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BOAST Guidelines
BOAST - Paediatric Forearm Fractures
Paediatrics

Early Management of the Paediatric Forearm Fracture

This BOAST guideline standardises the emergency assessment, manipulation thresholds, neurovascular documentation, and safeguarding considerations for paediatric patients presenting with acute forearm fractures.

Key standards

  • ›Perform and document a dedicated individual nerve and vascular assessment before and after any manipulation or splint application.
  • ›Obtain orthogonal radiographs displaying the entire radius and ulna, including both adjacent joints (elbow and wrist).
  • ›Screen every presentation for safeguarding flags and non-accidental injury, especially in pre-cruising or non-ambulatory children.
  • ›Provide prompt and adequate analgesia prior to obtaining radiographs or attempting manipulation.
  • ›Perform procedural reductions under controlled anaesthetic conditions (monitored sedation or theatre) rather than relying on inadequate bedside analgesia.
  • ›Split or appropriately mould casts to mitigate the risk of soft tissue complications and compartment syndrome.
  • ›Ensure consultant trauma review within 48 hours of presentation.
  • ›Schedule follow-up radiographs within 7-10 days for unstable or manipulated fracture patterns.

Introduction

Forearm fractures represent up to 40% of all paediatric fractures. Although children exhibit immense remodelling potential, significant variability exists regarding reduction thresholds, sedation methods, and documentation standards. In addition, evaluating clinicians must maintain a high index of suspicion for non-accidental injury (NAI) in pre-ambulatory infants and cases of inconsistent injury mechanisms.

Standards for Clinical Assessment

  • Comprehensive Neurovascular Examination: Document baseline motor and sensory function for the anterior interosseous (AIN), posterior interosseous (PIN), median, ulnar, and radial nerves, along with radial arterial pulse and capillary refill, both before and after any reduction or cast application.
  • Safeguarding and NAI Screening: Explicitly evaluate the plausibility of the mechanism of injury relative to developmental age. Fractures in non-ambulatory infants (<12 months), unwitnessed trauma, or delayed presentations mandate paediatric admission and formal safeguarding referral.
  • Pain Management: Provide age-appropriate systemic analgesia and early limb splintage prior to radiography.

Imaging and Reduction Standards

  • Radiographic Workup: Standard orthogonal anteroposterior (AP) and lateral views of the whole forearm, including both the wrist and elbow joints, are mandatory to exclude Monteggia or Galeazzi fracture-dislocation variants.
  • Manipulation Thresholds: Closed reduction should be reserved for fractures exceeding acceptable remodelling parameters based on patient age and fracture location (e.g., wrist vs. diaphysis). Off-ended or severe angular deformities require anatomical or near-anatomical reduction.
  • Sedation and Setting: Closed reductions performed in the Emergency Department must utilise safe and effective procedural sedation or regional anaesthesia (e.g., Bier's block or haematoma block in appropriate age groups) under monitored conditions.

Governance and Follow-Up

  • Consultant Review: All paediatric forearm fractures managed in the emergency setting must be reviewed by an orthopaedic consultant within 48 hours.
  • Immobilisation and Cast Care: Casts must be adequately padded, moulded, and split or bivalved if there is concern regarding progressive swelling or impending compartment syndrome.
  • Interval Radiography: Displaced or manipulated fractures require scheduled follow-up radiographs within 7 to 10 days to identify early loss of reduction.

Exam-tested points

  • ›Infants under 1 year presenting with long bone fractures must be evaluated for non-accidental injury (NAI) until proven otherwise; require admission, skeletal survey, and paediatric multidisciplinary workup.
  • ›Plastic bowing fractures and greenstick injuries have different remodelling potential; greenstick cortex completion is often required to prevent recurrent angular deformity.
  • ›Remodelling rules: Distal metaphyseal fractures adjacent to the wrist remodel up to 20-30° in children under 10, whereas mid-diaphyseal deformities remodel substantially less (<10-15°). Rotational deformity does not remodel and must be corrected.
  • ›Always check the radio-capitellar line on all views to rule out missed radial head dislocation associated with ulnar fractures (Monteggia lesion).
  • ›Median and anterior interosseous nerve (AIN) palsy (assessed via the 'OK sign' testing FPL and FDP of the index finger) is the most common neurologic compromise associated with displaced distal forearm and supracondylar injuries.
Official BOA source
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