Forearm Fractures:: Beyond Transverse, Oblique and Comminuted
While we as nurse practitioners learn the basics of fracture diagnosis and care in our NP programs, the world of orthopedics is a wide one to master. Most of us recognize basic fracture-describing terms like transverse, oblique, open and closed, but often our education often lacks more specific fracture descriptions.
Summer is trauma season so you're likely to diagnose at least a few forearm fractures over the next few months. Let's take a look at a few specialized types of wrist and forearm fractures so when X-Ray reports arrive back at your clinic, you have a better idea of what type of you're dealing with.
A greenstick fracture occurs when a bone bends and cracks rather than fracturing completely. The name greenstick refers to the analogy of fresh (green) wood which breaks on one side when bent. This type of fracture is most common in children whose bones are still soft. Greenstick fractures are typically treated with casting or splinting for about six weeks. Occasionally, the fracture may need to be reduced or surgically repaired.
Torus (Buckle) Fracture
A torus, or buckle fracture, occurs when the bone breaks on one side buckling outward on the other side without fully breaking. It is an incomplete fracture. Torus fractures are seen commonly in the radius and ulna of younger children. They are the most common type of forearm fracture in young children and are usually the result of falling on an outstretched hand. Torus fracture are treated with a short arm cast for about three weeks.
Colles fractures are the most common type of wrist fracture and occur in the distal radius. They consist of a fracture of the distal radius with associated dorsal angulation and impaction. Colles fractures usually occur as a result of a fall on an outstretched hand. In young children, the most common mechanism of injury is high impact sports. In older adults, osteoporosis predisposes individuals to Colles fractures. Reduction of the fracture is commonly required along with splinting and casting. Sometimes surgical treatment is necessary.
A chauffeur's fracture is an intraarticular fracture of the radial styloid process. These types of fractures are usually sustained by a blow to the back of the wrist or as a result of forced dorsiflexion. The name chauffeur's fracture originates from early chauffeurs who sustained these injuries when cars backfired while starting the car forcing the hand crank into the chauffeur's palm.
When evaluating these types of fractures, make sure there is no associated scaphoid fracture or scapholunate dislocation as these can be complications of the injury. These fractures are inherently unstable and usually require surgical repair and fixation with pins, screws and/or plates.
A Smith's fracture, also known as a reverse Colles fracture, is a fracture of the distal radius. The distal fracture fragment is displaced volarly rather than dorsally as in a Colles fracture. Smith's fractures occur most commonly in elderly females and young males usually as a result of a fall onto a flexed wrist or a blow to the back of the wrist. These injuries can be treated conservatively with closed reduction and casting but may require surgical fixation depending on severity.
A Galeazzi fracture-dislocation consists of a fracture of the radius with dislocation of the radioulnar joint. These types of fractures usually occur as the result of a fall on an outstretched arm with a flexed elbow and are most common in children with a peak incidence at 9-12 years of age. Most often Galeazzi fractures require surgical reduction and fixation. Monitor patients with this type of fracture closely for compartment syndrome as this can be a serious complication.
A Monteggia fracture-dislocation is a fracture of the shaft of the ulna and a dislocation of the radial head. Because the fracture is so obvious, it can be easy to miss the dislocation initially on X-Ray. This injury usually occurs as a result of a fall on an outstretched arm with excessive pronation. A direct blow to the back of the arm can also cause a Monteggia fracture-dislocation. Most often, this injury is treated surgically with open reduction and fixation.
Don't forget- every time you treat a patient for a sprain, strain, tear or fracture, you must assess motor function, sensation and vascular function of the affected region. If you find a deficit in any of these areas, consult a specialist. Always look for signs of and warn patients about compartment syndrome as it is a very serious complication of fractures.
Have you treated any forearm fractures this summer?