Since Borden reported the first cases in 1974, plastic deformation of the forearm bones in

children has become a fairly well known entity. Although it does not seem to be uncommon,
it often remains overlooked. Generally accepted features of traumatic bowing of the forearm
bones in children are: (1) the deformity consists of multiple microfractures, resulting in
deformation of the diaphysis of the bone without macroscopically visible fracture; (2) it
always results from axial compression; (3) complete remodeling is seen in children younger
than 4 years of age, partial remodeling up to 10 years of age; and (4) residual bowing results
in cosmetic deformity and in restricted and sometimes painful pronation and supination.
Crowe and Swischuk classified these lesions according to the possible fractures of the paired
bone. The cases described here raise some questions concerning the commonly accepted
mechanism of this injury. They make it necessary to add a new type to the classification of
Crowe and Swischuk.They also have implications toward treatment. The clinical and
radiographic evidence that long bones may bend is supported by the experimental work of
Chamay, Currey and Butler, and Tschantz and Rutishauser. Probably due to the lower
mineralization in children, their long curved bones are more susceptible to plastic
deformation. Borden and others state that bowing of the forearm bones in children can only
occur by a force in the axis of the forearm. They state that transverse stresses produce
transverse fractures of the epiphysis and metaphysis, because these are shearing forces. This
would explain why bent bones could only be associated with shaft fractures. In adults bowing
fractures of the forearm are rare, but the most common cause seems to be a progressive
transverse force. In children under the age of 15, this mechanism has never been reported.
We believe that bowing of the forearm bones can result from a transverse force as described
in adults. In the first presented case, the mechanism of injury suggests a transverse force.
Furthermore, a fracture of the distal metaphysis is normally caused by a transverse force. It
seems thus logical to accept that this injurya ventral bowing fracture of the forearm with an
associated distal metaphyseal fracture with ventral angulationwas caused by a transverse
force. In the second case, an axial compression force seems to be involved. When an axial
compression force first deforms the diaphysis, it is no longer longitudinal to the metaphysis.
The resulting shearing force could cause the metaphysis to break in the opposite direction.
Reduction of a bowing injury is difficult. According to Borden the force needed for reduction
is 100150% of the body weight of the patient applied over the fracture over several minutes.
If no reduction is achieved he suggests considering osteoclasis of the apex of the deformity.
Sanders and Heckman describe in detail a reduction method with which
they achieve 85% correction. They place the apex of the curve at a fulcrum consisting of a
rolled towel or a sandbag. Then, avoiding the epiphyseal growth cartilage, they apply a
firm and constant pressure over several minutes at right angles of the deformity. If necessary
this maneuver is repeated in a second plane. Sclamberg et al. and Reisch warn against
breaking of the bowed bone during such maneuvers because it often requires open reduction
and internal fixation. However, this complication was never described in children, but was
described twice in adults. In one of them the breaking seems to be done on purpose.
Furthermore, in the literature we found one adult in which reduction of the bowing could not
be achieved. These problems might be related to difficulties in exerting 150% of the weight
of an adult over the fracture during several minutes. As for the indications for reduction, the
recommendations in the literature vary. The capacity to remodel bowing fractures is
considered important in children of less than 4 to 6 years. For this reason some authors advise
no reduction at all. Others advise reduction only for deformities of more than 20. In children
between 4 and 10 years old there is no agreement concerning the need for reduction given the
diminishing capacity for remodeling. A few state that children less than 10 years of age have
no functional loss with persistent deformity and advise no reduction. Others advise reduction
reduction for deformities of more than 20 between the ages of 6 an 10 and most advise a
reduction attempt for those children who show obvious clinical deformity or have any
significant limitation of pronation and supination. There is a lack of remodeling capacity in
patients that are older than 10 years of age and reduction is advised for this age group,
certainly for deformities of more than 10 to 15.Furthermore, any bowing that prevents an
associated fracture and dislocation being reduced should be treated regardless of the patients
age. The described cases of two children 7 and 8 years old show little capacity to remodel,
with a persistent cosmetic deformity in one of them. We feel that diminished forearm rotation
at admission is a bad indication for closed reduction because a childs pain or fear sometimes
prevents proper examination, as illustrated by the first case. Since there is disagreement
concerning the capacity to remodel, since clinical examination is not always reliable, and
since the described cases show a lack of remodeling, we believe that reduction of a deformity
of more than 9 with the method of Sanders and Heckman is advisable in this age group.