Fracture of Both Bones of the Forearm

In this article, we’ll discuss fractures of both bones of the forearm. Before we proceed, let me give you a brief overview. Our forearm consists of two bones: the ulna and the radius. The radius aligns with our thumb, and the ulna is aligned with our little finger. If both bones are fractured in the middle, we call it a fracture of both bones of the forearm.

So, how will we define it? A fracture of both bones of the forearm refers to a fracture in both the radius and ulna, the two long bones located in the forearm.

This differs from other common forearm fractures such as a Monteggia fracture or a Colles’ fracture, which typically involve only one bone.

So, let us try to understand this with an X-ray of the radius and ulna. In the X-ray, you can see both bones are fractured. That’s why we call it a fractured both-bone forearm.

Mechanism of injury

So what is its mechanism?

1. Fall: One of the mechanisms is injury during the fall. The most common is a fall in the bathroom. Usually, senior citizens slip and fall in the bathroom.
2. Direct hit: This is when there is a direct hit or assault to the forearm. It can be hit with a stick or attacked with a heavy object.

Clinical feature

1. There will be swelling.
2. Pain.
3. Deformity: Because of the fracture, the forearm will remain pronated or supinated, or there will be a slight bending.

Clinical sign:

1. Tenderness: Tenderness means that when we touch the area, the patient will feel pain.
2. Crepitus: Crepitus means that with movement, there will be a slight sound.
3. Restriction of movement: If there is a fracture, there will be restriction of movement.
4. In a fractured forearm, always look for a pulse and neural deficit. Ask the patient to make a fist or extend the wrist. If they’re able to do this, it means they don’t have a neural deficit. If they can’t, it could be due to nerve damage.

Investigation

1. X-ray: AP view and lateral view. The X-ray may show displacement, tilt, overlap, and rotation of the fracture segments. Or even a shift. We may see a shift in the fracture. We should also take an X-ray of the posterior and digital joints, both digitally and proximally to the fractured segment. Proximally, our elbow joint is proximal to the fractured segment. Usually, a greenstick fracture is seen in children because the inner cortex bends and the outer cortex is broken. A greenstick fracture means that if you break a piece of raw wood, the outer part will crack, but the inside will remain connected. Similarly, in a bone, the inner cortex will remain connected, and the outer cortex will break.

Treatment

In children: Greenstick fracture is usually seen in children, so conservative treatment is preferred treatment in children. Conservative treatment involves closed reduction under anaesthesia followed by a POP cast for four to six weeks. But there’s a chance of angulation or displacement here.

In children, remodelling occurs very well. That is, when a bone joins, it automatically begins to align itself.

In adults: In adults a closed reduction under anaesthesia can be done. After reduction, X-rays need to be taken every three to four weeks, because it’s important to check whether the bone is joining properly or whether it’s displaced.

But in adults, there is a high chance of displacement. Therefore, in many cases, surgeons perform surgery.

The surgery involves open reduction internal fixation, using nails. Square nails or intramedullary nails, meaning the nails go inside the bone. Intramedullary nails, and then a plate is applied. After that, a plaster cast is applied for four to eight weeks. Dynamic compression plating is applied to the plates. A comparative study of these two fixation techniques found that dynamic compression plating showed greater biomechanical stability, fewer complications, and better functional recovery than intramedullary nailing in adults with both-bone forearm fractures¹.

As you can see in the X-ray, there is a DCP (Dynamic Compression Plating). There’s an X-ray showing the plates and screws. Intermediate nailing means a nail will go in through it like this. Look, a nail will go in through it; its circumference is square.

Complications

1. Immediately after the injury, there could be Injury to the blood vessels and the nerve.
2. There could also be compartment syndrome, where there is compression of the nerve.
3. Delayed union, in which the union is delayed. It is common in fractures of the lower third of the ulna.
4. There could also be non-union, meaning there may not be union at all. For this, surgery is performed. Open reduction internal fixation and then bone graft. Bone graft is from the iliac crest in our hip bone.
5. It can also be a malunion. That is, the bones are joined crookedly as they don’t align properly. The X-ray above shows an example of malunion and cross-union.
6. Cross union: There is also a chance of developing a cross union. In this, a callus bridge forms between the radius and ulna. If it’s not causing any problems, leave it as is. If there’s any difficulty with supination and pronation, the callus can be surgically removed. If there’s any stiffness in the proximal and distal joints, i.e., the wrist and elbow joints, it may also require surgical treatment.
7. Another complication is the possibility of infection.

Understanding the mechanism, clinical features, and treatment options for a both-bone forearm fracture is essential for accurate diagnosis and effective rehabilitation. For a step-by-step visual walkthrough of this topic, watch the video lesson linked above.

FAQ

Sunit. S. Ekka

The author is a physiotherapist who has been practising for the last 17 years. He holds a Bachelor's in Physiotherapy (BPT) from SVNIRTAR (Swami Vivekananda National Institute of Rehabilitation and Research), one of the prestigious physiotherapy schools in India.

Whatever he learns dealing with his patient, he shares it with the world through blogs and e-books. He also owns a YouTube channel, "Sunit Physiotherapist" with over 8 lakh active subscribers. Here, he shares everything he gets to learn serving the patient.