What is Forearm Fractures?
Your forearm, the part of your arm from your elbow to your wrist, is made up of two parallel bones. These bones are not only connected to your elbow and wrist joints, but they also form their own joints that help you turn (rotate) your arm. Hence, a break or fracture in these bones affects the movement of your arm and grip strength.
These forearm fractures are common in both kids and adults and are somewhat more complicated than breaks in other long bones in the body. They can involve just one of the two bones or both together, and include specific types known as Galeazzi and Monteggia fractures.
The Galeazzi fracture was first identified in the 19th century and involves a break in the lower part of the radius (one of the forearm bones) and a dislocation of the adjacent joint. An Italian doctor named Galeazzi later researched extensively about this fracture. It’s considered a somewhat unstable fracture that absolutely requires treatment.
The Monteggia fracture was also discovered in the early 19th century by an Italian surgeon named Giovanni Battista Monteggia. This involves a break in the ulna (the second forearm bone) and the dislocation of the radius. Another surgeon later expanded the concept, introducing the Monteggia lesion and equivalent injuries, which include a group of fractures that involve various breaks in the ulna and dislocation of the radial joint.
What Causes Forearm Fractures?
Forearm fractures can occur due to various reasons, ranging from minor accidents to major traumatic events. The most common cause is a fall onto an outstretched hand – imagine if you were trying to break a fall with your hands. This kind of impact is known as ‘axial loading’. In adults, fractures are often the result of car accidents, sports injuries, or falls from a significant height. These situations can either cause injuries directly or indirectly.
There are other, less common ways to fracture your forearm as well. This includes instances of gunshot injuries and what’s known as ‘nightstick’ injuries – this is when an object like a baton or similar item hits the forearm.
Risk Factors and Frequency for Forearm Fractures
Forearm fractures are common in children, occurring roughly in 1 out of every 100 kids each year. These fractures are most frequent in the age group of 5 to 14 years, accounting for about 34% of cases. When it comes to fractures of both the radius and ulna bones in the forearm, they make up about 5.4% of all fractures in children under 16. Adults between 25 to 34 years of age also tend to have a relatively higher incidence of forearm fractures.
- In terms of particular locations, the most common site for a forearm fracture is at the end (or “distal” part) of the radius or ulna bones, which account for 32.9% of cases.
- The least common place to get a fracture is the proximal (or closer to the body) region of the forearm, making up only 2.8% of cases.
- For open fractures, which are more severe because the bone breaks through the skin, the most frequently affected area is the diaphyseal region, or the shaft of the bone.
Signs and Symptoms of Forearm Fractures
Forearm fractures are often due to high-impact injuries. These patients typically first show up in the emergency department and it’s important to check for any other critical injuries at the same time. To do this, doctors carry out an examination protocol called ATLS, which consists of two parts: the primary and secondary surveys. The first part, the primary survey, is the initial assessment of the patient. The secondary survey is a more detailed check, including getting a detailed history, a complete physical examination, and a local check on the affected body parts after the patient is stable.
Forearm fractures themselves are diagnosed using a detailed history, a clinical examination, and relevant imaging tests. Patients usually describe severe pain, swelling, sensitivity near the fracture, and a visible misshape in the forearm. After getting the patient’s history, doctors carry out a physical examination to check for exposed fractures and related soft tissue injuries. A thorough neurological examination is done to make sure there’s no nerve injury. The function of the radial and ulnar arteries, which supply the forearm, is also recorded for future reference and to determine the prognosis. It’s imperative to identify early signs of compartment syndrome to prevent severe complications like tissue death and insufficient blood supply.
- Severe pain
- Swelling
- Sensitivity near the fracture
- Visible misshape in the forearm
- Possible nerve injury
- Status of radial and ulnar arteries
- Early signs of compartment syndrome
Testing for Forearm Fractures
Forearm fractures are typically diagnosed using plain radiographs or x-rays. This procedure includes capturing front-to-back (anteroposterior) and side (lateral) views of the forearm. A standard front-to-back view is taken with the elbow straightened and the forearm fully upside down. These x-rays should cover the elbow and wrist for a thorough evaluation. Sometimes, it can be hard to see the complete picture of a fracture from the side view since the two forearm bones can overlap. In such cases, an oblique (angled) view might be needed to understand the fracture pattern, such as whether the bone is broken into two pieces (simple fracture) or multiple pieces (comminuted fracture).
Forearm fractures frequently result in injuries to the joints at the ends of the forearm (distal and proximal radio-ulnar joints) and elbow dislocation. Signs of an unstable injury to the distal radio-ulnar joint include the lower arm bone moving towards the back of the wrist, change in the length of the ulna, fracture of the styloid at the base, and widening of the joint on the front-to-back view. If the lower third part of the radius bone fracture accompanies these signs, it typically suggests a specific type of fracture-dislocation known as the Galeazzi fracture-dislocation. Additional injuries should be assessed using front-to-back and side x-rays of the elbow and the wrist.
A CT scan is generally only needed if there is a suspicion of a fracture involving the joint at the lower end of the radius. However, CT scans and MRI scans are not routinely used for evaluating fresh forearm fractures. An MRI can be helpful in diagnosing injuries in the distal radio-ulnar joint and associated Triangular Fibrocartilage Complex (TFCC) injuries.
Although there are different systems to classify forearm fractures, only a few give useful predictions and guide treatment. No single system classifies all types of forearm fractures. Therefore, the location, pattern, angle, displacement, and any associated tissue damage are usually used to describe forearm fractures. The AO/OTA system is widely used to classify forearm fractures. Other systems like the Gustilo and Anderson or the OTA are used for open forearm fractures. There are special sub-classifications for specific types of fractures, like Monteggia and Galeazzi.
Treatment Options for Forearm Fractures
The ultimate goal when managing a fracture is to align the broken bones correctly, secure them in place, ensure they heal properly, and help the patient get back to their daily life as soon as possible. For fractures in the forearm, it’s crucial that the bones get back their original shape, length, and rotation to ensure good arm function.
Non-Surgical Management
Conservative or non-surgical management of forearm fractures is only advised in very few cases. These include fractures where the bone isn’t broken all the way or if it’s only slightly out of place. Fractures in the ulna bone, one of the two bones in the forearm, can often be successfully treated non-surgically. This involves using a long-arm cast or a functional brace and regularly checking the healing progress with x-rays.
Surgical Management
Usually, forearm fractures are operated on. The surgery can either involve closing up the wound and setting the bone internally, or opening up the wound to set the bone in place. The goal is to rearrange the bones to their original state, secure them, and allow early movement again. This way, the patient can return to their daily life sooner. Operating on this type of fracture is especially favorable in children, while in adults, it can sometimes be difficult to perfectly align the bones by only using a closed approach.
When two forearm bones are broken, the one with smaller shattered pieces (less comminution) is operated on first since it makes manipulating the other bone easier. Placing plates on the volar (palm) side of the forearm is often preferred, but placing them on the dorsal (backhand) provides better mechanical balance.
The medical approach for open fractures, where the bone punctures the skin, depends on how severe the fracture is. Less severe fractures with little contamination can be operated on immediately after cleaning the wound. If the fracture wound is more extensive and dirty, the fracture is temporarily fixed externally during initial debridement (cleaning of the wound) and later it is internally restored.
Surgical Approaches
For most forearm fracture surgeries, patients lie on their back. For operations from the front-side (volar), the limbs are set apart while for back-side (dorsal) and subcutaneous approaches, they are drawn together and the shoulder joint is internally rotated. Accessing the forearm from the back is facilitated by having patients lying face down.
In most cases, an individualized approach for treating both the ulna and radius bones is advised since using the same incision for both can lead to their fusion and restricted wrist movement.
Surgery on the radius is usually more difficult than on the ulna because the radius is surrounded by muscle and has important blood vessels and nerves running alongside it. The commonly used approaches include the Henry and Thompson approaches, making an incision from the wrist to the inside of the elbow.
The ulna is close to the skin along its entire length, so a subcutaneous approach where the surgeon cuts through the skin is used. The only potential complication is damaging the dorsal nerve of the ulna.
Fixation Methods
The most common ways to stabilize forearm fractures are Dynamic Compression and Limited Contact-Dynamic Compression. These techniques provide strong stability at the fracture site, helping to promote rapid healing. In more complex cases, a technique involving bridging the pieces together is employed. An internal metal rod can also be used which is less invasive and retains the initial clotting and bone lining blood supply.
The type of management for specific fractures like Galeazzi and Monteggia follows the same principles as a regular forearm fracture. Galeazzi fractures in adults are particularly unsafe and require open surgery, with plate fixation being the preferred choice. For a Monteggia fracture, management varies depending on the stability of the radial head and the complexity of the fracture and can include both closed and open reduction techniques.
What else can Forearm Fractures be?
When a doctor is trying to figure out if a person has broken their forearm, they have to consider other possible conditions that can cause similar symptoms. These can include:
- Strains or dislocations of the elbow or wrist
- Broken elbows or wrists
- Damage to the olecranon, a pointy bone at the tip of the elbow
- A specific type of wrist bone fracture
- Osteomyelitis, an infection in the bone
- Problems due to nerve disease affecting the bones and joints
- Tenosynovitis, the inflammation of the fluid-filled sheath that surrounds a tendon
- Bursitis, the inflammation of the cushioning pads around joints
To determine what is causing the symptoms, the doctor will conduct a thorough physical examination and may arrange for imaging tests to look at the bones and joints more closely.
What to expect with Forearm Fractures
Forearm fractures usually heal well with a high recovery rate of around 95% to 98%. Research has shown that fractures of the radius bone (one of the two bones in the forearm) tend to heal a bit better than fractures of the ulnar bone (the other bone in the forearm). In terms of treatment, forearm fractures typically get better outcomes from the plate osteosynthesis method (where a metal plate is attached to the bones to stabilize them) compared to using a third-generation intramedullary nail (a nail inserted into the bone marrow cavity).
Contrarily, the first-generation intramedullary nail, which doesn’t provide rotational stability, offers a less successful outcome compared to the compressive plating method (another type of bone stabilization technique).
Open fractures, where the bone breaks through the skin, depend on the severity and type of the injury for their outcome. These fractures may have complications, such as infection and non-healing of the bone, which can lead to extended illness and increased healthcare costs.
Possible Complications When Diagnosed with Forearm Fractures
Forearm fractures may cause injuries to the various nerves, such as the ulnar nerve, radial nerve, and the superficial branch of the radial nerve. These injuries may sometimes occur during surgical procedures.
Another related issue is Compartment Syndrome, which is a serious condition that commonly results from fractures. Its major cause is the fracture of the distal end of the radius. It’s diagnosed by checking the forearm’s compartment pressure and through physical examination. It demands swift treatment, usually through a fasciotomy, to avoid the risk of tissue death.
Infections are considered very debilitating complications of forearm fractures. The most common causative agent is the staphylococcus aureus bacteria. Infections generally exhibit symptoms such as redness, swelling, fever, and tenderness at the site of infection. Mild cases may be treated with oral antibiotics, but severe cases require surgical cleaning to prevent further complications and non-healing of the bone (non-union).
Speaking of non-union, this happens when the fracture does not heal and it is witnessed in 2% to 10% of all forearm fractures. It results from factors such as inadequate reduction or fixation, issues with bone healing like infection and metabolic disorders. Certain fracture types and locations along with patients’ lifestyle and health conditions also contribute to non-union. Management of non-union involves surgery and sometimes the addition of bone grafting.
Malunion, where the fracture heals incorrectly, is also common in forearm fractures but the exact occurrence rate is unclear. Depending on the angle and location of malunion, it can result in various degrees of loss of hand rotation. Some studies have shown that the degree of rotation loss equals the degree of malunion.
Radioulnar Synostosis is another possible complication of forearm fracture surgeries, particularly in cases where a single incision approach is used. It means the union of the radius and ulna bones, which is rare when separate approaches are used. Fracture location, infection, head injury, and soft tissue trauma increase the risk of synostosis. There are several ways proposed to prevent this outcome.
Lastly, refracture is a less common issue that usually happens in patients who’ve had implants removed after bone healing. Implants can create a rigid structure, cause reduced blood flow and bone thinning, which eventually leads to refracture.
Preventing Forearm Fractures
If someone injures their forearm, it’s crucial that they get medical attention quickly. Not treating these injuries promptly could lead to long-term disability. This is because the forearm plays a specific role in movements like twisting the wrist and arm, so poor treatment could result in a significant reduction in these types of movements, affecting everyday activities.
Moreover, it’s equally important to undertake the right exercises and physical therapy after the treatment for a forearm fracture, regardless of whether it was managed surgically or non-surgically. Doing so can help ensure the best recovery, maximising the ability to move and use the arm effectively again.
