[edit | edit source]

If one or more of these symptoms are present, the pediatric patient with a distal forearm injury must be referred for X-ray imaging:

• Patient > 16 years of age
• Obvious angulation/deformity (soft tissue swelling allowed)
• Injury > 48 h old
• Bone disease (e.g. osteogenesis imperfecta)
• Congenital forearm malformation (e.g. radius hypoplasia)
• Compound/open fracture
• Neurovascular compromise
• Suspicion for other fracture (i.e., scaphoid or elbow fracture)
• Inability to clinically assess child
• Clinical suspicion e.g. ‘pain out of proportion’ despite normal ultrasound findings^[12][13]

Additional Resources[edit | edit source]

• Fractures - Distal forearm or wrist

Acknowledgements[edit | edit source]

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References[edit | edit source]