Paediatric Clinical Practice Guideline

Wrist, scaphoid and forearm fractures

Author: Dr M Lazner / Mr S Naidu Maripuri / Mr T Crompton / Mr K James / Dr C
Bevan / Dr J Le Geyt / Dr E Walton
Approved by: Approved by the UHSussex MGC September 2022
Publication date: September 2022. Version 2
Review date: Setember 2024
Skip straight to: Buckle and greenstick fractures / Scaphoid fractures / Distal
forearm fractures including the manipulation under sedation guideline

Background
• Usually occur from a fall on to an outstretched hand (FOOSH)
• Very common area for children to injure. Child-specific injuries including buckle
and greenstick fractures occur due to relative strength and elasticity of periosteum.
• Scaphoid fractures are the exception being rare below 10 years and account for
only 0.3-0.5% of paediatric fractures. Peak age is 12-17 years.

The proximal pole of the scaphoid relies on the distal pole for blood supply.
If fracture is missed, potential complications include avascular necrosis and non-union
with early onset arthritis.
Have a high index of suspicion if clinical findings fit a scaphoid injury.

Buckle and greenstick fractures

• Buckling of the cortex of the distal metaphysis due to compression failure

• Buckle fractures are inherently stable but painful.
• Usually tender. Swelling and restriction of movement may be minimal
• Greenstick fractures occur when the cortex on one surface breaches. Less stable,
with a higher tendency to displace. Can be significantly angulated.

X-rays

Request wrist X-rays if buckle fracture is suspected, or if injury is more proximal or

angulated, request radius and ulna views.

Buckle fracture distal radius and ulna

On AP view – fracture appears as a bulbous

swelling of the cortex of the ulna, radius, or
both. May not be visible on AP view.

On lateral view – fracture appears as a bump

on one cortex (may be dorsal or volar).

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Greenstick fracture distal radius

On AP view – fracture may mimic buckle

fracture

On lateral view – fracture appears as a cortical

break on one surface with an intact cortex on
the other (may be dorsal or volar).
There may be angulation with the intact cortex
acting as a hinge.

Management

Apply a supportive bandage or Futura splint for 3 weeks with no follow up, providing
the fracture is:

• Single intact cortex only i.e. not a greenstick (on lateral view)
• Not angulated (check with senior Clinician if not sure)

If fracture is greenstick and/or angulated, apply a Futura splint and follow up in virtual
fracture clinic.

Provide parent information leaflet and safety-net for when to return – usually if no
improvement within 2 weeks of injury.

Scaphoid fractures

• Easily missed on x-ray. Acting on clinical suspicion is crucial.

• Always look at scaphoid bone and other carpals on wrist x-rays in older children.

Assessment
Look for clinical signs of scaphoid fracture:

Anatomical snuff box (ASB) Tenderness over scaphoid tubercle

tenderness

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Pain on ulnar deviation Pain on axial compression – telescoping of thumb

X-rays

Request wrist x-rays in the first instance unless high index of suspicion.
• Scaphoid views alone can result in the much commoner radial fracture being
missed

Management
No
Radiological confirmation of Negative wrist x-ray with clinical
scaphoid # suspicion of scaphoid #

• Below elbow VOLAR backslab • Futura splint

• Virtual Fracture clinic follow up • Virtual Fracture clinic follow up

Distal forearm fractures

• Usually greenstick fractures (incomplete) with intact periosteal hinge or Salter-

Harris type 2 injuries but can be any including:

− SH Types I – V
− Metaphyseal complete fractures – single or both bones
− Diaphyseal fractures – single or both bones

• Usually occur in the distal third of the forearm

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• Have high likelihood of remodelling without intervention, particularly in the
younger age group.

Always look out for two fracture types:

1. Monteggia fracture: Ulnar shaft fracture with dislocation of the radiocapitellar
joint.
2. Galeazzi fracture: Distal third radius fracture with dislocation of the distal
radioulnar joint.
If either is missed, irreversible chronic joint problems may occur.

Assessment

Always examine the joint above (elbow) and below (wrist).

Check distal neurovascular function

Test that sensation is

intact for each of the
three nerves.

Test the motor function of

the three nerves using the
‘Rock, Paper, Scissors,
OK’ game:

Ensure the child can fully

extend and flex all five
digits and that thumb
opposition is intact.

X-rays
Request forearm views to include the elbow and wrist.

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Management

1. If undisplaced simple radius and/or ulna fracture:

• Put in below elbow backslab for distal injuries, or above elbow backslab for
proximal injuries
• Follow up in virtual fracture clinic
• Provide plaster and VFC leaflets

2. If displaced or complex fracture:

• Keep nil by mouth

• Put in above elbow backslab for comfort if any delay or requirement for transfer
e.g. patient at PRH ED
• Refer Orthopaedic Registrar Bleep 8629

Child may be suitable for manipulation in the CED under 70% nitrous oxide sedation, or
a mix of 50% nitrous oxide (Entonox) with intranasal fentanyl, or ketamine (see
Procedural sedation in CED and acute pain management guidelines on microguide).

If not suitable for manipulation under sedation, the Orthopaedic team will arrange for
MUA at a later time, depending on age of child / degree of deformity or angulation.

Manipulation under sedation pathway

Meets criteria for manipulation under sedation in CED

1. Suitable forearm / wrist fracture (see next page)
2. Child meets criteria for sedation (see CED sedation guidelines)
3. CED senior clinician and nurse-in-charge confirm dept flow & staffing can support procedure

Sedation explanation, consenting, preparation with child and guardian (sedation team)
Manipulation explanation, consenting with child and guardian (orthopaedic team)

Procedure
Sedation by sedation-trained CED senior staff
Manipulation & full Plaster-of-Paris cast (not backslab) by orthopaedic team
(Stockinette, single layer wool snug and 50% overlap, snug POP, 3 point moulding)

Post procedure
1. Post manipulation Xray reviewed by orthopaedic on-call
2. Observation until medically fit for discharge

Follow-up
1. Refer virtual fracture clinic.
2. Orthopaedic team discuss case next morning with consultant

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Criteria for forearm and wrist fractures suitable for manipulation under sedation:

• Closed greenstick fractures and Salter-Harris II wrist fractures.

• Intact periosteal hinge on the concave side of fracture
• Any degree of angulation can be considered
• Any location of a forearm or wrist fracture can be considered (although a
proximal forearm fracture is less likely to be successful, it can still be attempted)

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