Common Fractures of the Radius and Ulna
Am Fam Physician. 2021 Mar 15;103(6):345-354.
Author disclosure: No relevant financial affiliations.
Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures. A fall onto an outstretched hand is the most common mechanism of injury for fractures of the radius and ulna. Evaluation with radiography or ultrasonography usually can confirm the diagnosis. If initial imaging findings are negative and suspicion of fracture remains, splinting and repeat radiography in seven to 14 days should be performed. Incomplete compression fractures without cortical disruption, called buckle (torus) fractures, are common in children. Greenstick fractures, which have cortical disruption, are also common in children. Depending on the degree of angulation, buckle and greenstick fractures can be managed with immobilization. In adults, distal radius fractures are the most common forearm fractures and are typically caused by a fall onto an outstretched hand. A nondisplaced, or minimally displaced, distal radius fracture is initially treated with a sugar-tong splint, followed by a short-arm cast for a minimum of three weeks. It should be noted that these fractures may be complicated by a median nerve injury. Isolated midshaft ulna (nightstick) fractures are often caused by a direct blow to the forearm. These fractures are treated with immobilization or surgery, depending on the degree of displacement and angulation. Combined fractures involving both the ulna and radius generally require surgical correction. Radial head fractures may be difficult to visualize on initial imaging but should be suspected when there are limitations of elbow extension and supination following trauma. Treatment of radial head fractures depends on the specific characteristics of the fracture using the Mason classification.
Fractures of the radius and ulna are the most common fractures of the upper extremity, with distal fractures occurring more often than proximal fractures.1–3 The rate of distal radius fractures is highest (nearly double) in people younger than 18 years and older than 65 years.1
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
Ultrasonography is an alternative to radiography for detection of forearm fractures, with a sensitivity of 97% and specificity of 95%.15 | A | Systematic review and diagnostic meta-analysis |
Distal radius and ulnar buckle fractures in children are treated with short-arm (below-the-elbow) immobilization. Several options are available, including removable splints, wraps, or soft casts, without evidence to support one option over another.4 | B | Cochrane review with limited evidence |
Recent evidence favors immobilizing nondisplaced distal radius fractures for three weeks rather than the traditional six weeks.7 | B | Systematic review of lower-quality cohort studies or with inconsistent findings |
Nondisplaced radial head fractures should not be immobilized for more than two weeks because of the risk of stiffness.9,10 | C | Expert opinion |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
SORT: KEY RECOMMENDATIONS FOR PRACTICE
| Clinical recommendation | Evidence rating | Comments |
|---|---|---|
Ultrasonography is an alternative to radiography for detection of forearm fractures, with a sensitivity of 97% and specificity of 95%.15 | A | Systematic review and diagnostic meta-analysis |
Distal radius and ulnar buckle fractures in children are treated with short-arm (below-the-elbow) immobilization. Several options are available, including removable splints, wraps, or soft casts, without evidence to support one option over another.4 | B | Cochrane review with limited evidence |
Recent evidence favors immobilizing nondisplaced distal radius fractures for three weeks rather than the traditional six weeks.7 | B | Systematic review of lower-quality cohort studies or with inconsistent findings |
Nondisplaced radial head fractures should not be immobilized for more than two weeks because of the risk of stiffness.9,10 | C | Expert opinion |
A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.
BEST PRACTICES IN ORTHOPEDICS
Recommendations from the Choosing Wisely Campaign
| Recommendation | Sponsoring organization |
|---|---|
Do not order follow-up radiography for buckle (torus) fractures if they are no longer tender or painful. | American Academy of Pediatrics Section on Orthopaedics and the Pediatric Orthopaedic Society of |
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