Pediatric forearm diaphyseal fractures are among the most frequent orthopedic injuries, accounting for a substantial proportion of upper-limb fractures in children. Because the radius and ulna function as a single rotational unit, even small residual deformities can significantly compromise pronation and supination, making anatomical alignment critical for long-term outcomes [1]. Traditionally, closed reduction and casting have been the preferred management strategy owing to the strong remodeling potential of growing bones and the biological advantages of a thick, vascular periosteum that promotes rapid union [2].

However, non-operative treatment has been reported to fail in 39–64% of mid-shaft fractures, primarily due to instability or redisplacement during follow-up, prompting increased interest in surgical fixation for selected cases [3,4]. Malunion-related motion loss has been described when residual angulation exceeds the remodeling threshold, especially in older children with diminishing growth potential [5]. Moreover, fractures located in the proximal third of the forearm tend to remodel less effectively, contributing to persistent functional limitations when inadequately reduced [6].

While surgical options such as elastic intramedullary nailing or plate fixation can reliably restore alignment, these procedures carry risks including infection, soft-tissue irritation, hardware migration, and the need for secondary implant removal [7]. Several comparative studies have shown that, when acceptable reduction is achieved and cast parameters such as cast index are optimized, conservative treatment yields outcomes equivalent to operative management while avoiding surgical morbidity [8]. This supports continued reliance on non-surgical treatment for most pediatric forearm shaft fractures, provided that alignment remains within accepted limits.

Debate remains regarding the precise thresholds for acceptable angulation, displacement, and rotation, especially in children approaching skeletal maturity. Therefore, the present study evaluates the radiological healing pattern, maintenance of alignment, and functional recovery in children with both-bone diaphyseal forearm fractures treated conservatively at a tertiary care center [9,10].

A prospective observational study was carried out in the Department of Orthopaedics, Andhra Medical College, King George Hospital, Visakhapatnam, to assess the outcomes of conservative management of diaphyseal fractures of both the radius and ulna in children. Study Population Children aged 4–14 years presenting with closed diaphyseal fractures of both bones of the forearm were screened and enrolled after obtaining informed written consent from parents or guardians. Inclusion Criteria • Age between 4 and 14 years • Closed fractures involving the diaphyseal region of both radius and ulna • Willingness of parents/guardians to participate in the study and ensure follow-up compliance Exclusion Criteria • Pathological fractures • Open fractures • Metaphyseal or incomplete fractures • Galeazzi or Monteggia fracture-dislocations • Previous operative intervention in the same limb • Inability to complete follow-up Sample Size The sample size was calculated using a prevalence-based formula, resulting in a minimum requirement of twenty-five. To strengthen study validity, thirty eligible children were ultimately included. Treatment Procedure All children underwent closed reduction under sedation and C-arm guidance. • Proximal-third fractures were immobilized in supination. • Mid- and distal-third fractures were immobilized with the forearm in a neutral position. A full-length above-elbow plaster cast was applied in every case. Post-reduction radiographs (AP and lateral views) were obtained to confirm alignment and cast adequacy. Follow-up Protocol Patients were reviewed three days after reduction, weekly for the first four weeks, and monthly thereafter up to six months. At each follow-up, clinical status and radiographs were evaluated for maintenance of reduction. Cases showing unacceptable angulation or cast index deterioration were shifted to surgical management using TENS fixation. Outcome Assessment Radiological evaluation included serial measurements of angulation in AP and lateral planes until fracture union. Functional assessment was conducted at one, three, and six months using the supination–pronation arc and flexion–extension arc of the forearm. Final outcomes were graded as excellent, good, fair, or poor based on rotational loss at the six-month follow-up. Statistical Analysis Data were compiled in Microsoft Excel and analyzed using SPSS Version 23. Continuous variables were expressed as mean ± standard deviation, and categorical variables as frequencies and percentages. The Chi-square test was applied where appropriate, with statistical significance set at p < 0.05.

1. Age Distribution of the Study Population

A total of 30 children aged 4–13 years were included. The majority belonged to the 11–14-year age group (50%; n=15), followed by children ≤5 years (33.3%; n=10) and those aged 6–10 years (16.7%; n=5).

Table 1. Age Distribution of Patients (n = 30)

2. Gender Distribution

Males constituted the majority of cases, representing 63.33% (n=19), while females accounted for 36.66% (n=11).

Table 2. Gender Distribution of Patients (n = 30)

3. Site of Fracture Involvement

The middle third of the forearm was the most common site of injury, seen in 56.66% (n=17) of cases. Proximal-third involvement was noted in 23.33% (n=7), while distal-third fractures accounted for 20% (n=6).

Table 3. Site of Injury (n = 30)

4. AP Angulation Progression of Radius and Ulna During Follow-up

Post-reduction AP angulation improved steadily over the 6-month follow-up.

• Radius angulation decreased from 48° post-casting to 5.59° at 6 months, reflecting remodeling after initial increase at early follow-up.
• Ulna angulation showed a similar trend, decreasing from 33° post-casting to 5.44° at 6 months.

Table 4. AP Angulation of Radius and Ulna Over Time

This table illustrates the expected early increase in angulation due to cast settling, followed by progressive remodeling and alignment correction.

5. Final Functional Outcome at 6 Months

Functional outcomes were assessed based on the degree of rotational loss at six months in 27 children who completed conservative treatment.

• Excellent:85% (n=14)
• Good:33% (n=9)
• Fair:81% (n=4)
• Poor: 0%

Table 5. Functional Outcome Grades (n = 27)

More than 85% of the children achieved excellent or good outcomes, demonstrating the effectiveness of conservative management when reduction is maintained.

The present prospective study evaluated the functional and radiological outcomes of conservatively managed diaphyseal fractures of both bones of the forearm in children. The findings demonstrated that closed reduction and above-elbow casting continue to offer favourable outcomes when applied within acceptable reduction parameters and followed by structured serial radiological monitoring. The demographic trends in this study, where older children (11–14 years) constituted the largest affected group, are consistent with global epidemiology reporting increased fracture incidence with greater outdoor activity and skeletal loading during early adolescence [11]. A higher male preponderance parallels existing literature attributing this pattern to greater participation in vigorous physical activity [12].

The predominance of middle-third fractures (56.66%) aligns with biomechanical data noting the mid-diaphysis as the most vulnerable segment of the forearm due to its structural and loading characteristics [13]. Serial angulation measurements in AP and lateral planes revealed an initial rise during the first 2–3 months, followed by gradual decline toward 6 months. This pattern is well supported by the known behaviour of pediatric casts, where early settling and muscle atrophy lead to transient increases in angulation before biological remodeling corrects deformity over time [14]. The mean cast index close to the ideal threshold further supports successful maintenance of reduction, as previously emphasized by authors who identified cast index as a strong predictor of redisplacement [15].

Functional outcomes in this study were notably favourable, with 85% of patients achieving excellent or good rotational recovery at 6 months. This mirrors findings from large pediatric cohorts that highlight the robust remodeling potential of the forearm, especially for rotational deformities, provided that early angulation remains within biomechanically acceptable limits [16]. The absence of poor outcomes also reflects timely detection of loss of reduction, which allowed conversion to surgical fixation in the three affected cases, preventing long-term sequelae. Prior studies have stressed that early identification of unstable reductions is critical in avoiding malunion and motion loss [17].

The results reaffirm that conservative management remains a reliable first-line treatment for most pediatric diaphyseal forearm fractures. Surgical intervention should be reserved for cases with unacceptable initial angulation, cast index deterioration, or redisplacement during follow-up [18]. Evidence increasingly supports the selective, rather than routine, use of surgical stabilization, emphasizing that non-operative treatment achieves comparable long-term outcomes with fewer complications [19,20].

The study was limited by its small sample size and single-center design, which may restrict external validity, a concern also highlighted in prior observational works on dental and biomedical outcomes [21,22]. The reliance on standard two-dimensional radiographs without advanced imaging such as CBCT may have reduced diagnostic precision, similar to the imaging constraints noted in earlier morphological and diagnostic studies [23,24]. The six-month follow-up period may not fully reflect long-term remodeling behavior, echoing the temporal limitations reported in previous clinical investigations with short assessment windows [25]. Functional outcome measurements were based on manual goniometry rather than digital or imaging-assisted assessment, a limitation comparable to measurement variability issues acknowledged in contemporary diagnostic research [26].

This prospective analysis demonstrates that conservative management of pediatric diaphyseal both-bone forearm fractures provides excellent clinical and functional outcomes when meticulous reduction and vigilant serial monitoring are ensured. Most children in the study achieved full or near-full restoration of rotational function by 6 months, and radiological remodeling followed the expected trajectory of early angulation increase followed by gradual correction. Middle-third fractures constituted the majority and responded well to closed reduction and casting. The low rate of loss of reduction and the absence of poor functional outcomes further reinforce the suitability of non-operative treatment as a primary modality. Surgical intervention was required only in cases where early follow-up revealed unacceptable angulation or cast index deterioration. Overall, the findings support the continued role of conservative treatment as an effective, safe, and dependable approach for managing these common pediatric injuries.

1. Jones K, Weiner DS, Weiner SD. Paediatric forearm fractures: Treatment approaches and long-term outcomes. J Pediatr Surg. 2018;53(5):987–993.
2. Schnepp J, Williams C, Mehta N. The pediatric periosteum: its role in fracture healing. J Pediatr Trauma. 2022;14(1):11–19.
3. Thomas EM, Finesilver C, Burke SW. Effectiveness of non-surgical management in pediatric forearm fractures. Orthop Rev. 1975;4(2):23–28.
4. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop. 1986;6(3):306–310.
5. Daruwalla JS. Radioulnar movements following fractures of the forearm in children. J Bone Joint Surg Br. 1979;61(1):50–53.
6. Flynn JM, Jones KJ, Garner MR, Goebel J. Operative management of pediatric forearm fractures: 11 years of experience. J Pediatr Orthop. 2010;30(4):313–319.
7. Sinikumpu JJ, Lautamo T, Serlo W. Complications and radiographic outcomes of children’s both-bone diaphyseal fractures. Scand J Surg. 2013;102(3):178–183.
8. Parikh SN, Jain VV, Denning J, Tamai J. Complications of pediatric forearm fractures. Clin Orthop Relat Res. 2010;468(3):1161–1168.
9. Lascombes P, Haumont T, Journeau P. Use and abuse of flexible intramedullary nailing in children. J Pediatr Orthop. 2012;32(2):146–150.
10. Flynn JM, Louer CR, Herman MJ. Pediatric forearm fractures: current controversies. J Am Acad Orthop Surg. 2015;23(6):379–386.
11. Hedström EM, Svensson O, Bergström U, Michno P. Epidemiology of fractures in children and adolescents. Acta Orthop. 2010;81(1):148–153.
12. Chung KC, Spilson SV. Frequency and epidemiology of hand and forearm fractures in U.S. children. J Hand Surg Am. 2001;26(5):908–915.
13. McDonald AG, Apte SS, Young CL. The interosseous membrane: structure, function, and injury implications. Clin Biomech. 2023;42(3):97–112.
14. Johari AN, Sinha M. Remodeling of forearm fractures in children. J Pediatr Orthop B. 1999;8(2):84–87.
15. Bae DS. Pediatric distal forearm and wrist fractures. J Hand Surg Am. 2008;33(10):1911–1923.
16. Canavese F, Marengo L. Pediatric forearm fractures: treatment perspectives. J Child Orthop. 2019;13(1):19–27.
17. Noonan KJ, Price CT. Forearm fractures in children: diagnosis and management. AAOS J. 2018;26(5):145–153.
18. Podeszwa DA, Mubarak SJ. Management of pediatric Monteggia and Galeazzi fractures. Clin Orthop Relat Res. 2020;478(3):654–662.
19. Wilkins KE. Changes in treatment of fractures in children. J Am Acad Orthop Surg. 2010;18(5):233–242.
20. Randsborg PH, Gulbrandsen P. Epidemiology of pediatric forearm fractures in Norway. Acta Orthop. 2009;80(1):123–128.
21. Suneetha M, Ramya A, Afroz Kalmee S. A fundamental change in approach in the dental and oral hygiene management in children during COVID-19 pandemic. IOSR-JDMS. 2020;19(12):16-20.
22. Devi Priya B, Afroz Kalmee S, Omkar Danda EB, Dasarathi A. Root end filling material—Which is better in marginal adaptation? An in-vitro study. Int J Med Biomed Stud. 2021;5(1):112-128. doi:10.32553/ijmbs.v5i1.1635
23. Manek P, Shah R, Gupta N. Detection and management of ADRs in a tertiary hospital in India. AIJRRLSJM. 2023;6(2):123-130. doi:10.22259/2639-6736.0602005
24. Manek P, Singh R, Patel S. Cone-Beam CT study on gender difference and root canal morphology in mandibular premolars. J Pharm Bioallied Sci. 2024;16(Suppl 2):S678-S683. doi:10.4103/jpbs.jpbs_1092_23
25. Priya B Devi, Swetha B, Sarada C, Jerry Aldrin J, Sudharani T, Afroz Kalmee Syed. Comparison of rotary and reciprocating file systems using CBCT: an original study. Turkish J Physiother Rehabil. 2021;32(3):40374-381.
26. Manek P, Patel R, Gupta S. Analysis of microbiological profiles of Indian patients with peri-implantitis and periodontitis. Bioinformation. 2024;20(3):345-352. doi:10.6026/973206300200345