Clinical Practice Guidelines

Radius /ulna shaft diaphysis fractures - Fracture clinics

  • Fracture Guideline Index

    See also: Radius / ulna shaft (diaphysis) fractures - Emergency Department  

    1. How often should these fractures be followed up in fracture clinics?
    2. What should I review at each appointment?
    3. What are the timeframes for the removal of fixation?
    4. What are the complications associated with this injury?
    5. When should I refer for an orthopaedic consultant opinion?
    6. What are the indications for discharge?

    1. How often should these fractures be followed up in fracture clinics?

    Table 1: Recommended follow-up for radial shaft (diaphysis) fractures.

    Fracture type

    First appointment

    Subsequent review appointments

    Discharge advice to parents

    Greenstick

    Within 7 days post-injury with x-ray in cast

    At 2 weeks post-injury with x-ray in cast

    At 6 weeks post-injury with removal of cast. X-ray if clinically indicated

    If clinical exam normal, discharge

    One in twenty shaft fractures will refracture. This occurs primarily in the first 6 months of injury. The risk is higher immediately after cast removal

    Contact sports should be avoided for a minimum of six weeks after cast removal. This will be case dependent

    Plastic deformation

    Within 7 days post-reduction with x-ray in cast

    At 2 weeks post-reduction with x-ray in cast

    At 6 weeks post-reduction with removal of cast. X-ray if clinically indicated

    If clinical exam normal, discharge

    As above

    Complete (no fixation)

    Within 7 days post-reduction with x-ray in cast

    At 2 weeks post-reduction with x-ray in cast

    At 6 weeks post-reduction with removal of cast. X-ray if clinically indicated

    If clinical exam normal, discharge

    As above


     2. What should I review at each appointment?

    Check for redisplacement and whether the cast is appropriate. After 2-3 weeks, 50% of casts will need to be 'repaired' or replaced.

    3. What are the timeframes for the removal of fixation?

    Once out of plaster, pins are removed at 4-6 weeks post-operatively. The removal of Titanium Elastic Nails (TENS) is made on a case-by-case basis and usually occurs 3- 6 months post-operatively. There is a higher rate of refracture if removed before 3 months.

    4. What are the complications associated with this injury?

    a) Loss of reduction

    • For displaced fractures of the diaphysis, up to one in four will lose position and will need a re-reduction. Loss of position and the opportunity for re-reduction can only happen with appropriately timed follow-up
    • Poor cast technique and residual angulation/displacement after the initial reduction are two major factors that can cause subsequent loss of alignment

    b) Refracture

    • Approximately one in twenty (5%) will have a refracture within 6 months of injury. The risk is higher immediately after cast removal. Parents and patients should be aware of this

    c) Malunion

    • Occurs after closed treatment. Consider patient's age and remodelling potential, as most will resolve with remodeling or be minimal

    d) Forearm stiffness

    • Most common complication with closed treatment of shaft fractures is loss of forearm rotation, with pronation being more affected. Rates are reported at up to 15% with a mild loss of motion (<25 degrees) and up to 8% with a severe loss of motion (>45 degrees)

    e) Delayed union or nonunion

    • Rare. Rate is reported to be 0.5% for delayed union. Nonunion is also rare, but is at higher risk with an open fracture. Average healing time of a radial shaft fracture is 5.5 weeks (range 2-8 weeks)

    f) Cross-union/synostosis

    • Rare. Usually is associated with high-energy injuries, radial neck fractures, and surgically treated forearm fractures

    g) Infection

    • Rates reported at 0.2% for deep infection and 3% for superficial infection with pinning/flexible nailing of these fractures. Open fractures are at higher risk, rates reported at 1.2% for deep infection

    h) Neuropraxia

    • Uncommon complication. Median nerve is the most commonly injured nerve with this fracture, but any nerve can be affected. Most injuries are neuropraxias. Superficial branch of the radial nerve is at risk with starting point of flexible nail insertion in radius

    i) Muscle entrapment/tendon rupture

    • Can occur with severely displaced fractures. Usually requires open reduction to remove interposed tissue from fracture site. There is an iatrogenic risk of tendon rupture with flexible nail insertion and removal from radius

    j) Complex regional pain syndromes

    • Uncommon. Often seen with less severe trauma. Most reliable physical exam finding is allodynia. May require referral to pain clinic for medical treatment

    5. When should I refer for an orthopaedic consultant opinion?

    Indications for a consultant orthopaedic surgeon opinion are:

    • fractures not in acceptable alignment (see Table 1, acceptable angulations, ED Section)
    • loss of position over one week, with concerns for further loss

    6. What are the indications for discharge?

    The indications for discharge are a healed fracture clinically and radiographically with acceptable alignment. Usually occurs at six weeks post-injury and immobilisation.

    References (Outpatient setting)

    Bae D. Pediatric distal radius and forearm fractures. J Hand Surgery 2008; 33: 1911-23.

    Mehlman CT, Wall EJ. Injuries to the shafts of the radius and ulna. In Rockwood and Wilkins' Fractures in Children, 7th Ed. Beaty JH, Kasser JR (Eds). Lippincott Williams & Wilkins, Philadelphia 2010. p.347-404.

    Tredwell SJ, Van Peteghem K, Clough M. Pattern of forearm fractures in children. J Pediat Ortho 1984; 4(5): 604-8.

     

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