Forearm Fractures

Understanding Pediatric and Adult Forearm Fractures

Forearm fractures are common upper extremity fractures in kids and adults alike, as they compose the part of the arm which is integral in everyday activities, sports and hobbies – and frequently utilized to slow the force of an impact or fall.

Fracture of one of the forearm bones

Forearm bones and illustration of a forearm fracture.

The forearm bones are known as the ulna and the radius.  They run parallel to one another and connect the wrist joint (distal end) to the elbow joint (proximal end).

A forearm fracture can affect one or both forearm bones.  In fact, the impact one forearm bone sustains often forces it into the other causing both to break.

When a forearm fracture occurs, the type of break is carefully assessed using both a physical examination and x-rays.  It is then identified as a fracture involving either the proximal, middle or distal “shaft.”

Some of the common types of forearm fractures include:

  • Radial Head Fractures
  • Olecranon Fractures
  • Distal Radius Fractures (wrist fracture)
  • Radial Shaft Fractures,
  • Ulnar Shaft Fractures
Both bone forearm fracture in a young football player

An x-ray of a both bone forearm fracture in an adolescent football player.

The fracture is identified based on a set of criteria and the location on the bone.  If both the radius and the ulna are affected, it is known as a “both bone forearm fracture.”

If the fracture does not pierce through the skin it is considered a simple or closed fracture.  One that pierces through the skin is considered a complex or open fracture.

Forearm Fractures in Children

Forearm fractures represent nearly half of all childhood fractures – most of those occurring at the distal, or wrist end of the radius. These fractures are classified by the area of the bone affected, whether it is stable or displaced, how clean the break and whether it is partial or complete across the bone.

The classifications include:

  • Torus fracture, also known as a “buckle” fracture.  It results when the top layer of bone on one side compresses upon a harsh impact.  It is considered a stable fracture.
  • Metaphyseal fracture.  This type of fracture affects the upper or lower shaft of the bone without affecting the growth plate.
  • Greenstick fracture.  This type of fracture extends through part of the bone, causing it to bend on the other side.
  • Galeazzi fracture.  This impact is often a displaced fracture disrupting the radius and also the wrist joint where the radius and ulna come together at the wrist.
  • Monteggia fracture.  This fracture usually involves the ulna shaft and disrupts the elbow joint where the radius dislocates requiring urgent care.
  • Growth plate fracture. This type of fracture occurs across the growth plate.

(Fracture classifications source:  American Academy of Orthopaedic Surgeons)

Fractures in children are different from those in adults, because their bones are still growing.  As a result, they have more cartilage and collagen resulting in a more “pliable” bone less subject to a break – or one less severe as an adult might sustain with the same impact.  In fact, many fractures in children may be so subtle they are difficult to detect on an x-ray and require an orthopedic specialist to assess.  A fracture in a child heals rapidly.  So, it is important that it is addressed quickly and properly set before it heals in improper alignment – causing other long term problems.

Also unique in children is the impact a fracture could have on their growth plates.  Depending on the extent of a fracture, the growth and function of the child’s limb could be negatively impacted as a result.

Adult Forearm Fractures

The same fracture classifications applied to those in children, with the exception of growth plate and greenstick fractures, apply to those in adults.  The adult bone is less “pliable” than that of a child’s and has a higher tensile strength, which can result in a more serious break.

Adults suffering from osteoporosis are particularly subject to breaks from an impact or activity seemingly unlikely to inflict such damage.

Treatment

Fracture treatment depends on the severity of the break and any other soft tissue damage that may have occurred as a result.  The right treatment will depend on the fracture, age and lifestyle of the patient – and may be nonsurgical or surgical with internal fixation.

All treatment includes hand therapy for the best results and most rapid return to activity.

Playing with an Injury

When is it Okay to Return to Play?

As fall sports heat up, we begin to see a lot of injuries.  The first question players ask after we confirm their injury is, “how soon before I can play again?

Whether it’s a junior high schooler, college athlete or professional player, this question is asked with the same passion and underlying conviction to do whatever it takes to get back in as soon as possible.  This is their sport and their heart is all in – despite the injured limb and challenge it now presents.

Kinkaid Team Captain and outside linebacker, Harris Green, not slowed by forearm fracture

As an orthopedic physician who wants to ensure the best outcome in their recovery and a team doctor who understands this drive distinct in athletes, it’s important to develop the right treatment plan – some of which might entail permission for immediate return to play.

Green back in the game as fracture heals

While this may seem counterintuitive, certain hand and upper extremity fractures once stabilized and placed in a cast are fine for an immediate resumption of play.  This is particularly true of the younger athlete.  Some of the types of fractures allowing athletes to return quickly back to the game despite their cast or splint include certain finger and distal radius fractures and ligament sprains.

While the position on a team will impact the enthusiasm in our recommendation to allow such return to play – linemen with the capability to restrict their hands in a cast verses a receiver or running back more fully engaging their injured limb – many are as capable to play their position with their injury as they were before.

The type of injury is also a determination – stabilized fractures are more likely to be considered for immediate return to play than ligament or tendon tears.

Now, there are some risks for further damage if the injured limb is hit in such a way and the inflexibility of the cast places other vulnerabilities on the uncasted portion of the limb.  Other risks include refracture, retear of a tendon or displacement of a fracture.

But, the only way to truly avoid further injury is to sit out of the game until the injury is completely healed. And this is rarely an option for an athlete.

So, we ensure that our patients know everything upfront.  And we give them the tools to keep their injured limb as strong as possible – regardless of the decision they make.   Continuing to keep the injured limb strong by exercising the muscles and joints around the injury, in conjunction with cardiovascular exercise for overall physical well-being….is key.  We remain very involved and ready to make any readjustments we need to the treatment.

Basal Joint Arthritis (Arthritis of the Thumb)

Basal joint arthritis (also known as Basilar Joint arthritis) affects the base of the thumb, known as the basal joint or carpometacarpal (CMC) joint.  It is, in fact, the range of motion permitted by this joint that most distinctly separates the hand movement of humans within the animal kingdom – as it’s function and wide range of motion is unlike any other.

Bones which comprise the basal joint of the thumb.

The basal joint, or the CMC joint, is an interesting joint consisting of the small bone of thewrist known as the trapezium and the first (metacarpal) bone of the thumb.  This joint allows the thumb to reach a unique range of motion – permitting not only up and down movement but also the ability to span across the palm and achieve a “pinching” position.

This type of arthritis of the thumb results when the cartilage, which cushions the meeting point of the bones comprising the joint, deteriorates.  In the absence of sufficient cartilage, the bones are allowed to rub together during movement – causing pain at the base of the thumb and in severe cases deformity as the thumb collapses into the palm.

Pain may hinder many daily activities when the basal joint is irritated during such activities as turning knobs, opening lids, and writing.

It is one of the most common forms of arthritis of the hand, and it is thought that those suffering from a previous fracture or dislocation which affected the joint may be at higher risk for developing basal joint arthritis. Those suffering from osteoarthritis may also suffer from this type of arthritis.

Diagnosing Basal Joint Arthritis

The first steps in diagnosing this type of arthritis may include a physical examination, a discussion of patient history, and review of the pain and limitations experienced. A grind test and an X-ray may also be used to help confirm the diagnosis.

Treating Basal Joint Arthritis

There are a number of nonsurgical treatments for less severe cases of basilar joint arthritis, including:

  • Hand Therapy, which includes: therapeutic hand splints to support the thumb and wrist during rest; posture modification exercises to reduce joint irritation during certain activities; and massage, heat and ice therapy.
  • Non steroidal anti inflammatory medications (NSAIDS) – ibuprofen, aspirin, naprosyn.
  • Injection therapy – such as steroid, viscosupplementation, etc.

More severe cases of basal joint arthritis may require joint reconstruction or other surgical intervention to restore joint stability.

Learn more about this type of arthritis and other conditions affecting the hand, wrist and elbow.

 

 

 

 

XIAFLEX® Injection Therapy for Dupuytren’s Contracture

Dupuytren’s Contracture is a condition that affects the hands – and while the exact cause is unclear, there are a number of factors that can increase an individual’s risk.

The condition causes the tightening of fibrous tissue in the palm of the hand – between the skin of the palm and underlying flexor tendons of the fingers.  As the condition progresses, these rope like cords contract and begin to pull one or more fingers inward towards the palm making everyday activities more challenging.

While the exact cause of Dupuytren’s is unclear, risk factors include a genetic predisposition and those suffering from other diseases such as diabetes, cirrhosis and epilepsy.  Though, many sufferers are affected by none of the above.

Symptoms of this condition develop gradually and may go unnoticed.  Patients may first develop a tender lump in the palm of the hand, though associated pain may eventually subside. The condition is generally diagnosed upon physical examination.  Signs of Dupuytren’s include the inability to completely flatten the hand (palm down) on a flat surface, dimples in the palm and puckering over lumps in the palm may be evident.  In more advanced cases, fingers may be curled inward and difficult to straighten.

When Dupuytren’s Contracture is mild to moderate no surgical intervention is required.  Though in advanced cases, it may be necessary to surgically remove the fibrous cords which are pulling the fingers inward.

Until recently, traditional open surgery was the only option available to address the tightening, movement restricting cords to restore normal hand function.

While the innovative and less invasive needle aponeurotomy reduced for many over the past few years the need for more invasive traditional surgical intervention, another even less invasive procedure is gaining attention and showing much promise.

XIAFLEX® injection therapy is a new treatment for Dupuytren’s Contracture, which is an FDA-approved injectable collagenase (extracted from clostridium histolyticum).  Injected directly into the cords, XIAFLEX works to dissolve them – breaking down the fibrous tissue.  The injection takes just five minutes in the office.  Over the next 24 hours, the treatment works to dissolve the contracted cord.  Patients then return to the office the following day and the cord is “released” in a simple procedure.  A “popping” sound is often heard as the finger is pushed open and the cord is released.

Rehabilitation and specialized hand therapy, also known as occupational therapy, can help patients restore hand function following a Dupuytren’s Contracture procedure.

Learn more about Dupuytren’s Contracture, Injection Therapy and other common hand injuries and conditions.

 

Pitcher’s Elbow

Image

Today’s youth sports are more demanding than ever.  Seasons are longer and the practice and game schedule is intense.  Though with proper training and the ability to understand what pain may be signaling, a career ending injury can be avoided.

One of the more common overuse sports injuries we see affects the elbow and is known as Pitcher’s Elbow.

Throwing a baseball, particularly repeatedly as a pitcher does, puts a tremendous amount of stress on the inside of the elbow.  This stress is concentrated on a ligament known as the ulnar collateral ligament (UCL).

Lateral Collateral Ligament / Ulnar Collateral Ligament

When there is pain on the inside of the elbow it may mean that the ligament has either been stretched or has micro-tears.  The goal is to avoid throwing to the point of such pain, as it may indicate that the damage is already done!

There are many factors that can lead to the injury of a young player’s elbow ligament.  The main problem is throwing too much.  Often times this player is young, talented and needed in much of the game in order for the team to win.  The player then gets “overplayed,” until the elbow pain prevents further throwing.  The team must then find another pitcher and the cycle repeats.

Below are some suggestions that will hopefully help young pitchers – enabling them to mature and develop their full potential before an injury cuts their season short:

1. Pitch Count

The definitive pitch count guideline generally adopted comes from the 1996 American Sports Medicine Institute (ASMI) study.  This guideline includes maximum pitches per day, and days of rest between pitching.  Below are websites that include more information on this.

2. All Season Baseball

As our youth become more competitive, they begin to play year round.  This includes spring…..and now also summer and fall.  The elbow never gets a chance to rest and re-strengthen.  Ideally, the young athlete would pursue a different sport during the off-season – engaging different muscles, ligaments and tendons.  If baseball is the only sport, the pitcher must limit the amount of pitching during the off-season and work on some of the other influencing factors listed below.

 3. Pitching Mechanics

The mechanics of pitching are often left to the weekend warrior coach.  It may be worthwhile to find a professional pitching coach who can not only see the subtle corrections that need to be made, but also find a way to help the player make these adjustments as they throw at ever increasing velocity.  Consider that the player is developing as he gets older.  This means that the lessons from last year may no longer apply.  Players are not only getting taller, but developing more muscle.  This will impact their pitching mechanics.  A player should be re-evaluated every year or two.

 4. The Shoulder

Pitching is a rotation sport!  The windup starts in the body and gets transmitted to the hand via the shoulder and elbow.  If the shoulder is weak, the elbow must compensate.  This leads to injury.  It is important to strengthen the shoulder, chest and back in order to support this movement.  Specifically, it is important to strengthen the shoulder muscles that rotate the shoulder called the rotator cuff.  It is also important to strengthen the muscles that control the shoulder blade (scapula).  Young players have open growth plates in their bones, and injury to these growth plates are avoided by keeping the weight low.  The goal is not to build bulk but rather to build strength and stamina.  Weight training is best done in the off-season.   Smaller muscles like the rotator cuff can be exercised two or three times per week.  More than three times a week will weaken and not strengthen these muscles.  Finally, it is important to stretch the shoulder joint, especially the posterior capsule.  This is done by bringing the arm across the body and feeling the stretch on the back of the shoulder.

5. Fatigue

There is a difference between strength and fatigue.  As the game progresses, the muscles become fatigued.  The player, in their effort to maintain speed, start to use other muscles and change their throwing mechanics.  This then leads to increased strain on the elbow and ultimately to injury.  This may be avoided by strengthening the upper muscles in the off-season and by watching the pitch count during the season.

6. Addressing an already painful elbow

Pain in the elbow could indicate that the elbow is injured.  The first step is to stop playing baseball and seek the assessment of an orthopedic specialist.

–  Once pain is resolved and the tenderness is completely gone, initiate a strengthening program focusing on muscles of the chest, back and shoulders

– After the strengthening program is well on its way, the player should seek an evaluation by a professional pitching coach.

-Gradually the player will increase pitching distance and speed – with particular focus on proper mechanics

– After completing these steps, players can return to the regular season.

Typically, once a player has elbow pain they generally require about six months to complete the steps above.  Since the pain often occurs at the start or middle of a pitching season, this usually means that they will lose out on the remainder of that season.  Though, this is preferable to permanently damaging the arm and eliminating any chance of playing another season.

Helpful Websites:

www.qcbaseball.com

www.WebBall.com

www.littleleague.org   (pitch count regulation)

www.pitchsmarter.com

The Different Types of Fractures

A fracture is a break in the bone. Within the hand and upper extremity it can occur anywhere from the fingertip to the shoulder.

Among the most common fractures and dislocations of the hand and upper extremity include:

  • Finger Fractures
  • Distal Radius Fractures (also called Colles Fracture)
  • Scaphoid Fractures
  • Forearm Fractures
  • Clavicle Fractures (collar bone)

There are a number of different types of fractures – partial or complete, simple or compound, clean or shattered …each with their own classifications.  It is important to first define the type of fracture and its severity before determining the most effective treatment plan.

Fractures are defined by the severity of the break and the impact it imposes to surrounding tissue. Some fractures known as partial fractures may only cause a slight crack in the bone, while others may result in a complete break or shattered bone.

A fracture may also be either open or compound, which is a fracture that pierces through the skin creating an open wound.  A closed or “simple” fracture is a fracture that does not break through the skin.

Other classifications that help determine the best treatment plan for your type of fracture include:

  • Transverse Fracture – A fracture that goes across the bone and is situated at a right angle to the long axis of the bone.
  • Greenstick Fracture – A fracture situated on only one side of the bone, causing a bend but not a complete break. These are most commonly seen in children with more “pliable” bones.
  • Comminuted Fracture – A fracture that results in three or more bone fragments.
  • Intra-articular Fracture – A fracture with joint involvement.

Depending on the severity of the fracture, treatment may entail the non surgical realignment of the bone and casting, also referred to as closed reduction. Or surgical repair utilizing fixation support may be indicated.

Wrist Fracture – Distal Radius Fractures Among the Most Common Wrist Fractures

X-ray of a Distal Radius Fracture, also known as a Colles Fracture

One of the most common hand and upper extremity fractures we see is a distal radius fracture.  This is because of its position at the end of the forearm bone where it meets the wrist and the essential involvement of our hands and wrist in everyday activities and sports.  Our hands and wrists are also the first line of defense in a trauma – used as a shield to soften the blow of a harsh impact or to break a fall.

There are many opportunities to injure the distal radius.

The radius is the larger of the two bones located in the forearm. “Distal” radius refers to the lower end of this bone where it meets the wrist. The other forearm bone is the ulna, and together these two bones form the radioulnar joint.

Also called a “Colles” fracture for the anatomist who first described it, a distal radius fracture is common among those involved in contact sports as well as those suffering from osteoporosis.  It is occasionally misdiagnosed as a sprain and improperly treated – which could eventually lead to joint instability and osteoarthritis.

Some of the symptoms associated with a distal radius fracture include:

  • Swelling
  • Weakness and reduced range of motion
  • Persistent pain
  • Possible numbness
  • Deformity

Once identified, initial treatment will depend on the severity of the fracture, other soft tissue damage, and the type of break (simple or complex).  A wrist fracture may be treated non surgically by manipulating the broken sections back into place (closed reduction) and stabilizing the wrist with a splint.  More severe breaks may require surgical repair.

Next month’s blog will discuss how fractures are categorized and how they determine the treatment selected.