Have you ever had a Ulnar Fracture?

What is a ulnar fracture?

The forearm comprises of two long bones, the radius and the ulna, which are located on each other's sides. The ulna bone lies on the inner side of the forearm and forms joints with the humerus bone (in the elbow), the radius (near the wrist and elbow), and several small carpal bones in the wrist. Fractures of the ulna bone can vary in location, severity and type. Different types of ulnar fractures include stress fracture, avulsion fracture, olecranon fracture, medial epicondyle fracture, displaced fracture, un-displaced fracture, greenstick fracture, comminuted fracture, etc.

What are the causes of the disorder?

The ulna bone undergoes stress during a fall on an outstretched hand or forearm, or a direct fall on the elbow. A traumatic stressful event may occur while playing certain contact sports that cause a fall on a hard surface like cycling, skating, running, football, basketball etc. Road accidents can also cause a direct blow to the forearm from a moving object or collision with a stationary object. The ulnar bone breaks when the stress is beyond its withstanding ability, causing an ulna fracture.

What one needs to know about symptoms or signs?

Immediate pain can be felt from the time of injury. The most visible sign of a forearm fracture is a deformity - the forearm may appear bent or shorter than the other arm, and may need support. Additionally, a patient will experience the following symptoms:

• Inability to rotate arm
• Swelling
• Bruising
• Weakness of numbness in the wrist or arm (rare)

Which specialist should be consulted in case of signs and symptoms?

An ulna fracture requires immediate medial help at the hospital emergency room. An orthopaedic surgeon treats broken bone injuries.

What are the screening tests and investigations done to confirm or rule out the disorder?

A doctor examines the affected joint to check for deformity, range of motion and any impairment of nerve function. An x-ray is used to confirm the presence of an ulna fracture. In some cases, a computerized tomography (CT) scan, a magnetic resonance imaging (MRI) scan or a bone scan may be required to confirm diagnosis and assess the severity of injury.

What treatment modalities are available for management of the disorder?

Treating broken bones requires placing the broken pieces back in position and preventing their displacement till healing process is completed. In the forearm, the radius and ulna support each other, and it is important that both are stabilised. Proper alignment of the bones is essential in preventing future problems in the wrist and elbow. Treatment plan includes:

• First aid or emergency treatment - In an emergency room, a doctor tries to temporarily align the pieces of the broken bone, a process known as reduction. The arm is then immobilised in a splint and sling. Controlling the movement of a broken bone is a crucial step as moving it can cause additional damage to the bone and surrounding blood vessels and nerves. Pain is controlled through pain relieving medication.
• Non-surgical treatment - if the broken bone is not displaced, placing it in a brace or cast treats it. The healing of the fracture is closely monitored through frequent x-rays.
• Surgical treatment - Surgical intervention becomes necessary if the fracture shifts in position, or if both forearm bones (radius and ulna) are broken, or if the bones have punctured the skin (open fracture). Open fractures are scheduled for surgery almost immediately to prevent the risk of infection; antibiotic shots are given and the cuts from the injury are thoroughly cleaned out, before fixing the broken bones. In case there is no bruising, surgery is scheduled only after the initial swelling has settled down (swelling is reduced by keeping the arm elevated for several days).

Open reduction and internal fixation - This is the most common type of surgery for forearm fractures. It involves repositioning (reducing) the bone fragments into their normal position and holding them together with metal plates and screws that are attached to the outer surface of the bone. Internal fixation may also be carried out by inserting a metal rod in the centre of the bone, through the marrow space. External fixation - Plates, screws and large incisions on the skin may cause further damage in case the skin and bone are severely damaged. In this case, an external fixator is used. Screws or metal pins are placed into the bone above and below the injury site and attached to a bar outside the skin. This stabilising frame holds the bone in proper position to allow it to heal.

What are the known complications in management of the disorder?

Complications arising from an ulna fracture include:

• Non-union and mal-union
• Median, radial or ulnar nerve injury
• Infection
• Radio-ulnar fusion (synostosis)
• Re-fracture
• Compromised radial or brachial artery blood supply

What precautions or steps are necessary to stay healthy and happy during the treatment?

Full recovery is possible in patients with a fractured ulna though return to normal activities or sports may take weeks to months and should be guided by the specialist or physiotherapist. Recovery time can get prolonged if other bones, soft tissue, nerves or blood vessels were involved in the injury. Physiotherapy is important in ensuring healing and can be achieved through soft tissue massage, joint mobilisation, electrotherapy, braces or tapes, and exercises to improve flexibility and strength. Slings, wrist braces, ice or heat packs and a resistance band are often recommended to speed recovery.

How can ulnar fractures be prevented from happening or recurring?

Avoiding the onset of osteoporosis and seeking adequate treatment for existing osteoporosis can prevent ulnar fractures. Protective gear like wrist and elbow guards must be worn during sporting activities like biking or skating.     Sources: "Adult Forearm Fractures," American Academy of Orthopaedic Surgeons, AAOS, https://orthoinfo.aaos.org/topic.cfm?topic=A00584 "Forearm Injuries and Fractures," Patient.co.uk, https://www.patient.co.uk/doctor/Forearm-Injuries-and-Fractures.htm "Forearm Fractures," Medscape.com, Gopikrishna Kakarala et al, https://emedicine.medscape.com/article/1239187-overview