What are the treatment options for recurrent popping and pain in the forearm after a fracture?

Treatment Options for Recurrent Popping and Pain in the Forearm After Fracture

For recurrent popping and pain in the forearm after a fracture, advanced imaging with CT without IV contrast or MRI without IV contrast is recommended to evaluate for potential osseous abnormalities or soft tissue injuries, respectively. 1

Diagnostic Approach

Initial Assessment

1. Radiography:
   • Standard radiographs should be the first imaging modality to assess for fracture healing, malunion, or hardware complications 1
   • If radiographs are normal or indeterminate but symptoms persist, proceed to advanced imaging

Advanced Imaging Options

Based on suspected underlying cause:

1. For suspected osseous abnormalities:

   • CT without IV contrast is recommended to identify:
     • Occult fractures
     • Malunion
     • Nonunion
     • Fracture fragment displacement
     • Joint incongruity 1

2. For suspected soft tissue injuries:

   • MRI without IV contrast or Ultrasound are equally appropriate to evaluate:
     • Tendon injuries
     • Ligament injuries
     • Muscle injuries
     • Nerve entrapment 1

Treatment Algorithm Based on Underlying Cause

1. Osseous Causes

• Malunion or Nonunion:

  • Surgical correction may be required for significant displacement or angulation 2
  • For minimal displacement, directed home exercise program 3

• Occult Fractures:

  • Immobilization for a minimum of three weeks for nondisplaced fractures 2
  • Surgical intervention for displaced fractures 2

• Joint Instability:

  • For forearm instability involving the radioulnar joints, surgical stabilization may be necessary 4, 5
  • For complex fracture-dislocations (Monteggia, Galeazzi, Essex-Lopresti injuries), surgical repair is typically required 6

2. Soft Tissue Causes

• Tendon Injuries:

  • Progressive range of motion exercises for minor injuries 3
  • Surgical repair for complete tears or significant dysfunction 1

• Ligament Injuries:

  • Directed home exercise program for partial tears 3
  • Surgical repair or reconstruction for complete tears with instability 1

• Post-traumatic Arthritis:

  • NSAIDs for pain and inflammation control 3
  • Activity modification
  • Consider intra-articular injections

Rehabilitation Approach

1. Early Phase (0-3 weeks):

   • Protection with appropriate splinting or bracing
   • Rest and ice for pain control
   • Gentle range of motion exercises as tolerated 3

2. Intermediate Phase (3-6 weeks):

   • Progressive range of motion exercises
   • Gradual strengthening exercises
   • Functional activities as tolerated 3

3. Late Phase (6+ weeks):

   • Advanced strengthening
   • Sport or activity-specific training
   • Full return to activities when pain-free with full strength and range of motion 3

Common Pitfalls and Caveats

• Missed Diagnoses: Forearm instability is often underrecognized, leading to inadequate treatment and poor outcomes 4
• Incomplete Evaluation: The forearm functions as a unit with three key stabilizers (radial head, interosseous membrane, triangular fibrocartilage complex); all must be evaluated 4
• Delayed Treatment: Persistent symptoms warrant prompt advanced imaging rather than prolonged observation 1
• Inadequate Rehabilitation: Stiffness is the most common complication; early range of motion is crucial when stable 3
• Ignoring Associated Injuries: Median nerve injuries may accompany forearm fractures and require evaluation 2

For patients with unremitting pain during follow-up, reevaluation with appropriate imaging is essential to identify potential complications such as malunion, nonunion, or post-traumatic arthritis 3.