Trying to break a fall by putting your hand out in front of you seems almost instinctive. But the force of the fall could travel up your lower forearm bones and dislocate your elbow. It also could break the smaller bone (radius) in the forearm. The breaks can occur at the wrist (Colles fracture), or near the elbow at the radial “head.”

Radial head fractures are common injuries, occurring in about 20 percent of all acute elbow injuries. They are more frequent in women than in men and occur most often between 30 and 40 years of age. Approximately 10 percent of all elbow dislocations involve a fracture of the radial head. As the upper arm bone slides back into its appropriate place after the dislocation, it can chip off a piece of the radial head, resulting in a fracture.

Signs and symptoms
If you have any of these signs or symptoms after a fall, see your doctor:

• Pain on the outside of the elbow.
• Swelling in the elbow joint.
• Difficulty in bending or straightening the elbow accompanied by pain.
• Inability or difficulty in turning the forearm (palm up to palm down or vice versa).

Fracture types and treatments
Radial head fractures are classified according to the degree of displacement (movement from the normal position).

Type I fractures are generally small, like cracks, and the bone pieces remain fitted together.

• The fracture may not be visible on initial X-rays, but can usually be seen if the X-ray is taken three weeks after the injury.
• Nonsurgical treatment involves using a splint or sling for a few days, followed by early motion.
• If too much motion is attempted too quickly, the bones may shift and become displaced.

Type II fractures are slightly displaced and involve a larger piece of bone.

• If displacement is minimal, splinting for one to two weeks, followed by range of motion exercises, is usually successful.
• Small fragments may be surgically removed.
  If the fragment is large and can be fitted back to the bone, the orthopaedic surgeon will first attempt to fix it with pins or screws. If this is not possible, however, the surgeon will remove the broken pieces or the radial head.
• For older, less active individuals, the surgeon may simply remove the broken piece, or perhaps the entire radial head.
• The surgeon will also correct any other soft-tissue injury, such as a torn ligament.

Type III fractures have more than three broken pieces of bone, which cannot be fitted back together for healing.

• Usually, there is also significant damage to the joint and ligaments.
• Surgery is always required to remove the broken bits of bone, including the radial head, and repair the soft-tissue damage.
• Early movement to stretch and bend the elbow is necessary to avoid stiffness.
• A prosthesis can be used to prevent deformity if elbow instability is severe.

Even the simplest of fractures will probably result in some loss of extension in the elbow. Also, regardless of the type of fracture or the treatment used, physical therapy will be needed before resuming full activities.

Description

The bones of the forearm are the radius and the ulna. If you hold your arm naturally by your side, the ulna is the bone closer to you and the radius is farther away.

Fractures of the forearm can occur near the wrist at the farthest (distal) end of the bone, in the middle of the forearm, or near the elbow at the top (proximal) end of the bone.

A child’s bones are also subject to a unique injury called a growth plate fracture. Growth plates are made of cartilage near the ends of children’s bones. They help determine the length and shape of the mature bone.

Fractures of both bones in the forearm.
Fractures in a child’s bones begin to heal much more quickly than an adult’s bones. If you suspect a fracture, you should obtain prompt medical attention for the child so that the bones can be set for proper healing.

Statistics
Forearm fractures account for 40% to 50% of all childhood fractures. About three out of four forearm fractures in children involve the wrist-end of the radius.

Cause
Children love to run, hop, skip, jump and tumble. But if a child falls onto an outstretched arm, he or she might break one or both of the bones in the forearm.

Classifications
Torus fracture. This is also called a “buckle” fracture. The topmost layer of bone on one side of the bone is compressed, causing the other side to bend away from the growth plate. This is a stable fracture and the broken pieces of bone have not separated apart (displaced).

Metaphyseal fracture. The fracture is across the upper, or lower, portion of the shaft of the bone and does not affect the growth plate.

Greenstick fracture. The fracture extends through a portion of the bone, causing it to bend on the other side.

Galeazzi fracture. The injury affects both bones of the forearm. There is usually a displaced fracture in the radius and a dislocation of the ulna at the wrist, where the radius and ulna come together.

Monteggia fracture. The injury affects both bones of the forearm. There is usually a fracture in the ulna and the top (head) of the radius is dislocated. This is a very severe injury and requires urgent care.

Growth plate fracture. Also called a physeal fracture, this fracture occurs at or across the growth plate. Usually these fractures affect the growth plate of the radius near the wrist.

Symptoms
In most cases, a broken forearm causes severe pain. Your child’s forearm and hand may also feel numb.

Examination, Signs

This child’s forearm fracture has resulted in a bent appearance of the forearm.
(Courtesy of Texas Scottish Rite Hospital for Children)

• Any type of deformity about the elbow, forearm, or wrist
• Tenderness
• Swelling
• An inability to rotate or turn the forearm

Your doctor will also test to make sure that the nerves and circulation in your child’s hand and fingers have not been affected.

Investigation, Tests
The hand, wrist, arm, and elbow can all be injured during a fall on an outstretched arm. To determine exactly what injuries have occurred, your doctor will probably want to see x-rays of the elbow and wrist, as well as the forearm.

Nonsurgical Treatment
Treatment depends on the type of fracture and the degree of displacement.

Casts support and protect broken bones while they heal.
Some mild fractures, such as buckle fractures, may simply need the support of a splint or cast until they heal. For more severe fractures that have become angled, your doctor may be able to push (manipulate) the bones into proper alignment without surgery, as long as the bones have not broken through the skin.

A stable fracture, such as a buckle fracture, may require 3 to 4 weeks in a cast. A more serious injury, such as a Monteggia fracture-dislocation, may need to be immobilized for 6 to 10 weeks.

Surgical Treatment
Surgery to align the bones and secure them in place may be required if:

• The skin is broken
• The fracture is unstable — the ends of the broken bones will not stay lined up
• Bone segments have been displaced
• The bones cannot be aligned properly through manipulation alone
• The bones have already begun to heal at an angle or in an improper position

After the bones are aligned, the physician may use pins, metal implants, or a cast to hold them in place until they have healed.

Long-Term Outcome
When the cast is removed, the wrist joint and elbow joint may be stiff for 2 to 3 weeks. This stiffness will go away without the need for physical therapy.

The forearm bones may temporarily be weaker due to the immobilization in the cast. Children should avoid playground structures, such as monkey bars, for 3 to 4 weeks after the cast is removed, in order to allow the bone to safely regain its normal strength.

If the fracture disrupts the growth plate at the end of the bone, your doctor will probably want to watch it carefully for several years to ensure that growth proceeds normally.

Description
Whether your child is an active athlete or just a toddler jumping on the bed, there’s a good possibility that he or she will take a spill at home or on the field or court at some time. These falls are usually harmless; but when a child falls on an outstretched arm, the velocity of the fall combined with the pressure of hitting the ground could be enough to break a bone.

That’s how most fractures around the elbow joint occur. These fractures account for about 10 percent of all fractures in children.

If your child complains of elbow pain after a fall and refuses to straighten his or her arm, see a doctor immediately. The doctor will first check to see whether there is any damage to the nerves or blood vessels. X-rays will help determine what kind of fracture occurred and whether the bones moved out of place.

Because a child’s bones are still forming, the doctor may request X-rays of both arms for comparison.

Types of Fractures

A child can experience a fracture in several places about the elbow, including:

Above the elbow (supracondylar): The upper arm bone (humerus) breaks, slightly above the elbow. These fractures usually occur in children younger than 8 years of age. This is the most common elbow fracture, and one of the more serious because it can result in nerve damage and impaired circulation.

At the elbow knob (condylar): This type of fracture occurs through one of the bony knobs (condyles) at the end of the upper arm bone. Most occur through the outer (lateral) knob. These fractures require careful treatment, because they can disrupt both the growth plate (physeal) and the joint surface.

At the inside of the elbow tip (epicondylar): At the top of each bony knob is a projection called the epicondyle. Fractures at this point usually occur on the inside (medial) epicondyle in children between 9 and 14 years of age.

Growth plate: The upper arm bone and both lower arm bones have growth plates located near the end of the bone. A fracture that disrupts the growth plate can result in arrested growth and/or deformity if not treated promptly.

Forearm: An elbow dislocation can break off the head of the thumb-side lower arm bone (radius), and excessive force can cause a compression fracture to the bone as well. Fractures of the tip (olecranon) of the other lower arm bone (ulna) are rare.

Fracture dislocation: A fracture of the inside bone (ulna) can be combined with the top of the thumb-side bone (radius) coming out of the socket at the elbow. This is called a Monteggia fracture. If the dislocation is not seen, and only the fracture is treated, this can lead to permanent impairment of elbow joint function.

Risk Factors / Prevention

If your child is an active athlete, make sure that he or she wears the proper protective equipment. Elbow guards and pads can help reduce the risk of a fracture about the elbow.

Symptoms

Regardless of where the break is, the symptoms of a broken elbow are similar:

• Acute pain
• Tenderness
• Swelling (may be severe or mild)
• Limited movement

Treatment Options
Treatment depends on the type of fracture and the degree of displacement. If there is little or no displacement, the doctor may immobilize the arm in a cast or splint for 3 to 5 weeks.

During this time, another set of X-rays may be needed to determine whether the bones are staying properly aligned.

If the fracture forced the bones out of alignment, the doctor will have to manipulate them back into place. Sometimes, this can be done without surgery, but more often, surgery will be needed. Pins, screws or wires are used to hold the bones in place. The child will have to wear a cast for several weeks before the pins are removed.

Range of motion exercises can usually begin about a month after surgery.

A broken arm is a common injury. Counting all fractures, about one in every 20 involve the upper arm bone (humerus). Children are more likely to break the lower arm bones (radius and ulna). Falling on an outstretched hand or being in a car crash or some other type of accident is usually the cause of a broken arm.

Most people know right away if their arm broke, because there may be a snap or a loud cracking sound. The broken arm may appear deformed and be swollen, bruised and bleeding. A person with a broken arm usually has:

• Extreme pain at the site of the injury.
• Pain increased by any movement.
• Loss of normal use of the arm.

First aid
First make sure the injured person is out of the way of further harm. Is he or she breathing normally? Is there a good pulse? Call 911 if there is serious bleeding, reason to suspect multiple broken bones or other injuries. To slow bleeding and reduce swelling, elevate the injured arm above the level of the person’s heart.

If a broken bone sticks out from the skin (open fracture), do not try to push it back in. Use a clean, dry cloth or bandage to cover it until medical help arrives.

It is important that the injured person not try to use the broken arm. Moving a broken arm would also cause more damage to blood vessels, nerves and other tissues. To immobilize a broken arm:

• Make a temporary splint. Immobilize the joints above and below the site of the injury. You can use wood or rolled up magazines, making sure both ends of the splint extend far beyond the injured region. You can use cloth, belts or tape to fasten the splint. Avoid any constriction of the arm with the supporting strap.
• Make a sling. This stabilizes the injury and supports the splint. A broken arm sling can be as simple as a loop of cloth supported from the neck. Take the injured person to a doctor right away.

Doctor’s treatment

Exam: Tell the doctor exactly what happened. He or she will physically examine the broken arm and check for other injuries, such as nerve damage. The doctor may want to see if the patient can flex and extend the wrist and fingers. Sometimes the doctor may use X-rays or other diagnostic imaging tools to see the bones of both the injured and uninjured arms.

If the patient is a child, the long bones of the arm are probably still growing. So the doctor will look carefully for any damage to growth plates.

Reduction: The doctor may need to move pieces of bone back into their correct positions (a process called reduction). Depending upon the severity of injury, the patient may or may not need anesthesia. Those with more serious fractures may require surgery.

Immobilization: With the broken bone back in place, the doctor immobilizes the arm. Most patients get a cast or splint. The doctor tells the patient how long to wear the cast or splint, and removes it at the right time.

Rehabilitation
It may take from several weeks to several months for the broken arm to heal completely. Rehabilitation involves gradually increasing activities to restore muscle strength, joint motion and flexibility. The patient’s cooperation is essential to the rehabilitation process. The patient must complete range of motion, strengthening and other exercises prescribed by the doctor.

Rehabilitation lasts until tissues perform their functions normally. After rehabilitation, the doctor may want to see the arm again to make sure healing is complete.

When you fall forward, your natural response is to put your hands out in front to catch yourself. As you land on your palm, your wrist bends backwards, which can stretch and perhaps tear the ligaments that connect bone to bone within the joint. The resulting injury is a sprain.

Signs and symptoms
Signs and symptoms of a wrist sprain may vary in intensity and location, depending on the degree of injury. Indications of a wrist sprain include:

• Swelling in the wrist
• Pain at the time of the injury
• Persistent pain when you move the wrist
• Bruising or discoloration of the skin
• Tenderness at the injury site
• A feeling of popping or tearing inside the wrist
• A warm or feverish feeling to the skin

Degrees of injury
Wrist sprains are graded, depending on the degree of injury to the tissues.

• Grade 1 or mild sprains occur when the ligaments are stretched, but not torn.
• Grade 2 or moderate sprains occur when some of the ligaments are torn. Grade 2 sprains may involve some loss of function.
• Grade 3 or severe sprains occur when there is a complete tear all the way through the ligament. These are significant injuries that require medical or surgical care to ensure recovery. As the ligament tears away from the bone, it may also take a small chip of bone with it, resulting in an avulsion fracture.

If you have any doubts about the severity of your injury, arrange to have a doctor examine your wrist. Sometimes, a sprain can have only mild swelling but still be serious enough to require surgery. To avoid problems later, proper diagnosis and treatment is important.

Diagnosing a wrist sprain
Your doctor will review your symptoms and ask how the injury happened. He or she will also ask about any numbness in your hand as well as about your medical and orthopaedic history, especially any previous injuries to your hand or wrist. The physical exam will cover your entire arm and hand to ensure that there are no other injuries. Tenderness in certain areas may suggest a broken bone.

If a severe sprain is suspected, your doctor will likely order X-rays. In some cases, a magnetic resonance image (MRI) or computed tomography (CT) scan may also be ordered.

Treating a wrist sprain
Mild wrist sprains can be usually be treated at home with the RICE protocol.

• Rest the joint for at least 48 hours.
• Ice the injury to reduce swelling. Do not apply ice directly to the skin. Use an ice pack or wrap a towel around the ice or a package of frozen vegetables. Apply ice for about 20 minutes at a time.
• Compress the swelling with an elastic bandage.
• Elevate the injury above the level of your heart.

You may also wish to take a pain reliever such as aspirin or ibuprofen. If pain and swelling persist for more than 48 hours, however, see a doctor. Moderate sprains may need to be immobilized with a wrist splint for 7 to 10 days. Severe sprains may require surgery to repair the fully torn ligament. Afterwards, you will need a period of rehabilitation and exercises to strengthen the wrist and restore motion. A wrist sprain can take anywhere from 2 to 10 weeks to heal completely, depending on the severity of the sprain.

Prevention
Because wrist sprains usually result from a fall, be careful if you must walk in wet or slippery conditions. Wrist sprains also occur during sports such as skating, skateboarding, and skiing. You can help prevent sports-related wrist sprains by wearing wrist guard splints or protective tape to support the wrist and prevent it from bending too far backwards. If you ski, try to remember to drop your poles during a fall to prevent wrist sprains.