Forearm Fractures in Emergency Medicine 

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

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.

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.

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.

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]

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.

Patient Education

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

 

Presentation

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 system[7, 8]  is as follows:

  • 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

 

DDx

 

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.[9] Open reduction and internal fixation (ORIF) becomes necessary when displacement greater than 5 mm or angulation greater than 10º persists.

A systematic review of published randomised, controlled trials and observational studies that assessed the outcome of nightstick fractures after above- or below-elbow immobilization, bracing, and early mobilization found that early mobilization was associated with the shortest radiologic time to union (mean, 8.0 weeks) and the lowest mean rate of nonunion (0.6%). Fractures that were treated with above-elbow immobilization, below-elbow immobilization, or bracing had longer mean radiologic times to union (9.2 weeks, 9.2 weeks, and 8.7 weeks, respectively) and higher mean rates of nonunion (3.8%, 2.1%, and 0.8%, respectively).[10]

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.

One study assessed the efficacy of the following treatment strategy for Monteggia fracture based on the ulnar fracture pattern: closed reduction for plastic/greenstick fractures; intramedullary pin fixation for transverse/short oblique fractures; and open reduction and internal fixation for long oblique/comminuted fractures. According to the authors, none of the 57 patients treated according to the strategy experienced failure. However, 6 of 32 patients who were treated less rigorously demonstrated recurrent radiocapitellar instability (3 patients), loss of ulnar fracture reduction requiring revision surgery (2 patients), or both events (1 patient). All treatment failures occurred in complete fractures treated nonoperatively.[11]

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. 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. See the image below.

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

Essex-Lopresti fracture

Essex-Lopresti fracture 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

Torus fracture 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 the images below.

Torus fracture of the radius. Torus fracture of the radius.
Torus fracture of the radius. Torus fracture of the radius.
 

Treatment

Prehospital Care

Stabilize the arm to prevent or limit neurovascular injury from sharp bone fragments.

Emergency Department Care

 

Immobilize the forearm and upper arm and provide effective analgesia unless the patient has other injuries with the potential for hemodynamic or respiratory instability.

Identify other injuries. Because forearm fractures require considerable force, perform a complete physical examination to exclude other injuries.

Assess the injured forearm. Perform a careful examination of the upper extremity to identify neurovascular deficits, tense muscle compartments, and disruptions of the skin. Obtain appropriate radiographs to define fracture(s) and evaluate for associated dislocation.

Treat the injury expeditiously. Provide adequate analgesia/anesthesia.

Perform emergent reduction, if necessary. The bone ends may shift, resulting in the loss of reduction. This may occur in the first 10-14 days, or it may occur 6-8 weeks later.

Immobilize the injury. Administer antibiotics and tetanus immunization, as indicated.

Immediate fracture reduction is indicated when any of the following exists:

  • Neurovascular compromise

  • Severe displacement

  • Tenting of the skin

ED anesthesia/analgesia options[12] include the following:

  • Axillary block provides complete anesthesia and muscle relaxation but carries the risk of arterial or nerve injury.

  • Hematoma block provides anesthesia and muscle relaxation but carries the risk of osteomyelitis.

  • Intravenous regional anesthesia (Bier block) provides anesthesia and muscle relaxation but carries the risk of lidocaine toxicity.

  • Conscious sedation provides effective anesthesia, muscle relaxation, and amnesia. It carries the risk of respiratory depression and requires increased nursing time.

The use of ketamine has been studied in pediatric patients undergoing forearm fracture reduction in the ED and has been found effective in 50% (ED50) and 95% (ED95) of healthy children aged 2 to 5, 6 to 11, or 12 to 17 years. ED50 was 0.7, 0.5, and 0.6 mg/kg and the estimated ED95 was 0.7, 0.7, and 0.8 mg/kg for the groups, respectively. The median total sedation time for the 3 age groups, respectively, was 25, 22.5, and 25 minutes if 1 dose of ketamine was administered and 35, 25, and 45 minutes if additional doses were administered.[13]

In a study of periosteal nerve block with local anesthesia in 42 patients with forearm fractures, 40 patients (95%) had successful fracture manipulation and did not require subsequent treatment. Of the 42 total patients, 40 underwent periosteal blocks in the emergency room or fracture clinic; 2 were already inpatients.[14]

Consultations

See the list below:

  • Consult an orthopedist for open fractures, operative fractures, or dislocations, and arrange close follow-up care.

  • Fracture reductions typically are deferred to an orthopedist unless evidence of neurovascular compromise is noted.

  • Insufficient evidence exists to support a specific management technique of isolated fractures of the ulna.

  • Some evidence indicates that distal radius fractures may have better outcomes with external fixation or pinning than with conservative, nonsurgical management.

Complications

Potential complications include the following:

  • Direct neurovascular injury

  • Physeal arrest if fracture involves the growth plate

  • Radioulnar synostosis after delayed treatment

  • Compartment syndrome - Associated with closed shaft fractures of the radius or ulna and with tight casts. It is less common in upper extremities than in lower extremities.

  • Loss of supination-pronation after a forearm fracture

 

Guidelines

Guidelines Summary

The American Academy of Orthopaedic Surgeons clinical practice guideline on the treatment of distal radius fractures includes the following[15] :

  • Rigid immobilization in preference to removable splints when using nonoperative treatment for the management of displaced distal radius fractures.

  • Removable splints is an option when treating minimally displaced distal radius fractures.

  • The work group suggests operative fixation for fractures with postreduction radial shortening >3 mm, dorsal tilt >10 degrees, or intra-articular displacement or step-off >2 mm, as opposed to cast fixation.

  • Distal radius fractures that are treated nonoperatively should be followed by ongoing radiographic evaluation for 3 weeks and at cessation of immobilization.

  • All patients with distal radius fractures should receive a post-reduction true lateral x-ray of the carpus to assess DRUJ (distal radial ulnar joint )alignment.

 

Medication

Medication Summary

Drugs used to treat fractures are generally NSAIDs and analgesics. In addition, administer proper antibiotics and tetanus prophylaxis for open fractures. According to a study involving 134 children treated for fracture in the ED, ibuprofen is just as effective as morphine for pain control. Children in the study received either four doses of normal-release morphine or four doses of ibuprofen every 6 hours, as needed, for 24 hours following discharge. No significant differences in pain scores between groups were seen after any of the four doses. Adverse effects of morphine included nausea, vomiting, and drowsiness. The percentage of patients in the morphine group experiencing adverse events was 56.1%, compared with 30.9% in the ibuprofen group (P<.01).<ref> 16</ref>[17]

Nonsteroidal anti-inflammatory agents (NSAIDs)

Class Summary

These drugs are used most commonly for relief of mild to moderately severe pain. Although effects of NSAIDs in the treatment of pain tend to be patient specific, ibuprofen is usually the DOC for initial therapy. Other options include flurbiprofen, ketoprofen, and naproxen.

Ibuprofen (Ibuprin, Advil, Motrin)

Usually DOC for treatment of mild to moderately severe pain, if no contraindications. Inhibits inflammatory reactions and pain, probably by decreasing activity of enzyme cyclooxygenase, inhibiting prostaglandin synthesis.

Ketoprofen (Oruvail, Orudis, Actron)

Used for relief of mild to moderately severe pain and inflammation. Administer small dosages initially to patients with small bodies, older persons, and those with renal or liver disease. Doses higher than 75 mg do not increase therapeutic effects. Administer high doses with caution and closely observe.

Naproxen (Anaprox, Naprelan, Naprosyn)

Used for relief of mild to moderately severe pain. Inhibits inflammatory reactions and pain by decreasing activity of enzyme cyclooxygenase, decreasing prostaglandin synthesis.

Flurbiprofen (Ansaid, Ocufen)

Has analgesic, antipyretic, and anti-inflammatory effects. May inhibit cyclooxygenase enzyme, inhibiting prostaglandin biosynthesis.

Analgesics

Class Summary

Pain control is essential to quality patient care. It ensures patient comfort, promotes pulmonary toilet, and enables physical therapy regimens. Many analgesics have sedating properties that benefit patients who have sustained fractures.

Acetaminophen and codeine (Tylenol #3)

Drug combination indicated for treatment of mild to moderately severe pain.

Hydrocodone bitartrate and acetaminophen (Vicodin ES)

Drug combination indicated for relief of moderately severe to severe pain.

Oxycodone and acetaminophen (Percocet)

Drug combination indicated for relief of moderately severe to severe pain. DOC for aspirin-hypersensitive patients.

Antibiotics

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the clinical setting.

Gentamicin (Gentacidin, Garamycin)

Aminoglycoside antibiotics used for gram-negative bacterial coverage. Commonly used in combination with both an agent against gram-positive organisms and one that covers anaerobes. Used in conjunction with ampicillin or vancomycin for prophylaxis in patients with open fractures.

Ampicillin (Omnipen, Marcillin)

Used for prophylaxis in patients undergoing dental, oral, or respiratory tract procedures. Interferes with bacterial cell wall synthesis during active replication, causing bactericidal activity against susceptible organisms. This drug is given in place of amoxicillin in patients unable to take medication orally. It is also used along with gentamicin for prophylaxis in patients with open fractures.

Vancomycin (Vancocin)

Potent antibiotic directed against gram-positive organisms and active against enterococcal species. Also useful in treatment of septicemia and skin structure infections. Used in conjunction with gentamicin for prophylaxis in penicillin-allergic patients undergoing GI or GU procedures. May need to adjust the dose in patients with renal impairment.

Toxoid

Class Summary

This agent is used for tetanus immunization. A booster injection in previously immunized individuals is recommended to prevent this potentially lethal syndrome.

Tetanus toxoid adsorbed or fluid

Used to induce active immunity against tetanus in selected patients. Tetanus and diphtheria toxoids are immunizing AOC for most adults and children >7 y. Necessary to administer booster doses to maintain tetanus immunity throughout life. Pregnant patients should receive only tetanus toxoid, not a diphtheria antigen-containing product. In children and adults, may administer into deltoid or midlateral thigh muscles. In infants, preferred site of administration is midthigh laterally.

Immunoglobulins

Class Summary

Patients who may not have been immunized against Clostridium tetani products should receive tetanus immune globulin.

Tetanus immune globulin (TIG)

Used for passive immunization of any person with a wound that may be contaminated with tetanus spores.