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 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.
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.
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