Are frequent radiographs necessary in the management of closed forearm fractures in children?

Introduction: A prospective pooled case series was used to assess the value of frequent radiographic examinations during treatment of closed forearm fractures in children from major university pediatric medical centers in Israel and China.

Methods: The sample consisted of 202 consecutive children (mean age 7 years; range 3-12 years) with closed forearm fractures treated nonoperatively. Children with open, growth-plate fractures or fractures associated with dislocation of the nearby joint (i.e., monteggia fractures) were excluded. In 28 children who had torus fractures, radiographic examination was performed at the time of cast removal, 3 weeks after the start of treatment. In 63 children who had stable fractures that did not require reduction (undisplaced or minimally displaced, complete or greenstick), radiographic examination was performed 1 week after the start of treatment and again at cast removal 4-6 weeks later. In the remaining 111 children with complete, displaced, or greenstick fractures (all with angulation of more than 15 degrees ) who underwent closed reduction, an additional X-ray was taken 2 weeks after cast placement. All children (except those with torus fractures) were followed clinically, without further radiographic examination, for 3 months after cast removal.

Results: Radiographs at cast removal showed good union in all stable fractures, indicating that additional X-rays on cast removal would have had no added value. In the children with unstable fractures, only 9 showed redisplacement with angulation of more than 15 degrees on repeated X-rays during the first 2 weeks after cast placement. All 9 underwent successful re-reduction. On clinical evaluation 3 months after cast removal, all patients in the sample had full range of elbow and forearm motion. Repeated fracture did not occur in any of the patients.

Conclusions: On the basis of these results, radiographs are recommended 2 weeks after cast placement for greenstick or complete fractures. At the time of cast removal, if clinical examination does not show signs of nonunion or malalignment, no radiographic examination is necessary.