The patient has sustained an angulated distal diaphyseal both bone forearm fracture. The optimal treatment is closed reduction and immobilization in a short-arm cast.

Both bone forearm fractures are common paediatric fractures, occurring after FOOSH injuries. Most paediatric forearm fractures can be treated non-operatively with a closed reduction and cast immobilization. Immobilization is best achieved with three-point molding. General indications for operative management are bayonet apposition in children older than 10 years of age, angulation >15 degrees and rotation >45 degrees in children <10 years, angulation >10 degrees and rotation >30 degrees in children >10 years, open fracture, and re-fracture. Less angulation is accepted for proximal fractures.

Paneru et al. randomized 42 children aged 4-12 to an above-elbow group and 43 to a below-elbow group. They found that pain and swelling on the next day and one week after reduction was significantly higher in the above-elbow group. As well, patients in the above-elbow group were more likely to undergo a re-manipulation than the below-elbow group (9.5% vs. 2.3%, p=0.173).

Webb et al. performed a RCT comparing short arm and long arm plaster casts for displaced distal both bone forearm fractures. They concluded that a well-molded short arm cast was equally as effective as a long arm cast, and interfered less with daily activity. They stressed the need for good cast molding, indicated by a lower cast index. Ideal cast index is less than 0.8.

Bohm et al. performed a RCT comparing below- and above-elbow casts. They found that below-elbow casts were as efficacious as above-elbow casts in maintaining reduction of distal both bone forearm fractures.

Figures A and B show AP and lateral radiographs of a distal both bone forearm fracture. Illustration A and B show AP and lateral radiographs of a distal both bone forearm fracture following closed reduction and immobilization in a short-arm cast. Illustration C demonstrates how to measure cast index (dividing the sagittal cast width (A) by the coronal cast width (B) at the fracture site). Illustration D demonstrates a typical reduction manoeuvre: 1) reproduce or exaggerate deformity to unlock fragments, 2) reduce fragments using periosteal hinge, 3) correct rotational deformity.

Incorrect Answers:
Answer 2: Long-arm casts are not necessary for immobilization of distal both bone forearm fractures.
Answer 3: A sling will not provide adequate immobilization, despite the fracture being stable under fluoroscopy.
Answers 4 and 5: Operative fixation is not required for most distal both bone forearm fractures.