Is it necessary to be in sling always for an arm fracture?

Question

Hi doctor,

My 4-year-old son fell down in the play area and got his left arm fractured in the region of the ulna and radius. We went to the emergency room immediately and the doctors did the alignment and put him in cast and sling. Can you please check the x-ray and confirm the alignment? Since he is 4 years old, he is not keeping the sling all time. While playing with toys inside the home, the sling is getting loosened. My worry is that will it delay the healing process. Does the kid always need to be in a sling while cast? I am attaching all the x-rays of my son. After looking into the x-ray, I asked about the second bone not being realigned properly. They told that it is fine if the alignment is greater than 20 % or something like that. We are again going for a follow-up in two days' time. Please suggest if we need to ask them anything else during our follow-up visit. Is whatever the doctor said appropriate in his case? Kindly guide us.

Answer 1

Hello,

Welcome to icliniq.com.

The reduction is not appropriate in this case, the bone might join in a 4-year-old child but this is certainly taking a risk. The child requires removal of the cast, reattempt at a close reduction, and application of slab for one week followed by a check X-ray elbow with forearm with wrist-anteroposterior and lateral view to confirm whether reduction is maintained or not. If a reduction is maintained then undergo cast immobilization. Children do not require a sling at all times. The role of the sling is to prevent edema of the limb by keeping it elevated and giving support. The child can play with a well-fitted cast provided there is no fall on the limb and the cast is not soft or broken. My answer is still the same. If the contact between two fracture ends is 100 % with no fracture displacement and no malalignment then the rate of bony union is high. In your child's case, bone is malaligned. Fractures may unite and later undergo a remodeling process. If a duration of three weeks has already passed since the injury, get a fresh x-ray done. If there are signs of union, continue cast. If there are no signs of union or less than three weeks then there are two options, either to wait or reattempt close reduction. Bone contact is separate for both bones. Ulna (one of the bones) is aligned with a near 95 % reduction which is satisfactory. Whereas the radius, another bone is not in contact. Bone contact is present in one view while not in the other which means there is no contact. The bone can still unite even when there is no contact, but the chances are very less. Ask your doctor to repeat the X-ray and follow up with those X-ray images to discuss the situation further. Ask your doctor whether the bones are showing signs of union or not. Please mention the total duration since the injury, slab and later cast.

Thank you.

Answer 2

Hi,

Welcome back to icliniq.com.

Thanks for your prompt reply. The fracture is still fresh. On the day of your follow up my recommendation is to attempt closed reduction one more time. If a better reduction is achieved chances of union are greatly enhanced. The reduction can be attempted under analgesia or under anesthesia. Confirm reduction under fluoroscopic C-arm control then apply POP (plaster of Paris) splinting. Ask your doctor for a second attempt at closed reduction as the current reduction is not satisfactory. Consider the matter open to discussion. Follow up with direct questions and doubts.

Thank you.