Common Forearm Fractures in Adults

U pper extremity fractures are often evaluated by primary care physicians at the patient’s initial presentation or at followup after the emergency department. 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. Initial fracture management generally follows the traditional PRICE (protection, rest, ice, compression, and elevation) protocol. The injured arm should be protected and placed at rest using splinting and a sling. Ice and elevation can help control pain and swelling. In the acute setting, compression of the limb should be avoided because of possible complications from swelling, such as acute compartment syndrome. Analgesics may be prescribed as necessary for pain control. Definitive treatment of forearm fractures can range from functional bracing to surgical fixation. Because loss of mobility is the most common complication, early mobilization is usually recommended. Initial Evaluation The goals of initial evaluation of forearm fractures are to define the mechanism of injury, delineate the extent of the fracture, and identify any additional injuries. This requires a thorough examination of the entire arm. Any breaks in the skin must be assessed to rule out the possibility of an open fracture. Joint dislocation, open fractures, and neurovascular injury are among the indications for immediate orthopedic referral (Table 1). Neurovascular examination includes assessment of capillary refill, as well as pulses in the radial and ulnar arteries. Sensory and motor function of the hand and wrist should be documented, with focus on the function of the median nerve because of its propensity for injury in forearm trauma. Much of the subsequent management is based on the radiologic evaluation of the fracture. Standard radiography should include posteroanterior and lateral views. Oblique views can be used to supplement the basic series if the presence of a fracture remains in doubt. Small, occult, or intra-articular fractures may not be noted on initial radiography. An anterior fat pad is normally visualized at the elbow, but an Fractures of the forearm are common injuries in adults. Proper initial assessment includes a detailed history of the mechanism of injury, a complete examination of the affected arm, and appropriate radiography. Open fractures, joint dislocation or instability, and evidence of neurovascular injury are indications for emergent referral. Fractures demonstrating significant displacement, comminution, or intra-articular involvement may also warrant orthopedic consultation. In the absence of these findings, many forearm fractures can be managed by a primary care physician. Initial management of forearm fractures should follow the PRICE (protection, rest, ice, compression, and elevation) protocol, with the exception of compression, which should be avoided in the acute setting. Distal radius fractures with minimal displacement can be treated with a short arm cast. Isolated ulnar fractures can usually be managed with a short arm cast or a functional forearm brace. Mason type I radial head fractures can be treated with a splint for five to seven days or with a sling as needed for comfort, along with early range-of-motion exercises. Patients with an olecranon fracture are candidates for nonsurgical treatment if the elbow is stable and the extensor mechanism is intact. (Am Fam Physician. 2009;80(10):1096-1102. Copyright © 2009 American Academy of Family Physicians.)