Management of Forearm Fractures in Adults Reviewed

Laurie Barclay, MD

December 09, 2009

December 9, 2009 — Primary care evaluation and management of forearm fracture in adults, which is a common injury in this age group, is presented in a review published in the December issue of American Family Physician.

"Upper extremity fractures are often evaluated by primary care physicians at the patient's initial presentation or at follow-up after the emergency department," write W. Scott Black, MD, and Jonathan A. Becker, MD, both from the University of Louisville Department of Family and Geriatric Medicine in Kentucky. "These fractures account for approximately 2 million emergency department visits annually. Eighteen percent of the visits are for humeral fractures; 31 percent are for radial or ulnar fractures; and 51 percent are for carpal, metacarpal, or phalangeal fractures. Falls are the leading cause of upper extremity fractures."

The objectives of initial assessment of forearm fractures are to determine the mechanism of injury and extent of the fracture and to identify any additional injuries. A comprehensive history of the mechanism of injury, a thorough examination of the affected arm, and appropriate radiographic studies are all required.

To rule out the possibility of an open fracture, any skin breaks must be thoroughly examined. Neurovascular examination includes evaluation of radial and ulnar pulses and of capillary refill. Hand and wrist sensory and motor examination are needed, particularly in the median nerve distribution because of its vulnerability in forearm trauma.

Standard radiographic assessment includes posteroanterior and lateral views of the affected arm, as well as oblique views if a fracture has not been definitively visualized or excluded. Initial radiography may fail to demonstrate small, occult, intra-articular fractures. Although an anterior fat pad is normally seen at the elbow, an effusion will cause elevation of the fat pad (sail sign); a posterior fat pad is an abnormal finding that also suggests a fracture or other intra-articular process.

Repeat radiography in 10 to 14 days may be appropriate when there is high suspicion of a fracture. Magnetic resonance imaging may be helpful if immediate confirmation or exclusion of fracture is required, or to further elucidate possible joint instability or associated ligamentous injury.

Emergent referral is warranted for patients with open fractures, joint dislocation or instability, and/or findings suggesting neurovascular injury. Orthopedic consultation may also be required for fractures with significant displacement, comminution, or intra-articular involvement.

Barring these scenarios, however, primary care clinicians can manage many forearm fractures using the protection, rest, ice, compression, and elevation (PRICE) protocol. Initial treatment includes splinting and a sling to protect the injured arm and place it at rest, and the application of ice and elevating the affected limb can help reduce pain and swelling. In the acute setting, however, compression should be avoided because of possible complications from swelling, such as acute compartment syndrome.

Analgesics may be given as needed for pain control.

Depending on the location and extent of injury, definitive treatment of forearm fractures may range from functional bracing to surgical repair and fixation. Early mobilization is usually recommended to avoid loss of mobility, which is the most common complication.

A short arm cast is appropriate for distal radius fractures (Colles fractures) with minimal displacement. Colles fractures, which account for up to one sixth of all fractures treated, occur most often in young adults (usually from high-energy trauma) and in older persons (usually from a simple fall or other low-impact injury).

"These fractures traditionally have been treated with closed manipulation and casting," the review authors write. "However, it is now recognized that many of these fractures are unstable, and casting may not maintain acceptable reduction. Additionally, advancements in surgical technique have improved fracture stability, allowing for earlier motion and rehabilitation."

For isolated ulnar fractures, a short arm cast or a functional forearm brace is indicated. Therapeutic options for Mason type 1 radial head fractures include a splint for 5 to 7 days, or a sling as needed for comfort, combined with early range-of-motion exercises. For an olecranon fracture in patients with a stable elbow and intact extensor mechanism, nonsurgical treatment may suffice.

Specific key clinical recommendations for practice, and their accompanying level of evidence rating, are as follows:

  • Risk for radiocarpal arthritis is increased with nonsurgical treatment of displaced intra-articular fractures of the distal radius (level of evidence, C). Even minimal articular incongruency is associated with increased complications, according to expert opinion.

  • Treatment with a functional brace or short arm cast is appropriate for isolated ulnar shaft fractures that are not displaced by more than 50 percent of the bone diameter and that are angulated less than 10 degrees (level of evidence, C). This recommendation is based on a systematic review of treatment methodologies, but evidence from randomized controlled trials is lacking.

  • For the treatment of Mason type 1 radial head fractures, early mobilization is preferred, based on consistent evidence from several randomized, controlled trials (level of evidence, A).

  • Casting appears to offer no benefit in the initial treatment of Mason type 1 radial head fractures (level of evidence, B), based on findings from a single randomized controlled trial.

"Because nonsurgical treatment of persons with intra-articular fractures increases the risk for complications, such as radiocarpal arthritis, a referral should be strongly considered for any fracture that extends into the radiocarpal joint or the distal radioulnar joint," the review authors conclude. "Additionally, fractures that require reduction are potentially unstable and may require surgical fixation. Unless the primary care physician has extensive experience with fracture management, it is best to refer patients with distal radius fractures requiring manipulation to an orthopedic surgeon."

The review authors have disclosed no relevant financial relationships.

Am Fam Physician. 2009;80(10):1096-1102. Abstract

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