What exactly is broken in a forearm fracture?
Also called a “both bone forearm fracture”, this injury involves the complete breaking in two of each of the two bones of the forearm: the radius (on the thumb side), and the ulna (on the pinky side).
Remember that break and fracture mean the same thing – these bones are broken in half!
This is different than a wrist fracture – the wrist is technically closer to the hand. The forearm bones are the two long bones between the elbow and the wrist.
How is a forearm fracture treated?
In children, these fractures can be treated with just casting or a couple of pins.
The first thing that happens after the injury is to put the patient’s arm in a temporary splint, usually made of fiberglass. This holds the bones still so the arm doesn’t hurt as much.
In adults, the standard treatment is to take the patient to surgery within a few days and fix each bone with a long metal plate and several screws. This is a fairly significant surgery involving making two large incisions over each bone, and moving muscles and nerves around to get access to the broken bones underneath. Surgery may take 1 or 2 hours and the patient can go home the same day.
How long is the recovery time after a forearm fracture?
An athlete with this injury will not be able to play for at least six weeks after surgery. It takes six weeks for bone to heal after it’s lined up correctly in surgery. After the bone heals, the athlete can return to playing sports.
This video shows how the surgery is typically done. It’s all done on fake bones, but with real plates and screws – nothing gruesome:
A fusion is a surgery done to stop two things: motion and pain. A fusion creates a solid bone where a joint used to be. In this article, I’ll share an example of a common fusion surgery I do to cure finger pain.
Why would someone want a fusion surgery?
A fusion (also called an arthrodesis) is almost always done for arthritis. It’s a cure for arthritis. Fusing a joint cures the arthritis forever and stops pain.
Because the pain of arthritis comes from a worn out joint grinding on itself, if you stop the grinding, you stop the pain.
Patients with arthritis in the fingers try many treatments – from splints, to steroid shots, to medicines, and even surgeries to replace joints and repair bones.
When all these stop working, a fusion is the last option to try in most cases. It’s a good, reliable operation that’s been working for centuries.
How does a fusion work?
In a fusion surgery, the surgeon opens up the joint, exposing the worn out joint surfaces. He uses tools (scraping tools and often a burr) to expose raw spongy bone on either side of the old joint.
Sometimes bone graft is packed into this space, and the two bones are held together by some type of hardware, like a screw or wires.
In this example, you can see an xray of a finger joint fused together by a single screw.
The hardware keeps the two bones still and squeezed next to each other while they heal. Eventually solid bone grows across the junction between the two bones, forming a solid bridge of hard, normal bone.
How long does it take for a fusion to heal?
Because I’m putting two bone surfaces together to let them heal, fusions heal like a fractured bone. Instead of two broken bone fragments healing together, there are two normal bones healing together.
This process takes about six weeks in a finger.
Signs of healing include new calcified bone on an xray – growing across like a bridge between the bones, and no tenderness when the patient pushes on the old joint.
Usually patients can use the finger for light activities while the fusion is healing – typing, writing, getting ready in the morning. The screw is strong enough to withstand some light daily activity.
How does a fusion cure arthritis?
In the process of fusing the joint, the old joint surfaces are removed. Therefore, technically, there isn’t a joint there anymore.
Without a joint, you can’t have arthritis, so it’s gone forever!
What’s the big downside to a fusion surgery?
The motion of the fused joint stops forever. The joints around the fused joint may move normally, but the fused bones become permanently stiff.
A fusion is a tradeoff between motion and pain. You get stiff, but the pain goes away forever. The happiest patients after a fusion surgery are patients who had daily pain in the finger before surgery, even with light activities.
Another thing that surprises patients is that the finger is still somewhat enlarged or lumpy after the fusion. This is common, and often cannot be corrected completely. However, the finger should be straight, not twisted, and pain-free once it’s healed.
What will the finger look like after the surgery?
Here’s a video of one of my patients with a fused, pain-free pinky finger joint after healing. The finger moves at the MCP and PIP joints, but the end knuckle doesn’t move at all.
Some fractures occur both in adults and kids – some fractures occur only in children. Forearm fractures occur in both, with some important differences. This article will cover some of the basics of forearm fractures in kids.
The forearm is a unique structure which provides stability and mobility at the same time. The forearm is made up of two bones – the radius and the ulna. The bones can be broken at any point along the shaft of the bone – down by the wrist, at the middle of the bone’s shaft, or up by the elbow.
How the bones are broken
Fracture of both bones of the forearm may occur directly or indirectly by force.
Direct injuries happen when a child falls directly on the forearm, or something hits the forearm with a direct impact. This could be during a fall onto the sharp edge of a curb, or if a child is hit with a baseball bat or other blunt object.
Indirect injuries are much more common – they happen when a child puts her hand out to break her fall and the force from the fall travels up the forearm and breaks both bones.
How the diagnosis is made
Fractured forearms are usually pretty obvious when the doctor sees the patient. There’s usually a pronounced deformity that involves swelling or bruising of the forearm area. If the break is near the wrist or elbow, those areas may be swollen as well, and the child will refuse to move the joints around the fracture (even the fingers).
Xrays are a critical part of making the diagnosis of a forearm fracture. Other tests like CT scan and MRI are almost never necessary.
In children, bone fragments are usually not displaced (moved out of place) because the periosteum (covering over the bone) is thick and functions as an extra layer that contains the pieces of the fracture.
How forearm fractures are treated in children
In childhood, conservative treatment is usually successful. Most forearm fractures don’t need to be straightened out in surgery. A cast is the most common treatment. Sometimes the cast is put on after a week or two in a fiberglass or plaster splint.
Kids rarely need surgery. However, “surgery” needs to be defined here.
Surgery on kids’ fractures could be anything from simply pushing on the arm with the child asleep in the operating room, to making an incision over the bone and moving the pieces with bone clamps.
The most common surgery in kids’ forearm fractures is when the surgeon straightens the bones and puts a splint on the arm while the child is asleep. No pins, no incisions required.
The more the pieces are moved out of place and the older the child, the more likely it is that surgery will be necessary for correct healing.
Other reasons for taking a child to surgery for a broken forearm:
- the bones are partially healed in the wrong position – a bad angle or not lined up at all
- the surgeon or doctor in the ER tries to line up the pieces but they don’t line up well or won’t stay lined up after a week or so
- pieces of the broken bones are highly displaced (moved out of place)
- it’s a compound, or open fracture – pieces of the broken bones came through the skin
Complications from pediatric forearm fractures
Complications are rare. The most common problems involve stiffness and leftover deformity of the bones.
It’s common for the forearm to look crooked after the cast comes off. The younger the child, the faster and better the body straightens out deformities.
Usually, even if the bones aren’t perfectly straight on the xrays, the arm functions normally and the mild deformity doesn’t prevent the child from doing anything she wants to do.
Some parents don’t want any deformity at all and are more aggressive about wanting surgery – other parents are OK with most of the straightening happening after the cast comes off. This is why having an open discussion in the office is so important!
What restrictions are necessary during the healing of a forearm fracture?
The same restrictions apply whether treating an adult or a kid who has a fractured forearm:
- no lifting
- no weight bearing or pushing with the arm
- keep fingers moving
- light activities like writing and playing video games are fine
Sometimes the most frustrating part of recovery involves dealing with the cast – keeping it clean, dry, and comfortable.
How long is the recovery time from a forearm fracture?
Healing time depends on the severity of the forearm fracture. Fractures in children generally heal in 6 weeks.
The younger the child, the faster the bones heal. Past 4 years old, the process takes a full six weeks.
Declaring a fracture healed is a combination of
- healing on the xray
- lack of pain when the doctor pushes on the arm
After the bone has healed, the arm will be stiff for several days. This usually goes away with time without any physical therapy.
A ganglion cyst is simply a fluid-filled sac. It can be visible from the outside or buried deep underneath the skin.
Sometimes it causes symptoms like soreness and pain; other times patients have no idea it’s there.
What is a mucous cyst?
Ganglion cysts in the finger are often called “mucous cysts”, because of the mucous-like, or jelly-like clear fluid inside them.
These cysts are filled with joint fluid that has partially thickened. The jelly looks a lot like hair gel when it squishes out of the cyst in surgery!
The most common location for these is in the middle finger. They usually don’t happen in patients younger than 45 or 50 years old.
This type of arthritis is more common in women than men, and usually doesn’t happen before age 40. Fractures and other trauma to the thumb joint may put you at risk for developing arthritis in the future.
What’s inside the cyst?
The fluid inside the cyst is joint fluid. Every joint produces this fluid normally. In arthritis, the worn-out joint produces more fluid than usual. The fluid builds up and eventually forces its way through the joint lining and through the tendon fibers on top of the finger. This forms a cyst that you can see underneath the skin.
Sometimes the skin has a normal thickness, and you just see the bulge of the cyst below the skin.
Other times the cyst puts so much pressure on the skin that the skin thins out and becomes translucent – you can almost see through the skin at that point!
These cysts can be tiny or huge – they can have a single chamber, or multiple lobes and chambers.
Where do mucous cysts come from?
The cysts almost always come from a mildly arthritic joint. In other words, the joint may not be worn out enough to be painful, like most people think arthritis would be. But the joint is worn out enough to make more fluid than normal.
I always take an xray of the finger when I see one of these cysts. Sometimes the xray will show big bone spurs and other signs of arthritis. Most of the time, though, the xray appears almost normal; just a little extra narrowing of the joint more than normal.
Can they go away on their own?
Sometimes they pop on their own – other times they last for years.
Usually, they go up and down in size with activity.
Some of my patients are adventurous and try to puncture them on their own before they come and see me. It’s amazing how often they come back, despite the multiple self-surgery attempts.
Nail deformity and fingertip ganglion cysts
Many patients see a deformity or groove in the nail along with the cyst.
This happens because the tissues that grow a nail are very close to the cyst. The cyst pushes on these tissues, called the nail bed, and the nail can’t grow normally. Grooves in the nail usually resolve completely once the cyst is removed in surgery.
How are fingertip ganglion cysts treated?
In almost every situation, it’s safe to leave these cysts alone. There’s no medical reason to take them out.
However – if the cyst has ruptured on its own, or the patient has repetitively punctured the cyst with a needle, trying to get rid of it, I recommend surgery.
Since the ruptured cyst comes from the joint, a hole in the cyst and in the skin provides a direct path for bacteria to get from the skin down into the joint and even into the bone.
It’s rare to see an infected joint from one of these ruptured cysts, but it is possible, and not worth the risk.
Pain is another reason patients want these removed. But I always caution them that the pain could be coming from the arthritis in the joint and not the cyst itself. Getting rid of the cyst may not take their pain away.
The surgery involves opening up the skin over the cyst and cutting out a small window in the joint lining. I then scrape the edges of the joint where the cyst comes from. I try to find the root of the cyst and destroy it so it can’t come back.
Surgery is done as an outpatient, under local anesthesia plus a little sedation through an IV. You wear a tiny finger splint on the tip of the finger for about 10 days until the stitches come out. It’s safe to take the splint off for showering and typing during that time. After 10 days, you can use the finger as much as you want for normal activities.
Can mucous cysts come back after surgery?
There’s always a theoretical possibility of the cyst coming back. I’ve seen two come back in 8 years of doing hand surgery, so it’s rare. Since the arthritis is still there after the surgery, the cyst can come back. The only way to permanently remove the arthritis is to fuse the joint, which is a pretty radical step for most patients with a mucous cyst.