O3258: Pediatric Both Bone Forearm Fractures: Re-Evaluating Unacceptable Alignment and Remodeling Potential

Background: Both bone forearm fractures (BBFF) are a frequent injury in the pediatric population, and non-operative management utilizing closed reduction and immobilization is considered the standard of care when alignment is within parameters outlined by Noonan and Price (JAAOS 1998). A previous series of patients at our institution revealed a subpopulation who healed initially outside of these parameters but were asymptomatic at their last follow up.

Methods: We conducted a prospective study of patients who healed at standard follow up (6-12 weeks) with residual sagittal or coronal angulation ≥15° and had minimum 2 years of follow up. Patients underwent forearm radiographs, physical examination and completed PedsQL. Standard forearm radiographs at 2 year follow up were compared to radiographs at the time of injury and at the time of the last standard follow up to evaluate remodeling potential. Physical examination was compared between the normal and injured side as well as to published norms. PedsQL scores below 1 standard deviation (SD) from the published mean were considered abnormal. Comparisons were made between groups using Fisher’s exact test for categorical variables, and the exact Wilcoxon rank sum test for continuous variables.

Results: Forty-eight patients, with initial malunions ≥15° in either plane were identified from 203 eligible patients with radius and ulna shaft fractures from 2019-2021, and 22 patients (average age 7.1 years SD 2.5) returned for 2 year follow up. No patients at 2 year follow up had coronal or sagittal angulation ≥15°. Average range of motion was wrist flexion 89.5° SD 6.6°, wrist extension 99.6° SD 8.2°, pronation 85.2° SD 5.0° and supination 88.1° SD 7.6°. Five (23%) patients had a ≥10° difference in pronation (average 73°, range 66-80°) compared to the uninjured side, and these patients showed no significant difference in age, BMI percentile, initial fracture characteristics or follow up radiographs when compared to the 17 patients with normal pronation (p > 0.05). Six (27%) patients scored more than 1 SD below the mean on PedsQL and these patients had no difference in the above variables or range of motion compared to patient’s who scored within 1 SD. When asked directly, no patients reported limitation to daily or sport activities.

Conclusion: All 22 patients demonstrated no residual deformity ≥15° on radiographs or consequential decrease in range of motion at 2 year follow up. Pediatric BBFF demonstrate significant remodeling potential without long term consequences to function or patient reported outcomes at 2 year follow up. Although this study has a small population, it may support the idea that within a certain age range, the current recommendations for acceptable alignment of pediatric BBFF are too stringent. Those with a difference in range of motion may be candidates for physical therapy at the discretion of the provider.