AUTHOR AND EDITOR INFORMATION

Section 1 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

INTRODUCTION

Section 2 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Background

The forearm, which consists of the radius and ulna, is essentially 2 conelike structures in parallel that are connected at their proximal and distal ends by joint capsules and along their shafts by a fibrous interosseus membrane.¹ Fractures of the forearm are classified as involving the proximal, middle, or distal shaft. Injuries to this area are intimately associated with the elbow and wrist and are discussed in those articles (see Differentials). The upper extremity is the most commonly injured extremity; thus, it is imperative that emergency physicians are familiar with the appropriate evaluation and management.   

The pediatric musculoskeletal system differs from that of adults. The relatively greater amount of cartilage and collagen reduces the tensile strength of the bone, making propagation of fractures less likely. They are also less identifiable on radiographs. Also unique to children is the growth plate, or physis (see Salter- Harris Fractures). Depending on the severity of the injury, these fractures can significantly impair further growth and functioning of the limb. 

Pathophysiology

Fractures of both the radius and ulna together are usually the result of a fall onto an outstretched hand (FOOSH) injury. Injuries can also occur as the result of a direct blow. 

For a related CME activity, see CME - Calcium Supplementation May Reduce Fracture Risk.

Frequency

United States

The upper extremity is involved in nearly half of all fractures seen, and wrist fractures account for about one third of these. Specifically, fractures of the forearm account for 10-45% of pediatric fractures, the majority occurring distally.² In a recent study looking at injuries relating to skate-boarding, fractures of the radius and ulna (or both) was the most common injury (48.2%).³

Mortality/Morbidity

Because of osteoporosis, postmenopausal women have a higher rate of forearm fractures than other adults. When the mechanism of injury seems trivial, suspect a pathologic fracture associated with a cyst or a tumor. Forearm fractures in older persons are associated with increased risk of future vertebral and hip fractures.

Race

Forearm fractures are less common in blacks because of a lower incidence of osteoporosis.

Sex

• In infants and toddlers, forearm fractures have no sex predilection.
• In children older than 2 years, fractures are more common in boys than in girls.
• In older persons, fractures are more common in women than in men.

CLINICAL

Section 3 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

History

History is usually consistent with a direct blow to the forearm or a fall directly onto the forearm or outstretched hand. Understanding the mechanism of injury helps direct the physical examination to detect injuries.

Physical

• Patients usually have localized pain, tenderness, and swelling at the fracture site.
• Fractures are classified as open or closed.
• • Consider any puncture or break in the skin over a fracture site evidence of an open fracture unless proven otherwise.
  • Infection is commonly seen with open fractures and warrants emergent orthopedic evaluation.
  • Incidence of open forearm fractures is second only to those of the tibia.
  • Open fracture classification system^{4, 5}
  • • Type I - Puncture wound less than 1 cm, minimal contamination
    • Type II - Laceration greater than 1 cm; moderate soft tissue damage; adequate bone coverage
    • Type IIIA - Extensive soft tissue damage, often high energy with massive contamination and adequate bone coverage
    • Type IIIB - Extensive soft tissue damage with bone exposure, flap coverage usually required
    • Subtype IIIC - Arterial injury requiring repair
  • The Gustilo classification system has significant interuser variability; the extent of the wound is often indeterminable until intraoperative exploration.
• Perform a neurologic examination.
• • Evaluate sensory function by 2-point discrimination.
  • Assess motor function by having the patient make the following maneuvers: "OK" sign tests median nerve, extending the fingers or wrist against resistance tests radial nerve, and separating the fingers against resistance tests the ulnar nerve.
  • Tendons or muscle bellies entrapped in fracture fragments may account for unusual functional deficits.
• Perform a vascular examination. Check capillary refill, radial pulse, and Allen test.
• Examine the wrist and elbow for tenderness and range of motion.
• • Palpate the wrist to evaluate for ulnar styloid fracture, dorsal prominence of the ulna, or wrist pain with rotation.
  • Tenderness or prominence of the radial head may be the only physical finding in patients with reduced Monteggia lesion or radial head fracture.

Causes

• Sports, particularly in-line skating, skateboarding, scooter riding, mountain biking, and contact sports
• Trauma, commonly from automobile collisions, blows with a blunt object, or child abuse

DIFFERENTIALS

Section 4 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

WORKUP

Section 5 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Imaging Studies

• General radiography principles
• • Anteroposterior and lateral views of the wrist, forearm, and elbow are required when forearm fracture is suspected from clinical findings.
  • Forearm radiographs, which include distal joints, are inadequate for absolutely excluding associated wrist and elbow injuries, as diagnosis of radioulnar dislocation requires the x-ray beam to be centered at the joint.
• Nightstick fracture: Defined as an isolated midshaft ulnar fracture, usually as a result of the forearm being held in protection across the face. It can also occur with excessive supination or pronation. These require orthopedic referral and can be immobilized with a long-arm splint with 90 degrees of elbow flexion and the hand in a neutral position. Some authors advocate that after 1 week the splint or cast be replaced by a prefabricated functional brace, which allows better wrist mobility and return to function.⁶ Open reduction and internal fixation (ORIF) becomes necessary when displacement greater than 5 mm or angulation greater than 10º persists.
• Monteggia fracture
• • Monteggia fracture is defined as a fracture of the ulna (usually proximal one third) with dislocation of the radial head. Anterior radial head dislocation is most common (60%), yet medial, lateral, and posterior dislocations also occur.
  • Isolated proximal ulnar fractures are rare. Always suspect a Monteggia fracture/dislocation, and closely examine radial head for dislocation or other evidence of injury.
  • Radial head dislocation can be missed when radiographs are misinterpreted, falsely negative, or inadequate. It also may go unrecognized when the dislocation reduces spontaneously prior to imaging. A line drawn through the radial shaft and head must align with the capitellum in all views to exclude dislocation.
  • Immobilize with a long-arm splint (with elbow flexed 90° and forearm neutral). Children may be treated by reduction and casting, while adults require admission for ORIF.
• Galeazzi fracture
• • Galeazzi fracture is defined as a fracture of the distal one third of the radius with dislocation of the distal radioulnar joint (DRUJ). It is also known as a reverse Monteggia fracture.
  • Galeazzi fracture is 3 times more common than Monteggia lesion.
  • Disruption of the DRUJ when overlooked results in a higher rate of morbidity.
  • Shortening of the radius by 5 mm, fracture of the base of the ulnar styloid, widening of DRUJ space by 2 mm, or subluxation of DRUJ all are associated with DRUJ pathology.
  • Obtaining comparison views of the uninjured wrist may be helpful.
  • A 10-20° rotation from normal radiographic position may give false-negative or false-positive readings for DRUJ dislocation.
  • Immobilize with a long-arm splint (with elbow flexed 90° and forearm pronated). Treatment requires admission for an ORIF.
• Concomitant radius and ulna fractures: Concomitant fractures usually result from a significant force applied directly to the forearm or major multisystem trauma. Swelling and deformity indicate the diagnosis, and radiographic confirmation is usually straightforward (see Media file 1). Compartment syndrome is a potential complication because of the degree of tissue injury and swelling involved. Treatment usually requires admission for an urgent ORIF, though in children younger than 10 years, if reduced to less than 10° of angulation, these fractures may be treated by casting alone.
• Essex-Lopresti fracture: This is defined as a fracture of the radial head and dislocation of DRUJ, with partial or complete disruption of the radioulnar interosseous membrane.
• Torus (greenstick) fracture: This occurs in children with only a moderate degree of trauma and can be managed with a long-arm cast for 4-6 weeks when angulation is less than 10° (see Media files 2-3). All require orthopedic referral.

TREATMENT

Section 6 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Prehospital Care

Stabilize the arm to prevent or limit neurovascular injury from sharp bone fragments.

Emergency Department Care

• Immobilize the forearm and upper arm and provide effective analgesia unless the patient has other injuries with the potential for hemodynamic or respiratory instability.
• Identify other injuries. Because forearm fractures require considerable force, perform a complete physical examination to exclude other injuries.
• Assess the injured forearm.
• • Perform a careful examination of the upper extremity to identify neurovascular deficits, tense muscle compartments, and disruptions of the skin.
  • Obtain appropriate radiographs to define fracture(s) and evaluate for associated dislocation.
• Treat injury expeditiously.
• Provide adequate analgesia/anesthesia.
• Perform emergent reduction, if necessary. The bone ends may shift, resulting in the loss of reduction. This may occur in the first 10-14 days, or it may occur 6-8 weeks later.
• Immobilize injury.
• Administer antibiotics and tetanus immunization, as indicated.
• Immediate fracture reduction is indicated when any of the following exists:
• • Neurovascular compromise
  • Severe displacement
  • Tenting of the skin
• ED anesthesia/analgesia options
• • Axillary block provides complete anesthesia and muscle relaxation but carries the risk of arterial or nerve injury.
  • Hematoma block provides anesthesia and muscle relaxation but carries the risk of osteomyelitis.
  • Intravenous regional anesthesia (Bier block) provides anesthesia and muscle relaxation but carries the risk of lidocaine toxicity.
  • Conscious sedation provides effective anesthesia, muscle relaxation, and amnesia. It carries the risk of respiratory depression and requires increased nursing time.

Consultations

• Consult an orthopedist for open fractures, operative fractures, or dislocations, and arrange close follow-up care.
• Fracture reductions typically are deferred to an orthopedist unless evidence of neurovascular compromise is noted.
• Insufficient evidence exists to support a specific management technique of isolated fractures of the ulna.
• Some evidence indicates that distal radius fractures may have better outcomes with external fixation or pinning than with conservative, nonsurgical management.

MEDICATION

Section 7 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Drugs used to treat fractures are generally NSAIDs and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures.

Drug Category: Nonsteroidal anti-inflammatory agents (NSAIDs)

These drugs are used most commonly for relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Drug Category: Analgesics

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Drug Category: Antibiotics

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Drug Category: Toxoid

This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Drug Category: Immunoglobulins

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

FOLLOW-UP

Section 8 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Further Inpatient Care

• Admit patient whenever the following conditions are present:
• • Open fracture
  • Presence of or potential for neurovascular compromise
  • Fracture requiring ORIF and orthopedist plans to operate expeditiously

Further Outpatient Care

• Most cases can be treated safely by splinting and referral to an orthopedist who will then schedule surgical repair (if necessary).
• Elevate the injured extremity and limit physical activities to prevent further injury.
• Provide instructional material on cast/splint care and symptoms requiring a return to the ED.

In/Out Patient Meds

• Prescribe oral analgesics (eg, NSAIDs, acetaminophen with codeine/hydrocodone).

Transfer

• Transfer to a facility with a higher level of care when no orthopedist is available and admission or urgent surgery is necessary.

Deterrence/Prevention

• Recommend wearing wrist guards while in-line skating, roller skating, or skateboarding.
• Prevent osteoporosis in postmenopausal women.

Complications

• Direct neurovascular injury
• Physeal arrest if fracture involves the growth plate
• Radioulnar synostosis after delayed treatment
• Compartment syndrome - Associated with closed shaft fractures of the radius or ulna and with tight casts. It is less common in upper extremities than in lower extremities.
• Loss of supination-pronation after a forearm fracture

Prognosis

• Prognosis for recovery of forearm fractures (ie, good bony union, maintenance of function) is related to severity and type of fracture and is optimized by treating fractures early and appropriately.
• Morbidity is related to missed or delayed diagnosis of an open fracture or dislocation associated with fracture.
• Improvements in internal and external fixation materials and techniques have allowed more aggressive treatment of forearm fractures, with fewer complications and improved recovery of function.
• Midshaft fractures tend to have worse outcomes than fractures in the distal or proximal third of the forearm.

Patient Education

• For excellent patient education resources, visit eMedicine's Breaks, Fractures, and Dislocations Center. Also, see eMedicine's patient education article, Broken Arm.
• For more information, see Medscape’s Fracture Resource Center.

MISCELLANEOUS

Section 9 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Medical/Legal Pitfalls

• Failure to suspect DRUJ pathology in the face of isolated radial fracture (Galeazzi type)
• Failure to suspect radial head dislocation in the face of isolated ulnar fracture (Monteggia type)
• • Radial head dislocations usually can be reduced or closed early in presentation, but delayed diagnosis commonly requires open reduction.
  • Lesions undiagnosed by the emergency physician are likely to be missed on outpatient follow-up visit.
  • Spontaneous reduction during splinting and loss of physical findings of pain at the radial head by the time of follow-up contribute to delayed or missed diagnosis
• Failure to appreciate an open fracture (attributing wounds to a simple soft-tissue injury)
• Failure to recognize neurovascular injury

Special Concerns

• Suspect child abuse when the mechanism of injury is inconsistent with fracture type, especially in newborns and infants.
• Realize that lesser amounts of mechanical force may result in fracture, especially in postmenopausal women.

ACKNOWLEDGMENTS

Section 10 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

The authors and editors of eMedicine gratefully acknowledge the contributions of previous authors, Enoch Huang, MD, and Peter Grimes, MD, to the development and writing of this article.

MULTIMEDIA

Section 11 of 12  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

Media file 1:  Fractures of the radius and ulna with dorsal angulation of distal fragments.
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Media type:  Radiograph

Media file 2:  Torus fracture of the radius.
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Media type:  Radiograph

Media file 3:  Torus fracture of the radius.
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Media type:  Radiograph

REFERENCES

Section 12 of 12

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• Acknowledgments
• Multimedia
• References

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Article Last Updated: Jul 11, 2008