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Fracture, Forearm
Updated: Mar 31, 2009
Introduction
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.
Fractures of the radius and ulna with dorsal angulation of distal fragments.
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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.
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
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 system4,5
- 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
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| References |
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References
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Further Reading
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
