General assessment and initial management

Some general principles should be followed for all forearm fractures. Specific points related to the different fracture types are discussed below. Forearm fractures in children can generally be treated differently from adult fractures because of continuing bone growth in the radius and the ulna after the fracture has healed.²

• • Assess Airway, Breathing and Circulation and manage as necessary.

  • Assess upper limb neurovascular function

    • • Sensory function: the median nerve supplies the thumb, index, middle and radial half of the ring finger on the palmar side of the hand and the tip of the thumb, index, middle and ring finger on dorsum of the hand; the radial nerve supplies the dorsolateral aspect of the hand and the dorsal aspect of the thumb, index, middle and lateral half of the ring fingers; the ulnar nerve supplies the dorsal and palmar aspects of the medial half of the ring finger and the whole of the little finger.

      • Motor function: test anterior interosseous branch of the median nerve by asking patient to make the 'OK' sign; test radial nerve by asking patient to extend their fingers or wrist against resistance; test ulnar nerve by asking patient to separate their fingers against resistance.

      • Vascular function: examine radial (and ulnar) pulse. Assess capillary refill.

  • Examine the wrist, elbow and forearm for tenderness and range of motion.

  • Perform a complete examination for other injuries.

  • Immobilize the forearm and upper arm whilst waiting for Xray.

  • Provide analgesia.

  • Immediate fracture reduction is required if there is neurovascular compromise, severe displacement or skin tenting.

Adult both-bone forearm fractures

• • Mechanism of injury: usually significant force injury.¹ Most commonly occur in motor vehicle accidents, also occur from direct blow, fall from a height or during sport.

  • Presentation: pain and swelling at site with obvious deformity.

  • Assessment: may be nerve involvement with paraesthesiae, paresis or loss of function. Do not elicit crepitus as may cause further soft tissue injury. Do not probe open fractures as may cause deeper contamination.

  • Investigation: X-ray entire length of forearm, wrist and elbow, with AP and lateral views.

  • Management: displaced fractures are the usual situation in adults. Operative treatment with internal fixation or intramedullary nailing will be needed in nearly all cases, so refer urgently. Closed reduction may be attempted (with sufficient sedation/analgesia ± muscle relaxants) if there is acute neurovascular compromise.

Fracture management

In children

In children, whose bones are still developing, there are risks of either a growth plate injury or a greenstick fracture.

• A greenstick fracture occurs due to mechanical failure on the tension side.

• That is, since the bone is not as brittle as it would be in an adult, it does not completely fracture, but rather exhibits bowing without complete disruption of the bone's cortex in the surface opposite the applied force.

• Growth plate injuries, as in Salter-Harris fractures, require careful treatment and accurate reduction to make sure that the bone continues to grow normally.

• These injuries may require an osteotomy (bone cut) to realign the bone if it is fixed and cannot be realigned by closed methods.

• Certain fractures are known to occur mainly in pediatric age group, as fracture clavicle & supracondylar fracture of Humerus.

Paediatric both-bone forearm fractures

Fractures may be of greenstick type (incomplete) or complete. A greenstick fracture can occur in one bone with a complete fracture in the other. Complete fractures may be undisplaced, minimally displaced or overriding. Fractures of the proximal third are relatively rare. Middle third fractures account for about 18% of both-bones fractures and distal third about 75%.³

• • Mechanism of injury: usually an indirect injury following fall on outstretched hand. Occasionally caused by direct trauma.

  • Presentation: pain, swelling and deformity at fracture site.

  • Investigation: X-rays of wrist, elbow and whole forearm should be taken.

  • Management: unlike adults, many both-bone fractures of the forearm can be treated by closed reduction. After reduction, forearm pronation and supination should be checked and arm placed in a long-arm cast or splint. Surgical treatment is by open reduction and plating/intramedullary nails depending on degree of overriding/angulation.³

Radial shaft fractures (Galleazzi fractures)

• • Definition: solitary fractures of the distal one third of the radius with accompanying subluxation or dislocation of distal radioulnar joint (DRUJ). Synonym is reverse Monteggia fracture.⁴

  • Mechanism of injury: commonly caused by fall on extended, pronated wrist.

  • Presentation: pain, swelling and deformity of the wrist and forearm. Tenderness and swelling at the distal radius and tenderness at DRUJ.

  • Investigation: X-ray the entire length of the forearm including wrist and elbow joints, AP and lateral views usually sufficient.

  • Management: in adults, requires surgical open reduction of the distal radius and DRUJ with internal fixation. In children the fracture can often be treated by closed reduction with longitudinal traction and correction of radial angulation. General anaesthesia may be required in difficult cases. If closed reduction under GA fails, K-wire insertion may be needed to lever the fracture into position. Open reduction may be needed in some cases.⁴

Ulna shaft fractures

• • Definition: isolated mid-shaft ulna fractures have the synonym 'nightstick fracture'.

  • Mechanism of injury: usually caused by a direct blow to the ulnar border, classically if someone receives a blow from an object whilst raising their arm in defence.⁵

  • Presentation: point tenderness over ulna shaft and forearm swelling.

  • Investigation: need to x-ray ulna from wrist to elbow.

  • Management: require orthopaedic referral. Non-displaced or minimally-displaced fractures can be treated with posterior splint from mid-upper arm to dorsum of the metacarpal joints with wrist in slight extension, forearm in neutral position and elbow at 90°. After 7-10 days, when swelling has subsided, use plaster sleeve or functional brace for next 4-6 weeks. Monitor weekly for first 3 weeks for any displacement. Fractures with marked displacement or angulation should be treated with open reduction and internal fixation.

Monteggia fractures

• • Definition: these are fractures of the proximal third (usually) of the ulna with associated dislocation of the radial head. Classified as:

    • • Type I - Fracture with anterior radial head dislocation. Commonest (60%).⁶

      • Type II - Fracture of the proximal ulna with posterior or posterolateral dislocation of the radial head (15%).⁶

      • Type III - Fracture of the ulna metaphysis with lateral or anterolateral dislocation of the radial head (20%).⁶

      • Type IV - Fracture of both radius and ulna at their proximal third with anterior dislocation of radial head (5%).⁶

  • Mechanism of injury: usually caused by a fall onto outstretched, extended and pronated elbow or direct blow.

  • Presentation: acute, severe pain and swelling in forearm and elbow. Damage may occur to the posterior interosseous nerve.

  • Investigation: X-ray the entire length of radius and ulna, including wrist and elbow, AP and lateral views usually sufficient but may need radiocapitellar views.

  • Management: in adults, immobilize joint in splint and refer for open reduction and internal fixation.

Complications of forearm fractures

See general article entitled 'Complications from Fractures'.

• • Non-union and malunion (uncommon)⁸

  • Compromise of brachial/radial artery blood supply

  • Median, ulnar or radial nerve injury

  • Infection (more likely if fracture secondary to crush injury)⁸

  • Compartment syndrome (more common in both-bone forearm fractures)

  • Radioulnar fusion (synostosis)

  • Re-fracture

Prevention of forearm fractures

• • Prevention of osteoporosis.

  • Adequate treatment of existing osteoporosis.

  • The use of wrist and elbow guards whilst taking part in certain sports activities such as mountain biking and skating.

Forearm overuse injuries⁹

• • Apart from tennis and golfer's elbow, forearm overuse injuries are not that common outside the realms of sports medicine.

  • Commonly affect athletes who take part in racket or throwing sports. If an activity involves repetitive flexion-extension of the elbow or pronation-supination of the wrist, it can lead to an overuse injury.

  • Examples of overuse injuries around the elbow are lateral and medial epicondylitis - see separate article on tennis and golfer's elbow.

  • Ulnar nerve injury and olecranon stress fractures can also occur if there is increased stress on the elbow joint.

  • Three major nerves cross the elbow joint: the median nerve, the ulnar nerve and the radial nerve. Overuse injuries or direct trauma to the elbow can affect these nerves.

  • Pronator syndrome and radial tunnel syndrome can occur in sports where there is excessive wrist flexion-extension or pronation-supination.

  • History taking is an essential part of the examination.

Pronator syndrome

• • Due to entrapment of the median nerve.

  • There is pain or paraesthesia over the median nerve distribution in the anterior proximal forearm. Aggravated by throwing/swinging a racket.

  • Distinguished from carpel tunnel syndrome because in carpel tunnel syndrome, sensation over the thenar eminence is preserved (the sensory branch of the median nerve that innervates the thenar eminence does not pass through the carpel tunnel).

  • Negative Tinel and Phalen tests at the wrist in pronator syndrome and difficulty making the OK sign (touching the tips of the 1st and 2nd fingers with the thumb).

  • Treatment is rest/modification of activity, ice, analgesia, physiotherapy and occupational therapy.

Radial tunnel syndrome

• • Due to entrapment of the radial nerve.

  • Pain experienced distal to the lateral epicondyle of the humerus and radiates down the dorsum of the forearm.

  • Often misdiagnosed as lateral epicondylitis.

  • A Tinel test approximately 6cm distal to the lateral epicondyle over the radial nerve can reproduce pain. Also pain on resisted supination with forearm extended.

  • Treatment is rest/modification of activity, ice, analgesia, physiotherapy and occupational therapy.

Complications From Fractures

Fracture is a common event: most of us will experience at least one during a lifetime. In modern times, with medical and surgical assistance, the majority heal without problem or significant loss of function. However, complications can pose risk to limb and even life.

Classification¹

Complications of fractures tend to be classified according to whether they are local or systemic and when they occur - early or late.

Early complications occur at the time of the fracture (immediate) or soon after. Early local complications tend to affect mainly the soft tissues.

Compartment syndromes

Fractures of the limbs can cause severe ischaemia, even without damage to a major blood vessel. Bleeding or oedema in an osteofascial compartment increases pressure within the compartment, reducing capillary flow and causing muscle ischaemia. A vicious circle develops of further oedema and pressure build-up, leading swiftly to muscle and nerve necrosis. Limb amputation may be required if untreated.

Compartment syndromes can also result from:

• • Crush injuries caused by falling debris or from a patient’s unconscious compression of their own limb.

  • Swelling of a limb inside an over-tight cast.

Compartment syndrome can occur in any compartment, e.g. the hand, forearm, upper arm, abdomen, buttock, thigh, and leg. 40% occur following fracture of the shaft of the tibia (with an incidence of 1-10%) and about 14% following fracture of a forearm bone. Risk is highest in those under 35 years.²

Presentation

• • Signs of ischaemia (5 P's: Pain, Paraesthesia, Pallor, Paralysis, Pulselessness) - but diagnosis should be made before all these features are present. The presence of a pulse does not exclude the diagnosis.

  • Signs of raised intracompartmental pressure:

    • • Swollen arm or leg

      • Tender muscle - calf or forearm pain on passive extension of digits

      • Pain out of proportion to injury

      • Redness, mottling and blisters

  • Watch for signs of renal failure (low-output uraemia with acidosis)

Where the diagnosis is uncertain, measure intracompartmental pressure directly. The pressure at which fasciotomy becomes mandatory is controversial.³

Management

• • Remove/relieve external pressures

  • Prompt decompression of threatened compartments by open fasciotomy

  • Debride any muscle necrosis

  • Treat hypovolaemic shock and oliguria urgently

  • Renal dialysis may be necessary

Complications

• • Acute renal failure secondary to rhabdomyolysis

  • DIC

  • Volkmann's contracture (where infarcted muscle is replaced by inelastic fibrous tissue)

Fat embolism

This is a relatively uncommon disorder that occurs in the first few days following trauma with a mortality rate of 10-20%.⁴ Fat drops are thought to be released mechanically from bone marrow following fracture, coalesce and form emboli in the pulmonary capillary beds and brain, with a secondary inflammatory cascade and platelet aggregation. An alternative theory suggests that free fatty acids are released as chylomicrons following hormonal changes due to trauma or sepsis.⁵ Risk of Fat Embolism Syndrome (FES) increases with number of fractures, but is also seen following severe burns, CPR, bone marrow transplant and liposuction.⁶

Risk factors

• • Closed fractures

  • Multiple fractures

  • Pulmonary contusion

  • Long bone/pelvis/rib fractures⁷

Presentation

• • Sudden onset dyspnoea

  • Hypoxia

  • Fever

  • Confusion, coma, convulsions

  • Transient red-brown petechial rash affecting upper body, especially axilla

Management

• • Supportive treatment

  • Corticosteroid drugs (used in treatment, more controversial in prevention)

  • Surgical stabilisation of fracture⁸

Problems with bone healing (non-union, delayed union and malunion)

Non-union is where there are no signs of healing after >3-6 months (depending upon site of fracture). Non-union is one endpoint of delayed union. Malunion occurs when the bone fragments join in an unsatisfactory position, usually due to insufficient reduction.

Causes of delayed union include:

• • Severe soft tissue damage

  • Inadequate blood supply

  • Infection

  • Insufficient splintage

  • Excessive traction

Causes of non-union are similar but also include:

• • Too large a space for bony remodelling to bridge

  • Interposition of periosteum, muscle or cartilage

Non-union occurs in approximately 1% of all fractures but is more common in lower leg fractures (19% non-union) or where there is motion at the fracture site.

Presentation

• • Pain at fracture site

  • Non-use of extremity

  • Tenderness and swelling

  • Joint stiffness (prolonged >3 months)

  • Movement around the fracture site (pseudarthrosis)

Investigations

• • Absence of callous (remodelled bone) or lack of progressive change in the callous suggests delayed union.

  • Closed medullary cavities suggest non-union.

  • Radiologically, bone can look inactive, suggesting the area is avascular (known as atrophic non-union) or there can be excessive bone formation on either side of the gap (known as hypertrophic non-union).

Management

Non-surgical approaches such as early weight bearing and casting may be helpful for delayed and non-union.

Surgical treatments include:

• • Debridement to establish a healthy infection-free vascularity at fracture site

  • Internal fixation to reducing and stabilize fracture.

  • Bone grafting to stimulate new callous formation.

Myositis ossificans

Myositis ossificans is where calcifications and bony masses develop within muscle and can occur as a complication of fractures, especially in supracondylar fractures of the humerus.⁹ It tends to present with pain, tenderness, focal swelling, and joint/muscle contractions. Avoid excessive physio, rest joint until pain subsides, NSAIDs may be helpful and consider excision after the lesion has stabilized (usually 6-24 months). It may be difficult to distinguish forosteogenic sarcoma.¹⁰

Algodystrophy

Sudeck's atrophy is a form of reflex sympathetic dystrophy (or complex regional pain syndrome type 1), usually found in the hand or foot. 89% of reflex sympathetic dystrophies follow trauma, notably fractures.¹¹ A continuous, burning pain develops, accompanied at first by local swelling, warmth and redness which progresses to pallor and atrophy . Movement of the afflicted limb is very restricted.

Treatment is usually multi-pronged:

• • Rehabilitation - physio and occupational therapy to decrease sensitivity and gradually increase exercise tolerance.

  • Psychological therapy

  • Pain management - often difficult and with a disputed evidence-base. Approaches used are neuropathic pain medications (e.g. amitriptyline, gabapentin, opioids), steroids, calcitonin, IV bisphosphonates and regional blocks.¹²

Iatrogenic complications¹³

Casts

• • Pressure ulcers

  • Thermal burns during plaster hardening

  • Thrombophlebitis

Prolonged cast immobilisation, or 'cast disease', can create circulatory disturbances, inflammation, and bone disease resulting in osteoporosis, chronic oedema, soft-tissue atrophy, and joint stiffness. Good physiotherapy should avoid these problems.

Traction

Traction prevents patients mobilising causing additional muscle wasting and weakness. Other complications include:

• • Pressure ulcers,

  • Pneumonia/UTIs

  • Permanent footdrop contractures

  • Peroneal nerve palsy

  • Pin tract infection

  • Thromboembolism

External fixation

Problems include:

• • Pin tract infection

  • Pin loosening or breakage

  • Interference with movement of joint

  • Neurovascular damage due to pin placement

  • Misalignment due to poor placement of the fixator

Document references

• 1. Apley AG & Solomon L, Concise system of orthopaedics and fractures, 2nd edition (1994), Butterworth Heinemann ISBN 0750617675

  2. Elliott KG, Johnstone AJ; Diagnosing acute compartment syndrome. J Bone Joint Surg Br. 2003 Jul;85(5):625-32.

  3. Gourgiotis S, Villias C, Germanos S, et al; Acute limb compartment syndrome: a review. J Surg Educ. 2007 May-Jun;64(3):178-86. [abstract]

  4. Kirkland L, Fat embolism, eMedicine. Last updated August 2005

  5. Parisi DM, Koval K, Egol K; Fat embolism syndrome. Am J Orthop. 2002 Sep;31(9):507-12. [abstract]

  6. Taviloglu K, Yanar H; Fat embolism syndrome. Surg Today. 2007;37(1):5-8. Epub 2007 Jan 1. [abstract]

  7. Aydin MD, Akcay F, Aydin N, et al; Cerebral fat embolism: pulmonary contusion is a more important etiology than long bone fractures. Clin Neuropathol. 2005 Mar-Apr;24(2):86-90. [abstract]

  8. Pape HC, Giannoudis P, Krettek C; The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery. Am J Surg. 2002 Jun;183(6):622-9. [abstract]

  9. Hartigan BJ, Benson LS; Myositis ossificans after a supracondylar fracture of the humerus in a child. Am J Orthop. 2001 Feb;30(2):152-4. [abstract]

  10. Gould CF, Ly JQ, Lattin GE Jr, et al; Bone tumor mimics: avoiding misdiagnosis. Curr Probl Diagn Radiol. 2007 May-Jun;36(3):124-41. [abstract]

  11. Duman I, Dincer U, Taskaynatan MA, et al; Reflex sympathetic dystrophy: a retrospective epidemiological study of 168 patients. Clin Rheumatol. 2007 Sep;26(9):1433-7. Epub 2007 Jan 13. [abstract]

  12. Quisel A, Gill JM, Witherell P; Complex regional pain syndrome: which treatments show promise? J Fam Pract. 2005 Jul;54(7):599-603. [abstract]

  13. Buckley R and Panaro C, General principles of fracture care, eMedicine, last updated July 2007

Document references

• 1. Huang E, Grimes P; Fractures, Forearm. eMedicine. Last Updated February 24, 2005.

  2. Rodriguez-Merchan EC; Pediatric fractures of the forearm. Clin Orthop Relat Res. 2005 Mar;(432):65-72. [abstract]

  3. Wheeless' Textbook of Orthopaedics; Pediatric Both Bone Forearm Fractures. Duke Orthopaedics. Cited from textbook online October 2007.

  4. Wheeless' Textbook of Orthopaedics; Galeazzi's Fracture (Adults). Duke Orthopaedics. Cited from textbook online October 2007.

  5. Wheeless' Textbook of Orthopaedics; Ulna/Ulnar Shaft Fracture. Duke Orthopaedics. Cited from textbook online October 2007.

  6. Wheeless' Textbook of Orthopaedics; Monteggia's Fracture. Duke Orthopaedics. Cited from textbook online October 2007.

  7. Wheeless' Textbook of Orthopaedics; Monteggia Fractures in Children. Duke Orthopaedics. Cited from textbook online October 2007.

  8. Kakarala G, Simons AW; Forearm fractures. eMedicine. Last Updated July 17, 2007.

  9. Disabella V; Elbow and Forearm Overuse Injuries eMedicine.com 2005