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Am Fam Physician. 2021;103(6):345-354

This clinical content conforms to AAFP criteria for CME.

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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.13 The rate of distal radius fractures is highest (nearly double) in people younger than 18 years and older than 65 years.1

RecommendationSponsoring 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 North America

The most common mechanism of injury for radius and ulna fractures is sudden axial loading onto the radius/ulna, often from a fall onto an outstretched hand with wrist extension.1,2 Although nondisplaced, or minimally displaced, fractures of the radius and ulna usually can be managed by family physicians, it is important to identify fractures that require referral to an orthopedist. The most common radius and ulna fractures, with a summary of their management and indications for referral, are shown in Table 1.2,411

Fracture location/typeInitial treatmentDefinitive treatmentDuration of immobilizationIndications for orthopedic referral
Distal radius buckle (torus)4 Short-arm splint, soft cast, wrapShort-arm splint, soft cast, wrap3 weeks
Greenstick/complete distal radius in children4,5 Short-arm splint, soft castShort-arm splint, soft cast3 weeks> 30 degrees of angulation or > 50% displacement
Distal radius in adults2,6,7 Reduction followed by a lateral radiograph to verify distal radioulnar joint alignment; sugar-tong splintShort-arm cast3 to 6 weeksConcurrent dislocation, carpal fracture, ulnar styloid fracture, fracture instability/comminuted pattern, injury to radiocarpal or radioulnar ligaments, malunion
Combined radial and ulnar midshaft8 Reduction, sugar-tong splintSurgeryDistal radioulnar joint instability, associated intra-articular fractures, displacement, angulation, shortening, comminution, or rotation
Ulnar midshaft7 Reduction, sugar-tong splint, posterior (ulnar gutter) splintConservative management if fracture is located in the middle or distal third of the diaphysis, displacement is < 50% of the bone diameter, and angulation is < 10 degrees
All other: surgery
Immobilization in posterior splint for 10 days, then transition to a plaster sleeve or functional brace for 4 to 6 weeksAny concurrent injuries of the radius, distal radioulnar joint, or elbow joint; comminution; displacement that does not meet the criteria for conservative management
Radial head911 Posterior arm splintSling2 to 3 weeksMason types III and IV fractures; possibly type II fractures (Table 3)

Most fractures of the radius or ulna seen by family physicians are distal radius, midshaft, or radial head fractures. Other fractures, such as proximal ulna fractures of the coronoid and olecranon, are less common and therefore not addressed in this article. Application of the various splints and casts discussed in this article was detailed previously in American Family Physician.12

Initial Evaluation

Patients with radius or ulna fractures often present with reduced range of motion in the joint adjacent to the fracture (i.e., wrist for distal fracture and elbow for proximal fracture).2,3,9 Among the examination findings that suggest a wrist fracture, painful dorsiflexion is the most sensitive (95.7%) and ecchymosis is the most specific (97.8%).13 Additional predictors of a distal fracture include wrist edema, deformity, and pain with forearm pronation.13 Proximal fractures often cause limited forearm pronation or supination and limited elbow flexion or extension.

Although initial studies of the elbow extension test (ability to fully extend the elbow) for ruling out elbow fractures were promising, more recent studies have not demonstrated high accuracy, even with concurrent focal tenderness.14

However, when evaluating patients for suspected proximal radius or ulna fractures, physical examination should include assessment for ulnar and radial collateral ligamentous injury using elbow varus and valgus stress testing14 (see https://www.youtube.com/watch?v=bCqPTSgW3-c). In addition, patients with a suspected fracture should be evaluated for neurovascular compromise or skin puncture, which require urgent orthopedic consultation.2,3,9

Imaging

There are no well-validated clinical prediction rules to help guide when to use radiography for suspected radius and ulna fractures, as with other fractures (e.g., the Ottawa rules for ankle fractures). In most cases, radiography is performed when fractures of the radius or ulna are suspected based on presentation and physical examination findings.

A two-view (posteroanterior and lateral) radiograph is generally sufficient for forearm fractures; however, a third (oblique) view should be obtained for suspected wrist or elbow fractures to assess the extent, angulation, and displacement of the fracture.2,3,9 If initial radiograph findings are negative but fracture is still suspected (e.g., there is pain, tenderness, or weakness), splinting and follow-up imaging in seven to 14 days are warranted.

Ultrasonography is an alternative to radiography for detection of forearm fractures, with a sensitivity of 97% and specificity of 95%.15 Ultrasonography can be performed at the point of care, costs less than radiography, and avoids radiation exposure. However, availability, technician expertise, and lack of patient cooperation with the imaging procedure may limit its use. Radiography and ultrasonography can detect pathognomonic features of injury, such as the presence of a posterior and elevated anterior elbow fat pad (sail sign) associated with proximal radius and ulna fractures (Figure 1).

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