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Fracture, Forearm: Differential Diagnoses & Workup

Author: Joneigh Slaughter Khaldun, MD, Resident Physician, Department of Emergency Medicine, State University of New York Medical Center, Kings County Hospital
Coauthor(s): Robert J Gore, MD, Clinical Assistant Professor, Attending Physician, Assistant Residency Director, Department of Emergency Medicine, Kings County/State University of New York Downstate Hospital
Contributor Information and Disclosures

Updated: Mar 31, 2009

Differential Diagnoses

Dislocations, Elbow
Dislocations, Hand
Dislocations, Wrist
Fractures, Elbow
Fractures, Hand
Fractures, Wrist

Workup

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 10 º 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.
Fractures of the radius and ulna with dorsal angu...

Fractures of the radius and ulna with dorsal angulation of distal fragments.

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Fractures of the radius and ulna with dorsal angu...

Fractures of the radius and ulna with dorsal angulation of distal fragments.


  • 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.
Torus fracture of the radius.

Torus fracture of the radius.

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Torus fracture of the radius.

Torus fracture of the radius.




Torus fracture of the radius.

Torus fracture of the radius.

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Torus fracture of the radius.

Torus fracture of the radius.


More on Fracture, Forearm

Overview: Fracture, Forearm
Differential Diagnoses & Workup: Fracture, Forearm
Treatment & Medication: Fracture, Forearm
Follow-up: Fracture, Forearm
Multimedia: Fracture, Forearm
References
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References

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  2. Benjamin H, Hang B. Common Acute Upper Extremity Injuries in Sports. Clin Ped Emerg Med. 8:15-30.

  3. Zalavras C, Nikolopoulou G, Essin D, et al. Pediatric fractures during skateboarding, roller skating, and scooter riding. Am J Sports Med. Apr 2005;33(4):568-73. [Medline].

  4. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. Aug 1984;24(8):742-6. [Medline].

  5. Zalavras CG, Patzakis MJ, Holtom PD, et al. Management of open fractures. Infect Dis Clin North Am. Dec 2005;19(4):915-29. [Medline].

  6. Gebuhr P, Holmich P, Orsnes T, et al. Isolated ulnar shaft fractures. Comparison of treatment by a functional brace and long-arm cast. J Bone Joint Surg Br. Sep 1992;74(5):757-9. [Medline].

  7. Anderson LD, Meyer FN, Lippincott JB. Fractures of the shafts of the radius and ulna. In: Rockwood and Green's Fractures in Adults. 3rd ed. Publishers: Lippincott-Raven; 1991:679-737.

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  17. Kay S, Smith C, Oppenheim WL. Both-bone midshaft forearm fractures in children. J Pediatr Orthop. May-Jun 1986;6(3):306-10. [Medline].

  18. Macule Beneyto F, Arandes Renu JM, Ferreres Claramunt A, et al. Treatment of Galeazzi fracture-dislocations. J Trauma. Mar 1994;36(3):352-5. [Medline].

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  24. Younger AS, Tredwell SJ, Mackenzie WG, et al. Accurate prediction of outcome after pediatric forearm fracture. J Pediatr Orthop. Mar-Apr 1994;14(2):200-6. [Medline].

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Further Reading

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Keywords

forearm fracture, broken forearm, broken arm, arm fracture, limb fractures, limb fracture, fractured forearm, proximal forearm fractures, middle forearm fractures, forearm shaft fractures, distal shaft forearm fractures, osteoporosis

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Contributor Information and Disclosures

Author

Joneigh Slaughter Khaldun, MD, Resident Physician, Department of Emergency Medicine, State University of New York Medical Center, Kings County Hospital
Joneigh Slaughter Khaldun, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Coauthor(s)

Robert J Gore, MD, Clinical Assistant Professor, Attending Physician, Assistant Residency Director, Department of Emergency Medicine, Kings County/State University of New York Downstate Hospital
Robert J Gore, MD is a member of the following medical societies: Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Tom Scaletta, MD, President, Emergency Excellence (EmEx) (www.emergencyexcellence.com); Assistant Professor of Emergency Medicine, Rush Medical College, Cook County Hospital; Chairperson, Department of Emergency Medicine, Edward Hospital; Past-President, American Academy of Emergency Medicine
Tom Scaletta, MD is a member of the following medical societies: American Academy of Emergency Medicine and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD, Medical Director, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

 
 
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