Plastic deformations are more common in the ulna, and are difficult to identify without comparison films of the contralateral forearm Given the “ring” structure of the forearm and resulting transmission of force, the presence of an apparent single-bone fracture should prompt close inspection for possible dislocation at the proximal and distal radioulnar joints The potential for remodeling decreases with increasing fracture distance from the epiphysis and with the age of the child As a result, less angulation is acceptable in midshaft fractures than in more distal injuries, and in adolescents relative to younger children The incidence of neurovascular complications from forearm and wrist fractures is low Current Evidence Forearm shaft fractures are the third most common fracture in children, and many require sedated reduction in the ED to obtain anatomic or near-anatomic alignment per guidelines of anticipated remodeling by age and fracture location Unfortunately, an estimated 39% to 64% of these reduced complete shaft fractures of the ulna and radius remain unstable and will require subsequent repeat manipulation or surgical stabilization ( Fig 111.25 ) While closed reduction and casting remains the standard of care, a primary surgical approach may be preferential for certain patients and fracture types This consideration is based on the potential for failed reduction and/or increased risk of permanent loss of motion secondary to waning remodeling potential of certain patients due to age or unstable fracture location Commonly unstable fracture patterns at higher risk for failed closed reduction include proximal third fractures, ulna fractures with angulation greater than 15 degrees, comminuted patterns, Monteggia fractures, and fractures in older children For these patients, orthopedics should be consulted While the standard of care has not changed, emergency clinicians should be aware of these potential options to guide their discussions with patients