This guideline is specific for the assessment and management of forearm fractures
- 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
- 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
- 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 (A3 folded sheet located in the Doctor’s offices)
- 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
- 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
- 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
Midshaft Radius & 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.
- Plastic deformity of radius and ulna with volar tilt
- Greenstick fracture of radius shaft with 20 degrees of dorsal angulation and minimally displaced ulna fracture
- Transverse fractures of radius and ulna with complete displacement of radius and significant dorsal angulation
- 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 Elbow Region Fractures) 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
- Monteggia fracture dislocation – ulna shaft fracture with radial head dislocation
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)
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