Authors

Dr Keran Sundaraj MBBS MSc (Trauma) FRACS FAOA

The forearm (between the wrist and the elbow) is made up of the radius and ulna bones. Forearm fractures are common in childhood. Approximately 75% of these fractures are at the distal (wrist) end. Commonly, fractures of the forearm occur during play or sport with the arm used to brace a fall.

Anatomy

The radius (thumb side) and ulna (little finger side) form a bony ring which is the forearm. In addition, growth plates are present at both wrist and elbow. These form the growing ends of the bone, with the majority of growth occurring from the wrist.

Types of Forearm Fractures

Fractures occur in various locations of the forearm:

• Distal - near the wrist

• Midshaft - in the middle

• Proximal - near the elbow

   

Several types of fractures exist, with various names assigned to them;

Buckle fracture

• Also called torus fractures, these occur at the wrist joint.

• The top side of the bone is compressed, with the undersurface bending.

• These are stable fractures.

Metaphyseal fracture

• The fracture occurs in the upper or lower end of the shaft.

• This is close to but not affecting the growth plate.

Greenstick fracture

• The fracture only extends through one side of the bone, while the other side remains intact.

• These are generally stable fractures

Galeazzi fracture

• This is a fracture of the radius, with a dislocation of the ulna.

• Both bones are affected, and these injuries require more urgent treatment.

Monteggia fracture

• This is a fracture of the ulna near the elbow, with a dislocation of the radius.

• Both bones are affected, and these injuries require more urgent treatment.

Growth plate fracture

• This is a fracture occurring at or across the growth plate.

• There are several types of growth plate injuries, each with varying risks of potential damage to the normal bone growth.

Imaging Tests

X-rays

• These are performed to understand the location, type and displacement of the fracture.

• They are used to ensure the treatment is adequate. X-rays may need to be taken in follow-up to monitor the progress of healing.

Treatment

The goal of treatment is to ensure the bones are appropriately aligned and adequately held in position.

Nonsurgical Treatment

Stable fractures, such as buckle fractures, may only need the support of a splint or cast to heal. However, fractures sometimes need to be manipulated into position if the fracture is displaced (moved from its normal position). If this is required, sedation and pain relief is provided, and a cast is applied to help hold the fracture. Some amount of displacement is allowed in children, as fractures will "remodel" with growth. This results in a straight arm over time.

Surgical Treatment

Surgery is rarely required for children's forearm fractures. It is usually reserved for open fractures (skin broken) or unstable fractures that cannot be held in position by a cast. Treatment options include wires, rods inside the bone or plates and screws. The choice of implant is based on the child's age and the type and location of the fracture. Pins and rods are removed after the fracture has healed sufficiently. Plates and screws are generally only removed in very young children.

Recovery

Splints or casts may be required for 3 to 4 weeks in young children with stable fractures. For older children or those with more unstable fractures, this time is extended to around 6-weeks. Progress x-rays are taken at 1 to 2 weeks to ensure the fracture is still in the correct alignment. X-rays are generally not required once the cast comes off unless pain at the fracture site is present.

After coming out of a cast, children still need to be careful with the arm. Activities where falling onto the arm is possible is best avoided for 4 to 6 weeks. Impact sports are best to avoid for 3 to 4 months.

What to Discuss with Dr Sundaraj

• How long can I expect off school?

• How long will I be in a cast/splint?

• Do I need to be screened for osteoporosis (weak bones)?

• When can I start physiotherapy?

• When can I return to school?

• When can I return to sport?

• What is the likely outcome from this treatment?

• When do I need to come back?