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Physical Examination and Medical History

It is important for your doctor to know:

• The circumstances of your injury. For example, if you fell from a ladder, how far did you fall?
• Whether you sustained any other injuries.
• Whether you have any other medical problems, such as diabetes or heart disease.
• Whether you take any medications.

After discussing your symptoms and medical history, your doctor will do a careful examination. The doctor may:

• Examine your skin to see if there are any cuts from the injury. Bone fragments can break through the skin and create lacerations. This leads to an increased risk for infection.
• Palpate (feel) all around your arm to determine if there are any other areas of tenderness. This can indicate other broken bones or injuries.
• Make sure that good blood flow is getting through your forearm to your hand.
• Check to see if you can move your fingers and wrist and can feel things with your fingers. Sometimes, nerves may be injured at the same time that the bone is broken, which can result in hand and wrist weakness and numbness.

The doctor may examine your shoulder, upper arm, elbow, wrist, and hand, even if you complain only of forearm pain.

X-rays

X-rays can show whether the bone is broken and whether there is displacement (the broken pieces of bone are separated and not aligned). They can also show how many pieces of broken bone there are.

Immediate Treatment

While you are in the emergency room, the doctor may try to temporarily realign the bones, depending on how far out of place the pieces are.

Afterward, your doctor will apply a splint to support your forearm and often will provide a sling to help you as you move around. Unlike a full cast, a splint can be tightened or loosened and allows swelling to occur safely.

The emergency room doctor may apply a splint to protect your arm.

Reproduced with permission from JF Sarwark, ed: Essentials of Musculoskeletal Care, ed 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010.

It is very important to control the movement of a broken bone. Moving a broken bone can cause additional damage to the bone, nearby blood vessels, and nerves or other tissues surrounding the bone.

Additional treatment may include applying ice to help reduce swelling, and providing you with pain medication.

Nonsurgical Treatment

If only one bone is broken and it is not out of place, it may be possible to treat it with a cast or brace. Your doctor will closely monitor the healing of the fracture and have you return to the clinic for X-rays. If the fracture shifts in position, you may require surgery to put the bones back together.

Surgical Treatment

When both forearm bones are broken, or if the bones have punctured the skin (open fracture), surgery is often required.

Because of the increased risk of infection, patients are typically given antibiotics by vein (intravenous) in the emergency room and may receive a tetanus shot.

During surgery for open fractures, the cuts from the injury will be cleaned out. The broken bones are typically fixed during the same surgery. In severe open injuries, multiple operations may be required to adequately clean the injured soft tissues.

If the skin around your fracture has not been broken, your doctor may recommend waiting until swelling has gone down before having surgery. Keeping your arm immobilized and elevated above the level of your heart for several days will decrease swelling. It also gives skin that has been stretched a chance to recover.

Open reduction and internal fixation with plates and screws. This is the most common type of surgical repair for forearm fractures in adults. During this procedure, the doctor first repositions (reduces) the bone fragments into their normal alignment. The bones are held together with special screws and metal plates attached to the outer surface of the bone.

The broken bones of the forearm are held in position by plates and screws while they heal.

Open reduction and internal fixation with rods. During this procedure, the doctor inserts a specially designed metal rod through the marrow space in the center of the bone.

External fixation. If the skin, muscles, and bone are severely damaged, using plates and screws and large incisions may injure the skin further. This may result in infection. In this case, you may be treated with an external fixator. In this type of operation, the doctor places metal pins into the bone above and below the fracture site. The pins and screws are attached to a bar outside the skin. This device is a stabilizing frame that holds the bones in the proper position so they can heal.

Complications from Forearm Fractures

Complications can arise from both operative and non-operative treatment of forearm fractures in adults:

• The ends of broken bones are often sharp and can cut or tear surrounding blood vessels or nerves.
• Excessive bleeding and swelling right after the injury may lead to compartment syndrome, a condition in which the swelling cuts off blood supply to the hand and forearm. It typically occurs within 24 to 48 hours of the injury and causes severe pain when moving the fingers. Compartment syndrome can result in loss of sensation and function and requires emergency surgery once it is diagnosed. In such cases, the skin and muscle coverings are opened and left open to relieve pressure and allow blood to return. Most often, the incisions can be closed after a few days. In some instances, a skin graft might be required to help close the incisions.
• Open fractures expose the bone to the outside environment. Even with appropriate treatment, the bone can become infected. Bone infection is difficult to treat and often requires multiple surgeries and long-term antibiotics.

Complications from Surgery

There are risks associated with all surgery. If your doctor recommends surgery, they believe that the possible benefits of surgery outweigh the risks.

• Infection. There is a risk of infection with any surgery, whether it is for a forearm fracture or another issue.
• Damage to nerves and blood vessels. There is a minor risk of injury to nerves and blood vessels around the forearm. Although some temporary numbness is common right after your injury, if you experience persistent (continued) numbness or tingling in your fingers, contact your doctor.
• Nonunion. Surgery does not guarantee healing of the fracture. If the fracture fails to heal, you may need further surgery.
• A fracture may pull apart, or the screws, plates, or rods may shift or break. This can occur for a variety of reasons, including:
  • The patient does not follow directions after surgery.
  • The patient has other health issues that slow healing. Some diseases, like diabetes, slow healing. Smoking or using other tobacco products also slow healing.
  • If the fracture was associated with a cut in the skin (an open fracture), healing is often slower.
  • Infections can also slow or prevent healing.
  • Even in the best of circumstances, nonunions can still occur.
• Stiffness. Depending on the severity and location of your fracture, you may develop elbow or wrist stiffness. You may lose the ability to fully rotate your palm up and down. Occasionally, abnormal healing between the two bones of the forearm with a bridge of bone, known as synostosis, may occur. This can decrease or eliminate the rotation of the bones an dprevent movement.
• Bothersome or painful implants. The plates placed on the bones may cause discomfort, especially when they are placed on the border of the ulna, which is just underneath the skin. Once the fracture has healed, plates that are bothersome may be removed later, but this can lead to other risks (injury at the time of surgery or re-fracture of the bone).

The most common complication during non-operative treatment is loss of reduction. This means that the bone ends at the fracture site move away from each other. This may require an operation. If you continue with non-operative management, you may experience stiffness with limited ability to rotate your palm up and down.

Pain Management

Pain after an injury or surgery is a natural part of the healing process. Your doctor and nurses will work to reduce your pain, which can help you recover faster.

Medications are often prescribed for short-term pain relief after surgery or an injury. Many types of medicines are available to help manage pain, including opioids, non-steroidal anti-inflammatory drugs (NSAIDs), and local anesthetics. Your doctor may use a combination of these medications to improve pain relief, as well as minimize the need for opioids.

Be aware that although opioids help relieve pain after surgery or an injury, their use has risks and complications. These medications can be addictive and potentially dangerous. It is therefore important to use opioids only as directed by your doctor, to use as little as possible for as short a time as possible, and to stop taking them as soon as your pain starts to improve. Talk to your doctor if your pain has not begun to improve within a few days of treatment.

NSAIDs may reduce the body's ability to heal a fracture. Consult with your surgeon before taking NSAIDs if you have a fracture.

Rehabilitation

Nonsurgical treatment. Rehabilitation typically begins after a few weeks of keeping the arm still by using a cast or brace. In many cases, a physical therapist will help with rehabilitation, beginning with gentle exercises to increase range of motion and gradually adding exercises to strengthen the arm.

Surgical treatment. Depending on the complexity of the fracture and the stability of the repair, you may need a cast or brace for 2 to 6 weeks or more after surgery. You will usually begin motion exercises for the forearm, elbow, and wrist shortly after surgery. This early motion is important to prevent stiffness. Your doctor may also prescribe visits to a physical or occupational therapist, depending on how long your arm was immobilized.

Outcome

Some stiffness after healing is common, but this does not usually affect the overall function of your arm.

Your doctor will advise you on when you may return to work and sports activities. The timing will depend on the fracture pattern and the type and stability of the repair.

If you have had surgery, the plates and screws are usually left in place forever. If you consider removal, this second surgery is typically not scheduled until your bones have fully solidified (1 to 2 years after initial surgery) and comes with additional risks.