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The purpose of this study was to evaluate a reduction

method that is based on the theory of Evans to reduceangulated greenstick fractures of the distal forearm

with a rotation manoeuvre, to evaluate an immobili-

sation technique and to evaluate a brief survey on

surgeon practice for treatment of these fractures. A

retrospective study was performed on 21 patients.

Fractures were reduced with a pronation or supina-

tion manoeuvre depending on the angulation of

the fracture and were immobilised in pronation or

supination. A good reduction was achieved in all

patients. Six weeks after manipulation a loss of reduc-

tion was seen in 6 out of 21 patients, but with a re-

angulation of less than 15. There was no significantdifference between fractures immobilized in prona-

tion or in supination. There was no need for re-

manipulation. At the 2008 Osteosynthesis and

Trauma Care Foundation (OTC) meeting, a brief

informal survey was performed concerning the

reduction method and the use of K-wires after reduc-

tion. No surgeons indicated they would perform only

a rotation manoeuvre.

Keywords : dstal forearm fracture ; chldre ; reduc-

to ; proato ; supato.

INTRODUCTION

The most commo fractures chldre are frac-

tures of the dstal radus ad ula wth greestck

fractures as the most commo fracture type (3,11-12).

The majorty have satsfactory outcomes, but poor

results do occur. if maluo occurs, t ca compro-

mse proato-supato (2). The amout of agu-

lato cosdered acceptable s stll ot completely

clear. Greater agulato has bee show to be

acceptable youger patets, but a actual thresh-

old s dffcult to establsh (5,9).

As Evas emphaszed, greestck forearm frac-

tures have a rotatory compoet to ther malalg-

met (4). The more commo apex volar fractures

represet a supato deformty, whereas the less

commo apex dorsal fractures are malrotated

proato. Correcto of malrotato s ecessary

to acheve aatomc algmet ; however morerecetly, there has bee a smplfcato of ths

theory (3,10,13). The objectve of the curret study s

No benefits or funds were received in support of this study Acta Orthopdica Belgica, Vol. 77 - 1 - 2011

Acta Orthop. Belg., 2011, 77, 21-26

Angulated greenstick fractures of the distal forearm in children :Closed reduction by pronation or supination

Alexader VAn TOnGEL, Peter ACKERMAn, Koe LiEKEnS, Bart BERGHS

From AZ St Jan Hospital, Brugge, Belgium

ORIGINAL STUDY

I Alexader Va Togel, MD, Orthopaedc Surgeo.

I Peter Ackerma, MD, Orthopaedc Surgeo.

I Koe Lekes, MD, Resdet Orthopaedc Surgery.

Department of Orthopaedic Surgery and Traumatology,

Ghent University Hospital, De Pintelaan 185, B-9000 Gent,

Belgium.I Bart Berghs, MD, Orthopaedc Surgeo.

Department of Orthopaedic Surgery and Traumatology AZ

St Jan Hospital, Ruddershove 10, B-8000 Brugge, Belgium.

Correspodece : Alexader Va Togel, Departmet of

Orthopaedc Surgery ad Traumatology, Ghet Uversty

Hosptal, De Ptelaa 185, 9000 Get, Belgum.

E-mal : [email protected]

2011, Acta Orthopdca Belgca.


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patets also had a fracture of the ula (71%). The

mea absolute agulato lateral vew was 23.6(SD 8.7 ; rage 15 to 42). Geeral aaesthesa

was used 15 patets, local aaesthesa 6. O

radographs take mmedately post-operatvely,

eghtee patets dsplayed a eutral posto lat-

eral vew ad three had 5 of agulato. A secod

closed reducto was ot ecessary ay case.

Callus formato was observed o the rado-

graphs take sx-weeks post-reducto all

patets. Fftee patets had o chage agula-

to lateral vew from mmedately post- to

6 weeks post-reducto. Fve patets showed a loss

of 10 of agulato ad oe showed a loss of 15.

There was o sgfcat dfferece age betwee

those patets wth ad wthout a loss of reducto

after sx weeks (p = 0.536). Furthermore, there was

o sgfcat dfferece pre-operatve agula-

to betwee those patets wth ad wthout loss of

reducto, wth a mea of 22.4 (SD 8.4) ad 26.7(SD 9.6), respectvely (p = 0.32). The patet wth a

Acta Orthopdica Belgica, Vol. 77 - 1 - 2011

AnGULATED GREEnSTiCK FRACTURES OF THE DiSTAL FOREARM in CHiLDREn 23

Table i. Survey

Question 1 : Would you and how would you reduce this

fracture ?

1. o reducto

2. hyperflexo

3. hyperflexo wth supato4. hyperflexo wth proato

5. hyperflexo after hyperexteso (Charley-maoeuvre)

6. proato

7. supato

Question 2 : Would you use a K-wire to stabilize the

fracture ?

1. o K-wre

2. K-wre

Table ii. Patet demographcs, jury detals ad pre-op ad postop radologcal results

* ula fracture : + = ula fracture, - = o ula fracture.

** agulato : < 0 = volar agulato, > 0 = dorsal agulato.

r = radal ; u = ular ; = eutral.

Geder left/

rght

Age

(moths)

ula

fracture*

volar/

dorsal

agulato

o lateral

vew

agula-

to**

lateral

vew pre-

op

AP

vew

agulato

AP vew

pre-op

agula-

to**

lateral

vew

postop 1 d

agulato

AP vew

postop 1d

agula-

to**

lateral

vew

postop

6 weeks

agulato

AP vew

postop

6 weeks

1 male Left 116 + volar -18 r -6 0 0 0 0

2 male Rght 81 - dorsal 19 0 0 0 0 0

3 female Rght 75 + dorsal 31 u 20 0 0 15 10

4 female Rght 65 + dorsal 18 0 0 0 0 0

5 female Left 144 + dorsal 29 u 23 0 0 0 0

6 male Rght 168 + dorsal 42 u 20 0 0 0 0

7 male Rght 72 - dorsal 15 0 0 0 0 0

8 female Left 144 + dorsal 38 0 0 0 0 0

9 male Left 144 + dorsal 39 0 0 0 10 0

10 male Left 136 + dorsal 16 u 20 0 0 10 0

11 male Rght 144 + volar -26 r -5 0 0 10 0

12 female Rght 100 + volar -20 0 0 0 0 0

13 male Left 72 + dorsal 33 u 15 0 10 10 10

14 male Rght 139 - dorsal 21 0 0 0 0 0

15 male Rght 133 + volar -15 0 0 0 0 0

16 male Left 124 - volar -20 r -10 0 0 0 0


18 female Left 119 + volar -15 r -10 -5 -5 5 0

19 female Rght 109 - dorsal 28 u 15 5 0 5 5

20 female Left 152 - volar -15 0 -5 0 5 -5



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loss of reducto of 15 had a pre-operatve dorsal

agulato of 31. Follow-up of ths patet showed

a eutral posto oe year after trauma.

There were fourtee patets the volar group

(66%) ad seve the dorsal group (33%). i the

volar group the mea pre-operatve agulato was

26.2 (SD 9.4, rage 15-42). Sx of these fourtee

showed radal agulato o AP-vew. There were

o patets wth ular agulato of the radus

ths group. i the dorsal group the mea agula-

to was 18.4 (SD 4.0, rage 20 to 15). The radus

fracture showed ular agulato three out of

seve patets (based o pre-operatve AP vew).

no patets had radal agulated fractures ths

group.

i the volar group, lateral ad AP radographs

take mmedately after reducto showed a eutralposto of the radus 13 patets. However, o

lateral vew, there was oe patet wth 5 resdual

dorsal agulato of the radus fracture ad o AP

vew, there was aother patet wth 10 ular ds-

placemet of the radus fracture. i the dorsal

group, there was a eutral posto o lateral vew

fve patets ad 5 of resdual dorsal agulato

two patets. O AP vew, sx patets showed a

eutral posto ad oe showed 5 radal dsplace-

met of the radus fracture. no agulato was see

o lateral vew for ths patet.Sx weeks after closed reducto, there was o

dsplacemet o lateral vew e cases the

volar group. i the remag fve patets, four

showed 10 of volar agulato ad oe had a

agulato of 15. i two of these cases there was

also dsplacemet to the ular sde o AP vew. i

the dorsal group, there was o dsplacemet see o

lateral vew sx cases ad oe patet had 10 of

dorsal agulato. There was o dsplacemet o

AP vew ths group. There was o statstcally

sgfcat dfferece betwee the volar group ad

dorsal group wth respect to rate of dsplacemet(p-value 0.3371).

To ga a geeral dea of surgeos opos

ths area, the two questos survey was dstrbuted

to 70 orthopaedc surgeos, of whom 40 respoded

(57.1%). All respodets stated they would reduce

the fracture by applyg hyperflexo, but oly 6

out of 40 (15%) would also perform a proato

maeuvre. no surgeos dcated they would

perform oly a rotato maeuvre. Twety-three

surgeos (57.5%) would break the tact cortex by

hyperexteso, thereby covertg a greestck

fracture to a complete fracture ad the reduce t

wth a flexo maeuvre. Fve out of 40 (12.5%)

surgeos dcated they would add a K-wre.

DISCUSSION

Most dsplaced ad malalged greestck frac-

tures of the radus should be reduced closed. The

areas of cotroversy the lterature for these frac-

tures are the degree of acceptable deformty,

whether the tact cortex should be fractured, ad

the posto ad type of mmoblzato. As Evas

emphaszed 1951, greestck forearm fractureshave a rotatory compoet to ther malalg-

met (4). He descrbed that the ma force actg o

the lmb s a vertcal compresso, but that some lat-

eral or rotatory elemet s to be expected ts

mometum, to whch the forearm wll respod by

proato or supato. Proato ad flexo are

closely alled, both mechacally ad developme-

tally, ad a fracture occurrg whle the forearm s

proatg s lkely to develop a forward devato of

the dstal fragmet, wth backward agulato at the

fracture ste. Supato ad exteso are smlarlyrelated, ad supato fractures wll, f they agu-

late, agulate forwards. Evas descrbes that the

apex volar fractures, represetg a supato

deformty, are more commo whereas the apex dor-

sal fractures, malrotated proato, are less com-

mo (4). Ths s cofrmed by our study were 66%

of the patets showed a apex volar fracture ad

33% ad a apex dorsal fracture. The rotatory com-

poet was also cofrmed by the fact that volar

agulated fractures could have radal, but ever

ular agulato, ad that dorsal agulated fractures

could have ular but ever radal agulato.Correcto of the malrotato s ecessary to

acheve aatomc algmet. Evas descrbed that

the reducto of a greestck fracture wth agular

deformity by full pronation or supination, according

to whether the angulation is forwards (supination

type) or backwards (pronation type), is surprisingly

easy (4). Ths theory has bee smplfed studes

24 A. VAn TOnGEL, P. ACKERMAn, K. LiEKEnS, B. BERGHS



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over the years. Davs ad Gree stated that As

Evas showed, dstal thrd greestck fractures are

easly reduced by maxmum proato of the fore-

arm. i ther cocluso they wrote Greestck

fractures should be reduced by mapulatg them

to the correct proper plae of rotato ; i.e.,

maxmum proato for dstal thrd fractures (3).

Smlarly, Rag emphaszed that forearm fractures

ca have a rotatory compoet to ther malalg-

met. But, cotrast to the proposed treatmet

mdshaft radus ad ula fracture, he does ot take

ths to accout whe descrbg the treatmet of

dstal forearm greestck fractures. istead, he

advocates to use a flexo type mold a apex

volar fracture ad a exteso type mold a frac-

ture wth apex dorsal agulato (10). Charley

descrbed hs book The closed treatmet of com-mo fractures that the agulated fracture has to be

straghteed ad that mapulato ofte results

the fracture becomg complete. i cotrast to ths

theory, he proposed to perform a rotato maeuvre

late dorsal agulated fractures after ttal per-

fect reducto (2). Our study showed that the org-

al reducto method descrbed by Evas s very

effcet ad we propose to perform ths maeuvre

the frst attempt.

Aother mportat topc the treatmet of

greestck fractures of the radus s the mmoblsa-to techque. i the same artcle of 1951 Evas

proposed to hold the posto by mmoblsg the

lmb a above-elbow plaster full proato or

supato accordg to the type of fracture oe s

dealg wth (4). i cotrast to Evas however, most

artcles fal to descrbe the rotato compoet

the mmoblsato techque. Zamzam et al

descrbed a retrospectve study of 183 chldre wth

dsplaced fractures of the dstal radus. Oe hu-

dred ad eght had a tal complete dsplace-

met. The reducto method was ot descrbed, but

they dcated mmoblsg the fractures aabove-elbow cast a posto of stablty whch

avoded extreme proato or wrst flexo (13).

Gupta et al descrbed a study about mmoblsato

proated, eutral ad supated posto for dor-

sally agulated soltary metaphyseal greestck

fractures the dstal radus 60 patets. Twety-

e patets eeded a reducto. They dd ot

descrbe the reducto method. Whe the wrst was

mmoblzed proato, the degree of re-agula-

to was greater the reduced tha the ure-

duced group of patets. if the wrst was mmob-

lzed the eutral posto or supato, there

was o dfferece the degree of agular dsplace-

met betwee reduced ad ureduced cases (7).

Bohm et al compared above ad below- elbow cast

types wth respect to the amout of resdual agula-

to of the fracture whle the cast. The below -

elbow casts were foud to mata the algmet

of dstal forearm fractures chldre as well as

above elbow casts. Ths study oly descrbed the

cast type, but ot the method of reducto ad pos-

to of the forearm the above elbow cast

(supato or proato) (1). Two more recet stud-

es also seem to support the fact that below elbowcast treatmet was comparable to above elbow

mmoblzato (8,11). However, also these art-

cles the rotato maeuvre was ot used (11) or ot

descrbed (8).

We treated our patets wth a above-elbow cast

because theoretcally a above - elbow cast pre-

vets flexo ad exteso of the elbow as well as

forearm rotato, whch mmzes the rsk of agu-

lato or dsplacemet.

Lmtatos of the curret study are the retro-

spectve desg ad the small sample sze. There so cotrol group of chldre wth agulated gree-

stck fractures who dd ot have a closed reducto.

There s oly a short-term radographc follow-up

ad there s o clcal comparso wth the

radographc results.

The results of our survey show that the reducto

method descrbed by Evas s ot commoly used

the treatmet of ths type of fractures. Aother

mportat fdg s the tedecy amog may

surgeos (57.5%) to break the tact cortex ad

thereby covert a greestck fracture to a com-

plete fracture. To our kowledge ths s the frststudy that evaluated the Evas reducto techque.

i our study, radographs mmedately followg

reducto proato or supato showed a

complete reducto 18 of 21 patets. Three

patets had a resdual agulato of 5 degrees. Ths

agulato s acceptable chldre wth more tha

two years of resdual growth (6).


AnGULATED GREEnSTiCK FRACTURES OF THE DiSTAL FOREARM in CHiLDREn 25


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CONCLUSION

Ths study supports the theory of Evas that the

most mportat maeuvre agulated greestck

fractures s rotato. The most commo dorsally

agulated greestck fracture ca be reduced by

proatg ad those volarly dsplaced ca be

reduced by supatg. There s o eed for com-

plete breakg of the cortex or the use of K-wres

patets wth agulated greestck fractures. The

survey demostrated that ths maeuvre s ot com-

moly used by orthopaedc surgeos.

REFERENCES

1. Bohm ER, V. Bubbar V, Yong Hing K, Dzus A. Above

ad below-the-elbow plaster casts for dstal forearm frac-tures chldre. A radomzed cotrolled tral. J Bone

Joint Surg Am 2006 ; 88-A : 1-8.

2. Charnley J. The Closed Treatment Of Common Fractures.

4th ed. Cambrdge Uversty Press, Cambrdge, 1999,

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3. Davis DR, Green DP. Forearm fractures chldre : pt-

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172-183.

4. Evans EM. Fractures of the radus ad ula. J Bone Joint

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5. Friberg KS. Remodellg after dstal forearm fractures

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6. Fuller DJ, McCullough CJ. Maluted fractures of the

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26 A. VAn TOnGEL, P. ACKERMAn, K. LiEKEnS, B. BERGHS


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