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Forearm — FAQ’s

Common questions about forearm fractures…

Q. When is the alignment “good enough”? 

A. Many parents will notice that after their child has their broken arm manipulated and put in a splint or cast that the bones do not look perfectly lined up.  A common comment from parents is, “ I’m not a doctor, but those bones don’t look quite right to me”.  So, how can you tell when it will be OK?  There are several good ‘rules of thumb’ for parents to note.  First, the younger the child, the greater the potential for remodeling of the fracture with growth.  Second, although angulation of the fractures bones can remodel, it is best if the overall longitudinal alignment is fairly straight, or the arm will look crooked for some time.  Third, when the ends of the bone are overriding one another, they can still heal and remodel, ultimately making a single bone again.

Q. When is surgery needed?

A. Fractures of the forearm need surgery in two situations:  One is when the fractured bone sticks out through the skin, and the second is when a reasonable alignment of the bone cannot be maintained in the cast.  There are a variety of different techniques for fixing forearm fractures in children, ranging from the use of plates and screws to placement of metal pins down the center of the bone to hold proper alignment.

Q. What is a compartment syndrome?

A. Compartment syndrome occurs when the swelling in the arm or leg becomes so severe that the soft tissues of the limb begin to lose their blood supply.  A thick, unyielding tissue termed “fascia” surrounds the bone and muscle of the forearm.  When swelling occurs within the fascial sheath of the arm, it can become severe enough to disrupt the blood supply to the muscles and nerves of the arm.  If this lasts more than 6 hours, the damage can be irreversible.

There are five common signs of a compartment syndrome following a fracture:

  • Pain:  This is always the first sign.  A splinted fracture in a child should be reasonable comfortable.  You should be able to get the pain under control with simple measures such as loosening the wrapping of the splint, elevation, ice, and some pain medicine that your doctor prescribed.  If the pain cannot be controlled in this manner, you should seek immediate attention in the emergency room.
  • Pallor:  This simply means that the fingers appear pale.  Typically, if you push on your fingers, they will blanch and then turn pink again.  If the fingers won’t blanch and appear dusky, try loosening the splint.
  • Paresthesias:  This refers to tingling in the fingers, like they are going to sleep.
  • Pulselessness:  If the splint will allow you to feel up where you would normally feel your pulse, check for it. If all of the other symptoms are there and you can’t feel the pulse, seek evaluation immediately
  • Paralysis:  This is a late sign of compartment syndrome.  If the swelling has lasted long enough to damage the nerves to the arm, then paralysis of the affected limb is the result.

Q. How would I know if my child has a compartment syndrome?

A. The most common sign of a compartment syndrome is pain that cannot be controlled with elevation of the limb, pain medicine, or loosening of the bandages.  Most splinted fractures in children are reasonably comfortable with simple measures.  If not sure, return to the emergency room and have a doctor check the arm for you.

Compartment syndrome is a surgical emergency.  The diagnosis is suspected based on the examination of the child’s arm, and confirmed by actually measuring the pressure in the arm compartments.  Most emergency rooms have the capability to do these measurements quickly. If a compartment syndrome is found, then immediate surgical release of the tight compartments must be done immediately to prevent further permanent damage to the arm.

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