Forearm fractures

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Fractures of the radius and/or ulna occur frequently. Important forearm fracture patterns include complete forearm fractures, Galeazzi fractures, and Monteggia fractures. Fractures of the forearm bones at the elbow level include radial head fractures and olecranon fractures, while those at the wrist level include distal radius fractures. The mechanism of injury can be low-energy, such as a fall on an outstretched hand (FOOSH), or high-energy, such as a motor vehicle collision (MVC). Clinical presentation is typically characterized by pain near the fracture site, gross deformity, and swelling. X-ray is the main diagnostic modality. Evaluation includes imaging of the forearm; wrist and elbow imaging are added for moderate to severe injuries. Management varies depending on the age group and fracture characteristics, and includes a thorough neurovascular assessment, acute immobilization, pain management, and referral to orthopedics for definitive open reduction and internal fixation (ORIF) or closed reduction and casting.

For more details on fractures involving the distal radius, see “Distal radius fractures.”

Relevant anatomy

Important musculoskeletal structures

• Radius: composed of the radial head, radial shaft, and distal radius (including radial styloid)
• Ulna: composed of the olecranon process, coronoid process, ulnar shaft, and distal ulna (including ulnar styloid)
• Connective tissue: interosseous membrane of the forearm, annular ligament of the radius
• Joints: elbow joints (i.e., radiohumeral joint and humeroulnar joint), proximal radioulnar joint , wrist joints (i.e., radiocarpal joints), and distal radioulnar joint (DRUJ)

Important neurovascular structures

• Nerves: the radial nerve , ulnar nerve , and median nerve (including its branch anterior interosseous nerve)
• Arteries: the brachial artery and its branches, the radial artery and ulnar artery

Overview of forearm fractures

• Although the term forearm fracture most often focuses on midshaft fractures of the radius and/or ulna, the proximal and distal portions of these bones which make up the wrist and elbow joints can also be involved.
• See “Overview of radius and ulna fractures” for the various fracture patterns that can affect these bones.
• For further detail on distal radius fracture patterns, See “Types of distal radius fractures.”
• For other bones that can be fractured in the wrist, see “Causes of wrist fractures.”
• For other bones that can be fractured in the elbow, see “Distal humerus fractures.”

The following are indicated irrespective of the fracture type and bones involved: ^[2][3]

• Perform neurovascular exam.
  • Assess radial and ulnar artery pulses and capillary refill time.
  • Evaluate for median nerve injury , radial nerve injury , and ulnar nerve injury.
• Consider indications for orthopedic consultation for fractures.
• Obtain imaging of the forearm and consider adding imaging of the elbow and wrist to check for associated injuries.
• Evaluate for signs of compartment syndrome in any patient with high-energy impact trauma.
• Provide analgesia for acute fractures.
• Continue with management specific to the injury identified on imaging, e.g., complete forearm fracture, Monteggia fracture, Galeazzi fracture

• Definition: fracture of both the radial shaft and ulnar shaft
• Epidemiology: more common in children ^[2]
• Etiology: FOOSH injury (common in children), high-energy trauma (e.g., MVC) ^[2]
• Clinical features ^[2]
  • Pain and swelling of the mid-forearm
  • Gross deformity
  • Nerve injury is uncommon with closed fractures.
• Diagnostics: x-ray ^[2][5]
  • May show nondisplaced, displaced, or greenstick fractures of both shafts of the radius and ulna
  • Injury from high-energy trauma: may show angulation > 10° and/or comminution
• Management: Begin general management of forearm fractures. ^[2][3][5]
  • Fracture-dislocations with signs of skin tenting or neurovascular compromise
    • Consult orthopedics for emergency reduction.
    • If timely access to orthopedics is unavailable, consider closed reduction by an experienced emergency physician.
  • Open fractures
    • Begin irrigation and IV antibiotics for open fractures.
    • Consult orthopedics for emergency operative management.
  • Closed fractures without reasons for urgent orthopedic consultation for fractures
    • All patients
      • Immobilize with a long-arm AP splint or sugar tong splint.
      • Refer for prompt follow-up with orthopedics, e.g., within 3–5 days.
    • Children: closed reduction under sedation and immobilization
    • Adults
      • Nondisplaced (uncommon): long-term immobilization
      • Displaced : typically requires ORIF

Thoroughly evaluate patients with complete forearm fractures for signs of compartment syndrome. ^[5]

• Definition: proximal (or middle) ulnar fracture with concomitant dislocation of the radial head
• Etiology
  • Fall on outstretched and pronated forearm (low-energy trauma)
  • Direct blow to the forearm, high-energy trauma (e.g., MVC)
• Clinical features ^[2][5]
  • Pain, crepitus, and limited range of motion at the elbow
  • Radial head palpable in antecubital fossa
  • Shortened forearm
  • Posterior interosseous nerve injury can occur.
    • Paresthesias to the dorsal aspects of the thumb, second, and third fingers
    • Loss of thumb extension
• Diagnostics: x-ray ^[2]
  • Shows a fracture of the proximal (or middle) ulna with dislocation of the radial head (dislocation can be anterior, posterior, or lateral)
  • Lateral view: The radiocapitellar line does not intersect the middle of the capitellum, suggesting elbow dislocation.
• Treatment Begin general management of forearm fractures. ^[2]
  • Children with uncomplicated fractures: Closed reduction by an orthopedic surgeon is often successful.
  • Adults and patients with complicated fractures
    • Initial: Immobilize in a posterior long arm splint.
    • Definitive: ORIF (e.g., plating, K-wire fixation) required for most injuries
• Disposition: Consult orthopedics urgently.

Adults with displaced Monteggia fractures require urgent ORIF. ^[3]

In patients with ulnar fractures, evaluate the radiocapitellar line to check for disruption of the proximal radioulnar joint. ^[2]

• Definition: radial shaft fracture with disruption of the distal radioulnar joint
• Epidemiology: more common in children
• Etiology: fall on outstretched and pronated forearm, MVC ^[2][3]
• Clinical features ^[2][3][6]
  • Pain and deformity at the distal radius
  • Limited range of motion at the wrist
  • Palpable displacement of the ulnar head
  • Neurologic injury is rare.
• Diagnostics: x-ray ^[3][7]
  • Shows a fracture at the mid to distal radial shaft, with subluxation or dislocation of the distal radioulnar joint (DRUJ)
  • A tear in the interosseous membrane can only be seen indirectly on x-ray.
  • Signs of DRUJ instability (e.g., widening of the space between the distal radius and ulna)
• Treatment: Begin general management of forearm fractures. ^[2][3]
  • Children with uncomplicated fractures: Closed reduction by an orthopedic surgeon followed by casting
  • All adult patients and all patients with complicated fractures
    • Initial: Immobilize in a posterior long arm splint.
    • Definitive: ORIF (e.g., plating, K-wire fixation) required for most injuries
• Disposition: Consult orthopedics urgently.

Almost all Galeazzi fractures require open reduction and repair of the distal radioulnar joint. ^[3]

• Definition: fracture of the radial head
• Epidemiology: more common in adults than radial head subluxation or dislocation ^[8]
• Etiology
  • FOOSH with the elbow partially flexed and pronated ^[9]
  • Stress fracture (e.g., in throwing sports)
• Clinical evaluation ^[9]
  • Perform a neurovascular exam. ^[10]
  • Radial head region is tender to touch.
  • Pronation and supination of the forearm are painful.
  • Effusion or hemarthrosis of the elbow joint may be present.
• Diagnostics: x-ray elbow (AP, lateral and oblique) ^[3][9][10]
  • Fracture through the radial head is not always visible.
  • Evidence of effusion (sail sign and/or posterior fat pad sign) may be the only finding.
  • Comminuted fractures: Consider imaging the wrist, as these fractures may be associated with additional injuries. ^[10]
• Treatment: Begin general management of forearm fractures.
  • Fractures with > 60 degrees of angulation often require open reduction and orthopedic consult. ^[3]
  • Nondisplaced fractures: conservative treatment
    • Immobilize in a sling or posterior long arm splint for 24–72 hours. ^[3][11]
    • Start early ROM exercises. ^[9][12]
  • Complex fractures: typically surgical treatment ^[9]
  • Pain management
    • Consider hemarthrosis aspiration only as an adjunct to splinting in select patients. ^[3][13]
    • Avoid intraarticular local anesthetic infiltration. ^[3]
• Disposition: typically outpatient management with short-term orthopedic follow-up ^[3]
• Complication: cubitus valgus

Treat a positive elbow fat pad sign with corresponding bony tenderness as an occult fracture. ^[3]

• Definition: fracture of the olecranon process
• Etiology ^[2]
  • Direct blow to the elbow: more likely to cause comminuted fractures
  • FOOSH with the elbow in flexion: more likely to cause transverse or oblique fractures
• Clinical evaluation ^[2][3]
  • Perform a neurovascular exam. ^[10]
  • Assess for ulnar nerve injury and document ulnar nerve function. ^[3]
  • Findings
    • Olecranon and surrounding soft tissue are swollen and tender to touch.
    • Hemarthrosis of the elbow joint
    • Inability to extend the forearm against resistance or gravity if there is concurrent triceps injury
• Diagnostics: x-ray elbow (AP, lateral)
  • Fractures and displacement are best visualized with lateral views of the elbow in 90° flexion.
  • An elbow fat pad sign is indicative of a fracture.
• Management: Begin general management of forearm fractures. ^[2][3][5]
  • Open fracture and/or neurovascular compromise: orthopedics consult within 30–60 minutes
  • Patients without reasons for urgent orthopedic consultation for fractures: Admission is typically not necessary.
    • Nondisplaced or minimally displaced (< 2 mm) fractures: conservative treatment
      • Immobilize with a posterior long-arm splint. ^[2]
      • Refer for orthopedic follow-up within 5–7 days, including repeat x-rays to exclude delayed displacement.
      • ROM exercises can begin 3 weeks after the injury.
    • Fractures displaced > 2 mm and/or loss of extensor mechanism
      • ORIF required
      • Orthopedics consult within 24–48 hours
• Complications ^[5]
  • Ulnar nerve injury
  • Decreased range of motion
  • Posttraumatic arthritis
  • Nonunion

Ensure rapid orthopedic follow-up for all patients with olecranon fractures, as most are considered intraarticular and require near-perfect reduction to preserve full ROM. ^[2][5]