A paediatric forearm fracture is a fracture of the radius or ulna in a skeletally immature child, and it is the commonest fracture site in children. Most are treated in a cast, because a growing bone remodels angulation an adult could not tolerate. The questions the panel asks are which ones need manipulation and which need theatre.
Key takeaways
- The May 2021 BOA Standard states that the forearm is the commonest fracture site in children and that casting is the gold standard of care for most of these fractures.
- That standard requires a fracture clinic appointment within 7 days of injury and a recorded consultant review of the case and images within 48 hours of injury.
- The CRAFFT trial randomised 750 children aged 4 to 10 with severely displaced distal radial fractures and found casting cost £1,665 less per patient with a 100% probability of being cost-effective.
- The FORCE trial randomised 965 children aged 4 to 15 with distal radius torus fractures and found pain at 3 days was equivalent between a soft bandage with immediate discharge and rigid immobilisation.
- NICE NG38 states plainly that a rigid cast should not be used for torus fractures of the distal radius, and that these children are discharged after first assessment.
- NICE NG38 also requires non-accidental injury to be addressed before discharge in every child with a femoral fracture, and NICE CG89 says to suspect maltreatment when a fracture has an absent or unsuitable explanation.
What makes a paediatric forearm fracture different from an adult one?
A paediatric forearm fracture is different because a growing bone remodels. The May 2021 BOA Standard states that children can heal with a greater degree of angulation or displacement than could be accepted in an adult without long-term consequences.
The same standard adds that the wrist is more tolerant of angulation and displacement than the forearm shaft, which is why a distal fracture and a midshaft fracture are not the same problem.
The patterns are also different: torus or buckle fractures, greenstick fractures, plastic deformation, complete fractures, and completely displaced or off-ended fractures with no cortical contact.
Importantly, the BOA Standard publishes no numerical limit for acceptable angulation in a paediatric forearm fracture. If you quote a number at interview, say it is a local protocol rather than a national standard.
How should a paediatric forearm fracture be assessed and imaged?
Assessment of a paediatric forearm fracture is documented at presentation and must include the radial pulse, digital capillary refill time and the individual function of the radial, median and ulnar nerves.
The May 2021 BOA Standard sets exactly that list, and requires the same recorded assessment to be repeated before the child is discharged.
The standard also asks for effective analgesia at the time of initial assessment, with pain scores recorded frequently so that pain relief is maintained throughout.
NICE NG38 states that children under 16 with suspected long bone fractures of the arm should be offered oral ibuprofen or paracetamol or both for mild to moderate pain, and intranasal or intravenous opioids for moderate to severe pain.
For imaging, the BOA Standard requires orthogonal X-rays to allow proper diagnosis and planning, and a further pair of orthogonal X-rays after any manipulation.
How is a torus fracture of the wrist managed?
A torus fracture of the distal radius is managed with a soft bandage or splint and immediate discharge. NICE NG38 says not to use a rigid cast, and to discharge these children after first assessment.
NICE NG38 adds that parents and carers should be advised that further review is not usually needed, which is the recommendation candidates most often forget to mention.
That recommendation rests on the FORCE trial, which randomised 965 children aged 4 to 15 from 23 UK hospitals to the offer of a bandage or to rigid immobilisation.
Pain at 3 days was 3.21 points with the bandage and 3.14 with rigid immobilisation, an adjusted difference of -0.10 against a prespecified equivalence margin of 1.0 point.
A later economic analysis of the same trial found the offer of a bandage saved £12.55 per patient, small individually but large across the number of these injuries.
When does a paediatric forearm fracture need manipulation?
A paediatric forearm fracture needs manipulation when the displacement or angulation exceeds what that child's remodelling can correct, and the May 2021 BOA Standard covers angulated but not off-ended fractures.
That standard says early closed reduction by manipulation, avoiding admission and general anaesthesia, is the treatment of choice for the majority of forearm fractures that exceed remodelling potential.
It requires every unit managing children's forearm fractures to have a protocol for early definitive manipulation and casting without admission, addressing procedural analgesia and sedation.
The manipulation must happen somewhere safe, with monitoring and facilities to manage complications of and recovery from sedation, and be performed by an orthopaedic practitioner judged competent under local protocols.
Consent matters here and the standard says so: the child if competent, the carers and the clinicians must all agree with the intervention, and consent is documented.
What did the CRAFFT trial show about severely displaced fractures?
The CRAFFT trial showed that most children with a severely displaced distal radial fracture can be treated in a cast, and that surgical reduction buys a small early functional gain at a high cost.
Published in the Lancet in April 2026, CRAFFT randomised 750 children aged 4 to 10 from 49 UK hospitals, 375 to non-surgical casting and 375 to surgical reduction, and 44% had completely off-ended fractures.
At 3 months the mean PROMIS Upper Extremity score was 44.9 with casting and 46.6 with surgical reduction, an adjusted difference of -1.64 with a confidence interval of -2.84 to -0.44.
That interval extended beyond the prespecified non-inferiority margin of -2.5 points, so non-inferiority was not demonstrated against that conservative margin in the main population.
However, in children with completely off-ended fractures the findings were consistent with non-inferiority against the wider margin prespecified for that group, which is the counter-intuitive result the panel enjoys.
Casting also reduced mean cost by £1,665 per patient, with a 100% probability of being cost-effective at both the £20,000 and £30,000 per quality-adjusted life year thresholds.
What are the BOAST time targets for a paediatric forearm fracture?
The May 2021 BOA Standard on early management of the paediatric forearm fracture sets two timings: a fracture clinic appointment within 7 days of injury, and a consultant review within 48 hours.
That consultant review is specified as a documented review of the case and the images by a consultant orthopaedic surgeon, which is a governance step candidates rarely mention.
Before a child with a forearm fracture goes home, the standard requires the recorded neurovascular assessment to be repeated, and oral analgesia plus a dedicated information leaflet to be provided.
That leaflet must include red flag symptoms and contact details, and the fracture clinic appointment must be made before discharge rather than left to be arranged.
The standard closes with audit: units should audit against these standards and monitor the rate of admission for further procedures on the limb.
When does a paediatric forearm fracture need surgery?
A paediatric forearm fracture needs surgery when closed treatment cannot hold or cannot be attempted safely: open fractures, an associated Monteggia injury, neurovascular compromise, and fractures that redisplace.
NICE NG38 states that in skeletally immature children with dorsally displaced distal radius fractures who have undergone manipulation, consider a below-elbow plaster cast, or K-wire fixation if the fracture is completely displaced.
The May 2021 BOA Standard excludes from its pathway any fracture that, after interdisciplinary discussion, needs theatre because of patient-related or injury-related factors.
In practice a diaphyseal paediatric forearm fracture that will not hold is stabilised with flexible intramedullary nails or a plate, and the choice belongs to the operating surgeon rather than to a national standard.
What are the complications of a paediatric forearm fracture?
The complications of a paediatric forearm fracture are redisplacement in cast, refracture, malunion with loss of forearm rotation, cast pressure problems, nerve irritation and, rarely, compartment syndrome.
In the CRAFFT trial refracture occurred in 13 of 750 children over 12 months, nine after casting and four after surgical reduction.
Most complications within 8 weeks in CRAFFT occurred in the surgical group, including six wound infections, five cases of scarring, two of pressure damage and one of nerve irritation.
That distribution is the point to make at interview: surgery for a paediatric forearm fracture moves risk rather than removing it, and the child still needs the cast afterwards.
When should a paediatric forearm fracture raise safeguarding concerns?
A paediatric forearm fracture raises safeguarding concerns when the explanation is absent or unsuitable, or when the child is not independently mobile and could not have generated the injury.
NICE CG89, last updated 3 December 2025, states that you should suspect child maltreatment if a child has one or more fractures with an absent or unsuitable explanation, in the absence of a condition predisposing to fragile bones.
The same recommendation names fractures of different ages and X-ray evidence of occult fractures, such as rib fractures in infants, as presentations that should prompt that concern.
NICE CG89 now defines a child as independently mobile if they can crawl, bottom shuffle, pull to stand, cruise, climb, or walk with or without a push-along walker, and says age alone should not decide it.
NICE NG38 requires non-accidental injury to be addressed before discharge in all children with femoral fractures, and particularly in children who are not walking or talking.
What is the interviewer listening for on paediatric forearm fractures?
The interviewer is listening for a recorded neurovascular examination before and after every intervention on a paediatric forearm fracture, and for the 7-day and 48-hour timings from the BOA Standard.
They want you to separate the torus fracture, which goes home in a bandage, from the off-ended distal radial fracture, which is now a shared decision rather than an automatic trip to theatre.
A strong candidate quotes CRAFFT honestly: casting did not meet the conservative non-inferiority margin overall, yet the difference was smaller than families considered meaningful and casting cost £1,665 less.
What are the common mistakes with paediatric forearm fractures?
The commonest mistake with a paediatric forearm fracture is putting a torus fracture in a rigid cast and booking a review, which NICE NG38 specifically advises against.
The second is quoting a numerical acceptable angulation as though it were national guidance, when the May 2021 BOA Standard publishes none.
Others are omitting the safeguarding question entirely, forgetting the post-manipulation orthogonal films, and sending a child home without the red flag leaflet and the clinic appointment the standard requires.
How this comes up at the ST3 interview
A paediatric forearm fracture arrives at the ST3 T&O clinical station as a radiograph and a stem: a six-year-old who fell from a climbing frame with an off-ended distal radial fracture.
The follow-ups are predictable: what you examine and record, how you consent a child, would you manipulate in the emergency department, what does CRAFFT say, and when would you worry about safeguarding.
orthointerview's question bank puts this into station form with model answers and AI-marked spoken practice, across 782 questions and 100 scenarios, so the CRAFFT numbers are rehearsed aloud.