Fractures - Forearm

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full PCH Emergency Department disclaimer.

Aim

To guide PCH ED staff in the assessment and management of forearm fractures in children.

Background

  • Fractures of the radius and ulna are common in children
  • The usual mechanism is a fall onto outstretched hand (FOOSH)
  • There may be various combinations of complete, greenstick or bowing (plastic deformity) fractures.

General

  • Midshaft radius and ulna fractures are common in school age children
  • Unless there is significant deformity, angulation or displacement, they can be managed with a simple above elbow plaster
  • Isolated shaft fractures of the ulna are rare – always look for an associated radial fracture or radial head dislocation
  • Monteggia Fracture-Dislocation is a proximal or mid-third ulna fracture, with associated dislocation of the radial head. It occurs from 2 years of age to puberty.
  • Galeazzi Fracture is a fracture of the radial shaft with radio-ulnar joint disruption. It is much less common than Monteggia fracture dislocations.
  • Always include the elbow and wrist when ordering X-Rays in suspected forearm fractures
  • Plastic deformity (bowing) usually occurs in the <10 year old age group and is important to recognise
  • Any clinical deformity of the forearm usually requires reduction.

Assessment

History

  • The most common mechanism of injury for forearm fractures are falls onto an outstretched hand (FOOSH) with forward momentum
  • Direct blows to the forearm account for a smaller proportion of radius and ulna shaft fractures
  • Consider non-accidental injury. Complete an Injury Proforma form in all children < 2 years.

Examination

  • There is usually swelling, tenderness and decreased range of movement, especially pronation and supination
  • There will be obvious deformity with displaced fractures
  • Remember to always examine the elbow and wrist joints
  • Look for open wounds and neurovascular deficits.

Investigations

Radiology

  • Standard AP and lateral views of the whole forearm including the elbow and wrist joints
  • Assess the radiocapitellar line and radio-ulnar joint. See Fractures - Elbow
  • For a description of the types of fractures see Fractures – Overview

Management

  • Minimally displaced and minimally angulated fractures should be immobilised in an above elbow plaster and followed up in the Orthopaedic Fracture clinic
  • Displaced, angulated and clinically deformed fractures usually require reduction.
  • Initial management

    • Analgesia
    • Examine for neurovascular injury (if deficits evident manage immediately) – urgent Orthopaedic team referral
    • Ice and elevation of effected limb
    • Immobilise suspected fracture before X-Rays (e.g. splint, board)
    • Keep fasted if there is clinical deformity
    • Antibiotics for compound fractures and consider tetanus.

    Further management

    Midshaft radius and ulna

    • Midshaft fractures may be greenstick, complete or bowed
    • Fractures with no or minimal displacement/angulation are managed in an above elbow backslab with Orthopaedic Fracture clinic follow up in 7-10 days. See Outpatient Clinics.
    • Fractures with clinical deformity, angulation > 10 degrees or any displacement should be discussed with the Orthopaedic Team urgently for possible reduction
    • Up to 15 degrees of angulation may be acceptable in young patients if there is no obvious clinical deformity. Keep these patients fasted until review by the Orthopaedic team.

     

    An X-Ray of Plastic deformity of radius and ulna with volar tiltAn X-Ray image of a Greenstick fracture of radius shaft with 20 degrees of dorsal angulation and minimally displaced ulna fracture

     

    Plastic deformity of radius and ulna with volar tilt (left)

     

    Greenstick fracture of radius shaft with 20 degrees of dorsal angulation and minimally displaced ulna fracture (right)

     

    Transverse fractures of radius and ulna with complete displacement of radius and significant dorsal angulation

     

    Transverse fractures of radius and ulna with complete displacement of radius and significant dorsal angulation (above)

     

    Monteggia fracture-dislocation

    • Proximal or mid-third ulna fracture, with an associated dislocation of the radial head
    • Clinically there may be elbow swelling and pain in addition to an obvious forearm (ulna) fracture
    • Always assess the radiocapitellar line on lateral elbow radiographs (see Fractures - Elbow) as radial head dislocations are often missed
    • Isolated radial head dislocation never occurs. Always look for an associated ulna fracture which may be a subtle plastic deformity.
    • All Monteggia fracture-dislocations should be referred to the Orthopaedic team urgently for reduction.

    An x-Ray image of a Monteggia fracture dislocation showing ulna shaft fracture with radial head dislocation

    Monteggia fracture dislocation - ulna shaft fracture with radial head dislocation (above)

    Galeazzi fracture dislocation

    • Radial shaft fracture (usually distal third) with distal radioulnar joint disruption
    • Clinical distal ulnar prominence with joint instability may be present
    • Galleazzi fractures should be referred to the Orthopaedic team urgently for reduction.

    Fractures of Radius & Ulna Requiring Urgent Orthopaedic Referral

    • Neurovascular compromise
    • Compound fractures
    • Significant displacement or angulation
    • Clinical deformity
    • Monteggia fracture dislocation
    • Galeazzi fracture.

    Referrals and follow-up

    • All children who have a plaster placed should have a plaster check at 24 hours. They can return to the Emergency Department to be assessed by the triage nurse.
    • All radius and ulna shaft fractures should be followed up in the Orthopaedic Fracture clinic in 7-10 days. See Outpatient Clinics.

    Health information (for carers)

    Advise parents of the signs and symptoms of compartment syndrome.



    Endorsed by:  Director, Emergency Department   Date:  Jun 2017


     Review date:   Jun 2020


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