Forearm Fractures in Emergency Medicine

Updated: May 09, 2016
  • Author: Toluwumi Jegede, MD; Chief Editor: Trevor John Mills, MD, MPH  more...
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Overview

Practice Essentials

The arm is the most commonly injured extremity; thus, it is imperative for emergency physicians to be familiar with the appropriate evaluation and management of forearm fractures.

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

 

Signs and symptoms

Patients usually have localized pain, tenderness, and swelling at the fracture site. Any puncture or break in the skin over a fracture site should be considered evidence of an open fracture unless proven otherwise.

Tenderness or prominence of the radial head may be the only physical finding in patients with reduced Monteggia lesion or radial head fracture.

See Clinical Presentation for more detail.

Diagnosis

Anteroposterior and lateral radiographic 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.

See Workup for more detail.

Management

Immobilize the forearm and upper arm and provide effective analgesia unless the patient has other injuries with the potential for hemodynamic or respiratory instability. Specific treatment strategies include the following:

  • Nightstick fracture: This requires orthopedic referral; the fracture can be immobilized with a long-arm splint with 90° of elbow flexion and the hand in a neutral position
  • Monteggia fracture: 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 open reduction and internal fixation (ORIF)
  • Galeazzi fracture: Immobilize with a long-arm splint (with elbow flexed 90° and forearm pronated); treatment requires admission for ORIF
  • Concomitant radius and ulna fractures: 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
  • 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°; all require orthopedic referral

See Treatment and Medication for more detail.

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

The pediatric musculoskeletal system differs from that of adults. [2] 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. [3] Injuries can also occur as the result of a direct blow.

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Frequency

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. [4] 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%). [5]

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Epidemiology

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

Using the 2010 National Electronic Injury Surveillance System database and 2010 US Census information for fractures in patients aged 0 to 19 years, fractures of the forearm were found to be the most common, accounting for 17.8% of all fractures in the entire study population. Finger and wrist fractures were the second and third most common. [6]

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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Patient Education

For excellent patient education resources, visit the First Aid and Injuries Center. Also see the patient education article Broken Arm.

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