What is Nightstick Fracture?
A ‘nightstick fracture’ is the term used for a break in the large, inner bone of the forearm, known as the ulna. Imagine if someone attempted to defend their face from a police baton or ‘nightstick’ by holding up their forearm; this could result in such a fracture. In the past, these fractures were usually not treated with surgery. However, it was thought that they often didn’t heal properly, which led to more careful consideration of how best to manage these injuries.
What Causes Nightstick Fracture?
The term “nightstick fractures” comes from incidents where people were hit by police batons in the forearm as they tried to protect their head. However, these fractures can occur from any direct hit to the inner side of the forearm. They could also happen when the forearm is twisted excessively in either direction.
Risk Factors and Frequency for Nightstick Fracture
Nightstick fractures, which are injuries to the forearm, don’t seem to affect men and women differently in terms of how often they happen. However, one study noted that men typically get these fractures at an earlier age (around 37 years old) than women, who get them around 52 years old.
Signs and Symptoms of Nightstick Fracture
A nightstick fracture is a type of injury that happens when your forearm is hit hard, often resulting in intense pain and difficulty using the injured arm.
When a doctor examines a patient with a possible nightstick fracture, they will first check the skin thoroughly to determine whether the fracture has pierced the skin. This step is crucial because it will significantly influence the immediate treatment plan. The doctor will also carefully check the patient’s elbow and wrist as other injuries may be present, like a Monteggia fracture or a wrist injury.
The doctor will also ask the patient to move their elbow as much as they can, looking for any unusual sounds at the site of the radial head, which is near the elbow. Additionally, a “shuck test” will be performed at the wrist. This test checks for any signs of weakness or instability at the distal radioulnar joint (DRUJ), which is located in the wrist.
Testing for Nightstick Fracture
If a fracture is suspected, the initial and most crucial test to be performed is an X-ray. X-rays of the elbow are necessary to check the alignment of the radial head and rule out a specific type of fracture known as a Monteggia fracture. X-rays of both wrists are also beneficial to examine the wrist joint and compare the two for any possible variations. It’s important to take these images with the patient’s wrists both in pronation and supination (meaning turned upwards and downwards), as the position can affect the X-ray results.
Computed tomography scans, also known as CT scans, are rarely required since any fracture that can’t be clearly detected on an X-ray can usually be managed without surgery. Advanced imaging options, like CT or magnetic resonance imaging (MRI), should only be used if there’s a need to rule out other potential medical conditions.
Treatment Options for Nightstick Fracture
Traditionally, closed fractures that are not out of place or only slightly displaced (less than 50%) could be treated without surgery, as the damage to the surrounding bone covering and interbone membrane is usually less for such fractures. Several studies affirm that early movement can be an effective treatment for fractures that are slightly displaced, particularly those located in the middle or end part of a bone shaft. This is due to the stabilizing effects of the radius (a bone in the forearm) and the interbone membrane. It seems that it doesn’t matter whether the limb is immobilized in a sideways position, as good results have been reported with mid-prone positioning (halfway between the positions of palm-down and palm-up).
However, fractures located near the top of the bone shaft are more likely to require surgery as they are often associated with instability of the radial head (a part of the radius bone near the elbow). Open fractures, where the bone is exposed, also necessitate formal surgical cleaning along with the use of internal fixation devices to repair the break. This is the standard procedure for such types of injuries. If a bone is displaced or shortened by more than 5 mm, surgical stabilization is indicated. Patients with multiple injuries (polytrauma) are also more likely to benefit from surgical stabilization since surgery enables easier and earlier use of the injured limb after trauma.
What else can Nightstick Fracture be?
If someone comes to the doctor with a fracture in the bone of their forearm, it’s important that they are checked for other related injuries. One could be a Monteggia fracture, where the bone of the forearm is not properly connected to the elbow. To check for this, the doctor should take a clear x-ray of the elbow to make sure the forearm bone is positioned correctly to the bone of the elbow. Monteggia fractures can be serious and need to be operated on quite urgently. During the procedure, re-positioning the bone of the forearm is very important in order to correctly re-connect it with the bone of the elbow.
Also, doctors should be aware that with forearm fractures, there can be other bone breaks and dislocations, especially around the wrist. X-rays of the other wrist can be very helpful in assessing the condition of the fractured wrist. During an operation, the doctor should compare x-ray views of the injured wrist with the good one, taking into account how the hands are rotated to ensure the forearm bone is of the right length.
Doctors should also do a “shuck test” regularly on the wrist joint. This test helps to check how stable the wrist is. If it’s found to be unstable, wires can be used temporarily to hold the wrist joint steady. This improves the patient’s chances of their wrist functioning well in the long run.
What to expect with Nightstick Fracture
There isn’t a lot of concrete data to compare surgery versus non-surgical treatment for situations where only the ulnar shaft (part of the lower arm bone) is broken. This is largely due to the fact that the severity of the fracture and the specific details of the break can greatly vary between the two treatment methods.
However, what is clear is that for fractures that are slightly displaced (not aligned properly) with little damage to surrounding tissue, starting to move the affected area early leads to a faster healing time. This is in comparison to keeping the area immobilized for a long period or using a functional support brace.
Great or good outcomes seem to be highest for the groups that used a functional brace and started moving early. Using a brace that is positioned below the elbow seems to be slightly better than one positioned above the elbow.
In situations where surgery is considered, compression plating (a method where a metal plate is screwed onto the bone) seems to yield the best patient results. Inserting a metal rod into the center of the bone, known as intramedullary nailing, could be an acceptable alternative, but it should be noted that patients receiving this treatment have shown poorer functional outcomes in some studies.
Possible Complications When Diagnosed with Nightstick Fracture
Nonunion, where the broken bone doesn’t heal, is typically a major worry when dealing with isolated fractures of the ulnar shaft (the inner bone of the forearm). However, recent findings indicate the nonunion rates may be lower than previously believed. For fractures managed without surgery, a comprehensive study reported that the rate of nonunion varies between 2% and 4%. When it comes to “nightstick” fractures that were managed through surgical methods, the nonunion rate ranged from 0% to 2% for fractures treated with plate fixation. Meanwhile, fractures treated with a method called intramedullary fixation had a 5% rate of nonunion.
Preventing Nightstick Fracture
Broken bones in the lower arm, particularly affecting the ulna, often happen because of a forceful hit to the forearm or a fall that twists the arm too much. So, one of the best ways to prevent these “nightstick fractures” is by making sure those who have trouble moving around or are more likely to fall have the right support, like a walking aid.
If you do get a nightstick fracture, it’s important to see an orthopedist – a doctor who specializes in bones. They can take the right X-rays to see how bad the break is and check to make sure there are no other injuries that might need extra treatment.
