Basics
Description
- Forearm shaft fractures (single or paired) are often displaced by contraction of arm muscles; sometimes associated with concurrent dislocations:
- Galeazzi fracture:
- Distal radius fracture with distal radioulnar dislocation
- Monteggia fracture:
- Proximal ulnar fracture with dislocation of radial head
- Distal fractures include extension, flexion, and intra-articular classifications:
- Colles fracture:
- Hyperextension fracture of distal radius
- Distal fragment displaced dorsally
- Radial deviation
- Often involves ulnar styloid and distal radioulnar joint
- Smith fracture:
- Hyperflexion fracture of distal radius
- Distal fragment displaced volarly
- Barton fracture:
- Intra-articular fracture of dorsal rim of distal radius
- Often associated with dislocation of carpal bones
- Hutchinson fracture:
- Intra-articular fracture of radial styloid
- Shaft fractures:
- Torus fracture:
- Compression (buckling) of cortex on 1 or both sides
- Greenstick fracture:
- Distraction of 1 side of cortex with opposite side intact
- Plastic deformity:
- Bowing of radius or ulna without apparent disruption of cortex
- Multiple microfractures
- Distal fractures:
- Salter-Harris type fractures (see Salter-Harris classification)
Etiology
- Direct blow to forearm
- Longitudinal compression load:
- Fall on outstretched hand (FOOSH)
- Horizontal force
- Excessive pronation, supination, hyperextension, or hyperflexion
Diagnosis
Signs and Symptoms
- Deformity
- Pain, edema, erythema
History
- Associated events and concurrent injuries
- Past history of bone disease or old fractures
- History of repetitive stress of forearm movement
- Occupation
- Hand dominance
Physical Exam
- Physical exam with special attention to skin integrity, deformity, and neurovascular status
- Forearm pain, crepitus, tenderness to palpation, deformity, shortening of forearm
- Forearm edema, ecchymosis, elbow or wrist joint effusions
- Abnormal mobility or loss of function at elbow/wrist/hand
- Neurologic abnormalities
- Vascular compromise
Impending compartment syndrome
Essential Workup
Suspected forearm fractures require anteroposterior (AP) and lateral radiographs, including joint above and joint below injury: Hand, wrist, and elbow.
Diagnosis Tests & Interpretation
Lab
Preoperative labs as warranted
Imaging
Some intra-articular fractures may require CT imaging.
Diagnostic Procedures/Surgery
Compartment pressures should be measured for suspected compartment syndrome.
Differential Diagnosis
- Upper extremity muscle, ligamentous injury
- Elbow or wrist dislocations, including pediatric nursemaids elbow
- Forearm contusions, hematomas
- Cellulitis, abscesses, soft tissue masses
- Forearm osteogenic tumors
- Osteomyelitis
- Upper extremity vascular or neurologic injuries
- Elbow or wrist arthritis, joint effusions
- Pediatric growth plates, nutrient vessels may be mistaken for fractures
Treatment
Pre-Hospital
- All suspected forearm fractures should be elevated, splinted, and immobilized, including elbow and wrist joints.
- All open fractures should be wrapped with sterile dressing before immobilization:
- Do not reduce open fractures back under skin in the field.
- In patients with isolated extremity trauma, analgesia may be administered.
Ed Treatment/Procedures
- Shaft fractures, nondisplaced:
- Long-arm splint
- Orthopedic referral
- Shaft fractures, displaced:
- Orthopedic consultation
- Often require open reduction, internal fixation
- Distal fractures, nondisplaced:
- Forearm sugar-tong or AP splint
- Orthopedic referral
- Distal fractures: Colles/Smith:
- Simple, noncomminuted, extra-articular Colles and Smith fractures may be reduced in ED:
- Splint (long-arm sugar-tong splint)
- Sling
- Referred to orthopedics
- Complicated Colles and Smith fractures require orthopedic consultation.
- Distal fractures: Barton/Hutchinson:
- Uncomplicated Barton and Hutchinson fractures
- Splint (AP or sugar-tong splint)
- Place in sling
- Referred to orthopedics
- Complicated fractures require orthopedic consultation.
- Open fractures:
- Cover with sterile dressings.
- IM/IV antibiotics
- Tetanus immunization (if indicated)
- Splint
- Immediate orthopedic consultation
- Forearm fractures associated with compartment syndrome or neurovascular compromise require immediate orthopedic consultation.
- Torus and Greenstick fractures with <10 ° of angulation may be treated with long-arm splint, sling, and orthopedic referral.
- Plastic deformities require orthopedic consultation:
- Some minimally displaced plastic deformities may be placed in long-arm splint and sling.
- Salter-Harris type fractures require orthopedic consultation.
Medication
- Acetaminophen: 325-1,000 mg PO q4h (peds: 10-15 mg/kg q4h PO)
- Antibiotics:
- Open fractures require IM/IV antibiotics.
- Cefazolin: 1-2 g IM/IV or equivalent 1st-generation cephalosporin; if contaminated, add an aminoglycoside
- Codeine: 15-60 mg PO/IM q4h (peds: >2 yr, 0.5-1 mg/kg q4h PO/IM)
- Hydrocodone: 5-10 mg PO q4h
- Ibuprofen: 200-800 mg q4-8h (peds: >6 mo, 5-10 mg/kg per dose q6h)
- Morphine sulfate: 2-10 mg IV/IM; titrate to pain (peds: 0.1 mg/kg per dose IV/IM)
- Tetanus: 0.5 mL IM every 10 yr
Follow-Up
Disposition
Admission Criteria
- Open fractures
- Fractures with compartment syndrome or neurovascular compromise
- Fractures needing immediate operative management or general anesthesia for reduction
- Suspected nonaccidental trauma
Discharge Criteria
- Appropriate reduction and immobilization
- Arranged orthopedic follow-up
- Adequate pain control measures
- Cast/splint care discharge instructions provided and understood by patient
- Documentation of intact neurovascular function after ED treatment
Issues for Referral
All fractures (or suspected fractures) discharged from ED should be referred to orthopedic surgeon for close follow-up.
Followup Recommendations
All patients should be referred to an orthopedic surgeon or hand surgeon.
Pearls and Pitfalls
- Missed 2nd fracture
- Missed concurrent dislocation or subluxation
- Impending compartment syndrome
Additional Reading
- Black WS, Becker JA. Common forearm fractures in adults. Am Fam Physician. 2009;80(10):1096-1102.
- Handoll HH, Pearce P. Interventions for isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev. 2009;(3):CD000523.
- Madhuri V, Dutt V, Gahukamble AD, et al. Conservative interventions for treating diaphyseal fractures of the forearm bones in children. Cochrane Database Syst Rev. 2013;4:CD008775.
- Perron AD, Brady WJ. Evaluation and management of the high-risk orthopedic emergency. Emerg Med Clin North Am. 2003;21(1):159-204.
Codes
ICD9
- 813.23 Closed fracture of shaft of radius with ulna
- 813.44 Closed fracture of lower end of radius with ulna
- 813.80 Closed fracture of unspecified part of forearm
- 813.42 Other closed fractures of distal end of radius (alone)
- 813.03 Closed Monteggias fracture
- 813.13 Open Monteggia's fracture
- 813.33 Open fracture of shaft of radius with ulna
- 813.41 Closed Colles' fracture
- 813.51 Open Colles' fracture
- 813.52 Other open fractures of distal end of radius (alone)
- 813.54 Open fracture of lower end of radius with ulna
- 813.90 Open fracture of unspecified part of forearm
ICD10
- S52.90XA Unsp fracture of unsp forearm, init for clos fx
- S52.509A Unsp fracture of the lower end of unsp radius, init
- S52.609A Unsp fracture of lower end of unsp ulna, init for clos fx
- S52.379A Galeazzis fracture of unsp radius, init for clos fx
- S52.209A Unsp fracture of shaft of unsp ulna, init for clos fx
- S52.209B Unsp fx shaft of unsp ulna, init for opn fx type I/2
- S52.279A Monteggia's fracture of unsp ulna, init for clos fx
- S52.279B Monteggia's fracture of unsp ulna, init for opn fx type I/2
- S52.309A Unsp fracture of shaft of unsp radius, init for clos fx
- S52.309B Unsp fx shaft of unsp radius, init for opn fx type I/2
- S52.379B Galeazzi's fracture of unsp radius, init for opn fx type I/2
- S52.509B Unsp fx the lower end unsp radius, init for opn fx type I/2
- S52.539A Colles' fracture of unsp radius, init for clos fx
- S52.539B Colles' fracture of unsp radius, init for opn fx type I/2
- S52.569A Barton's fracture of unsp radius, init for clos fx
- S52.569B Barton's fracture of unsp radius, init for opn fx type I/2
- S52.609B Unsp fx lower end of unsp ulna, init for opn fx type I/2
- S52.90XB Unsp fracture of unsp forearm, init for opn fx type I/2
SNOMED
- 91419009 Closed fracture of forearm (disorder)
- 33192001 Closed fracture of lower end of radius AND ulna (disorder)
- 208309008 Closed fracture radius and ulna, middle (disorder)
- 208322000 Closed Galeazzi fracture (disorder)
- 123971006 Colles fracture (disorder)
- 123973009 Monteggia's fracture (disorder)
- 208341002 Open Galeazzi fracture (disorder)
- 54645004 Barton's fracture (disorder)
- 88116004 Open fracture of lower end of radius AND ulna (disorder)
- 91296001 Open fracture of forearm (disorder)