Forearm Injuries

Forearm Pain symptoms are almost entirely caused by how you use your hands and arms now, and how you have used them in the past. Symptoms can also be caused by previous injury to your forearms as well.

Movements, habits, and injuries all create patterns of strain that are completely unique to you and your body. Your case of Forearm Pain will be different in many ways from any other case of Forearm Pain because of the tissue history you carry with you all the time.

True Forearm Pain symptoms will be primarily muscular. Forearm symptoms almost always include grabbing, aching, weakness, and/or possibly throbbing. You might even get some stabbing pain if you are straining your forearm muscles to their limit. (Stop that!)

The forearms rely on the coordinated movements that happen between the flexor muscles which are on the palm side of the forearm and the extensor muscles which are on the the back-of-the-hand side of the forearms.

In many cases of Forearm Pain, the muscles on one side of the forearms get overworked and begin to glue themselves together to support one another through the strain.

This "gluing together" is known as "adhesions". Adhesions are the main source of forearm pain problems. When side-by-side muscles become stuck together, or adhered, they begin to act like one big muscle rather than smaller, more action-specific muscles.

Here's an example. Let's say that you always carry a heavy briefcase in your right hand. The gripping causes the muscles on the palm side of your forearm to become overworked. So, they attempt to spread out their efforts by sticking themselves together and acting as a group.

After the adhesions have formed, you cannot push down with your index finger and expect the tiny index finger muscles alone to do all the work as they were designed. Instead, the whole stuck-together mass of muscle has to be dragged into action by the tiny index finger muscle. This leads to extreme fatigue and the chance for more serious injury.

Adhesions also prevent muscles from relaxing and lengthening fully. They are in a constant state of contraction to one degree or another. Result? Very tired and overworked muscles.

 1. Forearm Pain Symptoms can happen anywhere on the forearms.

2. Symptoms are closely related to the coordinated movements of the flexor and extensor muscles. When one group gets overworked, strain develops which you may or may not feel in that muscle group. Since the normal coordination between the two groups of muscles is disturbed, pain will result. It's only a matter of time.
Forearm Pain Self Care

Forearm pain self care takes on an interesting twist when you consider the anatomy of the forearms. When you use your hands, muscles on one side of the forearms contract while the muscles on the other side lengthen. In order for you to be pain free, these muscles must be able to work in a balanced way. So, if one side is tight or adhered, the other side will have to overwork to compensate. This can lead to pain and injury.

Stretching is the best way to relieve forearm pain. This encourages tissues that are adhered to release from one another in the quickest way possible. It's also a great way to balance the function of the muscles on both sides of the forearms.

It's important to choose stretching exercises that affect all of the muscles of the forearms independently. Because your injury has developed as a result of how you use your hands and arms, it is impossible to tell at the beginning which muscles are creating your problem. So, choose stretches that work on all the muscles of the forearms and pay attention to how they feel as you practice them. This will give you clues as to which muscles are causing your symptoms.

After any period of stretching, be sure to rest your arms for at least 30 seconds before doing something new with your hands. This allows the muscle tissue time to recover from the stretch. Remember that stretching should never be painful in any way.

In addition to stretching it's important to identify other sources of forearm strain and try to eliminate as much of that strain as possible. If you use your hands extensively in your work, your forearm muscles are already under a lot of strain in the normal course of your day. To avoid further strain to your forearms, consider eliminating stressful activities like hand-intensive sports and hobbies. Choose only to do the most essential things with your hands and arms while you are trying to recover and your arms will thank you.

As always, consistency and care are the most important concepts to grasp when restoring forearms to normal, pain-free function and range of motion. Pay close attention to the sensations your body sends as you stretch. Never overdo it and never cause pain.

Adequate water intake is also very important. Muscles are designed to slide and glide across one another. Imagine how that sliding and gliding would be affected if the tissues are dry and sticky

Forearm Injuries and Fractures

Injury to the forearm usually results from trauma secondary to, for example, a fall, a road traffic accident or a sporting injury. It can also result from overuse. Injuries include muscle strain and contusion, crush injuries, fractures and tendon and nerve injuries.

Anatomy of the forearm

The radius and ulna have an important role in positioning the hand. The ulna has a stabilising role, while the radius is articulated in a way which allows it to roll over the ulna, moving the hand from supination (external rotation) to pronation (internal rotation).

•      The two bones of the forearm are the radius, laterally, and the ulna, medially. Other components of the forearm include skin, blood vessels, and soft tissue.

•      At its upper end, the radius articulates with the capitulum of the humerus at the elbow, and with the ulna (superior radioulnar joint). At its lower end it articulates with the scaphoid and lunate bones and also with the ulna (inferior radioulnar joint).

•      At its upper end, the ulna articulates with the trochlea of the humerus, and with the head of the radius (superior radioulnar joint). At its lower end it articulates with the radius (inferior radioulnar joint).

•      The olecranon process at the upper end of the ulna forms the prominence of the elbow. The styloid processes of the radius and the ulna form prominences at the wrist.

Forearm fractures

Forearm fractures account for most limb fractures. Wrist fractures are the most common forearm fracture. Fracture risk factors include osteoporosis (more common in women than men) and malignancy (pathological fractures).

Classification

•      Forearm fractures can be classified as either proximal, middle or distal.

•      They can affect one or both forearm bones.

•      They are either open or closed.

•      Proximal forearm fractures may involve the elbow joint

•      Distal forearm fractures may involve the wrist

General assessment and initial management of forearm fractures

Some general principles should be followed for all forearm fractures. Specific points related to the different fracture types are discussed below. Forearm fractures in children can generally be treated differently from adult fractures because of continuing bone growth in the radius and the ulna after the fracture has healed.

•      Assess Airway, Breathing and Circulation and manage as necessary.

•     Assess upper limb neurovascular function

1.    Sensory function: the median nerve supplies the thumb, index, middle and radial half of the ring finger on the palmar side of the hand and the tip of the thumb, index, middle and ring finger on dorsum of the hand; the radial nerve supplies the dorsolateral aspect of the hand and the dorsal aspect of the thumb, index, middle and lateral half of the ring fingers; the ulnar nerve supplies the dorsal and palmar aspects of the medial half of the ring finger and the whole of the little finger.

2.    Motor function: test anterior interosseous branch of the median nerve by asking patient to make the 'OK' sign; test radial nerve by asking patient to extend their fingers or wrist against resistance; test ulnar nerve by asking patient to separate their fingers against resistance.

3.    Vascular function: examine radial (and ulnar) pulse. Assess capillary refill.

•      Examine the wrist, elbow and forearm for tenderness and range of motion.

•      Perform a complete examination for other injuries.

•      Immobilize the forearm and upper arm whilst waiting for X-ray.

•      Provide analgesia.

•      Immediate fracture reduction is required if there is neurovascular compromise, severe displacement or skin tenting.

Adult both-bone forearm fractures

•      Mechanism of injury: usually significant force injury. Most commonly occur in motor vehicle accidents, also occur from direct blow, fall from a height or during sport.

•      Presentation: pain and swelling at site with obvious deformity.

•      Assessment: may be nerve involvement with paraesthesiae, paresis or loss of function. Do not elicit crepitus as may cause further soft tissue injury. Do not probe open fractures as may cause deeper contamination.

•      Investigation: X-ray entire length of forearm, wrist and elbow, with AP and lateral views.

•      Management: displaced fractures are the usual situation in adults. Operative treatment with internal fixation or Intramedullary nailing will be needed in nearly all cases, so refer urgently. Closed reduction may be attempted (with sufficient sedation/analgesia ± muscle relaxants) if there is acute neurovascular compromise.

Pediatric both-bone forearm fractures

Fractures may be of greenstick type (incomplete) or complete. A greenstick fracture can occur in one bone with a complete fracture in the other. Complete fractures may be undisplaced, minimally displaced or overriding. Fractures of the proximal third are relatively rare. Middle third fractures account for about 18% of both-bones fractures and distal third about 75%.

•      Mechanism of injury: usually an indirect injury following fall on outstretched hand. Occasionally caused by direct trauma.

•      Presentation: pain, swelling and deformity at fracture site.

•      Investigation: X-rays of wrist, elbow and whole forearm should be taken.

•      Management: unlike adults, many both-bone fractures of the forearm can be treated by closed reduction. After reduction, forearm pronation and supination should be checked and arm placed in a long-arm cast or splint. Surgical treatment is by open reduction and plating/intramedullary nails depending on degree of overriding/angulation.

Radial shaft fractures (Galleazzi fractures)

•      Definition: solitary fractures of the distal one third of the radius with accompanying subluxation or dislocation of distal radioulnar joint (DRUJ). Synonym is reverse Monteggia fracture.

•      Mechanism of injury: commonly caused by fall on extended, pronated wrist.

•      Presentation: pain, swelling and deformity of the wrist and forearm. Tenderness and swelling at the distal radius and tenderness at DRUJ.

•      Investigation: X-ray the entire length of the forearm including wrist and elbow joints, AP and lateral views usually sufficient.

•      Management: in adults, requires surgical open reduction of the distal radius and DRUJ with internal fixation. In children the fracture can often be treated by closed reduction with longitudinal traction and correction of radial angulation. General anaesthesia may be required in difficult cases. If closed reduction under GA fails, K-wire insertion may be needed to lever the fracture into position. Open reduction may be needed in some cases.

Ulna shaft fractures

•      Definition: isolated mid-shaft ulna fractures have the synonym 'nightstick fracture'.

•      Mechanism of injury: usually caused by a direct blow to the ulnar border, classically if someone receives a blow from an object whilst raising their arm in defence.

•      Presentation: point tenderness over ulna shaft and forearm swelling.

•      Investigation: need to x-ray ulna from wrist to elbow.

•      Management: require orthopedic referral. Non-displaced or minimally-displaced fractures can be treated with posterior splint from mid-upper arm to dorsum of the metacarpal joints with wrist in slight extension, forearm in neutral position and elbow at 90°. After 7-10 days, when swelling has subsided, use plaster sleeve or functional brace for next 4-6 weeks. Monitor weekly for first 3 weeks for any displacement. Fractures with marked displacement or angulation should be treated with open reduction and internal fixation.

Monteggia fractures

•      Definition: these are fractures of the proximal third (usually) of the ulna with associated dislocation of the radial head. Classified a

1.    Type I - Fracture with anterior radial head dislocation. Commonest (60%).

2.    Type II - Fracture of the proximal ulna with posterior or posterolateral dislocation of the radial head (15%).

3.    Type III - Fracture of the ulna metaphysis with lateral or anterolateral dislocation of the radial head (20%).

4.    Type IV - Fracture of both radius and ulna at their proximal third with anterior dislocation of radial head (5%).

•      Mechanism of injury: usually caused by a fall onto outstretched, extended and pronated elbow or direct blow.

•      Presentation: acute, severe pain and swelling in forearm and elbow. Damage may occur to the posterior interosseous nerve.

•      Investigation: X-ray the entire length of radius and ulna, including wrist and elbow, AP and lateral views usually sufficient but may need radiocapitellar views.

•      Management: in adults, immobilize joint in splint and refer for open reduction and internal fixation. Most paediatric monteggia fractures are treated closed.

Complications of forearm fractures

•      Non-union and malunion (uncommon)

•      Compromise of brachial/radial artery blood supply

•      Median, ulnar or radial nerve injury

•      Infection (more likely if fracture secondary to crush injury)

•      Compartment syndrome (more common in both-bone forearm fractures)

•      Radioulnar fusion (synostosis)

•      Re-fracture

Prevention of forearm fractures

•      Prevention of osteoporosis.

•      Adequate treatment of existing osteoporosis.

•      The use of wrist and elbow guards whilst taking part in certain sports activities such as mountain biking and skating.

Forearm overuse injuries

•      Apart from tennis and golfer's elbow, forearm overuse injuries are not that common outside the realms of sports medicine.

•     Commonly affect athletes who take part in racket or throwing sports. If an activity involves repetitive flexion-extension of the elbow or pronation- supination of the wrist, it can lead to an overuse injury.

•      Examples of overuse injuries around the elbow are lateral and medial epicondylitis - see separate article on tennis and golfer's elbow.

•      Ulnar nerve injury and olecranon stress fractures can also occur if there is increased stress on the elbow joint.

•      Three major nerves cross the elbow joint: the median nerve, the ulnar nerve and the radial nerve. Overuse injuries or direct trauma to the elbow can affect these nerves.

•      Pronator syndrome and radial tunnel syndrome can occur in sports where there is excessive wrist flexion-extension or pronation-supination.

•      History taking is an essential part of the examination.

Pronator syndrome

•     Due to entrapment of the median nerve.

•     There is pain or paraesthesia over the median nerve distribution in the anterior proximal forearm. Aggravated by throwing/swinging a racket.

•      Distinguished from carpel tunnel syndrome because in carpel tunnel syndrome, sensation over the thenar eminence is preserved (the sensory branch of the median nerve that innervates the thenar eminence does not pass through the carpel tunnel).

•      Negative Tinel and Phalen tests at the wrist in pronator syndrome and difficulty making the OK sign (touching the tips of the 1st and 2nd fingers with the thumb).

•     Treatment is rest/modification of activity, ice, analgesia, physiotherapy and occupational therapy.

Radial tunnel syndrome

•      Due to entrapment of the radial nerve.

•      Pain experienced distal to the lateral epicondyle of the humerus and radiates down the dorsum of the forearm.

•      Often misdiagnosed as lateral epicondylitis.

•      A Tinel test approximately 6cm distal to the lateral epicondyle over the radial nerve can reproduce pain. Also pain on resisted supination with forearm extended.

•      Treatment is rest/modification of activity, ice, analgesia, physiotherapy and occupational therapy.