What is the treatment for a fracture of the forearm?

Treatment of Forearm Fractures

For adult forearm fractures, open reduction and internal fixation (ORIF) with plate fixation is the preferred treatment method for most displaced fractures, while pediatric forearm fractures should be managed conservatively with closed reduction and cast immobilization whenever possible, reserving surgery only for unstable or irreducible fractures.

Initial Diagnostic Approach

Imaging Protocol

• Obtain standard radiographs as the first-line imaging study to assess for fracture displacement, comminution, and joint involvement 1
• If radiographs are normal or indeterminate but clinical suspicion remains high, proceed with CT without contrast to identify occult fractures and clarify fracture morphology 1, 2
• Look for joint effusion on radiographs (posterior and anterior fat pad elevation), which suggests an occult fracture in the trauma setting 1, 2

Assessment for Urgent Referral

Immediate orthopedic consultation is required for 3:

• Open fractures
• Joint dislocation or instability
• Neurovascular compromise
• Significant displacement, comminution, or intra-articular involvement

Treatment by Age Group

Adult Forearm Fractures

Operative Management (Preferred)

• The majority of adult forearm fractures are best treated with ORIF using plate fixation, which allows early active function with low complication rates when surgical technique is meticulous 4
• Alternative methods include external fixation for high-energy open fractures 4
• Hardware removal is not necessary for all patients, though refracture remains the greatest risk if removal is performed 4

Conservative Management (Limited Role)

• Distal radius fractures with minimal displacement can be treated with a short arm cast 3
• Isolated ulnar fractures may be managed with a short arm cast or functional forearm brace 3
• Mason type I radial head fractures can be treated with a splint for 5-7 days or sling as needed, with early range-of-motion exercises 3
• Olecranon fractures are candidates for nonsurgical treatment only if the elbow is stable and extensor mechanism is intact 3

Pediatric Forearm Fractures

Conservative Management (First-Line)

• Closed reduction and cast immobilization is the primary treatment for over 90% of pediatric forearm fractures 5, 6
• Sugar-tong splinting following closed reduction effectively maintains reduction, particularly for proximal and mid-shaft fractures 7
• Apply sugar-tong splint initially, then transition to long-arm cast overwrap at first clinic visit 7
• All fractures typically heal within 8-10 weeks 5

Operative Management (Reserved for Specific Indications)

• Surgery is indicated only when acceptable reduction cannot be obtained or maintained with closed reduction and casting 6
• Intramedullary (IM) nailing is preferred over ORIF when surgery is necessary, as ORIF has significantly more major complications requiring return to the operating room 5
• Complication rates: closed treatment 5%, ORIF 33%, IM nailing 42% 5
• Despite higher overall complication rates with IM nailing, these are predominantly minor complications, whereas ORIF complications are more often major 5

Initial Management Protocol

Follow the PRICE protocol (protection, rest, ice, elevation), avoiding compression in the acute setting 3:

• Protect the injured extremity from further trauma
• Rest the affected limb
• Apply ice to reduce swelling
• Elevate above heart level
• Do not apply compression in acute phase

Follow-Up and Monitoring

Pediatric Patients

• 90% of loss of reduction (LOR) occurs within the first 2 weeks, requiring close monitoring during this period 7
• Distal radius fractures have highest LOR rate at 44%, compared to 14-17% for proximal and mid-shaft fractures 7
• Schedule follow-up at 1,2,4, and 6-week intervals 7
• LOR is defined as >10 degrees change in angulation from initial post-reduction radiograph 7

Common Pitfalls

• Avoid circumferential casting in the acute setting due to risk of compartment syndrome with swelling 7
• Do not assume all pediatric fractures require surgery—operative techniques have significantly higher complication rates than conservative management 5
• In adults, do not attempt conservative management for significantly displaced fractures, as ORIF provides superior outcomes 4