Forearm fractures — Medicine Library

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Summary

Fractures of the radius and/or ulna occur frequently. Important forearm fracture patterns include complete forearm fractures, Galeazzi fractures, and Monteggia fractures. Fractures of the forearm bones at the elbow level include radial head fractures and olecranon fractures, while those at the wrist level include distal radius fractures. The mechanism of injury can be low-energy, such as a fall on an outstretched hand (FOOSH), or high-energy, such as a motor vehicle collision (MVC). Clinical presentation is typically characterized by pain near the fracture site, gross deformity, and swelling. X-ray is the main diagnostic modality. Evaluation includes imaging of the forearm; wrist and elbow imaging are added for moderate to severe injuries. Management varies depending on the age group and fracture characteristics, and includes a thorough neurovascular assessment, acute immobilization, pain management, and referral to orthopedics for definitive open reduction and internal fixation (ORIF) or closed reduction and casting.

For more details on fractures involving the distal radius, see “Distal radius fractures.”

Overview

Relevant anatomy

Important musculoskeletal structures

Radius: composed of the radial head, radial shaft, and distal radius (including radial styloid)
Ulna: composed of the olecranon process, coronoid process, ulnar shaft, and distal ulna (including ulnar styloid)
Connective tissue: interosseous membrane of the forearm, annular ligament of the radius
Joints: elbow joints (i.e., radiohumeral joint and humeroulnar joint), proximal radioulnar joint , wrist joints (i.e., radiocarpal joints), and distal radioulnar joint (DRUJ)

Important neurovascular structures

Nerves: the radial nerve , ulnar nerve , and median nerve (including its branch anterior interosseous nerve)
Arteries: the brachial artery and its branches, the radial artery and ulnar artery

Overview of forearm fractures

Although the term forearm fracture most often focuses on midshaft fractures of the radius and/or ulna, the proximal and distal portions of these bones which make up the wrist and elbow joints can also be involved.
See “Overview of radius and ulna fractures” for the various fracture patterns that can affect these bones.
For further detail on distal radius fracture patterns, See “Types of distal radius fractures.”
For other bones that can be fractured in the wrist, see “Causes of wrist fractures.”
For other bones that can be fractured in the elbow, see “Distal humerus fractures.”

Overview of radius and ulna fractures
		Affected structures	Mechanism of injury	Management
Fractures with elbow involvement	Monteggia fracture	Fracture of the proximal or middle ulna Dislocation of the radial head	Fall onto an outstretched and pronated forearm and extended wrist Direct high-energy trauma to the forearm	See “Monteggia fracture.”
	Isolated radial head fracture	Fracture of the radial head	Fall onto outstretched hand (FOOSH) Stress fracture	See “Radial head fracture.”
	Olecranon fracture	Fracture of the olecranon process	FOOSH Direct trauma to the elbow	See “Olecranon fracture.”
Fractures of the mid-forearm	Complete forearm fracture (Combined radial and ulnar shaft fracture)	Radial shaft fracture Ulnar shaft fracture	FOOSH Direct high-energy trauma to the forearm	See “Complete forearm fractures.”
	Isolated radial shaft fracture [2]	Radial shaft fracture Pediatrics: greenstick fractures common	FOOSH Direct trauma	Initial immobilization with long-arm AP splint or sugar tong splint Definitive management depends on the fracture location and degree of displacement.
	isolated ulnar shaft fracture (Parry fracture; nightstick fracture) [2][3]	Ulnar shaft fracture Pediatrics: greenstick fractures common	Direct trauma (high or low-energy) Typically a defensive injury	Immobilize with a posterior long-arm splint Refer to orthopedics within 7 days. ORIF may be required (e.g., for displaced or unstable fractures).
Fractures with wrist involvement	Galeazzi fracture	Radial shaft fracture Subluxation or dislocation of the DRUJ	Fall onto an outstretched and pronated forearm and extended wrist	See “Galeazzi fracture.”
	Colles fracture	Radial and dorsal displacement of the distal fragment of the radius	FOOSH on extended wrist	See “Distal radius fractures.”
	Smith fracture	Radial and volar displacement of the distal fragment of the radius	Flexion fracture: fall onto a palmar-flexed wrist
	Barton fracture	Radial avulsion and dorsal displacement of the radiocarpal segment of the radius	Extension fracture: FOOSH
	Reverse Barton fracture	Avulsion and volar displacement of the radiocarpal segment	Flexion fracture: fall onto a palmar-flexed wrist
	Hutchinson fracture	Avulsion of the radial styloid	Extension fracture: FOOSH
	Die-punch fracture	Intra-articular fracture of the lunate fossa of the distal radius	Axial loading force applied against the distal radius
	Ulnar styloid fracture [4]	Avulsion or fracture of the ulnar styloid	FOOSH Often associated with distal radius fractures or other ulnar fractures	Nondisplaced fractures: Long-arm AP splint for 6 weeks Associated DRUJ instability: operative repair may be required Displaced > 2mm: ORIF (e.g., with K-wire fixation)
Fractures with elbow and wrist involvement	Essex-Lopresti injury [3]	Radial head fracture PLUS disruption of the interosseous membrane of the forearm PLUS dislocation of the DRUJ	FOOSH	Refer to orthopedics within 7–10 days for surgical management.

$Monteggia fracture$ $Galeazzi fracture$ $Colles fracture (distal radius fracture)$ $Smith fracture$ $Barton fracture$ $Reverse Barton fracture$ $Chauffeur fracture (Hutchinson fracture)$ $Die-punch fracture$ $Scaphoid fracture$

**Supination and pronation**
Right forearm; ventral view
Supination is an external rotational movement of the forearm that occurs at the proximal and distal radioulnar joints. When the forearm is in the supine position, the radius and ulna lie parallel to each other and the palm faces up. The supinator and biceps brachii (not shown here) are the supinators of the forearm.
Pronation is an internal rotational movement of the forearm that occurs at the proximal and distal radioulnar joints. When the forearm is in the prone position, the radius and ulna form an X shape and the palm faces down. The pronator quadratus and pronator teres (not shown here) are the pronators of the forearm.
The interosseous membrane stabilizes the proximal and distal radioulnar joints during pronation and supination.

© AMBOSS

**Proximal radioulnar joint**
A pivot joint formed by the head of the radius articulating with the radial notch of the ulna
The annular ligament is a thick, ring-shaped ligament that surrounds the head of the radius and is attached to the radial notch of the ulna, thereby stabilizing the proximal radioulnar joint (PRUJ).
Pronation and supination of the forearm occur at the proximal and distal radioulnar joints (the axis of rotation is depicted on the left). The PRUJ, along with the distal end of the humerus, also forms the elbow joint, at which elbow flexion and extension occur.

© AMBOSS

**Distal radioulnar joint**
A pivot joint formed by the articulation of the ulnar head with the ulnar notch on the radius. Pronation and supination of the forearm occur at the proximal and distal radioulnar joints. The distal radioulnar joint also articulates with the proximal row of carpal bones, forming a part of the wrist joint.
The palmar and dorsal radioulnar ligaments extend from the medial surface of the distal radius and insert into the ulnar styloid. They stabilize the distal radioulnar joint. During pronation, the dorsal ligament tightens, while the palmar ligament becomes lax. The opposite occurs during supination.

© AMBOSS

**Monteggia fracture**
Right forearm; medial/ulnar view.
Monteggia fracture is defined as a fracture of the ulna (most commonly proximal) with concomitant dislocation of the radial head.
This fracture is more common in children, therefore the illustration depicts the distal humerus, radius, and ulna with epiphyseal (growth) plates (dark blue) and incompletely ossified epiphyses (light blue).

© AMBOSS

**Radial head fracture**
X-ray left elbow (left: AP view; right: lateral view)
The radial head fracture shows intraarticular extension and slight distraction (widening) at the fracture line (red overlay).

Source: © IMPP

**Parry fracture**
X-ray left forearm (top: AP view; bottom: lateral view) of an adolescent patient
There is an isolated transverse fracture of the distal third of the ulna with minimal displacement (green overlay). A small amount of adjacent periosteal reaction (yellow overlay) is seen.
The findings are consistent with a parry (or nightstick) fracture, which is typically a defensive injury incurred when the forearm is used to block a blow.
Red overlay: growths plates

Source: “Figure 1, in: Is a Parry Fracture—An Isolated Fracture of the Ulnar Shaft—Associated with the Probability of Abuse in Children between 2 and 16 Years Old?” by Hermans K, Fransz D, Walbeehm-Hol L, Hustinx P, Staal H, MDPI, licensed under CC BY 4.0. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Ulnar shaft fracture**
X-ray forearm (left: AP view; right: lateral view) of a child
An isolated fracture of the mid ulnar diaphysis is accompanied by displacement of the distal fragment (indicated by arrows). There is no disruption of the distal radioulnar joint.
This type of fracture has been termed a “parry” or “nightstick fracture.” It occurs when the ulna is more exposed than the radius to injury. It may be the result of direct trauma (forearm raised in self-defense) or indirect trauma (fall).
Arrowheads: bracelet; R: radius; U: ulnar

Source: “Fig. 1, in: Locked Intramedullary Nailing versus Compression Plating for Stable Ulna Fractures: A Comparative Study” by Vito Pavone; Marco Ganzi; Giacomo Papotto et al., J. Funct. Morphol. Kinesiol., licensed under CC BY 4.0. Modifications: -cropped -letter removed. The supplementary image with overlays of relevant areas was adapted from the image mentioned above (© AMBOSS).

**Galeazzi fracture**
Right distal forearm

© AMBOSS

**Colles fracture (distal radius fracture)**
Fracture of the distal radius with radial and dorsal displacement. Commonly a result of falling onto the extended wrist.

© AMBOSS

**Smith fracture**
Fracture of the distal radius with volar displacement of the distal radial fragment and dorsal angulation at the fracture site.

© AMBOSS

**Barton fracture**
A partial fracture of the distal radius with a dorsal edge fragment. The cause is usually a fall onto the extended hand.

© AMBOSS

**Reverse Barton fracture**
A partial articular radius fracture with a volar edge fragment. The cause is usually a fall onto the flexed hand.

© AMBOSS

**Chauffeur fracture (Hutchinson fracture)**
Fracture of the radial styloid, commonly due to direct trauma. The term ''Chauffer fracture' was coined by the British surgeon Jonathan Hutchison in the days when cars were hand-cranked and the crank shooting back could hit and thus fracture the wrist.

© AMBOSS

**Die-punch fracture**
An impacted, intra-articular fracture of the lunate fossa of the distal radius. The cause is most commonly an axial loading force applied against the distal radius.

© AMBOSS

**Scaphoid fracture**
X-ray hand (PA view)
A nondisplaced fracture (red line) is visible through the waist of the scaphoid bone of the wrist.

© AMBOSS

Initial management

The following are indicated irrespective of the fracture type and bones involved: [2][3]

Perform
neurovascular exam.
- Assess radial and ulnar artery pulses and capillary refill time.
- Evaluate for median nerve injury , radial nerve injury , and ulnar nerve injury.
Consider indications for orthopedic consultation for fractures.
Obtain imaging of the forearm and consider adding imaging of the elbow and wrist to check for associated injuries.
Evaluate for signs of compartment syndrome in any patient with high-energy impact trauma.
Provide analgesia for acute fractures.
Continue with management specific to the injury identified on imaging, e.g., complete forearm fracture, Monteggia fracture, Galeazzi fracture

Pinch sign (anterior interosseous syndrome) Hand of benediction Radial nerve neuropathy Ulnar nerve neuropathy

**Radial nerve neuropathy**
Motor deficits:
- Wrist drop: inability to extend (dorsiflex) the wrist
- Inability to extend the fingers at the MCP joints
Sensory deficits:
- Dorsal aspect: radial 2½ fingers (less commonly, 3½ fingers), excluding the tips of the 2^nd and 3^rd fingers. The 1^st web space is the autonomous sensory zone of the radial nerve and is highlighted in red.
- Palmar aspect: the radial border of the thumb
Proximal lesion: complete loss of motor and sensory function
Distal lesion (radial tunnel syndrome): partial loss of motor function; preservation of sensory function

© AMBOSS

**Ulnar nerve neuropathy**
Motor deficits:
- Claw hand: The 4^th and 5^th joints are hyperextended at the MCP and flexed at the IP joints at rest (neutral position).
- Froment sign: The patient is asked to grasp a piece of paper between the thumb and the index finger. When the examiner tries to pull the paper away, the thumb flexes at the IP joint because the flexor pollicis longus (supplied by the median nerve) compensates for the paralyzed adductor pollicis (supplied by the ulnar nerve).
Also depicted here is hollowing of the intermetacarpal spaces and the 1^st web space due to the atrophy of the interossei, which is seen in chronic ulnar nerve palsy.
Sensory deficits:
- Dorsal aspect: ulnar 2½ fingers (less commonly, 1½ fingers), excluding the tips of the 3^rd and 4^th fingers
- Palmar aspect: ulnar 1½ fingers
Proximal lesion: complete loss of motor and sensory functions
Distal lesion: complete loss of motor function; preservation of sensory function

© AMBOSS

Complete forearm fractures

Definition: fracture of both the radial shaft and ulnar shaft
Epidemiology: more common in children [2]
Etiology: FOOSH injury (common in children), high-energy trauma (e.g., MVC) [2]
Clinical features
[2]
- Pain and swelling of the mid-forearm
- Gross deformity
- Nerve injury is uncommon with closed fractures.
Diagnostics:
x-ray
[2][5]

May show nondisplaced, displaced, or greenstick fractures of both shafts of the radius and ulna

Injury from high-energy trauma: may show angulation > 10° and/or comminution
Management: Begin
general management of forearm fractures.
[2][3][5]

Fracture-dislocations with signs of skin tenting or neurovascular compromise

Consult orthopedics for emergency reduction.

If timely access to orthopedics is unavailable, consider closed reduction by an experienced emergency physician.

Open fractures

Begin irrigation and IV antibiotics for open fractures.

Consult orthopedics for emergency operative management.

Closed fractures without reasons for urgent orthopedic consultation for fractures

All patients

Immobilize with a long-arm AP splint or sugar tong splint.

Refer for prompt follow-up with orthopedics, e.g., within 3–5 days.

Children: closed reduction under sedation and immobilization

Adults

Nondisplaced (uncommon): long-term immobilization

Displaced : typically requires ORIF

Thoroughly evaluate patients with complete forearm fractures for signs of compartment syndrome. [5]

$Mid diaphyseal radial and ulnar fractures$ $Comminuted fractures of the distal radius and ulna$

Monteggia fracture

Definition: proximal (or middle) ulnar fracture with concomitant dislocation of the radial head
Etiology
- Fall on outstretched and pronated forearm (low-energy trauma)
- Direct blow to the forearm, high-energy trauma (e.g., MVC)
Clinical features
[2]
[5]
- Pain, crepitus, and limited range of motion at the elbow
- Radial head palpable in antecubital fossa
- Shortened forearm
- Posterior interosseous nerve injury can occur.
  
  Paresthesias to the dorsal aspects of the thumb, second, and third fingers
  
  Loss of thumb extension
Diagnostics:
x-ray [2]

Shows a fracture of the proximal (or middle) ulna with dislocation of the radial head (dislocation can be anterior, posterior, or lateral)

Lateral view: The radiocapitellar line does not intersect the middle of the capitellum, suggesting elbow dislocation.
Treatment Begin
general management of forearm fractures.
[2]

Children with uncomplicated fractures: Closed reduction by an orthopedic surgeon is often successful.

Adults and patients with complicated fractures

Initial: Immobilize in a posterior long arm splint.

Definitive: ORIF (e.g., plating, K-wire fixation) required for most injuries
Disposition: Consult orthopedics urgently.

Adults with displaced Monteggia fractures require urgent ORIF. [3]

In patients with ulnar fractures, evaluate the radiocapitellar line to check for disruption of the proximal radioulnar joint. [2]

$Monteggia fracture-dislocation$ $Monteggia fracture$

Galeazzi fracture

Definition: radial shaft fracture with disruption of the distal radioulnar joint
Epidemiology: more common in children
Etiology: fall on outstretched and pronated forearm, MVC [2][3]
Clinical features
[2]
[3]
[6]

Pain and deformity at the distal radius

Limited range of motion at the wrist

Palpable displacement of the ulnar head

Neurologic injury is rare.
Diagnostics:
x-ray [3][7]

Shows a fracture at the mid to distal radial shaft, with subluxation or dislocation of the distal radioulnar joint (DRUJ)

A tear in the interosseous membrane can only be seen indirectly on x-ray.

Signs of DRUJ instability (e.g., widening of the space between the distal radius and ulna)
Treatment: Begin
general management of forearm fractures.
[2][3]

Children with uncomplicated fractures: Closed reduction by an orthopedic surgeon followed by casting

All adult patients and all patients with complicated fractures

Initial: Immobilize in a posterior long arm splint.

Definitive: ORIF (e.g., plating, K-wire fixation) required for most injuries
Disposition: Consult orthopedics urgently.

Almost all Galeazzi fractures require open reduction and repair of the distal radioulnar joint. [3]

$Galeazzi fracture and fracture of the first metacarpal bone$ $Galeazzi fracture$

Radial head fracture

Definition: fracture of the radial head
Epidemiology: more common in adults than radial head subluxation or dislocation [8]
Etiology
- FOOSH with the elbow partially flexed and pronated [9]
- Stress fracture (e.g., in throwing sports)
Clinical evaluation
[9]
- Perform a neurovascular exam. [10]
- Radial head region is tender to touch.
- Pronation and supination of the forearm are painful.
- Effusion or hemarthrosis of the elbow joint may be present.
Diagnostics:
x-ray
elbow (AP, lateral and oblique) [3][9][10]

Fracture through the radial head is not always visible.

Evidence of effusion (sail sign and/or posterior fat pad sign) may be the only finding.

Comminuted fractures: Consider imaging the wrist, as these fractures may be associated with additional injuries. [10]
Treatment: Begin
general management of forearm fractures.
- Fractures with > 60 degrees of angulation often require open reduction and orthopedic consult. [3]
- Nondisplaced fractures: conservative treatment
  
  Immobilize in a sling or posterior long arm splint for 24–72 hours. [3][11]
  
  Start early ROM exercises. [9][12]
- Complex fractures: typically surgical treatment [9]
- Pain management
  
  Consider hemarthrosis aspiration only as an adjunct to splinting in select patients. [3][13]
  
  Avoid intraarticular local anesthetic infiltration. [3]
Disposition: typically outpatient management with short-term orthopedic follow-up [3]
Complication: cubitus valgus

Treat a positive elbow fat pad sign with corresponding bony tenderness as an occult fracture. [3]

$Radial head fracture$

Olecranon fracture

Definition: fracture of the olecranon process
Etiology
[2]
- Direct blow to the elbow: more likely to cause comminuted fractures
- FOOSH with the elbow in flexion: more likely to cause transverse or oblique fractures
Clinical evaluation
[2]
[3]
- Perform a neurovascular exam. [10]
- Assess for ulnar nerve injury and document ulnar nerve function. [3]
- Findings
  
  Olecranon and surrounding soft tissue are swollen and tender to touch.
  
  Hemarthrosis of the elbow joint
  
  Inability to extend the forearm against resistance or gravity if there is concurrent triceps injury
Diagnostics:
x-ray
elbow (AP,
lateral)

Fractures and displacement are best visualized with lateral views of the elbow in 90° flexion.

An elbow fat pad sign is indicative of a fracture.
Management: Begin
general management of forearm fractures.
[2][3][5]

Open fracture and/or neurovascular compromise: orthopedics consult within 30–60 minutes

Patients without reasons for urgent orthopedic consultation for fractures: Admission is typically not necessary.

Nondisplaced or minimally displaced (< 2 mm) fractures: conservative treatment

Immobilize with a posterior long-arm splint. [2]

Refer for orthopedic follow-up within 5–7 days, including repeat x-rays to exclude delayed displacement.

ROM exercises can begin 3 weeks after the injury.

Fractures displaced > 2 mm and/or loss of extensor mechanism

ORIF required

Orthopedics consult within 24–48 hours
Complications
[5]
- Ulnar nerve injury
- Decreased range of motion
- Posttraumatic arthritis
- Nonunion

Ensure rapid orthopedic follow-up for all patients with olecranon fractures, as most are considered intraarticular and require near-perfect reduction to preserve full ROM. [2][5]

External Resources

References

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Roettges P, Turker T. "Ulnar Nerve Injury as a Result of Galeazzi Fracture: A Case Report and Literature Review". Hand. 12(5). :NP162-NP165. (2017)
Matthias R, Wright T. "Interosseous Membrane of the Forearm". J Wrist Surg. 05(03). :188-193. (2016)
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Foocharoen T, Foocharoen C, Laopaiboon M, Tiamklang T. "Aspiration of the elbow joint for treating radial head fractures". Cochrane Database Syst Rev. 22(11). (2014)
Logan AJ, Lindau TR. "The management of distal ulnar fractures in adults: a review of the literature and recommendations for treatment". Strategies in Trauma and Limb Reconstruction. 3(2). :49-56. (2008)
"Contributor Disclosures - Forearm fractures. None of the individuals in control of the content for this article reported relevant financial relationships with ineligible companies. For details, please review our full conflict of interest (COI) policy:"