Forearm Fractures in Emergency Medicine 

  • Author: Toluwumi Jegede, MD; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Mar 31, 2009
 

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 (see the image below) 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.

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

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.

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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.

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Epidemiology

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.
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Contributor Information and Disclosures
Author

Toluwumi Jegede, MD  Resident Physician, Department of Emergency Medicine, State University of New York Downstate Medical Center College of Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Antonia Quinn, DO  Assistant Professor, Assistant Residency Director, Department of Emergency Medicine, State University of New York Downstate Medical Center/Kings County Hospital Center; Consulting Staff, Department of Emergency Medicine, Kings County Hospital Center

Antonia Quinn, DO is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

Francis Counselman, MD, FACEP  Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School

Francis Counselman, MD, FACEP is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Tom Scaletta, MD  Chair, 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

Disclosure: Nothing to disclose.

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  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

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

Additional Contributors

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

References

  1. Simon RR, Sherman SC, Koenigsknecht SJ. Forearm. In: Emergency Orthopedics: The Extremities. 5th ed. McGraw-Hill; 2007:218-231.

  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.

  8. Carson S, Woolridge D, Colletti J, et al. Pediatric Upper Extremity Injuries. Ped Clin North Am. 2006;53:41-67.

  9. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: a study of 3,350 children. J Orthop Trauma. 1993;7(1):15-22. [Medline].

  10. Cramer KE, Glasson S, Mencio G, et al. Reduction of forearm fractures in children using axillary block anesthesia. J Orthop Trauma. 1995;9(5):407-10. [Medline].

  11. Eastell R. Forearm fracture. Bone. Mar 1996;18(3 Suppl):203S-207S. [Medline].

  12. Gleeson AP, Beattie TF. Monteggia fracture-dislocation in children. J Accid Emerg Med. Sep 1994;11(3):192-4. [Medline].

  13. Gregory PR, Sullivan JA. Nitrous oxide compared with intravenous regional anesthesia in pediatric forearm fracture manipulation. J Pediatr Orthop. Mar-Apr 1996;16(2):187-91. [Medline].

  14. Handoll HH, Madhok R. Closed reduction methods for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;4.

  15. Handoll HH, Madhok R. Surgical interventions for treating distal radial fractures in adults. Cochrane Database Syst Rev. 2003;4.

  16. Handoll HH, Pearce PK. Interventions for isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev. 2004;CD000523. [Medline].

  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].

  19. Metz VM, Gilula LA. Imaging techniques for distal radius fractures and related injuries. Orthop Clin North Am. Apr 1993;24(2):217-28. [Medline].

  20. Morgan WJ, Breen TF. Complex fractures of the forearm. Hand Clin. Aug 1994;10(3):375-90. [Medline].

  21. Newton EJ, Love J. Emergency department management of selected orthopedic injuries. Emerg Med Clin North Am. Aug 2007;25(3):763-93, ix-x. [Medline].

  22. Proust AF, Bredenkamp JH, Uehara DT. Injuries to the elbow and forearm. In: Tintinalli JE, ed. Emergency Medicine: A Comprehensive Study Guide. 6th ed. McGraw Hill Text: 2004:1690-1694.

  23. Singletary EM. Volar dislocation of the distal radioulnar joint. Ann Emerg Med. Apr 1994;23(4):881-3. [Medline].

  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].

  25. Zautcke JL. Forearm Injuries. In: Hart RG, Rittenberry TJ, eds. Handbook of Orthopaedic Emergencies. Lippincott Williams & Wilkins Publishers: 1999:222-232.

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