The only adult forearm shaft fractures in which a satisfactory functional outcome can be expected after nonoperative treatment are minimally displaced, or stably reduced, isolated ulnar fractures with no compromise of either radioulnar joint.
See:
- Mackay D, Wood L, Rangan A (2000) The treatment of isolated ulnar fractures in adults: a systematic review. Injury; 31(8):565-70.
- Sarmiento A, Latta LL, Zych G, et al (1998) Isolated ulnar shaft fractures treated with functional braces. J Orthop Trauma; 12(6):420-3; discussion 423-4.
- Handoll HH, Pearce P (2009) Interventions for isolated diaphyseal fractures of the ulna in adults. Cochrane Database Syst Rev; Jul 8;(3):CD000523.
In all other cases, if nonoperative treatment is necessary because of severe soft-tissue compromise or the patient being unfit for surgery, the functional outcome will inevitably be suboptimal.
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The basic principles of nonoperative treatment of adult forearm shaft fractures are:
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Both wrist and elbow joints must be included in the cast
Note: Mackay et al. and Sarmiento & Latta suggest that in isolated ulnar fractures, above elbow splintage is not necessary. - The cast should be well-padded and split along its whole length in any injury where progressive swelling is to be expected
- The general form of the forearm should be restored
- The elbow joint is immobilized in 90° flexion
- The cast should not extend beyond the proximal palmar flexor crease, in order to permit full flexion of the MCP joints of the fingers.
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The thumb should not be included in the cast
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Sarmiento and Latta (Closed Functional Treatment of Fractures, Springer Verlag, 1981, p.384) recommend that the cast be applied with the arm suspended from Chinese fingers traps and the elbow at a right angle. This results in a forearm posture of "relaxed supination": they combine this with careful moulding anteroposteriorly in such a manner as to separate the two bones and tension the interosseous membrane.
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Meticulous clinical observation for compartment syndrome must be undertaken. Watch out for increasing inappropriate pain, especially with passive stretching of the muscles of the affected compartment(s).
Additional authorities
- Charnley J (2003) The closed treatment of common fractures. 4th ed. Cambridge University Press.
- Tarr RR, Garfinkel AI, Sarmiento A (1984) The effects of angular and rotational deformities of both bones of the forearm. An in vitro study. J Bone Joint Surg Am; 66(1):65-70.